PGIMER Entrance Forensic Medicine and Toxicology Syllabus

Define mechanical asphyxia and list its general signs.

Asphyxia is interference with respiration (oxygenation) producing hypoxia. General signs: cyanosis, petechial (Tardieu) haemorrhages, congestion of organs, dark fluid blood, and engorgement of right side of heart.

Differentiate hanging from strangulation by ligature mark.

Hanging: ligature mark is oblique, high up on neck (above thyroid), incomplete, non-continuous, runs upward toward the knot, pale/parchment-like. Ligature strangulation: mark is horizontal, low on neck (below thyroid), continuous and completely encircling, with more local bruising.

What is the cause of death in typical hanging?

Most commonly asphyxia, but death can also result from venous congestion, cerebral anoxia from carotid/vertebral artery occlusion, vagal inhibition (reflex cardiac arrest), or fracture-dislocation of cervical vertebrae (judicial hanging - 'hangman's fracture' at C2).

Differentiate throttling from smothering and gagging.

Throttling = manual strangulation with the hands (nail/finger bruises on neck, fractured hyoid). Smothering = closure of external air passages (nose and mouth) by hand/cloth. Gagging = forcing material into mouth/throat obstructing the airway.

How do you distinguish antemortem drowning findings?

Fine, lathery (leathery) froth at mouth/nostrils, water and weeds in air passages, waterlogged heavy lungs (emphysema aquosum), cutis anserina (goose skin), washerwoman's hands, and diatoms in tissues (positive diatom test indicates antemortem drowning).

Classify burns by Dupuytren's classification (degrees).

Six degrees: 1st - erythema/redness; 2nd - vesication (blisters); 3rd - destruction of cuticle and part of true skin; 4th - whole skin destroyed; 5th - muscles involved; 6th - charring of whole limb including bone.

How do antemortem burns differ from postmortem burns?

Antemortem burns show a vital (inflammatory) reaction: line of redness, blister fluid rich in protein/chlorides with leucocytes, and carbon (soot) in air passages plus raised carboxyhaemoglobin if there was a fire. Postmortem burns lack these vital signs.

What is the 'pugilistic attitude' (heat stiffening) in burnt bodies?

A boxer-like posture with flexed limbs produced by heat coagulation/contraction of muscles in a body exposed to intense heat; it is a postmortem effect and has no relation to a defensive position before death.

What are the cardinal principles of medical ethics?

Autonomy (respect for patient's right to decide), Beneficence (act in patient's best interest), Non-maleficence (do no harm), and Justice (fairness in distribution of care).

Define professional (infamous) misconduct and name the body that regulates it in India.

Professional misconduct is conduct by a registered medical practitioner that is regarded as disgraceful or dishonourable by professional brethren of good repute. In India it is regulated by the National Medical Commission (NMC, formerly the Medical Council of India) under its Code of Ethics Regulations.

What are the '6 A's' commonly cited as professional misconduct?

Adultery (with patient), Association (with unqualified persons), Advertising (self-promotion), Addiction, Alcohol (treating while intoxicated), and issuing false certificates (Allegedly false documents) - examples of infamous conduct leading to disciplinary action.

What is the penalty erasure of name from the medical register, and who can do it?

'Penal erasure' (professional death sentence) is removal of a doctor's name from the medical register by the State/National Medical Commission's disciplinary body for proven professional misconduct; the doctor may be warned, suspended, or have the name erased temporarily or permanently.

Define consent and the types relevant to medical practice.

Consent is voluntary agreement by a competent person. Types: implied (e.g., extending arm for injection), expressed (oral or written), and informed consent (after disclosure of nature, risks, benefits and alternatives). For surgery and procedures, written informed consent is required.

At what age can a person give valid consent for medical examination/treatment in India?

Generally 12 years for examination, but valid consent for treatment/operation requires age 18 years and above (a person attains majority at 18). Below 18, consent of parent/guardian is needed (except in emergencies).

Define medical negligence and the '4 Ds' required to prove it.

Negligence is failure to exercise reasonable care and skill causing harm. The 4 Ds: Duty (of care owed), Dereliction (breach of duty), Direct causation, and Damage (resulting injury/loss to the patient).

What is the difference between civil and criminal negligence?

Civil negligence is a tort; the patient sues for compensation/damages, decided on balance of probabilities. Criminal negligence involves gross/reckless disregard for life (e.g., causing death), tried under IPC (Sec 304A), and requires proof beyond reasonable doubt.

What is the doctrine of 'res ipsa loquitur' and 'vicarious liability'?

Res ipsa loquitur ('the thing speaks for itself') applies when negligence is so obvious it needs no proof (e.g., swab left in abdomen). Vicarious liability means an employer (hospital) is responsible for negligent acts of employees ('respondeat superior').

Are medical services covered under the Consumer Protection Act in India?

Yes. Paid medical services are 'services' under the Consumer Protection Act, so a patient is a 'consumer' and can claim compensation for deficiency in service before consumer forums; free services (where no charge is taken from anyone) are excluded.

Differentiate the types of witnesses in court.

Common (ordinary) witness states facts seen/heard. Expert witness gives an opinion in his field of special knowledge (e.g., doctor). A doctor is usually a 'professional/expert' witness, and may also be a common witness for facts personally observed.

What are examination-in-chief, cross-examination and re-examination?

Examination-in-chief: questioning by the party who called the witness (no leading questions). Cross-examination: questioning by the opposite party (leading questions allowed, to test credibility). Re-examination: by the side that called the witness, to clarify points raised in cross.

What is a 'dying declaration' and its evidentiary value?

A statement (oral or written) made by a person who is dying, about the cause/circumstances of injury that led to death. Admissible under Sec 32 Indian Evidence Act; needs no oath, no corroboration if found reliable, and the declarant must be conscious and compos mentis.

What is a summons vs a subpoena, and what is conduct money?

A summons/subpoena is a document compelling a witness to appear and give evidence in court. Conduct money is the fee paid in advance to a witness (in civil cases) to cover expenses of attending court; failure to appear after a summons can lead to legal penalty.

Define rape as per Indian law (Section 375 IPC) in brief.

Rape is sexual intercourse by a man with a woman against her will, without consent, with consent obtained by fear/fraud, with consent of an unsound-mind/intoxicated person, or with a girl under 18 years (even with consent). Penetration is sufficient to constitute the offence.

What medical evidence is collected during examination of a rape victim?

Examination of clothes and body for stains/injuries, genital examination (hymen, tears, bruises), swabs (vaginal/anal/oral) for spermatozoa and DNA, pubic hair, blood/urine for intoxicants, and documentation of mental state. Consent and chain of custody are essential.

What is the medicolegal significance of seminal stains and the chemical/microscopic tests used?

Seminal stains help prove sexual assault. Tests: examination under UV (fluorescence), microscopy for spermatozoa, acid phosphatase test (raised in semen), Florence test (choline crystals), Barberio's test (spermine crystals), and DNA profiling for identity.

Define sodomy, incest and bestiality.

Sodomy = anal intercourse between humans. Incest = sexual intercourse between persons within prohibited degrees of blood relationship. Bestiality = sexual intercourse between a human and an animal. These fall under unnatural sexual offences.

What are the general principles of management of an acute poisoning case?

Stabilize ABC (airway, breathing, circulation); decontamination (remove poison - gastric lavage, activated charcoal, skin/eye washing); enhance elimination (forced diuresis, dialysis); administer specific antidotes; and give supportive/symptomatic care plus psychiatric referral if intentional.

List important specific antidotes for common poisons.

Organophosphates - atropine + pralidoxime; Opioids - naloxone; Paracetamol - N-acetylcysteine; Methanol/ethylene glycol - ethanol/fomepizole; Iron - desferrioxamine; Cyanide - sodium nitrite + sodium thiosulphate (or hydroxocobalamin); Benzodiazepines - flumazenil; Arsenic/lead/mercury - chelators (BAL/dimercaprol).

What are the features and antidote of organophosphate poisoning?

Organophosphates inhibit acetylcholinesterase causing cholinergic crisis - muscarinic (SLUDGE: salivation, lacrimation, urination, defecation, GI upset, emesis; miosis, bronchorrhoea), nicotinic (fasciculations, weakness) and CNS effects. Antidotes: atropine (for muscarinic) and pralidoxime (cholinesterase reactivator).

What are the features of corrosive (acid/alkali) poisoning and a key treatment caution?

Corrosives cause burning pain, dysphagia, corrosion/ulceration of mouth, oesophagus and stomach, and risk of perforation and later stricture. Treatment: do NOT induce vomiting or do gastric lavage (re-exposes tissue); dilute with water/milk, manage airway, and treat shock; alkalis cause deeper liquefactive necrosis, acids cause coagulative necrosis.

Describe arsenic poisoning: features, classic sign, and antidote.

Arsenic causes acute gastroenteritis (rice-water stools, vomiting, 'cholera-like' picture) and chronic features (Mees' lines on nails, hyperkeratosis/pigmentation 'raindrop', peripheral neuropathy). It is the classic homicidal poison. Antidote: chelation with BAL (dimercaprol), DMSA or DMPS.

What are the features of dhatura (datura) and oleander poisoning (common agro/plant poisons)?

Datura (an atropine-like plant) causes anticholinergic toxidrome - 'red as a beet, dry as a bone, blind as a bat, mad as a hatter, hot as a hare' (flushing, dry mouth, dilated pupils, delirium, fever); a railway/road poison. Oleander causes cardiac glycoside effects - vomiting, bradycardia, arrhythmias and is a common suicidal plant poison in India.

What are the features and management priorities of snake bite by venomous snakes in India?

The 'Big Four' are cobra, krait (neurotoxic - ptosis, ophthalmoplegia, respiratory paralysis), Russell's viper and saw-scaled viper (vasculotoxic/haemotoxic - local swelling, bleeding, coagulopathy, AKI). Management: reassure, immobilize the limb, do NOT cut/suck/tourniquet tightly, do 20-minute whole blood clotting test, and give polyvalent anti-snake venom (ASV) with supportive care (ventilation, neostigmine for neurotoxic bites).

Describe lead (plumbism) poisoning features.

Chronic lead poisoning causes a blue 'lead/Burton's line' on gums, anaemia with basophilic stippling of RBCs, abdominal colic (painter's colic/constipation), wrist drop/foot drop (peripheral neuropathy) and lead encephalopathy in children. Antidotes: calcium disodium EDTA, BAL, D-penicillamine, DMSA.