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 MASHABA FILES EDITED BY DR. NAFJA KHALID

Table of Contents
ECG........................................................................................................................................................................................... 2
CNS......................................................................................................................................................................................... 22
CTG OBS ............................................................................................................................................................................... 101
GYNECOLOGY ....................................................................................................................................................................... 119
OBS RECALLS ...................................................................................................................................................................... 214
CVS ADULT ........................................................................................................................................................................... 294
DERMA ................................................................................................................................................................................. 363
DRIVING QUESTIONS ............................................................................................................................................................ 398
DVT WARFARIN HEPARIN MCQS ........................................................................................................................................... 412
BIOSTATISTICS AND EPIDEMIOLOGY .............................................................................................................................. 445
DIABETES HIV HEP B & ENDO ................................................................................................................................................ 481
GIT........................................................................................................................................................................................ 549
#NEPHRO #RENAL #KIDNEY .................................................................................................................................................. 584
GIT LATEST QUES GIT... RECALLS ........................................................................................................................................... 623
BLOOD .................................................................................................................................................................................. 636
INFECTIOUS & TRAVEL MEDICINE ......................................................................................................................................... 696

MALE GENITAL SYSTEM ........................................................................................................................................................ 752

RENAL AND MALE PATHOLOGY ................................................................................................................................. 810
ORTHO ................................................................................................................................................................................ 858
PAEDS 1 ................................................................................................................................................................................ 934
PAEDS CVS CNS ..................................................................................................................................................................... 989

PSYCH ................................................................................................................................................................................. 1032

RESPIRATORY ADULT & PAEDS ........................................................................................................................................... 1088

#PAEDS ............................................................................................................................................................................ 1156

RHEUMATOLOGY (ADULT+PEADS) ...................................................................................................................................... 1157
EYE & ENT ........................................................................................................................................................................... 1201

ENT RECALLS ....................................................................................................................................................................... 1228

NECK LUMPS....................................................................................................................................................................... 1251

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ECG
1. MCQ 3.074
A 28-year-old man develops rapid palpitations and mild light-headedness following
a 20km run. He is not known to have cardiac disease and a recent cardiovascular
examination was normal. The pulse is rapid and regular. Which one of the following
rhythm strips would be most likely with this clinical picture?
paroxysmal supraventricular tachycardia jm 812

2. Young man developed palpitations after a 15km walk. Had to choose ECG rhythm strip.

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a) A fibà if bradycardia+irregular, but if tachycardia+regular: PSVT
b) V fib
c) A Flutter
d) VT

Summary of Electrocardiographic Features of hocm

• Left atrial enlargement

• Left ventricular hypertrophy with associated ST segment / T-
wave abnormalities
• Deep, narrow (“dagger-like”) Q waves in the lateral > inferior
leads
• Giant precordial T-wave inversions in apical HCM
• Signs of WPW (short PR, delta wave).
• Dysrhythmias: atrial fibrillation, supraventricular tachycardias,
PACs, PVCs, VT

3. an ecg question of a completely healthy 35 year old man after a jog rapid palpitations and light headedness
asking for the proper ecg
Afib - SVT but its rate was slow 75 - vent tachy -complete heart block

‫ ﺗﺎﺧﯿﻠﯨﺸﺎﯾﻌﮭﺴﺘﻦ‬٢ ‫ﺑﻌﺪورزش‬. Lone af‫و‬pac

4. Patient on polypharmacy, had stopped all his drugs, now comes with and ECG of Atrial Fibrillation, which drug to
start first?????????????
Perindopril
Beta blocker
Digoxin
Frusemide
(acute : rate control,chronic: rhythm control)
5. Pulmonary embolism case with ECG
S1Q3T3 pattern
This 'classic' pattern is often considered the pathognomonic ECG abnormality associated with acute pulmonary
embolism
• Deep S wave in Lead I: ≥1.5 mm
• Deep Q wave in Lead III: ≥1.5 mm
• T wave inversion in Lead III

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6. pt arrive from travel. Chest pain sibce 4 hrs which is worsening now, sweating , BP 90/60

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Lbbb
Inf mi with rbbb
Pul. Embolism – http://medicine.ucsf.edu/education/resed/Chiefs_cover_sheets/ecg_pe.pdf

pericarditis

7. A 4year child has come with this ECG,Has complained of 4hours lightheadedness & palpitations. HR 200 and PR
20/MIN What’s next step of management:vt
A.Oral Digoxin
B.Immerse face in water
C.IV adenosine
D.IV sotalol

(VT , SVT , WPW ‫ ھﺴﺖ‬wide complex tachycardia ‫ﻣﮭﻤﺎﯾﻨﮭﻜﮭﯿﻚ‬،‫ وﻟﯨﻤﮭﻤﻨﯿﺴﺘﭽﯿﮫ‬. ‫ ھﺴﺖ‬SVT with aberrancy ‫اﯾﻨﺒﮭﺎﺣﺘﻤﺎﻟﺰﯾﺎد‬
:‫ ﺑﺎﻗﻀﯿﮭﺒﺮﺧﻮردﻣﯿﺸﮫ‬VT ‫ﺑﻮدﻧﺸﺎﺻﻼًﻣﮭﻤﻨﯿﺴﺘﻔﻌﻼً( ودراﯾﻨﺠﻮرﻣﻮاردﻣﺜﻠﯿﻚ‬
D/C shock‫ ﺑﻮد‬unstable ‫اﮔﮫ‬-
‫ﻟﯿﮕﻨﻮﻛﺎﯾﯿﻨﯿﺎﺳﻮﺗﺎﻟﻮل‬،‫ ﺑﻮدآﻣﯿﻮدارون‬stable ‫اﮔﮫ‬-
‫ﻓﻘﻄﯿﻜﺘﺒﺼﺮھﺪارھﺪاﺳﺘﺎﻧﺎوﻧﻤﺎﯾﻨﻜﮭﺪرﺑﭽﮭﮭﺎاﮔﮭﺨﻮاﺳﺘﯿﻤﺪرﻣﺎﻧﺪاروﯾﯨﺒﻜﻨﯿﻤﺎوﻟﯿﻜﺪوزآدﻧﻮزﯾﻨﻤﯿﺰﻧﯿﻤﺒﻌﺪﻣﯿﺮﯾﻤﺴﺮاﻏﺪاروھﺎﯨﻔﻮق‬

8. young man ( more than 20) was playing football and when was standing alone, without being hit by anyone, lost
consciousness and regain it after 5 minute and was well and started playing again after 30 minutes. What is the
most likely cause
Vasovagal===few minutes
cardiac arthymia===few seconds
hypoglycemia===not gain conscious without giving sugar==gain consciousness gradually

9. patient with ECG of rapid response AF and palpitation ( rate 150) with hypothyroidism on thyroxin what should
be done?
Digoxin
Give metoprolol

10. Pt. with CHF taking b-blocker , furosemide , perindopril , K supplement , metformin for DM , start amiodarone
due to arrythmic problems , now complain of lightheadednes and palpitation & feeling like syncope , what is the
cause ? Same ecg of Ali nazzari recalls was given
A) perindopril + lasix
B)bblocker + lasix
c) K supplement + bblocker
d)amiodarne + furosemide===torsa de points,tachycardia, hypokalaemia\\\ttt magnesium correct electrolyes

11. an old lady presented to you with early diastolic murmur at apex, mid systolic murmur at right parasternal side
and diastolic murmur at left sternum. What is the lesion?
A)MR===systolic murmur
B)AR ....3 suffles
C)MS===diastolic murmur

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D)TR

12. A man presented with lightheadedness with multiple drug interaction, to me the ECG was of long QT syndrome,
not hyperkalemia-
Amiodarone +frusemide
Amlodipine+ frisemide
Frusemide + thaiazide

Combining Amiodarone +frusemide can increase the risk of an irregular heart rhythm. may need regular monitoring
of your electrolyte (magnesium, potassium) levels. You should seek immediate medical attention if you develop
sudden dizziness, lightheadedness, fainting, or fast or pounding heartbeats during treatment with amiodarone. In
addition, you should let your doctor know if you experience signs of electrolyte disturbance such as weakness,
tiredness, drowsiness, confusion, muscle pain, cramps, dizziness, nausea, or vomiting
http://www.drugs.com/interactions-check.php?drug_list=167-0,1146-0

Risk factors for torsade include the following:

• Congenital long QT syndrome.

• Female gender.
• Acquired long QT syndrome (causes of which include medications and electrolyte disorders such
as hypokalemia and hypomagnesemia)
• Bradycardia.
• Baseline electrocardiographic abnormalities.
• Renal or liver failure.

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VF
13. ECG of Bradycardia he is sure about it .. patient on polypharmacy what combination causes all
1-amiodaron frusemide (torsa de pointes)
2-amiodarone amlodipine ..(amlodipine causes tachycardia)
3- digoxin and other drug

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14. one LBBB ecg but im so sorry cant remember exactly was something like old case of mi , q waves were there too
and now come for follow up .was on polypharmacy acei , beta blocker , furosemide nd few more what would u
do ?
a) reassure and review in 6 months
b) stop the drugs one drug in each option stop BB
Never administer beat blocker in a patient with recent onset LBBB and ACS

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Rbbb===m pattern at v1 and w pattern at v6

Lbbb===w pattern at v1 and m pattern at v6

15. ECG hyperkalemia-- K>7.. ask Rx--

a. ca gluconate
b. iv dextrose

manifestations of hyperkalemia: muscle weakness or paralysis, cardiac conduction abnormalities, and cardiac
arrhythmias, including sinus bradycardia, sinus arrest, slow idioventricular rhythms, ventricular tachycardia,
ventricular fibrillation, and asystole
ECG changes: tall peaked T waves with a shortened QT interval; progressive lengthening of the PR interval and QRS
duration; disappearance of the P wave; and widening of the QRS complex to a sine wave pattern

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Tall T wave in all leads!

Rapidly acting therapies include the administration of calcium, insulin with glucose, beta-2-adrenergic agonists, and,
in selected patients, sodium bicarbonate . These therapies are primarily used in three settings:
• ECG changes
• serum potassium < 6.5 to 7 meq/L
• A lesser degree of hyperkalemia in patients with a serum potassium that is rapidly increasing

16. A little toddler came with parents because he ate his grandma "white pills" , they don’t know which one he ate
cuz she is taking many drugs for many things , the boy is drowzy has bradycardia by examination and u did
an ECG.
Which drug did the boy ingested
?
• beta blocker
• Digoxin
• K supplement
• Metformin
• TCA
Digoxin overdose:
Signs of overdosage include
vomiting, salivation and
diarrhoea, drowsiness,
bradycardia and arrhythmias.

17. HYPERKALEMIA ECG for a kid

who taken his grandparent
meds,,which med?
A- verapamil
b- k supplements
c -frusemide
d-digoxin
e-fifth I cannot remember but it was not ace or ARB
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digitalis toxicity
• Bradycardia
• hyperkalemia
• arrhythmia (any type with the exception of rapidly conducted atrial arrhythmias)
• Gastrointestinal: anorexia, nausea, vomiting, and abdominal pain
• neurologic signs: confusion and weakness
• Renal dysfunction

Chronic toxicity is more difficult to diagnose, as symptom onset tends to be more insidious. In addition to
gastrointestinal symptoms, visual changes may occur, including alterations in color vision, the development of
scotomas, or blindness

St elevation===hyperkalemia not due to digoxin

Scoppy t wave inversion bcz of===digoxin toxicity

18. another que pt on many medication metoprolol,digoxin,frusemideecg was given mobitz type 1 and nusea
vomiting and abd pain was there,digoxin level was given and it was normal.what to do?
1.cease digoxin
2.cease metoprolol
3.temporary pace making
4.angiogarphy
5.cease metoprolol and commence verapamil

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ü Toxicity is related to intracellular levels, not serum levels

1-Any patient with clinically significant manifestations of digitalis poisoning should be treated with digoxin -specific
antibody (Fab) fragments. include:
• Life-threatening arrhythmia (eg, ventricular tachycardia; ventricular fibrillation; asystole; complete heart
block; Mobitz II; symptomatic bradycardia)
• Evidence of end-organ dysfunction (eg, renal failure, altered mental status)
• Hyperkalemia (serum potassium >5 to 5.5 meq/L)

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2-As temporizing measures or if Fab fragments are not immediately available, symptomatic bradycardia or
bradyarrhythmia can be treated with atropine (0.5 mg IV in adults; 0.02 mg/kg IV in children, minimum dose 0.1 mg)
and hypotension with IV boluses of isotonic crystalloid

19. Pt. with CHF , DM , HT , mild renal impairement taking perindopril , bblocker , digoxin , aspirin , K supplement,
now have this ecg , what is the next to do ?
A) dec. perindopril
B) stop digoxin
C) inc. K suppl.
D)dec. b blocker

20. A very clear ecg of second degree / type 1, heart block, pt on poly pharmacy, acei, frusimide, digoxin, what to do
next. No option for temp pace,
Stop dig
Stop acei
Stop frusimde
Permanent pace maker

a progressively increasing PR interval until a P wave is not conducted

treatment for Mobitz type I AV block

1-Prior to initiating Tx, exclude reversible causes:
• MI
• increased vagal tone (younger persons or athletes)
• medications(ABCD):
Ø A…amiodarone&adenosine
Ø B…beta-blockers
Ø C…calcium channel blockers (especially verapamil and diltiazem )
Ø D…digoxin
2- If no reversible causes are present:
• asymptomaticà no specific therapy

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• symptomatic bradycardiaà implantation of a permanent pacemaker

21. LBBB ecg was given and the patient was taking perindropilspironolactone..atenolol .what to stop here?

A. Spironolactone
B. Atenolol==ansjm 965
C. perindropil

Hyperkalemia can cause LBBB

patients with heart failure who are taking spironolactone and ACE inhibitors-can develop severe hyperkalaemia in

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22. Patient had inf mi two days back. Today in hospital has bradycardia arnd 35/min. ecg strip was given , atropine
was given . no improvement .
A- adenosine
b- temp pacing
c- perm pacing

indications for temporary bradycardia pacing in patients with acute MI:

• A-systole
• Symptomatic bradycardia due to sinus node dysfunction or Mobitz type I that is not responsive to atropine
• Mobitz type II second degree
• Complete AV block
• Bilateral or alternating bundle branch block including RBBB with left anterior fascicular block or left posterior
fascicular block
• A new bundle branch block with first degree AV block
• An old right bundle branch block with first degree AV block and a new fascicular block

23. An old man with congestive heart failure and hypothyroidism. On levothyroxine, digoxin, and other medications
came with light headedness and palpitations. His HR was 140 regular. The ECG was sinus tachycardia as I've
noticed. Wt should you do:
1. cease thyroxine
2 . stop digoxin
3. Decrease digoxin
4 . add metoprolol

Sinus tachycardia = Exogenous hyperthyroidism

The symptoms and signs in patients who take excessive doses of thyroid hormone: weight loss, heat intolerance,
tremor, palpitations, anxiety, increased frequency of bowel movements, and shortness of breath
Discontinuation or reduction in the dose of thyroid hormone is usually the only treatment needed. Beta-blockers will
relieve many of the symptoms of hyperthyroidism promptly

24. A 60 y.o. man develops lightheadedness and palpitations. He has hx of thyroid disease and well-controlled heart
failure. He is on thyroxine, ACEI, diuretic. ECG is given – clearly showed AFib.
What is the next step?
a. Cease thyroxine
b. Start digoxine

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c. Start b-blocker
d. Start verapamil

25. Scenerio Of inferior MI within 2 hour what to do next

A. RTpa
B.angiography
C. nitroglycerine
Answer depends on proximity to tertiary center. If close to tertiary center next is coronary angiography from above
options for confirmatory diagnosis and PCI or coronary angioplasty for treatment. If very far from tertiary center and no
availability of PCI, then A.

26. a 50 year old man present with hypertension with asthma and reflux nephropathy .lab inv were given.there was
high urea,high creatinine and proteiuria 900 mg/day.what is the choice of anti HTN?
1.amlodipinejm 966
2.losartan
3.perindropil
4.indapamide
5.BB

ACEi or ARB are first choice in patients with proteinuric chronic kidney disease, The most common side effect of
therapy with ACE inhibitors is cough, so ACE inhibitors are not first-line therapy in patients with asthma or COPD, An
alternative is angiotensin II receptor blocker

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27. ECG of complete heart block given. Patient has hypertension with cardiac failure and is on ramipril, verapamil,
statins and diuretics. What is the most appropriate management?
a)Add adrenaline
b) Stop verapamil
c) Stop diuretic
d) Stop ramipril

Verapamil and, to a lesser degree, diltiazem can diminish cardiac contractility and slow cardiac conduction [3]. As a
result, these drugs are relatively contraindicated in :
• second or third degree atrioventricular block
• patients who are taking beta blockers
• severe left ventricular systolic dysfunction
• Sick sinus syndrome

28. pt on many medications , indapamide, verapamil, perindopril , aspirin….. present wth light headedness and
mobitz type 2 ecg given wt to do next
1.valsalva manover
2.cease verapamil
3.temporary pace maker==jm 815
4.ceaseindapamide

29. a pt with heart failure on many drugs stop medication for 2 weeks now came with odemauptoknee,chest was
clear and with sinus tachycardia what to give?
1.digoxin
2.metoprolol
3.commence all drugs again

30. another heart failure scenario pt on many medication and on digoxin .125 mg present with edema
,crepitation.first what to give
1.40 mg frusemide mane(1st)
2. 0.5 mg digoxin stat
3.metoprolol mane
4.all drugs together
No option for ACEI(1st)

31. A young guy while playing cricket suddenly had syncopal attack without any convulsive features. Soon he
spontaneously recovered and started fielding and continue playing rest of the game.What was the cause?
a)Vasovagal syncope
b)cardiac issue (arrythmia)
c)Epilepsy
• cardiogenic: the patient drops down suddenly and regains consciousness in seconds.
• Neurogenic: goes suddenly and come backs in minutes (vasovagal , seizure , etc)
• Metabolic: the patient goes gradually and come backs gradually

B between these options. if there is post ictal state then SEIZURE otherwise SYNCOPE.

If there is prodromal signs then more with Vasovagal if no prodromal sign and recover immediately(seconds) more
with cariogenic (there could be murmur),
no murmur arrhythmic syncope.
But there is some rare once too. Here I share a link for differential daignosis of SYNCOPE it was really help full for me

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32. young male who fall suddenly in the field of a match , without being touched , after a few
seconds/minutes he stood without any intervention and continued playing what is the case
a)vasovagal attack
B)Jacksonian seizures

33. An adolescent boy with episode of sudden fall in the playground regained consciousness with 5 mins and started
playing within 30 mins . diagnosis
a. postural hypotension
b. arythmias
c. vasovagal syncope

34. An 80-year-old man developed sudden loss of consciousness for about 1 minute with gradual recover. There is
no significant past medical history. 5ECG tracings given. Choose the most appropriate ECG tracing.
SVT
Atrial fibrillation
Ventricular fibrillation
Ventricular tachycardia
Complete heart bloc*** as a sick sinus syndrome can trigger loss of consciousness with prompt recovery…

35. 18 month old infant noticed by his parents to have a very fast heart rate last for 20 mins. heart rate was about
250-300/min. What would you do? a. Beta blocker b. verapamil c. cold water stimulation d. digoxin e.
reassurance
Svt is the most common arrythmia in children

36. A young pt with repeated dizziness and fall when standing only. Head tilt test lowers BP to 70/50
What advise will you give?
fludrocortisone
increase salt and water intake (dehydration)

• Doctors use tilt-table tests to find out why people feel faint or lightheaded or actually completely pass out.
• Tilt-table tests can be used to see if fainting is due to abnormal control of heart rate or blood pressure.
A very slow heart rate (bradycardia) can cause fainting.

initial intervention is to increase intravascular fluid volume by large daily salt intake, either added to food or as salt
tablets:
Continue with this until weight has increased by 1.3-2.3 kg; then can consider giving fludrocortisone, if necessary, to
increase sodium retention.
Can precipitate heart failure but peripheral oedema alone should not cause cessation of treatment.

37. A young pt with repeated dizziness and fall when standing only. Head tilt test lowers BP to 70/50 What will you
do?
a)Fludrocortisone Can’t remember other options but there was nothing like I/V fluid ***

Initial intervention: increase intravascular fluid volume by large daily salt intake, either added to food or as salt
tablets:
Continue with this until weight has increased by 1.3-2.3 kg; then can consider giving fludrocortisone, if necessary, to
increase sodium retention. It Can precipitate heart failure but peripheral oedema alone should not cause cessation
of treatment.
If symptoms still persist consider midodrine (not licensed for use in postural hypotension)!==postural orthostatic
tachycardia syndrome dx

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U can see wikkipedia link …1st increase salt and water then medication fludrocortisones

Notes:
Responses to Head-Up Tilt-Table Testing Condition
Physiologic response Normal Heart rate increases by 10 to 15 beats per minute Diastolic blood pressure
increases by 10 mm Hg or more Dysautonomia Immediate and continuing drop in systolic and diastolic blood
pressure No compensatory increase in heart rate
Neurocardiogenic syncope Symptomatic, sudden drop in blood pressure Simultaneous bradycardia Occurs
after 10 minutes or more of testing
Orthostatic hypotension Systolic blood pressure decreases by 20 mm Hg or more or Diastolic blood pressure
decreases by 10 mm Hg or more
Postural orthostatic tachycardia syndrome Heart rate increases by at least 30 beats per minute or Persistent
tachycardia of more than 120 beats per minute

38. A lady presented with light headedness and palpitation she has similar episodes in last 3 months. On
examination BP is 85/60 and pulse 98/min and after head tilt BP is 110/72 and pulse 74/min. treatment ?
Atropine

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Pacemakers
Fluids

39. A lady in her 20s with lightheadedness (and ECG given – heart block 1st degree, I think). When you
perform a table test (?) – after head tilt for few minutes her pulse drops to 50 and BP
to 70/40. What is the management?
a. Pacemaker***
b. Atropine
c. b-blocker
aaaaaaaaaaaaaaaa because of heart block + tilt +
Neurocardiogenic syncope is a relatively common entity. In the vast majority of people, there are well defined triggers that can be either avoided or appropriate
action taken when avoidance is not feasible. In a smaller number of individuals, there are recurrent syncopal spells without a clear trigger.

Neurocardiogenic syncope has been divided into three types (5,6). Type 1 is mixed characterized by a combination of both vasodepression and cardioinhibition.
In this group, the hypotension develops prior to the bradycardia and the bradycardia is generally not severe. The heart rate either does not fall below 40 bpm or
remains below 40 bpm for less than 10 seconds. Type 2 is cardioinhibitory with a major period of asystole and is subdivided into (a) and (b). In type 2a, the
hypotension precedes the bradycardia but the bradycardia is marked with sustained periods of asystole (Figure 1). On tilt table testing, the asystole is > 3
seconds. In Type 2b, the bradycardia either precedes or coincides with the development of hypotension. Again, the bradycardia is severe. Type 3 is pure
vasodepression where there is minimal to no decrease in the heart rate associated with the hypotension. In each case, there is usually a transient initial increase
in heart rate either coincident or following the onset of the hypotension.
If just tilt was the issue, B-b or mitodrine for neurocardiogenic shock (vasovagal) was good. But
here….
Interpretation of table test in hypotension evaluation .....
Normal test -: heart rate increase and bp decrease ......
Neurocardiogenic OR vasovagal snycope-:symptomatic sudden
drop of bp and simultaneous bradycardia.....
Orthostatic/postural hypotension-: bp significantly decrease
more than 20mmhg and heart rate no significant change.....,

40. A young athlete presents with palpitations after marathon. What ECG would you expect? (5 ECG strips given)
a. Sinus arrhythmia (not SVT, as different RR intervals, and P wave is present before every QRS)**
b. atrial flutter with variable block

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c. VTach
d. AFib
e. 1st degree heart block
Aaaaaaaaaaaaaa
Arrhythmia in athletes HB 3.074

41. pt with hypertension ,DM, well controlled congestive heart

failure presents with palpitation and irregular pulse which one
is appropriate first
a.digoxin …….choice for arrhythmia in CHFjm 981
b.warfarin
c.metoprolol
d.aspirin

The most important thing to look at here is The co-existing

DM. You dont give B blockers to DM patients so it is A

Picture of atrial fibrillation ecg with the ff scenario pt with

hypertension ,DM, well controlled congestive heart failure
presents with palpitation and irregular pulse which one is
appropriate first
a. digoxin
b. verapamil
c. metoprolol
d. Ramipril
e. Amlodipine

42. MI recent patient suddenly breasthlessness bp droped 80/50

ecg VT mx?
DC cardioversion –DC defibeliator –IV adenosine

ü VT unstable= dc
ü stable = iv lidocaine or procainamide
ü treatment= beta blocker

Paroxysmal supraventricular tachycardia (PSVT) occurs in less than

10 percent of patients after an acute MI, Mx:
1- Carotid sinus massage or a valsalva maneuver
2- Intravenous adenosine or verapamil
3- Intravenous beta blockade with metoprolol or esmolol or
amiodarone
4- Intravenous digoxin
5-If the arrhythmia persists ………Cardioversion

43. patient collapsed and CPR started first step?

Cardioversion
Defibrillation
IV lignocaine
IV adrenaline

ü VF pulseless unstable =defib

ü without reversible or transient cause= ICD

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44. A 4year child has come with this ECG,Has complained of 4hours lightheadedness & palpitations. What’s next
step of management:
A.Oral Digoxin
B.Immerse face in water
C.IV adenosine
D.IV sotalol

45. ecg showing AFIB asking what youll find in examination

prominant a wave - completely normal heart - idont remember the rest of choices

46. A patient presents with chest pain of 2 hours onset in the metropolitan hospital. ECG given showing lateral
STEMI in I, AVL and V5,V6. Morphine, Oxygen, Nitrates, Aspirin given. What is the next step?
a. tPA
b. Coronary angiography

• <1h symptomèacceptible delay of 60min

• 1-3hors of sympè90min ====
• 3-12hours of sympè120 min delay
• After 12 hèPCI not recommended

47. young guy while playing cricket suddenly had fallen without any convulsive features. Soon he spontaneously
recovered and started fielding and continue playing rest of the game.What was the cause?
a)Vasovagal syncope
b)Heart block
c)Epilepsy

48. 3 year old man took some of his grandma medications, she’s been taking
medications for CHF and herpetic neuralgia. The ECG was 2nd degree
heart block. What would be the cause :

1. digoxin
2.amitryptiline
3. Metoprolol

CNS
Topics
Epilepsy, mys gravis,GBS,tremor,parkinson,dementia,headache

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Photosensitivity & epilepsy

Photosensitive epilepsy is rare affecting only a small number of people with epilepsy. With photosensitive epilepsy
seizures are triggered by sensory stimuli such as flickering sunlight, strobe lights and flickering television. Simple
preventative measures can be taken to decrease seizures triggered this way such as wearing wrap-around sunglasses
to reduce glare and covering one eye to reduce the effects of flickering or flashing light. Most computer monitors do
not present a problem, however if you are sensitive to screen flicker, try using a non-interlaced monitor and take
regular breaks.

Parkinsonism

1. A 70-year-old man with extremely severe parkinsonism comes by ambulance to the emergency department secondary
to psychosis and confusion developing at home. He is maintained on levodopa/carbidopa, ropinirole, and tolcapone.
What is the most appropriate next step in management?
a. Stop levodopa/carbidopa (
b. Start clozapine. ANS IF OLANZAPINE QUITAPINE THEN CHOOSE IT
c. Stop ropinirole
d. Stop tolcapone( compt)
e. Start haloperidol
Haloperidol cause decrease in dopamine
Clozapine cause agranulocytosis
2. Parkinson with dementia started haloperidol for this confusion .two wk ago present by increase tremor and s/s of
Parkinson mx?
A. Inc haloperidol
B. Dec haloperidol (haloperidol is contraindicated in parkinsonism) or stop haloperidol... Treatment anticholonergic
drug...
C. Inc ant Parkinson drugs
D. Inc dose of levodopa
B ans (haloperidol also cause decrease dopamine)

3. a man presented with MMSE 27/30 history ofk HTN ,

parkinsonism on many medication complaints of seeing
green cat in his window. Asking diagnosis?
a. Lewy body dementia (a) ANS JM 58
b. Drugs causing

4. Which of the following clinical feature is helpful to

differentiate Lewy body dementia from Alzheimer’s
disease?
a. Parkinsonism
b. Persistent short term memory loss
c. Deterioration of social skills
d. Taking longer to do routine tasks
e. Forgetting well-known people or places

5. Male patient has trouble climbing stairs and also shoulder movement problems.
Diagnosis?
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A- polymyositis (JM 316)
B- SLE
C- myasthenia gravis (JM 335)
D- multiple sclerosis

#nov #med

A or C? if A how to exclude c? Ans a

6. Female with burning face pain and redness

Trigeminal neuralgia…Transient, wont stay long
Herpes simplex…With Vesicles
Varicella zoster (ans) jm 1330

7. old man presented to u complaining of rest tremor overriding brdykinesia. he has known ho of visual hallucination
and he is on risperidone and he has ho of forgetfulness. most likely dx
A.Parkinson disease.
B.lewy body dementia
C.Alzheimer disease
D.acute delirium.
e.schizophrenia
B is answer.. Risperidone atypical antipsychotic cause hyperprolactinemia, hallucinations
Long term use cause drug induced side effects

8. An old man is brought to you with bradykinesia and akathisia. He is on respiridal for his visual hallucinations. Now he
is complaining of fluctuating forgetfulness. What is the likely diagnosis?
a. Parkinson disease
b. Alzheimer disease
c. Acute delirium
d. Lewy body dementia

answer (d)

9. A few factors seem to increase the risk of developing

Lewy body dementia, including:
a. Being older than 60
b. Being male
c. Having a family member with Lewy body dementia
or Parkinson's disease jm - (ans)

10. pt with visual hallucinations , unstable walk, fluctuating

gait , u see urine on his clothes , he forgets alot what is
ur Dx ?

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1-normal pressure hydrocephalus. Kaplan.. Gait abnormality... Urine incontinence
2-LBD
3-parkinson disease

answer with refernce please.

11. Patient taking risperidone and another antipsychotic. Now develop cog wheel rigidity, visual hallucination, dementia.
a. Parkinsonism
b. Schizophrenia
c. Lewy body dementia( ans)

12. 43 old female has headache from occipital area moves towards frontal lobe every month 4days Before menses what
us your diagnosis ?!
a-Migraine
b-Cluster headache
c-Sinusitis
d-Premenstrual headache (ans)

13. A lady receptionist working round the clock...pain at bifrontal n parietal i think headache...relieved for 2 hrs after
analgesia.... dx?
a. tension headache/
b. migraine/
c. menstrual headache

14. Patient comes with repeated frontal temporal headache for more than a week. Responds to paracetamol for 2-3
hours then recurs. Diagnosis?
a. Migraine
b. Tension headache
c. Cluster headache
D rebound headache (best ans),,jm649

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15. female pregnant with normal blood pressure with headache, vision impairment ,rt abd pain what will u do help
diagnosis
a. ct head (CI in pregnancy until any emergency)
b. bl culture
c. us abdomen(ans) by exclusion
Mri. (P.apoplexy-After delivery when PPH/ any bleeding…Bcz pituitary enlarged throughout the pregnancy)

Ø (search q again)
Pregnant female 18 weeks pregnancy .. presenting with sudden severe headache .. mild blurring of vision ..
drowsiness .. exam revealed normal abdomen .. no uterine tenderness .. HTN don’t remember the exact number
.. you take blood sample for lab .. what to do next
A) Abd. US (not pregnancy) (think about it…could be pheochromocytoma as well)
B) Fundus exam
C) CT brain (sure not MRI) may be sah
D) Urine culrure and sensitivity

16. Parkinson with dementia started haloperidol for this confusion .two wk ago present by increase tremor and s/s of
parkinson mx?
A. Inc haloperidol
B. Dec haloperidol (ans)
C. Inc ant parkinson drugs
D. Inc dose of levodopa

17. GBS case with limb paralysis and mild dyspnea. What is the most important next step :
A. LP initial( investigation) imp thing...
B. Spirometery is important. (answer) for monitoring mild dypnea) to see fvc
( less then 1litre we have to intubate...)
C. MRI
Mild dyspnea we can start with spirometry...

18. Husband brought his wife to the doctor complaining that she is not behaving as usual .She forgets things and has few
falls as usual,the woman was mumbling something and her expressions were flat Husband also said that she would
fall asleep suddenly anywhere .What is the diagnosis?
a)Alzheimer's dementia
b)Lewy body dementia
c)Fronto_temporal dementia personality change, apathy, mumbling
words & complex calculation
d)Senile dementia
e) Schizophrenia

19. Elderly patient aged 55 presented with agraphia ataxia,acalculia asking for diagnosis.
Frontotemporal dementia
Parkinson's
Alzheimer's
http://www.alz.org/.../fronto-temporal-dementia-ftd

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Key Differences Between FTD and Alzheimer's

Age at diagnosis may be an important clue. Most people with FTD are diagnosed in their 40s and early 60s.
Alzheimer's, on the other hand, grows more common with increasing age.
Memory loss tends to be a more prominent symptom in early Alzheimer's than in early FTD, although advanced FTD
often causes memory loss in addition to its more characteristic effects on behavior and language.
Behavior changes are often the first noticeable symptoms in bvFTD, the most common form of FTD. Behavior changes
are also common as Alzheimer's progresses, but they tend to occur later in the disease.
Problems with spatial orientation for example, getting lost in familiar places are more common in Alzheimer's than in
FTD.
Problems with speech. Although people with Alzheimer's may have trouble thinking of the right word or remembering
names, they tend to have less difficulty making sense when they speak, understanding the speech of others, or
reading than those with FTD.
Hallucinations and delusions are relatively common as Alzheimer's progresses, but relatively uncommon in FTD.

20. Case of sudden behaivour change in a 40 year old with all the features of frontotemporal dementia what is the most
consistent sign the doubt was between
loss of short term memory
disorientation with place rather than time ans
https://en.wikipedia.org/wiki/Gerstmann_syndrome

21. What to monitor Guillain-Barre Initial investigation in GBS

A. Nerve conduction studies (EMG)
(imp-Spirometry is used to monitor gbs) jm
B. CSF initial investigation
C. USS
D. CT of lower limbs
If lt in emergency, then first spirometry
If no respiratory symptoms given in question then LP or CSF... After doing CSF we have to do EMG

Ø Previous healthy man with proximal & distal muscle weakness reflex lost recently he suffered from diarrhoea ,
mildly dyspnic spo2 95% initial inv (oxygen saturation is good)

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Gbs after c. Jejuni so diarrhea
A vital capacity
B LP

22. Mother came with child complain of staring suddenly with

movement of hand. Head twitching lip smacking for 60-90
sec. Then became confused for few min.dx?
A.Temporal lobe epilepsy,
B.Juvenile myoclonic epilepsy,
C.Absnt seizure- only have staring gaze no confusion

23. Patient had tachycardia, tremors, and occipital headache.

BP in 165/95.Diagnosis?
a. Anxiety
b. Hyperthytoidism
c. Pheochromocytoma (ans)

24. 8 yrs old recently started having movements of his arm and head turned towards one side. Eyes fixed, stays for 30 to
60 seconds. Many times a day for 2 weeks and then nothing in other week.Could it be?
a) Temporal lobe epilepsy? (with loss of consciousness)
De ja vu stage
b) juvenile myoclonic epilepsy (absence + partial seizures)
c) Absence seizures (without loss of consciousness) occurs several time in one day.. Just blinking of eyes...ans

25. 8yr old brought due to behavior changes. Noticed to have blank stare, with fidgeting of right hand, head twitching to
right side, sometimes chewing. These occurs in clusters for 3-4 days in a week, then symptoms free & back to normal
for several weeks. Dx
A- absence seizure (motor component will be intact) (ans)
B- Juvenile myoclonic epilepsy (627, 941 jm)
C- Temporal lobe epilepsy
(Complex absence seizure or Temporal lobe epilepsy)
Umn lesion + fasciculation in females ms

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26. A lady comes with weakness of lower limb.she drags her foot while walking.dorsiflexion and plantar flexion is
weak.reflexes are exaggerated. equivocal plantar response.Dx asked?
a. Cervical spine MS è ms +umn lesions
b. MND (ans)
c. Spinal canal stenosis (no wasting) Page 755 jm
A not possible because weak planter and dorsal indicate L5 and S1 leison and no sensory symptoms as
cord compression less likely with pure motor signs
C also not possible because of having pure motor symptoms
Spinal cord compression: in cord compression lmn at the level of lesion and umn lesion below the level.here symptom of
lmn.

27. A lady comes with weakness of lower limb. she drags her foot while walking.. reflexes are exaggerated. Equivocal
plantar response. Pt taking metformin and many drugs. Dx asked?
a. Cervical spine MS (UMNL symptom will be present in in upper limb- wasting and weakening of muscle,
exaggerated of reflexes)
b. Spinal canal stenosis (foot drop will be present, dragging of foot while walking)
c. Diabetic amyotrophy LP shows incr protine, 10% pt complain wt loss. Autonomic symptoms ilke
orthostatic hypertension. Pa have roblem with standing up from chair.
d. L5-S1 radiculopathy (shooting pain or radiating pain) page 412 jm
e MND (ans)

28. Lady with weakness in left leg, with power 4/5.No sensory deficit. Reflex exaggerated. Diagnosis?
a. Motor neurone disease (ans)
b. Polyneuropathy (bilateral symmetrical) page 333 jm
c. Spinal stenosis (Weakness with walking) page 755 jm

29. Patient on statins and has history of spinal canal stenosis now come with weakness of both lower limbs and (absent
knee and ankle jerks) and absent pulse , cause
A. myopathy( muscle weakness)
B. myopathy
C. spinal cord compression.
D.Peripheral vascular disease (pulses absent (ans) should be with ischemic pain

30. 50 y old woman complain pain in mid thoracic region + weakness of legs progressing over 2 past months O/E found
spastic paraparesis Dx
1-multiple sclerosis
2-tabes dorsalis (page 294)
3-motor neuron disease
4-spinal cord compression (ans)
5-parasagital meningioma

31. A 65yr old lady comes to ur practice with c/os of back pain while gardening O/E, presence of point tenderness in
lumber vertebrae. Which of the following is most appropriate diagnosis?
1. spinal cord stenosis
2. disc prolapse (sensory loss must be present... or may be lower motor neuron lesion)
3. cauda equina syndrome
4. muscle spasm
5. compression fracture (Fracture vertebra due to osteoporosis)

32. Non diabetic patient complaining of weakness and clumsiness of lft hand numbness on both feet, foot drop on left
side. What inv to find out the lesssion
A.Nerve conduction study (Peripheral Neuropathy)
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B.Muscle biopsy
C.Vit B12 (Subacute Degeneration of Spinal Cord)
D.MRI of spine (Multiple Sclerosis/ Cervical Spondylosis) HB 2.052

33. 58yrs old man, planter flexion & dorsiflexion are 4/5, weak ankle movements, equivocal plantar reflex, upper limb and
face are normal exam.Lesion site
a. Common perineal nerve
b. Cervical spinal cord
c. L5,S1 nerve root
d. Cerebral cortex????
e.Brain Stem

Ø Lady with drag left foot, reflexes on left lower limb are increased, planter flexion &
dorsiflexion are 4/5, weak ankle movements, equivocal plantar reflex, upper limb and face are normal.
a. Cerebral cortex
b. C spine
c. L5, S1 nerve root
d. Common perineal nerve
e. Brain Stem
Ø Old man, drag left foot, reflexes on left lower limb are increased, planter flexion & dorsiflexion
are 4/5, weak ankle movements, equivocal plantar reflex, upper limb and face are normal Xn. Lesion
site a. Common perineal nerve b. C spine c. L5,S1 nerve root d. Cerebral cortex
Ø 58yrs old man, drag left foot, reflexes on left lower limb are increased, planter flexion & dorsiflexion
are 4/5, weak ankle movements, equivocal plantarķ reflex, upper limb and face are normal exam. Lesion
site?
a. Common peroneal nerve
b. Cervical spinal cord
c. L5,S1 nerve root
d. Cerebral cortex
e. Brain Stem
Ø 58 years old man drag left foot, reflexes on left lower limb are increased, planter flexion and dorsiflexion are 4/5,
and weak ankle movement, equivocal planter response, Upper limb and face are normal
A . Common peroneal nerve
B . Cervical spinal cord
C . L5,S1 nerve root
D . Cerebral cortex
E . Brain stem

34. pt left sided fasciculation of deltoid,small muscles of hand,upper limb reflex normal.lower limb weakness and planter
reflex left extensor or equivocal may be and also foot drop.nothing mention about sensory loss.what is initial
investigation
A.CT
b.mri cervical spine. (ans) (Cervical Spondylosis) HB 2.052
c.Electromyelography
d.LP.

35. Old man developed pain in lower back on attempt to lift object. Pain radiates from buttocks to sole of foot. What will
be associated Sciatica
a) loss of sensation in inner leg
b) loss of sensation in outer leg
c) loss of ankle reflex. (Ans in sciatica) (746)
d) loss of knee reflex

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36. Old man developed pain in lower back on attempt to lift object. Pain radiates from buttocks to sole of foot. What will
be associated Sciatica
a) loss of sensation in inner leg
b) loss of sensation in outer leg
c) loss of ankle reflex. (Ans in sciatica)
d) loss of knee reflex
(JM 419, 746,747)
The straight leg raise clinical test has the best sensitivity, but a low specificity
Complementary testing procedures including dorsiflexion of the foot, impaired ankle reflex, sensory deficit

https://www.racgp.org.au/afp/200406/20040601govind.pdf

For ms we do mri.
Fasciculation with ms wasting. Emg

37. A man come with clumsy hands and tripping over. Upper limb weakness and fasciculation. Lower limb muscles also
has weakness, increased tendon reflexes (ankle reflex is not increased in one side). No wasting is given, no sensory
loss is given. Asked investigation.

a. EMG- Motor Neuron Disease if ask about diagnostic

b. (ALS)
c. MRI cervical spine if initial asked
d. -CT
Neuro-physiological studies are the most critical ancillary tool in the investigation of MND and may be regarded as an
extension of the physical examination. Routine studies include nerve conduction studies and electromyography. These
provide information for: • the support of a suspected clinical diagnosis • identification of subclinical upper or lower
motor neuron involvement • determination of the extent and distribution of lower motor neuron loss • the exclusion of
disorders that may mimic MND (Table 3).3
http://www.mndcare.net.au/getattachment/Diagnosis/Could-this-be-MND/MND_Diagnostic_Tool_FINAL.pdf.aspx
JM pg 323-24

38. Another man with almost similar clinical features without reflex information given (weird that the two questions are
very similar) Asked investigation. HB-2.052
Cervical Spondylosis with Cervical Myelopathy Page 132
a. EMG
b. MRI cervical spine
c. -CT
Jm pg 703
https://www.racgp.org.au/FSDEDEV/media/documents/Clinical Resources/Guidelines/MRI/Summary-sheet-–-
MRI-for-cervical-radiculopathy.pdf
https://www.racgp.org.au/your-practice/guidelines/mri-referral/mri-of-the-cervical-spine/cervical-radiculopathy/

39. A woman 33 weeks of gestation comes to your clinic with increased BP 145/105, blurring of vision, headache and
some other symptom which I cannot recall, what to check that will require an immediate response?

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a) presence of L5 jerks of clonus at ankle
b) tenderness at left costal margin
c) bilateral hand edema
d) Increase in blood pressure in the next 30 minutes
jm 1187
https://lifeinthefastlane.com/ccc/pre-eclampsia-and-eclampsia/

40. 6 yrs old recently started having movements of his arm and head turned towards one side. Eyes fixed, stays for 30 to
60 seconds.Many times a day for 2 weeks and then nothing in other week. Could it be?
a) Temporal lobe epilepsy
b) Juvenile myoclonic epilepsy
c) Absence seizures

JM 627

41. A 3yr old boy presents wit hx of ambulation delayed till 16 months of age, toe walking, calf hypertrophy and proximal
hip girdle muscle weakness. His pediatrician , considering a mild static encephalopathy did not request screening for
myopathy but referred him to an orthopedic surgeon, who found that his ck levels are elevated, indicating need for
referral to a neurologist. His older siblings are ok. Diagnosis?
A. Dupuytren contracture
B. Cerebral palsy
C. Polymyosities
D. Duchenne muscular dystrophy
E. Becker muscular dystrophy
Ans d
ANS JM 162
X LINKED, BOYS, FALLS, WEAKNESS IN HIP SHOULDER GIRDLE , BULKY CALVES, CK LEVEL DIAGNOSTIC .NO TREATMENT, DIE
DUE TO RESP IN 25 YEAR

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https://www.mda.org.au/disorders/overview/dmd-bmd/
https://www.rch.org.au/kidsinfo/fact_sheets/Duchenne_Muscular_Dystrophy_DMD/

42. Low back pain , 58 yrs old man , felt tenderness at Lumbar spine (levels mentioned maybe L1L2) no neuro deficit. wt
will u do
a. X-ray
b. mRi spin
C continue activity
43. an old man with diagnosed Huntington few years ago and drive intentionally under alcohol influence and get caught
by police and presented to emergency deparment .he is agitated when he is told for admission and want to go back
home because lambing(yes lambing) season is beginning.whats next
A inpatient detoxification at emergency deparment (ans)
B outpatient detoxification and inlvolved in alcohol counseling group
C detained under medical mental ????
D refer to huntinton support group

Ø Patient recently diagnosed with Huntington Disease, he has been drinking, and acting erratic. The police have
brought him to ED as he was caught drink driving. What is your best next management?
a. Detoxification in ER
b. To refer him to Huntington support group
c. To send to drug and alcohol clinic
d. Admit and detoxify

https://americanaddictioncenters.org/withdrawal-timelines-
treatments/alcohol?fbclid=IwAR37zynlCuXEeoTfjX6PgbDO5T6xiOXeF_IWE27eESr93j3HndBsNVM44a8

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44. 14 month baby who has history of roll over on 4 month, sitting without support from 8 month , claps hand, plays peak
a boo, now has started walking without support, moves things from one hand to other , babbling but no words...
a. normal development
b. Gross motor delay
c. Fine motor delay
d. Social delay
e. Speech delay

45. Old man with back pain, tender lumbar spine region
Hb 10
ESR 109
Calcium normal
a. Thyroid test
b. PSA
c. MRI
d. BM Xn (ans)

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46. What to monitor Guillaine-Barre

Initial investigation in GBS
A. Nerve conduction studies (EMG)
B. CSF initial
C. USS
D. CT of lower limbs
for monitoring…. spirometry is best
http://emedicine.medscape.com/article/315632-workup

https://lifeinthefastlane.com/ccc/guillian-barre-
syndrome-gbs/
if patient present in a week then csf and if after two
weeks then emg

47. 24 month old child can do which of the following?

a. Can speak 2 pronouns
b. Can make 4 word sentences
c. knows family name
d. Name 4 colors
Kaplan peads pg 44

48. Non diabetic patient complaining of weakness and clumsiness of lft hand numbness on both feet, foot drop on left
side. What inv to find out the lesion
A.Nerve conduction study (JM 324)
B.Muscle biopsy
C.Vit B12
D.MRI of spine

https://www.racgp.org.au/afp/2015/march/paraesthesia-and-peripheral-neuropathy/

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cause of peripheral neuropathy depend on etiology and medication
Clinicians will often overlook the potential for iatrogenically induced peripheral neuropathy, as may occur
with frequently used medications, including amiodarone, statins, antiretrovirals, tacrolimus or even agents
not often considereed to be associated with peripheral neuropathy, such as levodopa, which is commonly
used to treat Parkinson’s disease.3 It is widely accepted that various chemotherapies for malignancy can
cause peripheral neuropathy, including taxanes, platinum compounds, vinca alkaloids, proteasome
inhibitors and antiangiogenic/immunomodulatory agents.4 Deficiencies of vitamins, such as B6 or B12, may
evoke peripheral neuropathies and may be associated with therapies, including levodopa.3 This may
necessitate special consideration, especially in vegans.
Other dietary deficiencies may be associated with peripheral neuropathy. For example, toxic levels of
homocysteine are associated with vitamin B6 and B12 deficiencies.2 Medications such as metformin cause
B12 deficiency5 as do other medications, such as phenytoin, which reduces folate needed for B12.6 There
has been a push to offer dietary supplements, including vitamins B6, B12, D and E, and magnesium to
address problems with peripheral neuropathy.2,7 Patients who are alcohol-dependent often have a variety
of causes for peripheral neuropathy, which include both direct toxic effects of excess alcohol as well as poor
diet, particularly deficient in thiamine (vitamin B1).8 It follows that the history obtained should include the
usual causes of nerve damage being explored but doctors often ignore taking an adequate dietary history
and nutritional neuropathies may be overlooked.9 to exclude b12 def look at this
http://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectiona/1/a1.14.pdf

49. Low back pain , 58 yrs old man , felt tenderness at Lumbar spine (levels mentioned maybe L1L2) no neuro deficit. wt
will u do
a. X-ray
b. mRi spine
c. continue activity

50. Old lady with back pain after falling, complaining there is pain in her rt lumbar region radiating upto toe,on exam
there was no neuro deficit, wat will be your mx?
a. Xray (ans)
b. Mri
c. Continue activity
**This radiating pain is simply referred pain. If it was radicular pain, then there should be some
neurological deficit (eg. Loss of sensation in particular dermatome, loss of jerk) ...in our ques it is
simple radiating pain with no neurological deficit so I will do simple xray as this pt is supposed be in
red flag bcz she is old (>50 yrs)

51. 8yr old child brought by his mother , he complained from episode of staring suddenly that occur along with fidgeting
of right hand and movement of right arm head twitching to right side, sometimes chewing and lip smacking each
episode last for 60-90 second then the child remain dizzy and confused for 1-2 minutes after the episode . These
occurs in 3-4 days and then the child back to his normal activity and behaviour for several weeks. what is the most
likely diagnosis?
A- Temporal lobe epilepsy (ans)
B- Juvenile myoclonic epilepsy
C- Absence seizure
D- other don’t remember
52. man with parkinson disease started having visual hallucinations n ataxia
A. Haloperidol…typical antipsychotic is contraindicated in parkinson
B. Queitipine
jm331

53. Old man, back pain one week ago while working in the garden, now: point tenderness, low grade fever, what is the
most likely diagnosis?
a. Discitis (ans). Bcz of fever

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b. Herniation.
c. Sepsis.
d.Vertebral fracture(no fever)

jm406 pg

54. pt has muscle weakness, both upper limb and lower limb, hand small muscle weakness as well. What’d o next?
A)EMG
b) MRI

55. old man had back pain, sometimes it wakes him up from sleep. No injury history.what is the cause.
A)mechanical back pain (as no leg neurological symptoms)
b)lumber disc prolapse

56. patient with 10 minutes weakness in the body. no vision loss.

B. lacunar infarct
C.carotid stenosis

57. Middle age man, pain in buttock and thigh during 100 m walk on ground, can walk 20 m uphill, femoral pulse not
palpable, dorsalispedis is palpable, ABI 0.3. Best way to diagnose?
A. Arterial Doppler
B. Digital subtraction arteriography
C. CT angiogram
D. Arteriography

58. A man with history of limb claudication on 100 meters relieved by rest, on examinations there was absent left
femoral pulse and absent dorsalispedis pulse, ABI was done and it was 0.25. What is the most appropriate test
leading you to the diagnosis?
a. Arteriography
b. Ct angiography
c. compression Doppler ultrasound
d. MR angiogram
e. X-ray

59. 72 year old man living alone is brought to ED by daughter. He’s so confused and gave incomprehensible answers
to questions and couldn’t follow any commands. There’s no other abnormality on examination. CT was given
large dark area is in left temporo- occipital region with shifting of left lateral ventricles plus surrounding oedema.
Asked diagnosis
a. Cerebral tumour
b. Cerebral infarction
c. Cerebral haemorrhage
d. Cerebral tuberculosis
e. Subarachnoid haemorrhage

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60. 8yr old child brought by his mother , he complained from episode of staring suddenly that occur along with
fidgeting of right hand and movement of right arm head twitching to right side, sometimes chewing and lip
smacking each episode last for 60-90 second then the child remain dizzy and confused for 1-2 minutes after the
episode. These occurs in 3-4 days and then the child back to his normal activity and behavior for several weeks.
what is the most likely diagnosis?
A- Temporal lobe epilepsy
B- Juvenile myoclonic epilepsy
C- Absence seizure
D. Hypsarrhythmia
E. Rolandic seizures

61. Family history of father and paternal aunt died at 50 years of age. Patient complaint of wide based gait and
verbal dysfunction. What is your next management? New question
a. Genetic counseling
b. Lumbar puncture
c. Serum copper and ceruloplasmin
d. MRI
e. CT head

62. Old man presented to you complaining of rest tremor and bradykinesia, also taking risperidone & he has a
known history of visual hallucination and forgetfulness. what is the most likely dx?
A. parkinson disease
B. lewy body dementia
C. alzheimer disease
D. acute delirium
E. Schizophrenia

63. Patient with weakness of the left upper limb, weakness of interosseous muscles and right plantar response is
equivocal, left is increased; reflexes are normal. What investigation will you do to reach diagnosis?
A. MRI cervical spine
B. Ach receptor antibodies
C. EMG
D. CT brain

64. Lady with 24 hours of muscle weakness and tingling sensation +, weakness more in lower limbs, no other
sensory loss, no other symptoms mentioned
a) acute inflammatory polymyopathy
b) multiple myeloma
c) myasthenia gravis

** Synonyms of Guillain-Barré Syndrome

acute polyneuritis.
acute inflammatory neuropathy.
acute inflammatory polyneuropathy.
GBS.
post-infective polyneuritis

65. . Concern women come to you asking for antibiotic for her son who has fever, her son visited child clinic which
was visited by a girl documented to be meningococcal meningitis, the girl visited the clinic from Monday to
Wednesday, but her son visited on Friday. Hospital gave all the contacts of girl rifampicin as prophylaxis, what to
do?
a) treat her son

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b) giver her son rifampicin
c) ask her to get her son ER for review
d) provide information about symptoms to mother
e) nothing need to give like reassure
** for fever ... is not smth ... that can be check by gp .... ?? is nt ER F ... if smthng serious suspected ....
and gp is also counselling the mother abt the meningitis ... if menin sysp. appears then send the boy ER
... that my thinking may be wrong .... remember also not a contact ... low chance of contracting menin.

66. A young man brought to ED after brawl in bar in which he hit someone. He is alcoholic, take multiple drugs and
aggressive. What in history will you to know if he has personality disorder?
a. Childhood sexual abuse
b. H/o cruelty to animals in adolescence
c. Drug and alcohol dependence
d. H/o of hitting partner one week back
e. H/o depression in mother

67. Young man after a quarrel had a fracture of floor of eye what is the most consistent symptom with that?
a- Conjunctival hemorrhage
b- loss of visual activity
c- anesthesia around the cheek
d- Cant open the mouth completely
e- Epistaxis

68. Patient I forget the scenario, but he has loss of plantar flexion, and inversion, also loss of ankle jerk; But he has
intact dorsiflexion and eversion. Knee jerk normal. Which nerve injury:
a. sciatic
b. tibial
c. Common peroneal ( loss of dorsiflexion and eversion)
d. forget others

69. Patient complaining of loss of sensation over lateral arm, lateral forearm, loss of triceps jerk, asking about the
site of injury
a. C5,6?? ( may be bicep jerk)
b. C6,7 jm6700

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c. C8, T1
d. Can’t remember

70. 4 ys old child present with headache, ataxia, vomiting , O/E there is a mass in the upper part of post triangle of
the neck. He has also nystagmus I remember, asking what is the Dx
a. Medulloblastoma ??
b. meningioma
c. Astrocytoma

Medulloblastoma (/məˌdʌloʊblæˈstoʊmə/) is the most common type of pediatric malignant primary

brain tumor (cancer), originating in the part of the brain that is towards the back and the bottom, on
the floor of the skull, in the cerebellum, or posterior fossa

Symptoms:
The child typically becomes listless, with repeated episodes of vomiting, and a morning headache, which
may lead to a misdiagnosis of gastrointestinal disease or migraine.[4] Soon after, the child will develop
a stumbling gait, truncal ataxia, frequent falls, diplopia, papilledema, and sixth cranial nerve palsy.
Positional dizziness and nystagmus are also frequent, and facial sensory loss or motor weakness may be
present. Decerebrate attacks appear late in the disease.

71. 35ys old man brought by wife, presented with confusion, ataxia, right upper abdominal pain, changed behavior,
memory loss, weakness, pt drink alcohol and smoke some per day, T 37.5, vitals normal.
He has his father and paternal aunt has same history when at his age. Asked what investigation to reach Dx
a. CT brain
b. CT abdomen
c. MRI brain dx Huntington…RUQ pain due to alcoholism
d. Check serum ceruloplasmin
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On imaging, it is classically characterised by atrophy of the caudate nucleus with concomitant enlargement of
the frontal horns of the lateral ventricles.

72. 40 years old lady with back pain at L4 level with severe shooting pain to leg to toe next, no neurological deficit
A. Observation
B. X-ray lumbosacral ??
C. CT lumbosacral
D. MRI lumbosacral

73. man 58yrs presents following sudden onset of pain and

tenderness of lower back following lifting a heavy weight.
There is tenderness in the L4/L5 region and numbness of the
leg. Which of the following is the next option after giving
analgesics?
a.refer to orthopedics
b. continue daily activities
c. lumbar corset
d. Pelvic traction
e. Bed rest

74. A man with history of limb claudication on 100 meters

relieved by rest, on examinations there was absent left
femoral pulse and absent dorsalis pedis pulse, ABI was done
and it was 0.25. What is the most appropriate test leading
you to the diagnosis?
Arteriography ??
Ct angiography ??
compression Doppler ultrasound
MR angiogram
X-ray

75. A young boy is brought to you in the rural ER. Neurosurgery unit is 1 hours away. Earlier today he was hit during
football where he lost consciousness and fell to the ground. A few minutes he regained his consciousness and
walked out of the field. His family brought him to you complaining that he has developed headache after the
incident. His GCS is 10/15. What is the next plan for him?
a. Do a ct scan ??
b. Transfer to neurosurgery unit
c. Hyperventilation and mannitol infusion
d. Burr hole

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e. Craniectomy

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76. . A man in brought to the ER after he recived a kick to the side of his face. On examination you have found an
orbital floor fracture. Which of the following is the accurate predictor of this diagnosis?
a. Inablity to open the mouth
b. Subconjunctival haemorrhage
c. Anesthesia on cheek

77. A man presents following sudden onset of pain and tenderness of lower back following lifting a heavy weight.
There is tenderness in the L4/L5 region and numbness of the leg. Which of the following is the next option in
treating this patient?
a. MRI
b. Prescribe analgesia and continue daily activities
c. lumbar corset
d. Pelvic traction
e. Bed rest and analgesia

78. Old man with back pain. (Xray given which shows collapse of L4 or L3 as well as osteopenic type bones).
Lumbosacral xray was done. Which of the following is the next best step?
a. MRI
b. PSA
c. DEXA
d. Bed rest

79. 25-year-old man came to ER with history of back pain L4-L5 level. He denies any history of back injury.
Previously, he was drug abuser and Hepatitis C positive. Physical examination is normal. He has an erythema at
the back which is painful. Which of the following is the most appropriate?
A. HIV serology
B. CT spine
C. MRI spine to rule out spinal epidural abcess or osteomyelitis do ct if no mri
D. Kaposi sarcoma
E. Erythema multiforme

80. LBP 40 yrs with pain radiating to legs-

40 years lady with sudden severe pain while gardening. Pain is radiation to thigh and leg with no neurological
deficit what will you do as next?
A. Spine X-ray
B. MRI
C. Bed rest
D. Observation
E. Refer to orthopedic

81. Anthology vertebral fracture picture with 40 years lady with sudden severe pain radiation to thigh and toe with
no neurological deficit next investigation
a) Spine Xra

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b) MRI
c) Bed rest
d) Analgesia

82. 65 years complaining back pain after gardening o/e tenderness in lumbar vertebrae L3,L4 & limited flexion &
extension,after giving analgesics what is ur next mx?
bedrest
continue activity****
refer to orthopaedics
corset
MRI
83. A 55-year-old woman presented with discomfort in her both legs with an urge to move for last 4 months. She
remains awake at night due to creeping & crawling sensation at night and sometimes electric current-like
sensations. Relieves after walking & massage of leg. Her current medication include paracetamol, oxycodone and
multivitamins. Blood tests show normal renal function, normal electrolytes .slightly low haemoglobin.What inv
you do next?
A. Iron studies
B. Sleep studies
C. Nerve conduction test
D. Serum Calcium level
E. Cease oxycodone

84. Cluster Headache Q

Pt presented with left sided headache,Unilateral, in the
periorbital, retro-orbital, Suddenly started at night, peaking
in 10-15 minutes lasting for 5 minutes. O/E Ptosis. What is
Imp to make diagnosis ? ( No mention of Unilateral
Rhinorrhea & Lacrimation )
A. Confirm with 100% oxygen by face mask-
B. CT Scan

85. 58 year old woman after lifting some heavy thing, develops
pain in the right buttock and tenderness in her back at L4-5,
has difficulty and restrictions of movement in extension and
flexion and rotations , what will you give beside analgesic?
A- spinal xray acc to GP for fracture***osteoporosis fracture -
Spine point tenderness ??
B- spinal mri
C- bed rest
D- referral to orthopedics senior colleagues
E- keep active

86. 40 yr old lady with back pain at L4 level with severe shooting
pain to leg to toe next, no neurological deficit
A. Observation
B. X-ray lumbosacral
C. CT lumbosacral
D. MRI lumbosacral

87. 23 yr old lady came with weakness on all limbs but especially
at lower limbs, diminished reflex ( not sure ) tingling
sensation at foot, no other sensory symptoms .
HB reduced
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MCV – 100 ( normal 80- 100 )
WBC, platelet – normal
B12 level- reduced
Likely cause ?
a. Pernicious anamia ??

88. Foot drop cause?

L5 nerve root

89. Alzheimer patient was brought to clinic from shelter which she moved 2 weeks ago because her family member
cannot tolerate her odd behaviors and accusing them of stealing sth like that. Cause?
1. worsening Alzheimer
2. depression
3. dementia
4. Delirium
90. A woman who presents with her husband, he has history of AD, saying she is tired of taking care of him. On their
way to the hospital, he urinates on the public place, he seems to be unaware of his actions on interaction.
What’s the diagnosis?
A) worsening Alzheimer
B) Parkinson disease
C) Mental disorder
D) not relevant
91. a girl came with two months history of visual problems. Seeing flash lights ( moving lights ) for 10 minutes .
sometimes suffer from global headache worse on exertion
what’s the possible cause ?
a. Occipital lobe tumor
b. Migraine with aura
c. Focal epilepsy
92. An old woman taken many tablets, now unconscious, pinpoint pupil, his son brought her to hospital, and also
tablets she might have taken, methadone, oxycodone, buspirone patch
A-methadone(ans)
B-oxycodone
C-buspirone

93. temporal lobe epilepsy recall

.8yr old brought due to behavior changes. Noticed to have blank stare, with fidgeting of right hand, head
twitching to right side, sometimes chewing. These occurs in clusters for 3-4 days in a week, for 3O to 60 Post ictal
confusion for 30-60 sec s,then symptoms free & back to normal for several weeks. Dx
A- absence seizure
B- Juvenile myoclonic epilepsy
C- Temporal lobe epilepsy
D- Tourette syndrome

94. treatment of temporal lobe epilepsy

1.ethosuxamide
2.Phenytoin
3.Na valproate 2nd line but should not be given <2 yrs of age
1st line is carbamazeoine

95. cluster headache ..scenerio

Pt with headache with ptosis Unilateral, in the periorbital, retro-orbital, Sudden, peaking in 10-15 minutes lasting
for 5 minutes ..
What is Imp to make diagnosis ¿

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Confirm with 100% oxygen by face mask
Rest i forgot.. Sorry

96. an old lady loosing track of time, keep forgetting where she kept her things, when examined she becomes
agitated. what in MENTAL STATE EXAMINATION will help you to reach diagnosis?
A)-orientation
B)-impaired insight
C)-praxis
D)-thoughts form

97. Old man 84 years old attack his wife 83 yrs old According to his wife her husband now is changing behaviour,
more aggressive. What is the cause?
A. Depression
B. Dementia
C. Temporal lobes epilepsy

98. a middle aged female presents with lt wrist pain after colliding her car with a pole. On examination her lt pupil
was constricted and also had decreased field of vision which she was unaware of. What is the next app in?
ct head ??
b. iop measurement
c. slit lamp examination

99. Case scenario of lumbar spinal compression with paresthesia on the plantar and lateral aspect of the foot.ask
wts most specific sign for it
A.urinary incontinence
B.absent knee reflex
C.leg pain
d. absent ankle reflex

100. an old women who is widow who seems well in past but since she became a widow and she moves to the
house and start to stay alone one of neighbour had noticed her strange behaviour. she starts to dig some ground
in front of the house and when neighbour reached near her and looked at her, she then aroused him and get
aggressive and accused him and all neighbors as imposters. After that she became calm down and agreed to be
seen at the medical clinic.Which one of the following explains her condition?
A)thought forms ??
B) mood
C)orientation
D)delusion

101. Paraesthesia and numbness of both upper limbs and lower limbs with blurring of vision.
A.diabetic neuropathy ?? retinopathy
B. B 12 deficiency
Don't remember

102. Ct brain of brain abscess (in R frontal area with contrast CT)
Pt was febrile since week, getting confused, brought by daughter .what do u see in CTscan?
A.cerebral tumour
B. Brain abscess ??
C.mets
D.cerebral h'ge

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E.cerebral infarction

103. Patient with weakness of the left upper limb, weakness of interosseous muscles and right plantar response is
equivocal, left is increased; reflexes are normal. What investigation will you do to reach diagnosis?
A. MRI cervical spine…cervical myelopathy
B. Ach receptor antibodies
C. EMG
D. CT brain
CT head( white lesion)
104. Mild headache for 3 weeks, sever in morning, focal sign(+), fever 37.3’C, melanoma history (+) last 3 yr
A. ICH
B. SDH
C. Metastasis melanoma
D. Brain abscess
E. Glioma

105. 3 month( 6 month??) boy normal until 6 week of age. Now, hypotonia in all four limb, feeding difficult, can’t
control head. Sometimes he smile
A. Early cerebral palsy
B. Botulism paralysis
C. SMA.. though there should be
resp problem
D. Prader will

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106. 58 year old woman after lifting some heavy thing , develops pain in the right buttock and tenderness in her
back at L4-5, has difficulty and restrictions of movement in extension and flexion and rotations , what will you
give beside analgesic?
A- spinal xray
B- spinal mri
C- bed rest
D- referral to orthopedics
E- keep active
107. Old lady with back pain after falling, complaining there is pain in her rt lumbar region radiating upto toe,on
exam there was no neuro deficit,wat will be your mx?
a.Xray
b. Mri
c. Continue activity…tahera
108. Old man with back pain. Xray given which shows collapse of L4 or L3 as well as osteopenic bones.
Lumbosacral xray was done. On DRE examination prostate was found irregular. Which of the following is the
next best step?
a. MRI
b. PSA
c. DEX
109. 38yrs old female presented with ascending weakness from distal to proximal in lower limbs & decreased
lower limb reflexes + weakness. Asking diagnosis.
A. Multiple Sclerosis –
B. Transverse Myelitis…take it if no gbs in option
C. MND
D. Inflammatory ….. ( sorry, forgot the name )
E. Myasthenia Gravis.
** Synonyms of Guillain-Barré Syndrome
acute polyneuritis.
acute inflammatory neuropathy.
acute inflammatory polyneuropathy.
GBS.
post-infective polyneuritis
110. 60 yrs old male presented with complaints of right sided headache since last 6 hrs. He never experienced
such headache before. No abnormality O/E, except as given in pic ( right sided very very mild ptosis with meiosis.
Next inv…
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A. CT Head
B. Right sided Carotid Doppler (carotid artery dissection)
**in sah pupil is dialated
111. A man comes with clumsiness of hands and tripping over. Upper limb weakness and fasciculation. Lower
limb muscles also has weakness, increased tendon reflexes. Ankle reflex is not increased in one side. No wasting.
No sensory loss is given. What will help to reach the diagnosis?
A. EMG
B. MRI Spine
C. CT scan
D. CSF examination
E. Cervical spine X-ray

112. A dementia patient taking donepezil and mobeclomide at elderly care, masturbates near nurse station and
tries to cuddle nurses who help bathe him. What causes him this?
A. Frontal lobe SOL
B. Progression of Alzheimer
C. SE of drugs

113. A dementia patient taking donepezil and mobeclomide at elderly care, masturbates near nurse station and
tries to cuddle nurses who help bathe him. What causes him this?
A. Frontal lobe SOL
B. Progression of Alzheimer
C. SE of drugs

114. yr male complaint of Severe headache on left side and also neck pain on at same side. He never suffered on
this pain before. He has history of 2-3 glass of wine, 20 pack year smoking(+). Photo is given ( I see ptosis and
pupil constricted on left side) . Eye examination is normal and vision is unimpaired. What investigation to get
diagnosis?
A. CXR
B. Otoscopy
C. Slip lamp examination
D. Carotid Doppler USG ??
E. MRI

**Dx is carotid artery dissection which causes partial horners(no anhidrosis) and inx is first carotid
doppler, gold standard is CT angiogram nxt is MRA NOT MRI
**Typical presenting symptoms of carotid artey dissection are as follows:
Headache, including neck and facial pain – This can be constant, instantaneous, gradual, throbbing, or
sharp
Transient episodic blindness (amaurosis fugax) – This is caused by decreased blood flow to the retina
Ptosis with miosis (partial Horner syndrome) – This is usually painful when caused by internal carotid artery
dissections
Neck swelling
Pulsatile tinnitus – This can occur in as many as 25% of patients with dissection of the internal carotid
artery
Decreased taste sensation (hypogeusia)
Focal weakness
Migrainelike symptoms (eg, a scintillating scotoma, which is loosely defined as a transient visual field
disturbance in the form of shimmering or arcs of light)

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115. A 58 yr old man c/o forgetfulness He forgets where he keeps his tools. And he can’t sleep at night because
worries abt it. When doing cognitive test he became distressed and decline to do the test .What to check in
MMSE to get dx
A. Orientation ??
B. Hopelessness
C. Hallucination
D. Imparied insight…mse
E. Constructional apraxia
(no option for memory

116. PAIN IN THE BUTTOCKS&POSTERIOR THIGH&DEADLY LEG PAIN AFTER WALKING 100 M ON NORMAL FLOOR
&20 M ON UNEQUAL LAND WELL FELT PEDAL PULSATION NEXT?
A..DOPPLER LEGS ?? jm 743
B.CT ANGIO.
C.MRI LUMBOSACRAL ?? Why( from Amedex-spinal canal stenosis)
D.X.RAY
Neurogenic pain
From <https://www.facebook.com/groups/1442556592721801/search/...>

117. patient with history of claudication, smoke 30 pack cigarette per day, drink alcohol, obese with diabetic
history. he refuse surgery although he was fit for it. He asked you for the appropriate advice that will improve his
symptoms of claudication?
A-Reduce smoking
B-reduce alcohol drinking
C-supervised exercise ??
D-control his hypercholesterolemia

From <https://www.facebook.com/groups/1442556592721801/search/...>

118. Patient with claudication pain. Doctor advises surgery, but patient not fit to do surgery. Femoral bruits +. He
has DM, hypertension and obese. What will you advice for long term management to reduce his claudication
symptom?
a) Reduce smoking
b) Supervised exercise
c) Hypertension control ???
d) DM control
e) Weight reduction
119. scenario of a lady who become agitated and confused at shopping center for 1-2 mins. She has h/o same
attacks . and during attack she stares blankly, doesn’t respond to any command followed by confusion.
Sometime during conversation with relatives it happens and she doesn’t follow the conversation. What is ur dx?
a) Panic attack
b) GAD
C) Complex partial seizures ??
d)PTSD
120. Middle aged man presents with pain from sole to great toe of right foot, which awakes him from his sleep.
O/E: inflammation from sole to great toe, non tender, active and passive movements are painless and free. No
sensory loss, SLR- positive @30 degree. Pedal pulses normal. No h/o dm/gout/arthritis. Reflexes are normal.
What investigation is most important for diagnosis?
a) Serum urate
b) MRI lumbar spine ??
c) Others I forgot
121. 62,Patient present with c/o shooting pain along the back of the leg and sole of foot. What additional finding
helps to localize the lesion?

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a) Loss of ankle jerk ??
b) Loss of knee jerk
c) Loss of sensation on medial foot
d) Loss of sensation on medial leg

122. A man in brought to the ER after brawl hit to the side of left eye. On examination, you have found an orbital
floor fracture. Which of the following is the accurate predictor of this diagnosis?
a) Sub conjunctival haemorrhage
b) inability to open his mouth
c) loss of sensation of his cheek ??
d) decreased visual acuity

123. 40 year old woman after lifting some heavy thing , develop pain in the right buttock and tenderness in her
back at L4-5 and difficulty and restrictions of movement in extension and flexion and rotations , what will you
give beside analgesic? (Dx-muscle sprain)
a) spinal xray
b) spinal MRI
c) bed rest
d) referral to orthopedics
e) keep active

124. Parkinsonism like feature What is the diagnosis?

a) Parkinson’s disease
b) Alzheimer’s disease
c) Drug induced psychosis
d) Frontal lobe lesions
e) Lewy body dementia ??

125. 8 years old boy brought due to behavior changes. Noticed to have blank stare, with fidgeting of right hand,
head twitching to right side, sometimes chewing. These occurs in clusters for 3-4 days in a week, then symptoms
free & back to normal for several weeks episodes lasts for 40 to 60 seconds and he remain confused for
sometimes after the episode. Diagnosis?
a) Absence seizure
b) Juvenile myoclonic epilepsy
c) Generalized tonic clonic epilepsy
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d) Temporal lobe epilepsy
e) Tourette

126. Numbness in little and ring fingers and pincer grip weakness. Triceps jerk loss.
A- Nerve root compression
B- MS
C- Spinal stenosis
D- Cervical lesion

127. 54 years old lady complaining back pain after lifting heavy object. No numbness nor sensory loss. Pain down
through buttock to thigh. What to give in addition to analgesia
A- Continue activity
B- Refer to orthopedic
C- Corset
D- Traction
E- Bed rest
128. 40 years old lady complaining of back pain after gardening On examination, there was tenderness in the
lumbar vertebrae L3 / L4 with limited flexion and extension. After giving analgesics what is your next line of
management?
A. X-ray
B. observation
C. refer to orthopedics
D. corset
E. MRI
129. A man presents following sudden onset of pain and tenderness of lower back following lifting a heavy
weight. There is tenderness in the L4/L5 region and numbness of the leg. Which of the following is the next
option in treating this patient?
a. MRI
b. Prescribe analgesia and continue daily activities
c. lumbar corset
d. Pelvic traction
e. Bed rest and analgesia
130. 65 years old lady complaining of back pain after gardening On examination, there was tenderness in the
lumbar vertebrae L3 / L4 with limited flexion and extension. After giving analgesics what is your next line of
management?
A .bedrest
B. continue activity
C. refer to orthopaedics
D. corset
E. MRI

Like this picture – ring enhancement lesion in frontal region

131. 65 yr old man present with three weeks history of headache & vomiting. He has history of Clark 1
melanoma and surgery 3 years ago. On examination, temperature 37.3 & no other abnormal findings.
CT given. What is the most likely diagnosis? Exact scenario
a. Brain abscess
b. Melanoma metastasis
c. Glioma
d. Cerebral infarct
e. Tuberculous meningitis
Exact option

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132. 25 years old man came with severe headache since 4 hours, retro orbital pain, eye examination
revealed one eye was slightly drooping and pupil was constricted, no vomiting. Diagnosis asked
a. Migrane
b. Cluster headache
c. Carotid artery dissection
d. SAH

133. A woman works at a part-time job, and complaints of early morning headache, frontal &
bilateral, dull in character, varying in intensity, she takes paracetamol & ibuprofen, which only
cause relief for 2-3 hours. What is the cause?
a. drug rebound headache
b. migraine
c. tension headache
d. cerebral tumor
134. Pt comes with H/O of unilateral temporal side headache for last 4 hours. He didn’t
experience such type of headache before. He is also complaining of mild pain of same side.
Pain is not subsiding by taking regular pain killers. Pic of the pt is given below. What will be the
next step in management?

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a. CT head
b. ESR
c. Temporal artery biopsy
D. CXR
e. Visual evoke potential test
135. Pt comes with H/O of unilateral temporal side headache for last 4 hours. He didn’t experience such type of
headache before. He is also complaining of mild neck pain of same side. Pain is not subsiding by taking regular
pain killers. Pic of the pt is given below What will be the next step in management?
a. CT head
b. ESR
c. Temporal artery biopsy
d. CXR
e. Magnetic Resonance Angiography
dx carotid artery dissection
136. Nerve palsy picture with man presenting with
itching…discomfort and diplopia…
a. Left 3rd nerve
b. Right 3rd nerve
c. Left 4th nerve
d. Right 4th nerve
e. 6th nerve may be…with viral conjunctivitis
137. Old woman right sided weakness, confusion, ataxia, BP 190/110, wat next?
- ct scan head ??
- MRI
138. Female patient with burning sensation of the rt side of the face with decrease sensation of the same side of
the face, with left limbs weakness and decrease sensation with ataxia , what is the most likely Dx ?
- Frontal lobe ischemia
- Left temporal ischemia
- Right parietal ischemia
- Herpes zoster encephalitis
139. pt cones.with history of headache (no word of mild or severe just headache) with retrorbital pain and ptosis.
He has history of previous recurrent headaches also. Now gives history of neck pain but NO STIFFNESS.
neurological exam is normal...what 2 do
A) Do urgent CT
B) give him trial of 100 % Oxygen dx cluster headache
140. A 5-year-old girl presents with recurrent seizures. The seizures usually occur at night and are witnessed by
her parents. Clinical examination reveals an area of roughed skin lumbar spine what is the most likely diagnosis?
A) Homocystinuria
B) Herpes simplex encephalitis
C) Acute promyelocytic leukemia

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D) Tuberous sclerosis

141. A 49 year old female presented with progressive back pain. She has a history of Breast Ca and lumbar
osteoarthritis. What of the following clinical features will help you decide the investigation (MRI) to do?
a. Past history of breast Ca
b. Back pain without trauma
c. Past history of vertebral osteoarthritis
d. High blood pressure
e. Radicular Pain radiating to the buttock

142. 5y boy is brought in by his parents. They state that he has been staring at the wall and rolling his eyes,
moving his hand and twitching his neck. Boy is confused after the episode that lasts 1-2 mins. What is the
therapy?
A) Ethosuximide
B) Valproate
C) Carbamezepine
D) Phenytoin

143. scenario of a lady who become agitated and confused at shopping center for 1-2 mins. She has h/o same
attacks . and during attack she stares blankly, doesn’t respond to any command followed by conusion. Sometime
during conversation with relatives it happens and she doesn’t follow the conversation. What is ur dx?
a) Panic attack
b) GAD
C) Complex partial seizures
d)PTSD
144. Given X-ray of Interior dislocation of shoulder asking which statement is correct.
Loss of sensation upper arm
Loss of sensation triceps
Loss of sensation forearm
No option for deltoid sensation loss
145. Man with scenario of claudication in left calf. On exam, all peripheral pulses palpable on right side. Left side
all pulses palpable but dorsalis pedis weak and hardly palpable. Bilateral weakness of ankle reflex and loss of
sensation in foot. ABI on right side 1, left side 0.75. Appropriate investigation?
A. Conventional angiogram
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B. CT angiogram
C. CT spine
D. EMG….spinal stenosis
146. A young boy is brought to you in the rural ER. Neurosurgery unit is 1 hours away. Earlier today he was hit
during football where he lost consciousness and fell to the ground. A few minutes he regained his consciousness
and walked out of the field. His family brought him to you complaining that he has developed headache after the
incident. His GCS is 10/15. What is the next plan for him?
a. Do a ct scan
b. Transfer to neurosurgery unit
c. Hyperventilation and mannitol infusion
d. Burr hole
e. Craniectomy
147. Young boy is brought to the rural hospital ER after trauma to the head. He was in a motor vehicle accident.
After that he developed extreme unconsciousness with GCS of 6/15. You have intubated the patient. The
Neurosurgery unit is 3 hours from the rural ER. What is the next appropriate plan for this patient?
a. Transfer to neurosurgery unit
b. Do a ct scan…think about it as well
c. Burr hole ??
d. Craniectomy
148. Woman present with back pain after lifting heavy objects at work. She has lifted these boxes before and
there is no previous injury. When ask about degree, she said 4/10. Pain not radiating to another site. She is
worrying that she might lose her job because of the pain and said one of her friends who got back pain has
retrenched. Which one of the followings cause chronic pain syndrome?
Being woman
No radicular pain
Pain 4/10
No previous injury
Anxiety about employment ??
149. A man presents with c/o left leg pain, can walk up to 100 meters , due to pain has to rest for sometimes
relieved by rest, on examinations there was , right leg good peripheral pulses, left leg weak pulses , ABI done and
it was 0.25(exact value). What is the most appropriate test leading you to the diagnosis?
A. Arteriography
B. CT angiography
C. Compression Doppler ultrasound
D. MRI
E. X-ray
150. Patient with claudication pain. Doctor advises surgery, but patient not fit to do surgery. Femoral bruits +. He
has DM, hypertension and obese. What will you advice for long term management to reduce his claudication
symptom?
a) Reduce smoking
b) Supervised exercise
c) Hypertension control
d) DM control
e) Weight reduction
151. patient with history of claudication, smoke 30 pack cigarette per day, drink alcohol, obese with diabetic
history. he refuse surgery although he was fit for it. He asked you for the appropriate advice that will improve his
symptoms of claudication?
A-Reduce smoking
B-reduce alcohol drinking
C-supervised exercise ??
D-control his hypercholesterolemia
152. A 12yearold boy is brought to the Emergency Department. He was hit on the side the head by a cricket ball
during a match. His teacher describes him initially collapsing to the ground and complaining of a sore head. After
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two minutes he got up, said he felt OK and continued playing. After 30 minutes he suddenly collapsed to the
ground and lost consciousness. What type of injury is he most likely to have sustained?
a. Cerebral contusion
b. Subarachnoid haemorrhage
c. Intraventricular hemorrhage
d. Extradural haematoma
e. Subdural haematoma

153. A 34 years old female presents with recurrent , sharp pain radiating from left ear to her mouth. She
describes the pain as intense but intermittent, precipitated by cold, light touch and chewing. Neurological
examination is normal. A tentative diagnosis of trigeminal neuralgia was made and carbamazepine prescribed.
She returns 6 weeks later complaining of the same pain on both sides of her face and a new onset of urinary
incontinence. Which of the following is most likely diagnosis?
A. Acoustic neuroma
B. Bells palsy

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C. Multiple sclerosis
D. Myasthenia gravis
** Trigeminal neuralgia, sometimes called tic douloureux, is a type of nerve (neuropathic) pain in the side of
the face and can be a symptom of multiple sclerosis. ... For some people it is a sudden severe sharp pain like
an electric shock but for others it may be a more long lasting aching or burning sensation

154. builder 48 year, weakness in left side of body for few minutes. past same episode for 5 times. advice after
giving aspirin and discharge with follow up by local doctor
a. More antiplatelet
b. Can’t drive 6months
c. Can’t go to work without local doctor’s permission
d. No strenuous work
155. A man presents with sudden onset of Horner's syndrome, 9th & 10th cranial nerve palsy and loss of touch
and temperature sensation on the opposite side of the body. What is the site of lesion?
a. Basilar artery
b. Middle cerebral artery
c. Vertebral artery
d. Vertebrobasilar artery
e. Carotid artery

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156. A neonate presents with vesicles over his body 48 hours after delivery, and is kerning’s positive. Lumbar
puncture shows a predominance of lymphocytes, an increase in proteins, and normal glucose. What is your next
step in management?
a. Acyclovir
b. Ceftriaxone
c. Penicillin
d. Observation
e. IV fluids and support
157. Women with burning pain on left side of face , droopy eyelid, meiosis, some sensory impairment, no
areflexia..
a. Cerebellar artery aneurysm
b. Herpes zoster encephalitis
C. HERPES ZOSTER opthalmicus
d. PICA
158. Woman with photo of hemi facial palsy(looks like bells palsy) and icterous sclera. Has discharge and pain
from ear starting befor the facial palsy What next?
1.acyclovir
2.ct
3.prednisolon
4.Antibiotic

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5.Analgesic
159. You review a 70yearold woman four days after she was admitted with a suspected stroke. Unfortunately she
has been left with right sided sensory loss affecting her arms more than the legs and a right sided homonymous
hemianopia. Functionally she has difficulty dressing her self. Examination of her cranial nerves is unremarkable.
What area is the stroke most likely to have affected?
a. Middle cerebral artery
b. Lacunar
c. Anterior cerebral artery
d. Posterior cerebral artery
e. Posterior inferior cerebellar artery
160. A patient comes to you with confusion, neck rigidity, photophobia. LP shows increased Lymphocyte, protein
normal, glucose decreased. What will be your DX?
a. Bact menin
b. Viral menin
c. Tubercular menin
d. Meningococcal

161. Pic of a man with droopy right face can’t open right eye. frontalis muscle weak?
a.CT
b.MRI
c.Nerve conduction
d.no further investigation
e.Swallowing test by speech pathologist

** Bell's phenomenon (also known as the palpebral oculogyric reflex is a medical sign that allows
observers to notice an upward and outward movement of the eye, when an attempt is made to
close the eyes. The upward movement of the eye is present in the majority of the population, and is

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a defensive mechanism. The phenomenon is named after the Scottish anatomist, surgeon,
and physiologist Charles Bell. Bell's phenomenon is a normal defense reflex present in about 75% of
the population, resulting in elevation of the globes when blinking or when threatened (e.g. when an
attempt is made to touch a patient's cornea). It becomes noticeable only when the orbicularis oculi
muscle becomes weak as in, for example, bilateral facial palsy associated with Guillain–Barré
syndrome. It is, however, present behind forcibly closed eyelids in most healthy people and should
not be regarded as a pathognomonic sign.

162. Old woman had watery discharge from left ear. Two days later left facial paralysis. Most appropriate
investigation?
a) MRI head
b) CT head
c) ESR
d) CRP

Probable diagnosis otitis externa

But if diabetic do CT scan to rule of osteomyelitis
163. .Picture given of facial palsy and deep jaundice of eyes. The old lady presents with facial palsy for one day
duration. She also had painful vesicle in the ear the day before. What is the management?
A-prednisolone
B-acyclovir

164. A 39 years old man comes to u coz his face is lopsided for the past 2 days .. he did not have any pain behind
the ear nd also complaining tht his left eye has been drier than usual and he has had to use lubricating drop. It's
seems like facial nerve Bell's palsy .. the most appropriate way to test for a facial nerve palsy is to
A. Ask him to clench his teeth while you palpate the masseter muscles
B.ask him to show you his teeth
C.have him close his eye and tell you when you are touching his cheek with Gauze
D.have him turn his head to the right against ur hand
E.touch the posterior pharyngeal wall with an applicator stick

165. Baby 2 years started walking at 16months , absent lower reflexes and
distal weakness in lower limbs .. mother have pes cavus. what inv. To do ?

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a-muscle biopsy — Diagnositic
b-ecg
c-emg
d-nerve conduction

166. 60 yr old man with symtom of TIA bp 180/90 angiogram shows 50% rt and 60% lt carotid stenosis, He is also
suffering from vertigo for long time and recently it is increased a lot. what is most appropriate management?
a)control BP
b)aspirin…amedex q bank (50-69% doing CEA benefit is marginal compared to aspirin)
c)warfarin
d)carotid end arterectomy
167.

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168. A man with chronic subdural hematoma will have all except
A)Dementia
B)Ocular signs
C)Neck rigidity
D)Blood in csf

169. A 30 years male pt was in hospital and falled had tibial fracture then after discharge came after a week
agitated and blaming doctors they let him fall, he was not hit on head and many saw this next:
a- talk to him about his attitude
b- check for special frontal lobe testing
c- ct….subdural haematoma
170. Headache, after 2 hours spontaneously resolved. Patient watches zigzag line. What is your probable
diagnosis?
a.SAH
b.Atypical migraine….occular migrane
c.SDH

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171. Girl with severe occipital headache resulting transient unconsciousness. Later recover with some nausea,No
history of post confusion . CT head was done and shows nothing. Asking dx
a. Epilepsy
b. SAH
c. SDH
d. Cardiac syncope

172. A young boy presents with vertex headache diffuse increase on movement nd cough history of trauma one
week back the velocity of trauma was to extent that his helemet break . neurological exam normal most likely
a. Subdural hematoma
b. Extradural hematoma
c. Subarachnoid hemorrhage
d. Cereberal edema
e. Inter-ventricular hemorrhage

173.

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174. A 40yr old lady with a H/O migraine , polycystic kidney disease, sudden occipital headache, no neck
stiffness, no photophobia . CT was normal and 2 LP done were unsuccessful . What is the next appropriate
investigation?
a) repeat CT
b) MRI
c) cerebral angio (berry aneurysm)
d) Repeat LP

175.
ans is b

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176. Q.30 years Lady presented with pain and tenderness supraorbital was diagnosed to have sinusitis.she has fever
and now she developed neck stiffness.LP revealed polymorphonucleocytes.what is the diagnosis?
A.frontal sinusitis

B.meningeococcal meningitis

C.Pneumococcal meningitis

E.gram positive diplococci

177. A clear history of meningitis without skin rash in a woman. What is the most appropriate next step?
a.ct brain

b.LP. Next

c.IVF

d.MRI

178. .That lady with meningitis. Child had rash and fever. CSF protein 0.45, glucose 3.5, cells- Monocytes. With typical
features of meningitis, Cause?
A. HSV

B. Enterovirus
C.protein is .meningococcus

D.Group B strep

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179. A 9 year old patient was brought to you due to headache and frequent vomiting for the past few days. On
examination, you noticed patient walking with head tilted to right, nodules palpated on the right side of her neck.
Neck was stiff. Limping gait was also observed. what is your INITIAL investigation?
A. Plain cranial ct scan

B. Neck ultrasound

C. Lumbar puncture

D. Blood culture

E. Chest xray

**Dx – posterior fossa tumor = Meduloblastoma> headache, vomiting, ataxia, torticollis*

180. .A child with typical clinical picture of meningitis with neck stiffness and seizures for 5 mins twice and temp 39 c.
what to do next?
A-IV cefotaxime

B-analgesia

C-oral paracetamol

D-rectal dizapam

E- iv fluids (not hypertonic saline

181. Mother came with meningitis. Child had history of fever and generalized lymphadenopathy and rash last day.. On
CSF monocytes, glucose 3.5( 2-4.5 normal), no RBCS, protein>45 (or 0.45...i couldn't get the exact value).Most
probable cause?
Meningococcus

Echovirus

HSV

pneumococcus

h-influenzae

182. Scenario of meningitis suspected in a clinic, u advised referral to hospital .. what should be done till reaching the
hospital ?
A ceftriaxone inj

B blood culture

C CT head

D urine analysis

E give analgesic

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183. Child present with fever, neck stiffness, anterior frontanellae
full/bulge , lymphocytes 5400cumm(n <5) , glucose is normal ,no
organism on gram stain, meningitis like scenario
A. Intravenous phenytoin

B. Rectal diazepam

C. Intramuscular morphine

D. Oral paracetamol

E. Intravenous dexamethason

184. Q.A 30 years woman brought her husband to you he was confused they they were camping for three days in
western Australia where they were insects.what is your probable diagnosis?
a.enterovirus encephalitis

b. australia encephalitis

c. malaria…not in australia

d. ross river fever…joint pain

e. Japanese B encephalitis

• Western Australia camping === chances of Australian encephalitis

MVE virus(murrey valley) is endemic (always present) in northern Australia (northern Western Australia and the top end
of the Northern Territory) and probably in Papua New Guinea,

185. patient old age with lethargy and hemiparesis with mild fever ,he had complaint of pharyngitis for a while
,physical examination is normal except few RBC in CSF , dx ?
a.herpes simplex encephalitis

b.meningococal meningitis

c.stroke

d.tumor

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186. A patient with a known spinal cord ependymoma presents to his neurologist for a check up. He complains that he
has had difficulty walking, which he attributes to left leg weakness. On exam, he is noted to have 1/5 strength in his
left lower extremity, as well as decreased vibration and position sensation in the left lower extremity and decreased
pain and temperature sensation in the right lower extremity. Which of the following spinal cord lesions is most
consistent with his presentation?
a. Left-sided Brown-Sequard (hemisection) (same side of motor loss)
b. Right-sided Brown-Sequard (hemisection)
c. Anterior cord syndrome
d. Posterior cord syndrome
e. Syringomelia
187. 28 yrs old male patient presents with distal weakness and atrophy of small muscles of both hands. What is the
most likely diagnosis?
a. Multiple sclerosis
b. Bilateral median nerve palsy
c. Syringomyelia
d. Bilateral unlnar nerve palsy
e. Brainstem infarction
188. A 45 yrs old man develops weakness
and wasting of the small muscles of the
right hand. Which of the following is least
likely to be the cause?
A. Old injury to the right elbow
B. Bronchogenic Ca of the right upper
lobe
C. Multiple Sclerosis
D. Syringomyelia
E. Motor Neuron Disease
189. A 64 year old man presents to hospital with his first epileptic seizure whilst sat reading a newspaper at home.
Drug history – Nil clinical examination reveals the following: •Temp 371•BP 182/102 •O2 Sats 99% Air •GCS 15/15
•Finger prick blood glucose 3.9 mmol/l •No Jaundice, Anaemia, Clubbing, Cyanosis, Lymphadenopathy •CVS,RESP,GI:
(-) Neurological examination: including cranial nerves and Fundoscopy (-)His blood tests show the following: His chest
X-ray shows a ill defined lesion in the left mid zone. All normal xcept Na=129. What is the most likely aetiology of his
seizure?
a. Brain Metastases
b. Hypercalcemia
c. Syndrome of inappropriate ADH secretion (SIADH) –na is not low enough to cause seizures
d. Hyponatraemia not caused by SIADH
e. Idiopathic epilepsy

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https://geekymedics.com/syndrome-of-inappropriate-antidiuretic-hormone-secretion-siadh/

190. Pt smoker for 20 years, enlarged tonsils, on exam 1*1.5 mass in tonsillar fossa. Most probable Dx?
a) Mets from CA
b) SCC
c) Lymphoma
d) Nasopharyngeal CA

Carcinoma of the tonsil is a type of squamous cell carcinoma. The tonsil is the most common site of squamous cell
carcinoma in the oropharynx.

191. Man with right eye- droopy eyelid, diplopia, eyeball depressed inferiorly and laterally. Blur on looking left. Cause?
a. Right 6th Nv
b. Posterior communicating artery aneurysm –causing 3rd nerve palsy causinf the feats abv
c. Occipital lobe

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Anterior communicating artey aneurysm: Cause optic nerve palsy (2nd)

Posterior communicating artey aneurysm: Cause oculomotor nerve palsy (3rd)
PICA===MIOSIS or contrictited pupil==horner
PICA===dilated pupil===3rd nerve palsy

192. A man comes with clumsiness of hands and tripping over. Upper limb weakness and fasciculation. Lower limb
muscles also has weakness, increased tendon reflexes. Ankle reflex is not increased in one side. No wasting. No
sensory loss is given. What is the initial investigation?
A. EMG
B. MRI Spine
C. CT scan

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D. CSF examination
E. Cervical spine X-ray

the most useful neuroimaging technique in mnD is magnetic resonance imaging (mRi) of the brain and
spinal cord. structural lesions, especially at the level of the spinal cord, and intrinsic parenchymal lesions,
as seen in multiple sclerosis, can be effectively excluded with mRi.
Cervical spondylysis===cervical myelopathy same like MND but present with gait problem

193. Patient complaining of tiredness and lethargy (don’t remember the exact question). What do you expect on
neuro exam?
- Slow, depressed reflexesans===hypothyroidsm===delayed relaxation of ankle jerk
- Dysdidokinesia-cerebellar dysfunction

194. yr male complaint of Severe headache on left side and also neck pain on at same side. He never suffered on this
pain before. He has history of 2-3 glass of wine, 20 pack year smoking(+). Photo is given ( I see ptosis and pupil
constricted on left side) . Eye examination is normal and vision is unimpaired. What investigation to get diagnosis?
a. CXR
b. Otoscopy
c. Slip lamp examination
d. Carotid Doppler USG====aortic dissection====horner syndrome
e. MRI-its MRA NOT MRI===definite
SAH=====pupil is dilated====3rd nerve palsy

Typical presenting symptoms of carotid artey dissection are as follows:

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• Headache, including neck and facial pain – This can be constant, instantaneous, gradual, throbbing,
or sharp
• Transient episodic blindness (amaurosis fugax) – This is caused by decreased blood flow to the
retina
• Ptosis with miosis (partial Horner syndrome) – This is usually painful when caused by internal
carotid artery dissections
• Neck swelling
• Pulsatile tinnitus – This can occur in as many as 25% of patients with dissection of the internal
carotid artery
•
• Decreased taste sensation (hypogeusia)
• Focal weakness
• Migrainelike symptoms (eg, a scintillating scotoma, which is loosely defined as a transient visual
field disturbance in the form of shimmering or arcs of light)

Dx is carotid artery dissection which causes partial horners(no anhidrosis) and inx is first carotid doppler,
gold standard is CT angiogram nxt is MRA NOT MRI

195. scenario of a lady who become agitated and confused at shopping center for 1-2 mins. She has h/o same attacks .
and during attack she stares blankly, doesn’t respond to any command followed by confusion. What is ur dx?Jm 615
a) Panic attack
b) GAD
C) Complex partial seizures aka temporal lobe epilepsyrx: carbamazepine
d)PTSD
e) absence seizure

196. 4 ys old child present with headache, ataxia, vomiting , O/E there is a mass in the upper part of post triangle of
the neck. He has also nystagmus I remember, asking what is the Dx
a. medulloblastoma
b. meningioma
c. astrocytoma

Medulloblastoma (/məˌdʌloʊblæˈstoʊmə/) is the most common type of pediatricmalignant primary brain

tumor (cancer), originating in the part of the brain that is towards the back and the bottom, on the floor of
the skull, in the cerebellum, or posterior fossa

Symptoms:
The child typically becomes listless, with repeated episodes of vomiting, and a morning headache, which
may lead to a misdiagnosis of gastrointestinal disease or migraine.[4] Soon after, the child will develop a
stumbling gait, truncal ataxia, frequent falls, diplopia, papilledema, and sixth cranial nerve palsy. Positional
dizziness and nystagmus are also frequent, and facial sensory loss or motor weakness may be present.
Decerebrate attacks appear late in the disease.

197. 45 yr old lady with b/l headache, headache is there for 3 months also ptosis and meiosis left eye. headache is mild
and dull. dx?(tension headache but no myosis and ptosis)
post fossa tumor????-diplopia nystagmus mydriasis
Cluster headache-strictly unilateral
Maybe horners???

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Posterior fossa tumor - UT Medical Center

Symptoms from posterior fossa tumors also occur when the tumor damages local structures, such as cranial nerves.
Symptoms of cranial nerve damage include: Dilated pupils. Eye problems. Face muscle weakness. Hearing loss. Loss of
feeling in part of the face. Taste problem

198. Diagnosis?
(a) Cerebral hemorrhage
(b) Cerebral infarct
(c) Subdural hematoma
(d) Subarachnoid hemorrhage
(e) Craniophargngioma- symptoms result from pressure on the optic tract and pituitary gland. Headache(obstructive
hydrocephalus)Obesity, delayed development, impaired vision, and a swollen optic nerve are common.===bilateral
hemianopia
Cerebral haemorrhage

Craniopharyngioma (optic chiasm)

Cerebral infarct

Subdural hematoma

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sabarachnoid haemorrhage

199. Young girl with cushing triad features on dextrose drip. Dolls eye reflex present but not responding to painful
stimulus. Rr 12 hr 50 sao2 100 bp 180/100. You are working on tertiary hosp.. next step of management
Urgent ct
Stop dextrose and start ns (dextrose increases icp)
Give steroids
Intubate
Neuro reference

Intubation and ventilation:

• Child unresponsive or not responding purposefully to pain

• GCS persistently <8
• Loss of protective laryngeal reflexes
• Respiratory irregularity

Typical picture of subacute compound degeneration with posterior and lateral cloum signs and ask for the test-
diagnosis
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Subacute combined degeneration of spinal cord, also known as Lichtheim's disease,[1][2] refers to degeneration of the
posterior and lateral columns of the spinal cord as a result of vitamin B12 deficiency (most common), vitamin E
deficiency,[3] and copper deficiency.[4] It is usually associated with pernicious anemia.
Symptom:
Patients present with weakness of legs, arms, trunk, tingling and numbness that progressively worsens. Vision
changes and change of mental state may also be present. Bilateral spastic paresis may develop and pressure,
vibration and touch sense are diminished. A positive Babinski sign may be seen.[5] Prolonged deficiency of vitamin B12
leads to irreversible nervous system damage. HIV-associated vacuolar myelopathy can present with a similar pattern
of dorsal column and corticospinal tract demyelination.[citation needed]

200. Non diabetic patient complaining of weakness of lft hand numbness on both feet, foot drop on left side, vibration
and touch sensation impaired below inguinal ligament. What inv to find out the lesssion
a. Nerve conduction study
b. Muscle biopsy
c. Vit B12
d. MRI of spine

201. child scenario of meningitis with fever, nausea and vomiting, head
tilted to the right. wat investigation?
a) Lumbar puncture
b) blood culture
c) CT
d) sputum culture

202. A 55-year-old woman visits her physician because of double vision,

eyelid droop, difficulty chewing and swallowing, and general weakness
in her limbs. All these symptoms are made worse with exercise and
occur more frequently late in the day.
The physician suspects myasthenia gravis and orders a Tensilon test.
The test is positive.What is the treatment?
Atropine
B) Botulinum toxin antiserum
C) Curare (anticholinergic)
D) Halothane
E) Neostigmine (anticholinesterase drug) jm 326

203. Lady came with tremors appear at rest and stop with activity also stop when she looks to her hands.Asking
Rx ? (anxiety disorder) contro
A.Propranolol
B.Benzhexol****
C.Pramepexole

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204. 9 year old patient was brought to you due to headache and
frequent vomiting for the past few days. On examination, you
noticed patient walking with head tilted to right, nodules
palpated on the right side of her neck. Neck was stiff. Limping
gait was also observed. what is your INITIAL investigation?
A. ct scan****-subtentorial brain lesion???(plain cranial ct scan)
B. Neck ultrasound
C. Lumbar puncture
D. Blood culture-for meningitis
E. Chest xray

205. 79 yo female came with decreased memory

for few months which makes her write notes and
stick those notes all around, she says she is not
like herself anymore, CT which wasn’t given!
Shows general mild cortical atrophy. what’s the
Dx?
A- Alzheimer’s dis( dilated ventricle)
B-vascular dementia
C-senile dementia****

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Preferred examination
Structural imaging, preferably with MRI when possible
and computed tomography (CT) when not, should be
obtained as a first-tier approach. MRI can be
considered the preferred neuroimaging examination
for Alzheimer disease

magnetic resonance imaging (MRI) scan in a patient

with moderate Alzheimer disease. Brain image reveals
hippocampal atrophy, especially on the right side.

Temporal predominance atrophy==ventricules dilated

206. A patient has pneumonia. His hip muscles become

weak. CT shows a spinal stenosis. He is on statins and multiple other drugs. On examination knee jerk is absent,
lower limb power is 3/6, absent dorsalis pedis pulses and sensation over thigh is loss. Next investigation?
(contro)
A) Mri😎 ****
Xray.
C) Arterial duplex
D) CK
E) LP

207. man taking polypharmacy warfarin ,rosuvas. Upper limb power 3/6, lower limp power 4/6 . muscle
tenderness . lower limb tip to knee loss of sensation.( MYOPATHY)
a- Peripheral neuropathy
b.MND
C .mri LS
D. emg****

Symptoms/signs
Symptoms of neuromuscular disease may include the following:[2][6]
o Numbness
o Paresthesia
o Muscle weakness
o Muscle atrophy
o Myalgia (muscle pain)
o Fasciculations (muscle twitches)
Diagnostic procedures that may reveal muscular disorders include direct clinical observations. This usually
starts with the observation of bulk, possible atrophy or loss of muscle tone. Neuromuscular disease can also
be diagnosed by testing the levels of various chemicals and antigens in the blood, and using
electrodiagnostic medicine tests[4] including electromyography[18] (measuring electrical activity in
muscles) and nerve conduction studies

208. Meningitis in a baby 2 month neck stiffness, CSF low glucose, high protein, leukocytosis and have
commenced antibiotic. What next will you add? a. dexamethasone******* b.i.v ceftriaxone c. antiviral

209. Question on traumatic patient with clear fluid draining from the nose. What to give? Jm-1458
Dx-csfrhinorrhoea(base of skull fracture)

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Ans-Cotrimoxazole

210. At ED a pt after MVA with clear nasal fluid and dark periorbital zones. What will you do? Base of the skull
fracture
a. insert nasogastric tube
b. insert orogastric tube
c. tamponade the nose
d. do a post tamponade of nose
211. A man fell from horse n presented after 2.5 hours. Peri orbital edema n clear discharge from nose. What to
do?
Antibiotic
Dexamethasone
Oroppharyngeal tube
Nasogastric tube
Nasal packing
212. Head injury, clear fluid from nose, initial management?
A) Orogastric tube
Ng tube
C) CT
D) x-Ray

Co-trimoxazole - Life in the Fast Lane Medical Blog

https://lifeinthefastlane.com/ccc/co-trimoxazole
PO – each tablet = 80mg trimethoprim and 400mg sulfamethoxazole

213. a woman on ocp and having nausea, dizziness, can’t move her hand.had same symptoms 2-3 times in
previous 12 months which resolved in 24 hours.on examination everything was normal.asked diagnosis
a.conversion disorder
b.malingering
c.transient cerebral ischaemia

214. 79 yo female came with decreased memory for few months which makes her write notes and stick those
notes all around, she says she is not like herself anymore, on examination verbal impaired.CT which wasn’t
given! Shows general mild cortical atrophy. what’s the Dx?
A- Alzheimer’s dis
C-normal aging

Vascular dementia, also known as multi-infarct dementia (MID) and vascular cognitive impairment (VCI), is
dementia caused by problems in the supply of blood to the brain, typically a series of minor stroke
No option for vuscular dementia
Posterior cortical atrophy (PCA), also called Benson's syndrome, is a form of dementia which is usually
considered an atypical variant of Alzheimer's disease (AD).

People with vascular dementia present with progressive cognitive impairment, acutely or subacutely as in
mild cognitive impairment, frequently step-wise, after multiple cerebrovascular events (strokes). Some people
may appear to improve between events and decline after further silent strokes. A rapidly deteriorating
condition may lead to death from a stroke, heart disease, or infection.[4]

Signs and symptoms are cognitive, motor, behavioral, and for a significant proportion of patients also
affective. These changes typically occur over a period of 5–10 years. Signs are typically the same as in other
dementias, but mainly include cognitive decline and memory impairment of sufficient severity as to interfere
with activities of daily living, sometimes with presence of focal neurologic signs, and evidence of features
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consistent with cerebrovascular disease on brain imaging (CT or MRI).[5] The neurologic signs localizing to
certain areas of the brain that can be observed are hemiparesis, bradykinesia, hyperreflexia, extensor plantar
reflexes, ataxia, pseudobulbar palsy, as well as gait problems and swallowing difficulties. People have patchy
deficits in terms of cognitive testing. They tend to have better free recall and fewer recall intrusions when
compared with patients with Alzheimer's disease. In the more severely affected patients, or patients affected
by infarcts in Wernicke's or Broca's areas, specific problems with speaking called dysarthrias and aphasias
may be present.

215. -pt had generalized tonic clonic seizures & he is also on warfarin & other drugs.What to give??
A.Amiodarone
B.sodium valproate
C.carbemazepine
D.phenytoin
E.topiramate llamotrigine, oxcarbazepine,
tiagabine, vigabatrin and topiramate safe

warfarin and amiodarone r inhibitor

216. A 65yr old lady comes to ur practice
with c/os of back pain while gardening O/E,
presence of point tenderness in lumber
vertebrae. Which of the is most appropriate
diagnosis?
1. spinal cord stenosis
2. disc prolapse
3. cauda equina syndrome
4. muscle spasm
5. compression fracture (ans) (Point tenderness
over the spine with palpation or percussion may indicate
fracture or an infection involving the spine)

217. 58yrs old man, drag left foot, reflexes on left

lower limb are increased, plantar flexion &
dorsiflexion are 4/5, weak ankle movements,
equivocal plantar reflex, upper limb and face are
normal exam.Lesion site
a. Common peroneal nerve
b. Cervical spinal cord( handfacicuktion/wkness will b
there)
c. L5,S1 nerve root
d. Cerebral cortex***(no eye involvement.MND)
e. Brain Stem( diplopia, facial paralysis)

dx: primary lateral sclerosis

Definition
Motor neuron disorders (MNDs) are a clinically and pathologically heterogeneous group of neurologic
diseases characterized by progressive degeneration of motor neurons; they include both sporadic and
hereditary diseases. Either or both of the following 2 sets of motor neurons can be affected:
Upper motor neurons (UMNs), which originate from the primary motor cortex of the cerebrum (precentral
gyrus) and possess long axons forming corticospinal and corticobulbar tracts
Lower motor neurons (LMNs), which originate in the brainstem (cranial nerve [CN] motor nuclei) and spinal
cord (anterior horn cells) and directly innervate skeletal muscles

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218. Patient I forget the cenario but he has loss of planti flexion, and inversion, also loss of unkle jerk; But he has
intact dorsiflexion and eversion. Knee jerk normal. Which nerve injury:
a. sciatic
b. tibial
c. common peroneal
d. forget others.

Inversion is only done by posterior tibial not anterior tibial

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219. Patient complaining of loss of sensation over lateral arm, lateral forearm, loss of triceps jerk, asking about
the site of injury (contro)
a. C5,6
b. C6,7-jm 688
c. C8, T1
d. Can’t remember

220. A boy who was involved in a head-on collision MVA and

developed a loss of consciousness, was brought to the ED.
On arrival, he was not opening the eyes(1) but could
withdraw to painful stimulus(4), with a confused
conversation(4). What is next in management? (incomplete
stem)
a.Give mannitol
b.Do a head CT scan****(score 9)JM 856
c.Intubate patient(if <8)

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8 to 10: monitor airway

Less than 8 ==intubate

221. CT of glioma, history of Clerk 1 melanoma on leg 3 yrs ago.

Drowsy, lethargic. No neurological
symptoms. Temperature normal. Dx?
Brain abscess
Metastasis melanoma More than 60% of all Stage IV melanoma patients will develop brain metastases at some point
Haemorrhage
Glioma

ctmets ct glioma

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ctmets

222. A 70 year old lady starting forgettg recently when she speaks she get confused difficulty to utter ‫ ﯾﺘﻔﻮه‬words
she even forget and leave her Stove open Which part of CNS effected on ct asked
Pareto occipital
Medial temporal (memory and expressive apasia)
Orbitofrontal

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223. A 75 year old man can’t copy a diagonal shape where is the lesion ? a. Frontal cortex b. Dominant parietal
lobe c. Non dominant parietal lobe d. Hypothalamus e. Occipital lobe

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224. Scenario of head injury, GCS 10, PR 60/min, 110/70 1 hr drive to nearest tertiary hospital
a. CT head
b. Ivmannitol
c. Refer to tertiary hospital
d. (no burr hole in options)

225. Young boy is brought to the rural hospital ER after trauma to the head. He was in a motor vehicle accident.
After that he developed extreme unconsciousness with GCS of 6/15… pupil dilated. You have intubated the
patient. The Neurosurgery unit is 3 hours from the rural ER. What is the next appropriate plan for this patient?
a. Transfer to neurosurgery unit
b. Do a CT scan
c. Temporary Burr hole
d. Craniotomy

226. old pt ,speech, behavioral problem & patient is right handed .where is the problem
A. Left parital lobe
B. Rt parital lobe
C. left Frontal lobe #May

227. Old man with recurrent falls in nursing home, he is found to have many bruises in head, ECG showed sinus
tachy, multiple ventricular ectopics and ventricular hypertrophy (written), on enam/thiazide combination, BP
150/90 sitting and systolic 90 in standing, what invx for diagnosis?
a. 24 hr ECG\\\\24 hr hotler
b. 24 hr BP
c. Repeated BP measurements with postural change
d. CT head

228. Man with clumsy right hand and weakness of both legs. On examination wasting of muscles and
fasciculations in legs . What inv?
a. MRI cervical spine===initial
b. EMG

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MND-The senses of eyesight, hearing, taste, smell and touch are not affected.

Dx lmnd

229. Lady presents with right arm weakness.... on xm tone and reflex normal, voluntary movement not possibl by
pt. Had similar history few months back which resolved within 24 hrs. What is the cause?
a. transient attack-reflexes not normal
b. Conversion disorder

230. Pt had sinusitis... now comes with neck stiffness recall... asking diagnosis
a. Pneumococcal meningitis

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b. Meningococcal meningitis
c. Viral meningitis

Another vit b12 q ... romberg positive, dorsal column

symptom, tingling in hand and feet for many yrs now gloves
and stocking... ask inv. I chose vit b12 level
Loos like peripheral neuropathy

231. woman with decrease, sensations, tsock and glove fashion, proprioception lost in lower limbs. Romber
sign positive Ix?
a. -CT lumbar spine
b. -Nerve conduction studies
c. Vit B12 level
d. Folate level

COMMON CAUSES OF POSITIVE ROMBERG TEST:

1) Vitamin B12 deficiency - Subacute combined degeneration of the cord,
2) Diabetic peripheral large fibre neuropathy,
3) Friedrich's ataxia,
4) Tabes dorsalis

232. Measure gcs- eyes open to pain, says words, localise to pain
a. -8
b. -9
c. -10
..... (p-856)......JM DIFFERENT SLIGHTLY

233. . mnd scenario with wasting and weakness, no

sensory, asks inv
a. emg
b. ncs
c. mri

An Electromyogram is done to help find diseases

that are related to muscle tissue damage, damage
to the nerves, or problems related to gaps that may be found between nerves and the muscles. Usually, an EMG
is requested if your physician thinks that you might have herniated disc. It is also requested to rule out ALS, or
amyotrophic lateral sclerosis. It may also be requested for a certain illness called MG, myasthenia gravis.

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What is nerve conduction study?

This study is requested to know if there is damage to the peripheral side of your nervous system, which means
all the nerves that lead away from the brain, spinal cord, and smaller nerves going out to the different nerves. A
sample illness that can be diagnosed from this test is carpal tunnel syndrome.

The senses of eyesight, hearing, taste, smell and touch are not affected.

234. pt collapsed on work, colleagues say limb movement for 1-2 min… then confused till now but follows command
a. eeg
b. mri
c. ct

235. Patient comes with severe bradykinesia and cog wheel rigidity. He is commenced sertraline 0.5mg for his visual
hallucinations. He forget the things and more forgetful. What is your diagnosis?
A lewy body dementia***-has feats of both parkinsons(rigidity and tremors) and alzheimers(forgetfulness) plus has
hallucinations also
b . Alzheimer disease
c Neuroleptic malignant syndrome
236. 72 year old man with Parkinson's, takes Levodopa. Wife says he sees children and animals at home and talks to
his pet which died 1 year ago. MMSE 26/30. Diagnosis? Jm 318
Late onset psychosis
Lewy body**
Parkinsons
Drug side effect (as no forgetfulness)

237. Patient taking risperidone and another antipsychotic. Now develop cog wheel rigidity,visual hallucination,
dementia.
A. Parkinsonism
B. Schizophrenia
C. Lewy body dementia

238. Lady complains headache start 3-5 days before menses, headache start from occipital and radiate to frontal side,
aggravate by walking. Difficult to bare loud noices. Dx? Menstrual migraine
a. Premenstrual tension

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b. Migraine without aura
c. Brain tumor
d. Tension headache
e. Tension vascular headache

239. A woman with ataxia, nystagmus, diplopia. Cant perform finger

nose test. (signs of cerebellar lesions given, a bit long scinero and I
can’t remember all symptoms but are of cerebellar lesion) Asking
diagnosis.
a. lateral medullary syndrome
b. cerebellar tumor-all symptoms +in this

240. lady brought her baby born normal now on 6 weeks having
hypotonia and areflexia off all limbs,poor sucking and progressive
difficulty in respiration.diagnosis
a. spinal muscular atrophy — muscles don’t work properly, causing
muscle weakness and wastin, Sometimes, feeding and swallowing
can be affected. Involvement of respiratory muscles (muscles
involved in breathing and coughing) can lead to an increased
tendency for pneumonia and other lung problems
b) pradderwilli syndrome — rare genetic disorder affecting
development and growth, has an excessive appetite, which often
leads to obesity
c) early cerebral palsy

241. 10 minutes weakness of right side of body with some speech trouble.Nownormal.What could be ?
a) Lacunar infarct
b) Vertebro basilar
C) ischaemiacaotid artery-tia

The most common presenting symptoms of TIA are focal neurologic deficits, which can include, but are not limited
to:[9]

• Amaurosis fugax (painless, temporary loss of vision)

• One-sided facial droop
• One-sided motor weakness
• Diplopia (double vision)
• Problems with balance and spatial orientation

242. 8yr old child brought by his mother, he complained from episode of staring suddenly that occur along with
fidgeting of right hand and movement of right arm head twitching to right side, sometimes chewing and lip smacking
each episode last for 60-90 second then the child remain dizzy and confused for 1-2 minutes after the episode . These
occurs in 3-4 days and then the child back to his normal activity and behaviour for several weeks . what is the most
likely diagnosis?
A- Temporal lobe epilepsy ***(post ictal confusion more than 1 minute),(complex parial seizure)
B- Juvenile myoclonic epilepsy (adolescence, postictal confusion < 1 minute, triad: absence seizure, tonicclonic
seizures and myoclonic jerk. Can get this within 30 minutes of waking up at morning)
C- Absence seizure – no muscle involvement like hand unless atypical type,only eyelid fluttering,lip smacking , stare +
D- other don’t remember

243. 8 yrs old recently started having movements of his arm and head turned towards one side. Eyes fixed, stays for 30
to 60 seconds. Many times a day for 2 weeks and then nothing in other week.Could it be?
a) Temporal lobe epilepsy
b)juvenile myoclonic epilepsy absence + partial seizures h
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c) Absence seizures-atypical absence seizures

244. Young boy is brought to the rural hospital ER after trauma to

the head. He was in a motor vehicle accident. After that he
developed extreme unconsciousness with GCS of 6/15. You have
intubated the patient. The Neurosurgery unit is 3 hours from the
rural ER. What is the next appropriate plan for this patient?
a. Transfer to neurosurgery unit
b. Do a ct scan
c. Burr hole***( ifgcs<8 = immediate bur hole, gcs>8= ct first)
d. Craniectomy

245. A young boy is brought to you in the rural ER. Neurosurgery

unit is 1 hours away. Earlier today he was hit during football
where he lost consciousness and fell to the ground. A few minutes
he regained his consciousness and walked out of the field. His
family brought him to you complaining that he has developed
headache after the incident. His GCS is 10/15. What is the next
plan for him?
a. Do a ct scan***
b. Transfer to neurosurgery unit
c. Hyperventilation and mannitol infusion
d. Burr hole
e. Craniectomy

246. Woman with attack of TIA/stroke with body weakness and

visual loss (Homonymous hemianopsia) Her muscle weakness is
resolved now but her vision isn't. She wanted to drive.
A. She can't drive anymore.***
B .more occupational trial ?

247. 82 yr pt came with numbness ,heaviness of the rt hand & leg together with left homoanyomous
hemianopia .Her hand & foot state resloved after 2 weeks but her visual field defect is still present 6 wk
later.wht would u do?
a. Cannot drive for 2wks
b. Cant drive for 2 months
c. Cant drive for 6 months

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d. Cant drive forever

248. A 22 yr pt came with numbness ,heaviness of the rt hand & leg together with left homoanyomous hemianopia
.Her hand & foot state resloved after 2 weeks but her visual field defect is still present 6 wk later.wht would u do?
Cannot drive for 2wks
Cant drive for 2 months
Cant drive for 6 months
Cant drive forever
Advise MRI

249. builder 48 yr,weekness in left side of body for few minutes.past same episode for 5 times.advice after giving
aspirin and discharge with follow up by local doctor
More antiplatelet
Can’t drive 6months
Can’t go to work without local doctor’s permission
No strenous work

250. CT scan look like cerebral hemorrhage with cerebral oedema? BP – 180/100 mmHg. PR 80 per min. GCS – 10 What
to do next?
a. perindopril
b. IV mannitol
c. Neurological assessment and observe
d. labetalol****JM 1430

Medications used in the treatment of acute stroke include the following:

• Anticonvulsants - To prevent seizure recurrence

• Antihypertensive agents - To reduce BP and other risk factors of heart disease
• Osmotic diuretics - To decrease intracranial pressure in the subarachnoid space

Management begins with stabilization of vital signs. Perform endotracheal intubation for patients with a
decreased level of consciousness and poor airway protection. Intubate and hyperventilate if intracranial
pressure is elevated, and initiate administration of mannitol for further control. Rapidly stabilize vital signs,
and simultaneously acquire an emergent computed tomography (CT) scan. Glucose levels should be
monitored, with normoglycemia recommended. [1]

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251. . 8yr old child brought by his mother , he complained from episode of staring suddenly that occur along with
fidgeting of right hand and movement of right arm head twitching to right side, sometimes chewing and lip smacking
each episode last for 10-20 second then the child remain dizzy and confused for 1-2 minutes after the episode . These
occurs in 3-4 days and then the child back to his normal activity and behaviour for several weeks . what is the most
likely diagnosis?
A- Temporal lobe epilepsy****
B- Juvenile myoclonic epilepsy
C- Absence seizure

252. GBS case with limb paralysis and mild dyspnea. What is the most important next step :
A. LP-to diagnose
B. Spirometery***-to assess resp function (vital cacity))
C. MRI

253. A lady comes to you with complaints of pain in both thighs after she spent one week in hospital suffering from
pneumonia,ankle jerk and knee jerk is lost.muscle power of both quadriceps is 3/5 .And foot pulses are absent.What
will lead you to diagnosis
a.L.P****GBS –preceeded by resp illness or stomach flu
b.Mri spine
c.Doppler usg of legs
d. Lumbo sacral xray

dorsalis pedis is normally absent in 15% of population

GBS

254. Child had chicken pox.After some days He developed ataxic gait and difficulty balancing.Mother is
concerned.Other findings are normal.What could be the cause?
Encephalitis
Post infectious cerebellitis****acute cerebellar ataxia-common aft varicella infections provided no localizing signs+
GBS
http://www.rch.org.au/clinicalguide/guideline_index/Ataxia/

Neurological complications secondary to chicken pox are very scarce; commonly they may occur during or after
exanthemas. ... Cerebellar ataxia, encephalitis and rarely, facial paralysis can be seen as neurological complications
of chickenpox

Chicken pox in children is usually self-limiting with cerebellitis as the most common neurological complication

255. 20 years old boy comes with fever of 37.9 and sore throat and headache for one week,Examination is
unremarkable and long lab interpretation was given only showing raised TLC.During his childhood his mother often
had to visit GPs. Single episode of vomiting 1 day back and he is feeling as his right side of body is not healthy,what is
the cause of his condition?
a) GBS
b) Meningitis
c) brain abscess****-raised tlc
e) pneumonina
f) Brain tumor-unremarkable tlc just after radiation therapy it decreases

Brain abscess (or cerebral abscess) is an abscess caused by inflammation and collection of infected
material, coming from local (ear infection, dental abscess, infection of paranasal sinuses, infection of
the mastoid air cells of the temporal bone, epidural abscess) or remote (lung, heart, kidney etc.)
infectious sources, within the brain tissue.

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The famous triad of fever, headache and focal neurologic findings are highly suggestive of brain
abscess. These symptoms are caused by a combination of increased intracranial pressure due to a
space-occupying lesion (headache, vomiting, confusion, coma), infection (fever, fatigue etc.) and focal
neurologic brain tissue damage (hemiparesis, aphasia etc.).

256. patient with generalized muscle weakness and tenderness of calf muscles and thigh with limited abduction of
shoulder joint due to deltoid tenderness with weakness of arm and forearm muscles,cutaneous sensations all normal
,jerk reflexes are
preserved ,dx ?
a.GBS
b.myopathy***\\\emg
c.motor-neuron disease — MND presents with mixed picture of UMNL and LMNL, thence hyperreflexia, +vebabinski
sign, yet, weakness and inconsistent muscular atrophy
d.peripheral neuropathy

257. A case with genital ulcer with h/o multipartner and signs of meningitis.on CSF raised glucose,polymorph nuclear
cells predomonantly.which organism responsible for? (contro)
1.HSV-rbc
2.HIV????
3.pneumococcus
4.meningococcus
5.treponema pallidum????-SYPH-csf lymphocytes.

Here history of genital ulcer and having multiple sex parter with meningitis manif. D/d will be either
1)herpes meningitis 2)Hiv 3)syph

So in CSF of syphilis and HIV the cell type is leukocyte , glucose remains normal protein elevated in
varying level.....
But only for herpes in early stage the cell is POlymorphonuclear type, glucose elevated or normal ..
For why it is A...

Genital ulcer seen in HSV HIV and treponema

Polymorph nuclear cells r granulocytes could b neutrophils basophils eosinophil
Low glucose rule out HSV
HIV meningitis findings depend on etiological agent hx of multipartner and genital ulcer we assume if
painless could b due to HIV
Syphilis cause aseptic meningitis in 3rd stage ulcer in that stage not possible because it occur after many
years of secondary stage
By excluded all B is the answer

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258. 34 years man presents with fever, chills, rigor, fatigue , lymphadenopathy. History of having sex with male
partner( healthy ) and history of penile ulcer weeks ago but resolved. CSF ++ prominent monocytes . Diagnosis?
(contro)
A.EBV
2. Primary HIV
3.Syphilis****JM 281
4.CMV

259. A boy sustain a head injury in an accident, present to the ED, with no eye opening, withdrawal to pain, irrational
conversation. How will u mange him? Gcs 10
a. intubate ****
b. CT
c. mannitol

260. 40 yr women have shooting pain in thigh and lower limb while walking . history of lumber pain in lumber region.
Bilateral pulse present
Mri spine**** (spinal canal stenosis)
Xray
CT angiogram
Doppler usg

261. patient old age with lethargy and hemiparesis with mild fever ,he had complaint of pharyngitis for a while
,physical examination is normal , dx ?jm 844
a.herpes simplex encephalitis****
B.meningococcal meningitis

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c.stroke
d.tumor

262. 72 year old man living alone is brought to ED by daughter.

He’s so confused and gave incomprehensible answers to
questions and couldn’t follow any commands. There’s no other
abnormality on examination. CT was given large grey lesion is in
temporo- occipital region with shifting of lateral ventricles plus
surrounding oedema.
Asked diagnosis
a) Cerebral tumour***-minimal shift
b) Cerebral infarction — wedge shaped,acute
c) Cerebral haemorrhage
d) Cerebral tuberculosis
E. Subarachnoid haemorrhage — minimal shift

CEREBRAL TUMORS

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263. Old man presented with his wife. Wife says he sometimes gets confused and forgetful. He still drives and has
stopped reading newspapers. MMSE was 26/30. Ct scan of the brain is normal. What is the most appropriate
management? Jm 51
a. Cease drive at night
b. Repeat MMSE after 3 months
c. MRI of brain
d. Encourage physical activities

264. 75 yr old man living alone found to have increasing forgetfulness.diagnosis

1) cerebral infarct
2) cerebral tumor
3) cerebral abscess
4) cerebral hemorrhage

265. 12 years old girl presents with a sudden history of loss of sensation on the lower limbs associated with decreased
reflexes and progressive ataxia . Which of the following is most likely the cause of her condition
A. B12 deficiency( old age )
B. Friedreich´s ataxia **** (young age 7-15)- Foot deformity, scoliosis, diabetes mellitus, and cardiac
involvement are other common characteristics.
Friedreich's ataxia is an autosomal recessive inherited disease that causes progressive damage to the
nervous system.
Symptoms typically begin sometime between the ages of 5 to 15 years, but in Late Onset FA may occur
in the 20s or 30s. Symptoms include any combination, but not necessarily all, of the following: Muscle
weakness in the arms and legs Loss of coordination Vision impairment Hearing impairment Slurred
speech Curvature of the spine (scoliosis) High plantar arches (pes cavus deformity of the foot) Diabetes

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(about 20% of people with Friedreich's ataxia develop carbohydrate intolerance and 10% develop
diabetes mellitus)[2] Heart disorders (e.g., atrial fibrillation, and resultant tachycardia
The following physical signs may be detected on physical examination:
Cerebellar: nystagmus, fast saccadic eye movements, truncal ataxia, dysarthria, dysmetria. Lower
motor neuron lesion: absent deep tendon reflexes.
Pyramidal: extensor plantar responses, and distal weakness are commonly found.
Dorsal column: Loss of vibratory and proprioceptive sensation occurs. Cardiac involvement occurs in
91% of patients, including cardiomegaly (up to dilated cardiomyopathy), symmetrical hypertrophy,
heart murmurs

C. Charcot marie tooth diseases- Patients usually do not complain of numbness. This may be because
patients with CMT disease never had normal sensation and, therefore, simply do not perceive their lack
of sensation , hammertoes, genetic, abnormal gait, Inverted champagne bottle legs,EMG ,no
cure,physio
D. Dermatomyositis — accompanied with rash(painful and itchy violet) with muscle weakness.

266. builder 48 yr,weekness in left side of body for few minutes.past same episode for 5 times.advice after giving
aspirin and discharge with follow up by local doctor
More antiplatelet
Can’t drive 6months-cant drive aft TIA for 2 weeks to 1 month.
Can’t go to work without local doctor’s permission
No strenouswork

A no role of more anti-platelet in prevention of recurrent TIAs

B recurrent TIAs more than 6 months not drive
C strenuous work related to stroke questionable
D by exclusion criteria is the answer

267. A 22 yrpt came with numbness ,heaviness of the rt hand & leg together with left homoanyomous hemianopia .Her
hand & foot state resloved after 2 weeks but her visual field defect is still present 6 wklater.wht would u do?
Cannot drive for 2wks
Cant drive for 2 months
Cant drive for 6 months
Cant drive forever
https://www.onlinepublications.austroads.com.au/items/AP-G56-17

268. 25 Man who is mechanic and drives commercial vehicle has history of seizures. He has been advised to not drive
for the next 6 months. He however believes that he should continue driving as he doesn't want to disappoint his
customers. He starts driving within 2 weeks of having seizure. Which of the following is the most appropriate action?
A) Notify his employer
B) Notify licencing authority
C) Let him drive as he needs to continue work
D) Ban him from driving
269. Patient truck driver was on phynetoin Na for epilepsy, not well controlled, his doctor changed his medication to
carbamazepine which worked well asking when he can drive again
after 6 months
after 12 months
after 2 years
now
he can’t drive any more
***ans should be 10 year

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270. scenario of a lady who become agitated and confused at shopping center for 1-2 mins. She has h/o same attacks .
and during attack she stares blankly, doesn’t respond to any command followed by conusion. What is ur dx?
a) Panic attack
b) GAD
C) Complex partial seizures
d)PTSD

271. -scenario of resting tremor stop when activity also

Rigidity ask rx....benhexazole-antiparkinsonian drug..propanolol

272. scenario of multiple sclerosis of young girl loss of vision and pain behind the eye inx....
a.ct....
b.LP.....
c. Visual evoked potential
ansmri (from amedex)

273. young female pt with weakness of both leg ,paraesthesia ,vertigo, loss of vision and pain behind eye. What invs to
be done
1.ct
2.LP
3.Visual Evoke Potential
4.Temporal Artery biopsy

274. A patient with lower limb weakness and absent lower limb reflexes h/o diarrhea one or 2 week ago what is the
next investigation required to make a diagnosis ?
A. CT scan of Brain
b. mri cervical spine
c. Electromyelography (best)
d. LP (GBS J.M pg.325) (albumin cytological dissociation)

275. A case of acute back pain in a middle old woman with pain radiating to buttocks and thigh and there is tenderness
at L4-L5 disc, no urinary problem mentioned. Which of the following symptoms indicate a need for an urgent MRI?
a. radicular pain
c. disc prolapse
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d. disc herniation (revised) (mri to prveventquadaquina syndrome)

Cauda equina syndrome most commonly results from a massive disc herniation in the lumbar region

276. yo female came with decreased memory for few months which makes her write notes and stick those notes all
around, she says she is not like herself anymore, CT which wasn’t given! Shows general mild cortical atrophy. what’s
the Dx?
A- Alzheimer’s dis-variant of alzheimers
B-vascular dementia
C-senile dementia
277. 12 yrs old school girl suddenly collapsed at school.she was
brought by ambulane with dextose drip 60/ml min.on exam dolls
eye reflex were present but she was not responding to painful
stimulus.her vitals signs were as follows: > R/R 12/min > PR
50/min > SaO2 100% > bp 180/110(?) > if you are working in a
tertiary hospital.What is the Next step of management?
A) Arrange for urgent CT Scan
B) Stop her dextrose infusion and start on saline
C) Give Steriods
D) Intubate the patient
E) Nuerosurgical Reference

http://site.cats.nhs.uk/wp-
content/uploads/2013/12/cats_neurosurgical_2013.pdf
first intubate bcos of cushings triad-hypertension, bradycardia and
abnormal rr.
then give mannitol iv or if raised icp give hypertonic saline iv

278. . A lady comes with sudden severe headache subsiding after 2

hour + vomiting. Normal ct scan. No fever but neck
stiffness present. No trauma history. Cause?
a. Acute cerebral haemorrhage
b. Sub arachnoid haemorrhage sometimes not visible 6 hours< (from amedex)
c. Atypical migraine
d. Temporal arteritis

279. MND scenario with foot drop,asking initial inv ?

a.mri---
b.ct
c.EMG-----always confirmatory,not initial

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d.NCT
ans.mri (BCOZ of foot drop)

280. #MND FINAL FEB MARCH 2018 ..Patient with frequent tripping of right foot; weakness of interosseous muscles;
right foot drop; right plantar response is equivocal, left increased; reflexes are normal. What investigation will you do
to reach diagnosis?
A. EMG
B. Ach receptor antibodies
C. MRI cervical spine

281. weakness of left lower limb,power 4/5 weak dorsiflexion and plantar flexion, reflexex exaggerated in lower limb .
UPPER LIMB NORMAL ,where is the lesion ?
a. cortex
b. common peroneal
c. brain stem
d. L5 S1

282. Patient with weakness of the left upper limb, weakness of interosseous muscles and right plantar response is
equivocal, left is increased; reflexes are normal. What investigation will you do to reach diagnosis?
MRI cervical spine===cervical myelopathy
Ach receptor antibodies
EMG
CT brain
(this question came for twice)

**it is cervical myelopathy..cz lower motor sign in upper limb and upper motor in lower limb and there is no
fasciculation

CTG OBS
1. Pregnant40 weeks does not feel fetal movement for 36 hours, CTGnormal fetal heart rate 140, the mother is still
worried and not convinced with the CTG:
a) amniotomy
b ) repeat CTG
c) Come back in next routine followup
d) Come back in 24hr
Ans. If not convinced then do usg

2. 32 years old lady , 39 weeks pregnant presents wth complaint of did not feel fetal movement for past 12
hours .She was seen 2 weeks ago and everything was normal. what do you do?
A. CTG
B. USG
C. Reassure
D. Review in 24 hours
E. Admit and observe

3. 39 wk pregnant lady comes to you because she did ’t feel fetal movement for 2 days, general condition good. No
pain and no loss per vagina. A CTG was given showing normal pattern. How will you advice her?
a. Come back in 24hr
b. Come back in next routine followup
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c. Admit and induce
d. Admit and observe
e. Continuous CTG
4. A pregnant of 37weeks gestation comes with complains of reduced fetal movements for the last 24hrs..CTG done
it was normal and pt was sent home with reassurance…she now comes again after 3days that she is not feeling any
baby movements..what’s the most appropriate next step?
a-immediate CTG
b-obstetric USG (as patient is not in labour)
c- reassure that its normal at this gestation
d-Amniotomy
e-induction with prostaglandins

5.Pregnant woman 40 weeks , no fetal movement , CTG normal.....what to do Next :

A)Reassure and ask her to come after 24 hours
B)Induction of labour
C)C section
D)Reassure and ask her to come in the next visit

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Q. Women came in labour (labour pain was there). Cervix 4cm full effaced.Ctg monitoring was ongoing. Suddenly no
heart rate. Usg confirmed baby was dead. What to do?
A. Amniotomy
B. Allow spontaneous progress of labour

Lady presents at 34 wks GA , worried that her baby has not made any movement d last 48 hours. What is the best
next step ?
A.Usg
B. Ctg
C. Intermittent auscultation
D. CS
E. Reassure

Pregnant woman 40 weeks , no fetal movement , CTG normal.....what to do Next :

A)Reassure and ask her to come after 24 hours
B)Induction of labour
C)C section
D)Reassure and ask her to come in the next visit

5: patient in labour, amniotmy done, Irregular contraction..CTGgiven BHR DROP to 80..for few min.Diagnosis asked
1:Amniotc fluid emoblism
2:Placenta abruption
3:cord prolapse
4:vasa previa

24/pregnant lady – CTG showed deceleration with fetal heart dropped to 70/min at 4min and then
improved.
What to do Stop synto
a. Continue
b. Iv normal saline

Patient is in labor and fetal heart rate dropped down to 70... but after 2 minutes came back to normal.
A. Stop oxytocin
B. IV fluids
C. Continue monitoring CTG
D. C/S

Pregnant woman had 4 cm cervical dilatation, pethidine given to her 3 times.the fetal head is lop. What is the cause
of ctg abnormality?
a. prolonged Labour
b. Sedative drugs
c. Elevated resting uterine pressure
d. molding of fetal head
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8. A 34 year old primi came at term with rapture membranes and meconium stained lecor , you did a CTG , in review
of the CTG wts the next best step ?
a. CS
b. Fetal scalp ph
c. Induce labour at once with cintocynon
d. Wait for normal delivary
e. High forceps

24/pregnant lady – CTG showed deceleration with fetal heart dropped to 70/min at 4min and then
improved.
What to do Stop synto
a. Continue
b. Iv normal saline

A case of spontaneous rupture of membrane at term . Now cervix is 8cm dilated and head at ischial spine. CTG
shows heart dropping to 70 for 3 minutes with baseline heart rate 110bpm. What next?(hb3.316)
a.Fetal scalp ph
b. Immed CS
c.Ventous delivery

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1. 12. A 26 week antepartum patient comes to clinic due to watery vaginal discharge. On examination, CTG tracing
is unremarkable, speculum exam revealed fluid pooling which was straw colored.
What’s your next step?

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A. IV antibiotics
B. Salbutamol
C. IV betamethasone
D. Send patient home
E. Tocolysis

2. Fullterm female in oxytocin suddenly fetal heart rate decreased to 70 and returned to baseline of145 after
2minutes
_stop oxytocin
_continue oxytocin
_continuous ctg
_immediate cs now
3. 34 weeks pregnant lady comes with bleeding per vagina, about 1000 ml. Uterus is tense and tender and it's
about 38 weeks size. After fluid resuscitation, which is the next appropriate management?
Left lateral position
USG
Speculum examination
Intubation
CTG
4. 39 weeks pregnant lady came with labour pain..she was put in left lateral position having oxygen mask in place.iv
fluids with syntocinon is running 5 unit in 500 ml of Ringer latate. Ctg was done which shows heart rate of 140
which dropped to 70 and came back to 140 in 2min.asking next appropriate treatment.
A. Fetal scalp sampling
B. stop syntocinon
C. C section
D. Give 1 L of ringer lactate
E. Titrate to increase
5. A pregnant of 37weeks gestation comes with complains of reduced fetal movements for the last 24hrs..CTG
done it was normal and pt was sent home with reassurance…she now comes again after 3days that she is not
feeling any baby movements..what’s the most appropriate next step?
a-immediate CTG
b-obstetric USG
c- reassure that its normal at this gestation
d-Amniotomy
e-induction with prostaglandins
6. 18 year old primi comes in labour at term , she told u she wants no interference in the labour process whether
medical or surgical , she was 3 cm dilated head at 0 station , after 4 hours she is 9 cm dilated and head at +1
station , she is ok , u gave some analgesic only and the CTG is normal , wts the best next to be done ?
a. CS
b. Ventouse
c. Re examin her in an hour or 2
d. Give oxytocin drip
e. Episiotomy
7. A woman with 38 wk pregnancy complained of absence fetal movement for 2 days. CTG shows normal FHR
140/min.She comes back after 12 hr complaining of absence fetal movement again . What will u do?
LSCS
Continuous CTG monitoring
Admit & observe
Induction of labour
8. 41 weeks pregnant lady was admitted for induction.Patient is in left lateral position and oxytocin is
running.Her CTG revealed heart rate decelerations for 4 minutes.Cervix is 8 cm dilated.What's next?
a)Fetal scalp sample
b)Stop Oxytocin
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c)Do cesarean section
d)Ventouse delivery

http://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectionb/2/b2.15.pdf

https://geekymedics.com/how-to-read-a-ctg/

file:///C:/Users/Ravia/Downloads/Cardiotocography_July2015.pdf

9. A scenario of Lithium toxicity, the patient came with disturbed level of conscious, the level was given
(Cannot recall) what’s the treatment?

A. Dialysis

B. Activated charcoal

C. NaHCO3

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10. A 32 year old woman has increasing white vaginal discharge. She is 7 weeks pregnant. Her Chlamydia swab
is positive. All other tests are normal. What is the single most appropriate treatment?

a. Amoxicillin

b. Clindamycin

c. Doxycycline

d. Erythromycin

e. Metronidazole

pg+bacterial veginosis by gerdenella=clindamycin

pg+trichomonus vaginitis=clotrimazole vaginal tablet

pg+candida=oral fluconazole/clotrimazole vaginal tablet. jm 1160

11. IOL planned due to pre-eclampsia... Bishop score 2...what to do next..

A. Arm nd oxytocin

B. Elective lscs

C. Induce and arm at 4 or 24 hrs

12. 39 weeks pregnant female with Mild Preeclampsia With Bishop score 2. Best MX-

a.PGE2and amniotomy in 6 hr.

b.PGf2 and amniotomy in 12 hrs

c.Syntocinon

d.CS

3. 37 wk preg with mild PE for induction of labour. Bishop score 2 . What will u do ?

El LSCS

Induction with PGE1 & ARM after 4 hr

Induction with PGE2 & ARM after 12 hr

Urgent LSCS

Synto infusion

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7. Pt is on low dose OCP, complaining of break through bleeding, what to give….confusing options

a. increase estrogen…

b. increase progesterone…

c. advice high dose of both

PREGNANT LADY PRESENTS WITH BRUISHES ON HER ARM AND LEGS, NO ASSAULT WAS MENTIONED, ASKING NEXT
TO TO ? A) COAGULATION PROFILE, B) FBC, C) DOMESTIC ASSAULT.
Dx: gestational thrombocytopenia

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29. 23 year ole woman with breast mass, scenario of fibroadinoma, what advice to give….

a. reassurance

b. reassurance and follow up after 6 months

c. reassurance and follow up after 1 year

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Gynecology

1. 71 yr old whats is most imp screening in women above 75 years
a. mammography
b.pap smear
c.FBS
d.chest x ray
2. presents with complains of heavy bleeding and prolonged menstrual period. What is the most appropriate tx for
her?
a. Tranexemic acid
b. COCP
c. Mefenemic acid
d. IUCD
e. Norethisterone
3. A 17yo senior school girl with complain of prolonged irregular menstrual period and heavy blood losses. What is
the most appropriate tx for her?
a. Mefenemic acid
b. COCP
c. POP
d. IUCD
e. Mirena

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4. A 32yo presents with heavy blood loss, US: uterine thickness>14mm. What is the most appropriate tx for her?
a. Mefenemic acid
b. COCP
c. POP
d. IUCD
e. IU system (mirena

5. A 32 year old woman has increasing white vaginal discharge. She is 7 weeks pregnant. Her Chlamydia swab is
positive. All other tests are normal. What
is the single most appropriate treatment?
a. Amoxicillin
b. Clindamycin
c. Doxicycline
d. Erythromycin
e. Metronidazole

6. .A menopausal woman present with Bleeding per vagina after sexual intercourse. Pap smear last year is normal
but no endocervical cells. On exam, vagina is atrophic, others are normal. Treatment
A. Repeat PAP smear
B. Vaginal USG
C. Local oestrogen therapy (if next step then this )
D. Curettage and biopsy

As mentioned vaginal atrophy: so local estrogen, otherwise repeat pap and colposcopy

8. Discharge for 6 day, she is sexually active, what is the cause, previous pap smear normal
a. Chlamydia- cause of mucopurulent discharge (early sign of PID) JM- 1153
b. endometrial Ca – 90% present as vaginal bleeding – JM-1141
c. cervical Ca
The following sites are, in descending order, the most common sites of involvement found during
laparoscopy in endometriosis:
o Ovaries,
o Posterior cul-de-sac, Broad ligament ,Uterosacral ligament, Rectosigmoid ,colon Bladder,
o Distal ureter

Secondary metastases on ovarian tumor most common primary site==colon

9. 53 yrs old came for advice brother colon cancer dx at 63 . she had not seen dr for 5 years. what will u do? Male
or female???
a. colonoscopy.. LESS THAN 55 YRS
b. pap smear
c. chlymidia testing
D .fobt MORE THAN 55 IF 1ST DEGREE 2 YRLY CORRECT

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10. .68 year old female have menopause at 55 , present with brown-greenish vaginal discharge for 6 day , she is
sexually active, what is the cause , previous pap smear normal
a. Chlamydia
b. endometrial Ca
c. cervical Ca
11. 54 lady came for pap smear and all are fine
..but has slight heavy period…what next
important? Already given iron therapy.whats
next ??
A iron studies
B mammogram
C colonoscopy
D usg (to see endometrial thickness)— jm1140
E CT

12. A 6 week pregnant woman had an induction of

abortion following a H. mole. Regarding
management which is correct?
A Monthly follow up with Chest X-ray.
B Advice hysterectomy.
C COC till Beta HCG becomes normal.
D Weekly follow up with HCG.
E Weekly U/S.

Weekly; 3 month
Monthly: 1 year jm 1193

13. a 34 year old woman has her PAP smear and it shows a definite CIN I , her last PAP 2 years ago was normal,
whats the next best step ?
a. hpv testing after 1 yr
b. do colposcopy
c. do cone biopsy
d. refer to gynecologist
e. repeat PAP in 2 years

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14. 52 y/o female has 1y amenorrhea, 2 years ago pap smear was normal but 4 years ago pap smear was cervical
wart, she has had sexual contact after 1 year, during sex, she had not any discomfort or pain. After that she
developed 24 hour vaginal bleeding. Cause?
a. vaginal atrophy
b. cancer cervix POSTCOITAL BLEEDING
c. cancer endometr
d. relapse of condyloma
e. menstrual cycle

15. 48 yr old female ,wearing (Burqaa) ‫ ﺑرﻗﻊ؟‬come for regular pap smear, which came normal
What is the most important to screen about other than that?
A. Vit D
B. Fasting blood sugar

16. 22 year old needs OCP as she is sexually active, you check history and physical exam, you prescribe the OCP
what is next important step
a. Check for Chlamydia
b. Check for Syphillis

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c. Pap smear

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17. Old man, drag left foot, reflexes on left lower limb are increased, planter flexion & dorsiflexion are 4/5, weak
ankle movements, equivocal plantar reflex, upper limb and face are normal Xn. Lesion site
a. Cerebral cortex
b. C spine
c. L5,S1 nerve root
d. Common perineal nerve

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18. Patient underwent cone biopsy for abnormal pap smear
2-3 days back. Now presents with fever 39, pain lower
abdomen and tenderness. What’s the most
appropriate place to take a swab?
a. Blood culture
b. Endocervical swab PID jm 1154
c. High vaginal swab
d. Low vaginal swab
19. GP to give a education in school for 13 yrs old girl, sex education has covered, which one to give next?
a. sunscreen
b. pap smear
c. skin cancer
d. bullying
e. .alcohal
20. Q.Pregnant lady comes to u for antenatal check up at 16 weeks , she never had pap smear , and no abnormality
now too.. what to do next:
a. do pap now
b. pap after 6 weeks after delivery
c. no pap needed in pregnancy
21. mother has goat milk allergy and other family members has atopic eczema she is pregnant now and she want to know
what be effect on her child and ask for advice pre and post term
a. Don't drink goat milk during pregnancy
b. Don't give child goat milk
c. .keep away child from dust pollen

22. 18 years old girl come to clinic for HPV vaccination. Her Pap test last 6 months ago is normal. She has regular
three sexual partners. What will you recommend for her?
a) Give HPV vaccine as she request
b) Do Pap test now
c) Tell her that HPV vaccine is not effective for her
d) Check STD screenings and then give HPV vaccine
Std screening is mandatory as she has 3 sexual partners and her pap months ago was normal.

23. POP INDICATIONS: AGE MORE OR EQUAL TO 45, LACTATION, MIGRAINE, OESTROGEN INTOLERANCE, DM, WELL CONTROLLED
HTN

24. contraception.. Women on phenytoin wants contraception for 2 yrs only..best option for her.
a) Implanon
b) Depo medroxy
c) Mirena
d) Pop
e) Iucd
25. Woman with 3 kids, has otosclerosis with hearing aid. Which contraceptive method is best for her?
a. Low dose combined OCP
b. High dose
c. POP
d. Condom
e. IUCD

Women with a family history of otosclerosis who are anxious about the COC may wish to consider the
use of progesterone only methods of contraception, an intrauterine or barrier methods.

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26. 3.A 38 year nulliparous woman comes in your GP clinic for contraception advice. She revealed that she had
problem of premenstrual headache and her sister has breast cancer;. Which one of the following is most
important contraindication for prescription of oc pill in this patient?
a) DVT
b) Breast cancer
c) Migraine
d) Patient's age
e) Benign breast lesion

27. 4.A 53 year old woman come to you with complains of hot flushes 3-4times a day, vaginal dryness. Vaginal
examination shows atrophic vaginitis. She had hysterectomy IO year ago. She also says that she has history of
DVT. Which is the most appropriate treatment?
a) Low dose oral oestrogen
b) Low dose transdermal oestrogen
c) Low dose progesterone
d) Low dose oestrogen and progesterone
e) Vaginal oestrogen cream

28. Women on phenytoin wants contraception for 2 yrs only

a. Implanon
b. Depo medroxy
c. c) Mirena
d. Pop
e. Iucd.

29. 50. woman with 3 sexual partner, last pap smear was 2 month ago and normal. Now coming for HPV
vaccination, what to do?
a. cervical swab for HPV
b. give vaccination
c. repeat pap smear
d. urine PCR for chlamydia

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30. A 28-year-old female presents with post-coital
bleeding on two separate occasions. Her Pap smear
was normal 2 months ago. What is next?
a. Hpv serology
b. Chlamydia pcr CEERVICITIS
c. Pap smear now
d. Thin film pap smear
e. Repeat pap smear after 3 month

31. A 30 years old woman comes to your clinic asking

you for the best contraception for her.She doesn’t
smoke, and she has negative family and personal
history of breast cancer. But-she has one episode of
DVT few months ago, what will be your best
contraception advice for her:
A- Use condoms
B- Use natural methods of contraception
C- Use low dose combined oral contraceptive pills
D- Use progesterone only pills jm 1112 pg
E- Transdermal estrogen patch

32. Tetanus vaccine, 5 year old boy fell from tree,

superficial abrasions and lacerations. Had first 2 DTP
vaccine at 2 and 4 months. No vaccine after. What
to give?
a) toxoid and topical antibiotics
b) toxoid and 5 days oral antibiotics(((it was not in
the choices ))!!!!!!!
c) toxoid plus IG
d) DTP plus IG
e) DTP plus booster after 2 months

33. A 26 yr old lady came at 18th week gestation with clear vaginal discharge, however she told that the pregnancy
was unplanned, fetal movement normal heart rate 144/min, her last pap smear was one year ago. She had no
abd pain, what inv will you do
a.Fetal fibronectin test (after 22wks )
b. Low vaginal swab
High cervical swab
Urine microscopy and culture
e.Repeat Pap

34. 53 yr old woman comes to you. No family history of CA. What is your first screening? (contro btwn a and b)
a. Pap smear
b. Mammo
c. FBS
d. Colonoscopy

35. 48 yr old woman comes to you and done pap smear. What is your next step after pap smear?
a. Mammogram. ans-audsrisk
b. Colonoscopy
c. Skin

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36. A 53 year old woman has not been screened for the past 5 years. Sister diagnosed with colon cancer at 63 years.
Father and mother died of heart disease at 65 years. What screening will you do for her now?
a. Colonoscopy
b. stress ECG
c. Pap smear

37. Ultrasound breast exam

**ans should be cervical screening or mammography

38. Q.81 yrs female Postmenopausal and with vaginal bleed. Pap smear no endocervical cell seen.
a. Repeat pap
b. Colposcopy
c. Nothing
d. LLETZ LOOP EXCISSION BIOPSY

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39. Q.4.You have been sent to a school to give sex education. What else would you give advices about?
A.Regular cancer screening
B.Prevention of acne
C.Chalmydial infection
D.Pap Smear

40. gp to give a education in school for 13 yrs old girl,sex education has covered,which one to give next?
a. Sunscreen
b. pap smear
c. skin cancer
d. bullying
41. 6.you are to give a lecture for 13 yr old girls at school, sex education has been covered before, what is the best
to talk about:'
a. alcohol
b. Sun screen.
c. pap smear.
d. 4.bullying.

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42. Q.Helen Jones is a 19 year-old secretary who presents with a one year history of painless post-coital bleeding.
She takes a tri-sequential contraceptive pill. Clinical examination is normal except for a degree of cervical
erosion. Her Pap smear is reported as "inflammatory ". The MOST APPROPRIATE management is:-
a. Repeat smear after treatment with triple-sulpha cream
b. Change OCP to a more estrogenic balance
c. Reassure, but review in six months
d. Refer for colposcopy— next
e. Change OCP to a more progestognenic balance
A then d
43. 18 year old came with complaint of minimal vaginal bleeding 4 weeks after surgical abortion. All other findings
are normal. What else is the most important?
a. Education on contraceptives
b. pap smear
c. abdominal USG

44. Patient with Downs syndrome, she had inter menstrual bleeding, she is not sexually active, not on contraceptive
pill.The patient refused to be examined. What to do next?
a. Request pelvic usg
b. Do pelvic exam under general anesthesia
c. Talk to the patient regarding her understanding of intermenstrual bleeding
d. Take consent of the carer to do Pap smear

45. 20 year old came for HPV examination ( pap smear). She is sexually active. On examination, yellowish exudates
obstructing the endocervical space. What best next?
a. do pap smear as requested
b. tell her it is not beneficial for her age
c. treat infection and perform pap smear after 3 months

INDICATIONS
o Screening for cervical cancer
o Post treatment follow-up for cervical dysplasia, malignancy
o Any visible or palpable lesion of the cervix (also need colposcopy)
o Any abnormal vaginal bleeding or discharge
o After hysterectomy for dysplasia, carcinoma
o After supracervical (subtotal) hysterectomy
o As part of the initial workup for victims of rape, incest, abuse
CONTRAINDICATIONS
o No absolute contraindications to obtaining a Pap smear are known.
o Relative contraindications include clinical circumstances in which sample
collection is difficult to obtain or difficult to interpret.

46. A 30-year-old obese white female comes to the physician with a six months history of oligomenorrhea. She
never had this problem before. She has no galactorrhea. She has gained significant weight over the past two
years despite a regular exercise program. She has also experienced hair loss during this time. She has had
regular Pap smears since the age of 20; pap smears have shown no abnormalities. She takes no medications. She
does not use tobacco, alcohol, or drugs. Her mother has a history of endometrial carcinoma and her
grandmother had a history of ovarian carcinoma. Physical examination shows male pattern baldness. Abdominal
and pelvic examination shows no abnormalities. A urine pregnancy test is negative. Serum prolactin level and
thyroid function tests are normal. Which of the following is the most appropriate next step in management?

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a. Screening mammogram
b. Oral glucose tolerance test ( PCOS )
c. CA- 125 levels, annually
d. Diagnostic laparoscopy
e. Iron studies
47. 40 years old female menorrhagia for 6 months, IUCD 18 months, she had CIN 1 which successfully treated; Pap
done 1 year bak was normal next (contro)
a. IUCD removal
b. OCP
c. Hysteroscopy and D&C
d. Pap smear
IUD removal should be performed at any time secondary to patient request. The most common
reasons cited by patients requesting IUD removal are side effects, including bleeding, pain, or
infection (45%); this is followed by device-related issues (32%), fears or misconceptions (12.6%), and
desire for current pregnancy (9.7%). [13] Current literature suggests that many of these requests for
removal, particularly those requested secondary to side effects and fears or misconceptions may be
prevented by thorough preinsertion counseling regarding expectations with IUD insertion and
continued use. [14, 15]

Mild pain with insertion is common, and some women continue to experience cramping pain for
days to weeks following insertion. Severe pain is uncommon and is cause for prompt evaluation and,
possibly, IUD removal. Patients who present requesting IUD removal secondary to unscheduled
bleeding, amenorrhea, or pain should have a history and physical examination performed. They
should be counseled that these effects maybe an expected outcome with IUD use. A urine pregnancy
test should also be performed. If the patient feels the side effects are not acceptable to her despite
counseling, or laboratory or examination results are concerning for malposition of IUD or pregnancy,
then the IUD should be removed.

Notably, presence of newly diagnosed gonorrhea or chlamydia infection is not an indication for IUD
removal. [16, 17, 18] The American College of Obstetricians and Gynecologists (ACOG) recommends
a preinsertion physical examination to evaluate for signs of cervicitis and screening tests for
gonorrhea or chlamydia in high-risk women. If cervicitis is suspected based on physical examination,
IUD insertion should be delayed until after treatment. Otherwise, screening may be performed and
the IUD inserted on the same day.

If this screen returns positive for gonorrhea or chlamydia, the patient can be treated with the IUD in
place. Concern in this setting is for ascending genital tract infection or pelvic inflammatory disease
(PID) and related sequelae. The risk for PID related to IUD insertion is greatest within the first 20
days after insertion, indicating that the likely mechanism of infection is contamination of upper
genital tract from infection present at the time of insertion. [19, 20]

This underscores the need for screening in high-risk women. The risk for PID in women with a
sexually transmitted infection at time of insertion is higher than in women without infection at the
time of insertion; however the overall risk is still low, around 5%. [21] Although placing an IUD is
contraindicated in a patient with PID, if they acquire PID with an IUD in place treating without
removing the IUD is safe. [17, 18] In this situation, patients should be followed closely, and the IUD
should be removed if appropriate clinical improvement does not occur. IUDs should be removed in
patients with pelvic tuberculosis. [17, 18

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Notably, presence of newly diagnosed gonorrhea or chlamydia infection is not an indication for IUD
removal. [16, 17, 18] The American College of Obstetricians and Gynecologists (ACOG) recommends
a preinsertion physical examination to evaluate for signs of cervicitis and screening tests for
gonorrhea or chlamydia in high-risk women. If cervicitis is suspected based on physical examination,
IUD insertion should be delayed until after treatment. Otherwise, screening may be performed and the IUD
inserted on the same day.

48. 15. CIN stage II, upper border of lesion not seen? What to do next?
A – Large Loop Excision of the Transformation Zone of the cervix
B – Radiotherapy
C- Chemotherapy
D- cold knife conization/biopsy
E- hysterectomy

Source. WHO
https://screening.iarc.fr/colpochap.php?lang=1&chap=11.php

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49. a 34 year old woman has her PAP smear and it shows a definite CIN I , her last PAP 2 years ago was normal, wts
the next best step ?
a. repeat PAP after 1 year FOR 2 YRS IF NORMAL THEN 2YRLY
b. do colposcopy
c. do cone biopsy
d. refer to gynacologist
e. repeat PAP in 2 years (jm 1092)

50. A mother brings her two year old child who has genital warts. The mother had CIN 1 lesion 3 years ago. What
could be a possible cause for the warts in the child now
A. Swimming in the river
B. Sexual abuse
C. Acquired during birth through infected birth canal

51. 55. A pregnant woman with CIN 3 lesion wht will u do

A. Cone biopsy
B. colposcopy
C. Observe
D. LEEP

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52. What is the best way to prevent cervical cancer in Australia

a. increase colposcopic clinic and Rx CIN I
b. cervical smear more available
c. develop a vaccine against human papilloma virus(Gardasil vaccine)
d. definitely vaccines are primary prevention whereas Pap smear is secondary.

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53. Most common cause of post coital bleeding in 20

year old female?
A) CIN
B) Endometrial Cancer
C)Atrophic vaginitis
D) Cervical ectropion
54. 37 ys old lady has Pap smear +ve with lower CIN 1
last 2 pap were -ve next step ?
a. Colposcopy
b. Repeat pap in 1 yr
c. Repeat pap in 2 ys

55. 37 years old lady with CIN-1 on PAP smear, her last
smear was negative but 4 years back genital warts history what to do (contro)
A) do nothing
B) Colposcopy
C) Cone biopsy
D) hysterectomy
E) LEEP
56. 45 yr old lady complains of irregular menstrual bleeding. She has been treated for CIN-II previously and a Pap
smear done 6 months ago was found normal. WOF is the most appropriate investigation for her?
a. Colposcopy
b. USG to detect endometrial thickness CORRECT
c. Cone biopsy
d. Endometrial curettage (endometrial ca ) IF MORE THEN 35 TUS, IF
e. Repeat Pap smear

57. 50 yr old woman,bleeding after menopause,is taking warfarin drugs.This is least likely with:
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a. A.CIN 3
b. B.Cervical carcinoma
c. C.Endometrial carcinoma
d. D.Vaginal atrophy
e. E.Anovulatory cycles

woman is menopausal . The anovulatory cycle is a menstrual cycle characterized by varying degrees of
menstrual intervals and the absence of ovulation and a luteal phase. In the absence of ovulation, there will
be infertility. here woman is menopausal means 1 to 2 yr passed from last menstrual cycle so should be E

58. scenario of women has heavy bleeding every cycle for 6 months...e iud for 18 months...her husband will travel
for 6 months for working another place without her...her last pap was cin 1 from 2 years and treated by ablation
well...next now
A.endocerv pap
B.exocerv pap
C.urine midstream collect
Remove iud
E.d n c
59. A 45 yr old lady complains of irregular menstrual bleeding. She has been treated for CIN-II previously and a Pap
smear done 6 months ago was found normal. WOF is the most appropriate investigation for her?
a. Colposcopy
b. USG to detect endometrial thickness
c. Cone biopsy
d. Endometrial curettage — if old person
e. Repeat Pap smear
If hpv normal but unexplained bleeding we refer dor colpo regardless of result. Co test
indicated. Hpv + dx LBC + REFERRAL FOR APPRopriate Ix. Jm 1101

60. A pregnant woman with CIN 3 lesion wht will u do

a. Cone biopsy
b. Loop excision under colposcopy
c. Observe
61. 25 yr nulliparous, 6 weeks amenorrhoea, home pregnancy test positive, presented with bleeding PV and
abdominal pain. What investigation need to be done?
a. Serial b HCG
b. Urine pregnancy test
c. Serum b hcg level
d. USG

62. A 36 year old woman with 3 children and BTL done, presents with some vaginal bleeds after intercourse. PAP
smear shows a CIN 3, her last PAP 2 years ago was normal. What is next in management?
a. Excision biopsy
b. Repeat Pap smear
c. Hysterectomy
d. Hysteriscopy and biopsy
e. Cone biopsy
llj 312
https://emedicine.medscape.com/article/1998067-overview#a1

An alternative method of treatment is large loop excision of the transformation zone (LLETZ), with ball
cautery to the exposed area of the cervix if needed to achieve haemostasis.

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The advantage is that the tissue can be examined histologically to exclude invasive cancer, particularly if
the suspect areas extend up the cervical canal and their upper limit cannot be identified by
colposcopic inspection. The whole transformation zone and some of the cervical canal area is
excised. If the procedure is performed by an experienced gynecologist there appears to be no
adverse effect on the duration of a subsequent pregnancy.
If the upper limit of abnormality cannot be adequately visualized then a cone biopsy is indicated

63. a woman her age 24 years old came to you after 12 days of postpartum she is asking you about suitble cocp for
her.as she is planning to get pregnant again next year .what is your advice for her
a. give her cocp
b. give low dose of pop
c. mirena
d. .don’t remember

64. 24 yr female with new sex partner.pap was normal 2 months back.now came with bleeding on 2 occasion within
1 week after sex.wats most appropriate-
a. repeat pap
b.urine pcr for chlmadia
c.hpv identification from cervix

65. 18 years old girl come to clinic for HPV vaccination. Her Pap test last 6 months ago is normal. She has regular
three sexual partners. What will you recommend for her?
A. Do Pap test now
B. Give HPVvaccine as she request
C. Tell her that HPVvaccine is not effective for her
D. Check STD screenings and then give HPVvaccine
B or D???

66. 28 yr female postcoital bleeding on two separate occasions... Pap smear normal 2 months ago...what next
a. Hpv serology
b. Chlamydia pcr
c. Pap smear
d. Thin film pap smear
e. Repeat pap smear

67. Pregnant lady at 28 weeks of POA comes and ask for HPV vaccination
a. need to do PAP test before vaccination
b. Need to check for antibody levels
c. HPV is contraindicated in pregnancy

68. 25 year old on OCP with post coital bleeding, last pap 18 months ago was normal. what next
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a. Assure
b. Colposcopy
c. Repeat Pap
d. Do Thin Prep
e. Check for HPV. JM-1140

69. 18 yr grl started getting a boyfriend, goin to hav sexual course soon, h/o some ovarian cancer in 2nd degree
relatives.(very complicated question). . wht to do
a. -start regular screening
b. -wait till 2 yrs
c. -give hpv
d. -talk with partner abt safe sex
70. 3…lady had hpv warts on vulva .treatment asked (contro)
a. Topical imiquimod 5%
b. Topical podophyllotoxin 0.5%
c. Diathermy

Jm 1269

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Cream is best used in perianal area, introital area and under the foreskin.

71. 4…16 years old girl comes to you asking for HPV vaccine. She heard about it on TV. What will you do?
a. Ask her to come when she is sexually active
b. Take consent from parents
c. Give vacvine
d. Give ocp and vaccine

72. ….6 weeks amenorrhoea with HGSIL.Next step?

a. Colposcopy
b. Termination of pregnancy
c. HPV serology
74. 25 year old lady came for her regular Pap smear previous all are negative this one revealed LSIL and you ordered
a colposcopy. She asks about HPV
vaccine.. what is the most suitable
advise
Wait for result of colposcopy
a. Give vaccine now
b. She should receive it only if HSIL
c. No need for vaccine

indication for GARDASIL 9

GARDASIL 9 is a vaccine indicated in

females 9 through 45 years of age for
the prevention of cervical, vulvar,
vaginal, and anal cancers caused by
human papillomavirus (HPV) Types 16,
18, 31, 33, 45, 52, and 58; precancerous
or dysplastic lesions caused by HPV
Types 6, 11, 16, 18, 31, 33, 45, 52, and 58; and genital warts caused by HPV Types 6 and 11.

75. 20 year old came for HPV examination ( pap smear). She is sexually active. On examination, yellowish exudates
obstructing the endocervical space. What best next?
a. do pap smear as requested
b. tell her it is not beneficial for her age
c. treat infection and perform pap smear after 3 months

76. A young pregnant lady is complaining of a recurrence vaginal condylomata acumanata (genital wart). She has
been treated with a liquid nitrogen,but has unsuccessfully. What is the next management?
a. give HPV vaccine now
b. surgical removing
c. apply again nitrogen
d. electrocauterisation

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77. How would you decide about HPV vaccine for a 9-year-
boy, a 12-year-girl and a 27-year-old woman who had
warts last year?
a. give vaccine to all
b. vaccine only to 9 and 12 (FEMALE 9-25YR BOY
9-18) (9-26 years)
c. vaccine only to 27years
d. vaccine only 12years
e. vaccine only girls

78. 37 yr old female her pap shows CINIwhat is the next step
in management ?
a. repeat after 6 mo …… à without 2-3 y NL pap
b. 😎 rpeat after 1 year…… à with 2-3y NL pap
c. colposcopy
d. D)cone biopsy now
e. E) HPV dna test now

79. Q) Drug of choice for endometriosis treatment (contro)

a) COC pills JM 1139[1][KM2]

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progesterone -- wants to maintain fertlity and danazol near menopausal age where pt family is completed
b) Progesterone pills
c) Danazol
d) Leuprolide (GnRH)
e) Estrogen

80. the woman with pre-menstrual symptoms affecting her marriage and daily life. husband also annoyed.but she
can go out and enjoy with friends.whats the Rx?
A sertraline—if low bleed
B evening primrose oil
C interpersonal
D COC pill without pill free interval— if heavy bleeding
Jm 1158
81. A 6 week pregnant woman had an induction of abortion following a H. mole. Regarding management which is
correct?
A Monthly follow up with Chest X-ray.
B Advice hysterectomy.
C COC till Beta HCG becomes normal.
D Weekly follow up with HCG.
E Weekly U/S.
82. A lady with BP 150/90 and smoker (I think also obese), on COC for 5 or 8 years came for renewal of
contraception prescription. You tell her it’s time to stop coc. She refuse to use another method of contraception
that works for her and her partner and she’s determine to avoid pregnancy
a. POP
b. Mirena
c. COC
83. 48 year old woman.complains of heavy menstrual bleeding for last 4 months. She underwent a hysteroscopy
and D&C but the symptoms did not subside. She looks pale and Her hemoglobin is 8.5 g/dl. What is the most
appropriate management in this case?
A-oral tranexamic acid during the period
B-northisterone from 15-25 days of cycle
C-mirena
D-implanon
E-COC
Jm 1138

84. Mentally challenged girl brought by mother asking for contraception trial of OCP didn’t work well options had
a. mirena ,
b. implanon,
c. ablation,
d. coc.

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85. 30 yr old lady came after delivery of her baby, wants contraception, she is breast feeding baby,wants to
concieve in 12 month time, asking which contraception to suggest
a. pop
b. coc
c. iud
d. implano
86. Risk factor of Ca endometrium
a. Smoking
b. Cervical dysplasia
c. Obesity
d. COC pills (1141)

87. 16yrs girl need contraception advice, mother & sister both has DVT, what is the most appropriate advice?
a. start low dose coc
b. thrombophilia screening first then decide
c. start pop (norethisterone or levonorgestrel best )

Factor V Leiden and prothrombin variant genetic testing is only available on the Medicare Benefits
Schedule (MBS) if the patient has a: personal history of VTE
B: family histroy of a diagnosed inherited thrombophilic condition

88. Young lady with 2ry amenorrhea for two years all her labs are normal except high FSH. u/s show no abnormality
in uterus or ovaries , asking treatment ?(premature ovarian failure)
A-COC
B- HRT

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Ref:
racgp

89. In relation to molar pregnancy which of the following statement is not correct
a. it is associated with ovarian
cancer
b. iucd are C/I until HCG drops to
normal
c. -COC is C/I for at least six
months
d. oxytocin infusion should be
delayed until after the uterus is
emptied
e. there is increased risk of
malignancy in women over 40
years

Weekly serum (or urine) hCG until zero

(usually takes 8–12 weeks), then
monthly for 12 months.

Avoid pregnancy for 12 months after hCG levels normal.

The oral contraceptive pill is appropriate

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90. Women who is on Rifampicin for Pulmonary TB came to GP clinic for contraception . After counseling pros and
cons, she still asked for hormonal contraception. what to give?
a. OCP
b. 😎 Mini pill
c. Pill
d. COC containing 35 mg of EE
e. COC containing 50 mg of EE ( increase dose ) ñ rifampicine enzyme inducer

91. 1)Young lady with secondary amenorrhoea for 2 years .All her labs are normal.US shows no
abnormalities.Diagnosis?(incomplete stem)
a. Idiopathic Hypothalamic pituitary axis dysfunction
b. Ovarian failure.
2)Exact same question with raised FSH asking management?
c. COC
d. HRT
92. Secondary amenorrhea woman 2 years Lh fsh above normal. estroidal low.prolactin 250 .Not interested in
concieving.
a. Pop
b. Coc(young girl)
c. Manoposal hormone
93. Patient had history of focal migraine. Now came for contraception. Which one is best.
a. Coc
b. Implanon
c. Condom
d. Mirena
94. Q39: A woman comes to u she is 38 years old for contraception having heavy menstrual bleeding ,shedon’t want
more children whtull give her
a.coc
b.minera
c.implanon
95. 25 y/o female with no menstruation for 2 years, high FSH and LH, low oestrogen, USG shows 2-3 cysts in the
ovaries, she’s NOT sexually active and doesn’t want to get pregnant, how to manage:
a.HRT
b.Low dose POP
c.COC pills pg

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96. 35 F cough fever 38 chest pain on coughing crepts on rt side . She is on coc and travelled from england 2 days
back whats most appropriate next inv
a. Xray
b. CTPA
c. no D dimer

97. An 80 years old lady come with large enterocele. It was giving discomfort but no urinary and bowel symptoms..
n no bleeding or pain.. some more history features to suggest she’s not fit for surgery I think.. asked
management..
A. Pelvic floor exercise
B. No treatment needed..
C. Vaginal repair
D. Ring pessary

By elimination - the prolapse is large so no point doing exercises , she is not fit so repair not possible ,
she has discomfort so cant leave it like tat. Ring pessary is just insertion , not a surgery and would
relieve the discomfort

98. . Strong f/h of dvt and pt with factor v laiden def comes for contraception. What to give beside condom
Ocp
Pop
Spermicidal gel
transdermal estor patch...

99. Shelter woman contraception,

a. IM medroxyorogesterone?
b. Condom,
c. POP?
d. IUD should be there in option

100. 16 years girl came for contraception,stays either in women refugee camp or on road some times abuses socially
with her friend,what to give?
A,OCP
b.pops
C,condoms to prevent STI
101. .35 year old lady h/o DVT, had a child, want 5 year gap for next pg, what contraceptive method will be suitable.
a) . Merina
b) depot
c) POP
d) Norplant
102. 24yrs. old woman with secondary amenorrhea, normal BMI, FSH: 55, LH: 54, oestradiol: 77, Prolactin: normal, in
USG of ovaries: 3-4 cyst, all hormone elevated.if she is not interested in her sexual life and not want to conceive
what is the most appropriate treatment?
a. POP
b. menopause hormone therapy
c. OCP povarian failure fsh increased
d. d.. Metformin
e. Clomiphene
http://www.racgp.org.au/afp/2017/june/premature-ovarian-
insufficiency-in-general-practice-meeting-the-needs-of-
women/ (POF )

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103. 39. A woman came three days after abortion at 7 weeks gestation. She got pregnant bcz she missed several
contraceptive pills. No children before. She and her boyfriend dont want children for three years n want
contraception RIGHT FROM TODAY.
a. Condoms
b. IUD
c. Depo provera
d. POP
e. OCP
104. Female patient 43y had tubal ligation she has 3 children come with flushing.
a. Cyclic HRT perimanaupusal
b. Cocp
c. Pop
105. A 40yrs old woman on cocp for 8yeaes. She is a smoker and her BP is high. She doesn't want to get off pills.
What is your advise?
a. Stop pills and rely on condom
b. Copper IUD
c. Implanon
d. POP
106. Pop (plaster of paris) on child what will be indication to remove pop immediately
a. Pain
b. Nunmbness
c. Color change
107. Lady came with abortion due to missed pill now she doesn't want to concieve for three yrs wht to give
a. Cocp
b. Pop
c. Mirena incompliance
d. Depo
108. A 28 year old lady presenting with irregular menses, hot flushes, irritability and agitation. Her serum FSH and LH
levels are high, serum Prolactin level is normal. She doesn't want to conceive, what will be most appropriate to
prescribe?
a. COCP.
b. POP.
c. Menopausal hormone replacement therapy.
d. Fluoxetine.
e. Clonidine.
109. 38 year old woman with history of smoking and family history of breast and ovarian cancer.For combined
coc,what is the main contraindication?
a. Smoking
b. Family history of breast cancer
c. Family history of ovarian cancer
110. 1-Woman, 39-40 years, taking OCP for 15 years, now high BP and doctors suggests to stop OCP now. She
doesn’t want to change the pill which works for her for a long time. She doesn’t want to conceive.
a. POP-
b. B-Copper
c. C-IUCD
d. D-Implanon
111. 2- Old lady taking HRT for 5 years, now her menopausal symptoms (hot flushes and some others) are
completely cured and she’s fine otherwise. What’s your management?
a. continue HRT-
b. B-stop HRT /trial of ceasing
112. 3- Woman around 40-45 years having heavy painful menstrual loss. With anemia which was corrected with
iron therapy. Her D&C and hysteroscopy is normal. What to give?-
a. Mirena-
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b. B-copper
c. C-IUCD-
d. D-OCP-
e. E-implant

113. Couple come for fertility clinic,woman is BMI 32,acne , hirsuitism and olidomenorrhoea . most appropriate next
step to Dx investigation to this woman?
A.Pelvic US pcos
B.FSH
C.LH
D. testosterone (young and adolescent)
E.endometrial biopsy

According to Rotterdam criteria 2 of the following three should be present:

1) oligomenorrhea/infertility
2) hyperandrogenism either present clinically (hirsutism) or biochemically (free testosterone level increased)
3) multiple cysts in ovaries on u/s (10 or more)

114. Female 35 years of age obese she has normal regular cycle 5 days cycle no other disease husband 40 yrs of age
cannot conceive after 2 yrs trying previously had 2 childern what is initial (contro)
a. A)semen analysis
b. B)US abdomen subfirtility
c. C)check BMI

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115. new mother, dischargd 5days after delivery,wishes to breast feed for 12mnths,wants to conceive after
12mnths,cntracptive of choice
a. a)low dose pop (after 4 week)
b. b)low dose cocp
c. c)DMPA
d. d)mirena
e. e)iucd
116. Mother breast feeding for 6 weeks postpartum and want to conceive after 12 months.What to give?
a. Condoms
b. Levenorgestrel
c. iucd
d. Coc

117. 6 wk postpartum come for contraception. She is now on Breastfeeding & plan to give BF till 1 yr & want to
conceive immediately after she stopped contraception. .What to give ?
a. Cont. BF
b. OCP
c. POP
d. Levonogestrol IUD
e. Condoms

118. 89.female using 30mg ocp. presents with continuing painful periods. want to conceive after 12 to 15 months.
what’ll u advise?
a. coninue same ocp
b. pop injectable.
c. use 50mg ocp.
d. use condoms and nsaids or iud and nsaids

119. 52.Couple try to conceive last 12 mo. , female had all examinations normal , male SFA shows 35% motile(40
normal) %, 45% normal morphology(>20% normal forms) , count 19 *10^6(>20 million) , asking your advice?
a. spontaneous pregnancy could be occur in the next 12 mo
b. spontaneous pregnancy will not occur
c. advice them to do IVF
d. they need semenal donation

120. female with persistent dysmenorrhea, she’s on 30 ug microgenon, she wants to conceive in 12 months, what’s
the best management.
a. increase oestrogen dose to 50 ug
b. continue same regimen
c. condom and NSAIDs
d. mirena

121. Primigravida got abortion at 12 wks & want to conceive again. ask ur advice when to concieve??
a. she can start as soon as possible
b. take ocps for 12 monthes

**f you feel mentally, emotionally, and physically ready to get pregnant again, there’s no need to
wait. However, if you had any complications following your abortion or aren’t emotionally ready, it
may be wise to wait until you’re feeling better again…..healthline

122. Women had menorregia and endometriosis don't want to conceive for 5 years advice on contraception?
a. ocp or mirena

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123. A 28 year old lady presenting with irregular menses, hot flushes, irritability and agitation. Her serum FSH and LH
levels are high, serum Prolactin level is normal. She doesn't want to conceive, what will be most appropriate to
prescribe?
a. COCP.
b. POP.
c. Menopausal hormone replacement therapy.
d. Fluoxetine.
e. Clonidine.

124. a)Pregnancy with rheumatoid arthritis ...How to treat the patient? stop mtx continue other drug
125. b) Also what if the patient with RA trying to conceive ?
Answers are present in the following slide..

**Disease-modifying anti-rheumatic drugs (DMARDs) vary widely according to their safety in pregnancy.
Sulfasalazine is considered a pregnancy category B drug. ... Methotrexate should be discontinued at least three
months prior to becoming pregnancy and leflunomide should be avoided for two years before pregnancy.

126. A pt was on resperidone consta has amennorhea from one yr want to conceive labs were given lh was normal
fsh low tsh low normal range prolactin raised around 1465. what is the reason?
a. pituitary microadenoma
b. hypo pituitary dysfunction
c. pri hypothyroidism
d. resperidone

A or D??

127. Patient with history of orchidopexy and corrected with surgery want to conceive. Semen analysis count one
million with reduced motility.A.serum testosterone B.FSH LH

128. couple trying to conceive. Female everything normal. Male azoospermia and small testes of 3ml size. Cause
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a. Gonadotrphin deficeincy
b. Pituitary adenoma
c. Obstruction in vas deference
d. Klienfelter xd

129. Scenario of POF and the woman does not want to conceive. Management?
a. OCP
b. HRT

130. . Pts 41 yr old, was trying to conceive form last 2 year, after getting pregnant, there was spontaneous abortion
at 12 week. Now whats next.
a.. tell her to conceive as soon as possible
b.. ivf
c.egg donation

131. patient with depression , had treatment with sertraline and controlled.Now she is going to conceive and anxious
about getting relapse . Come to u if there is any other medication other than sertraline which is more
appropriate in pregnancy?
A.recommence sertraline
B.add olanzapine
C.refer to psychotic counselling
D.start both

132. pt conceived after IvF at is at 22 week gestation , preprom, going to deliver in one hour you are a gp at rural
area. Pts husband is anxious wt of baby is 270 g what is your next step in management of this pt?
a. arrange a neonatal retrivalfor successful referral after delivery
b. no active resuscitation
c. refer her to tertiary care
d. arrange for active resuscitation
e. conticosteroids

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133. 42 years female trying to conceive from 5 years, with family history of premature ovarian failure and she had
history of treated mild endometriosis and treated Chlamydia. What will affect her future fertility?(question just
written in this way):
A- Her age
B- Family history of POF
C- C- Endometriosis

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D- Chlamydia

134. A lady has history of PID and endometriosis of the uterosacral ligament surgery done 4 years ago and she had
chlamydia infection treated 2 years ago which of the following will lead to future infertility
Surgery
Chlamydia
PID
Endometriosis

135. Q.Couple wants to conceive.The MALE partner has rheumatoid arthritis for which he is taking methotrexate and
hydroxychloroquine.What is your advice?
a-stop metho but continue hydroxycloroquine
b-stop both and add adalimumab
c-stop hydroxyl,continue metho
d-continue current medication

It's safe for women to continue to use sulfasalazine when trying for a baby and during pregnancy. ...
Sulfasalazine can cause a fall in sperm count, leading to a temporary decrease in male fertility, but
must not be relied upon for contraception.

136. the woman with premenstrual symptoms affecting her marriage and daily life. she was worried tht it will affect
her marriage cos of loss of libido. but she can go out and enjoy
with friends.whats the best therapy option available ?
a. Psychotherapy (cbt) jm 1144
b. Relationship therapy.
c. Distress management IF PAROXETINE WILL BE
ANSWER
d. Sexual therapy

137. patient on ecitalopram for disturbed sleep now having

premenstrual symptoms. Irritated behaviour. Mx
A Increase ecitalopram
B add fuvoxamine PARTICULARLY OCD IN CHILD
C add olanzapine
D some TCA /
E resperidone?

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PREMENSTRUAL SYMPTOMS SERTRALINE, FLUXETINE PAROXITEN

138. Women came with infertility.has irregular period of avg 48days. Sex 3times weekly. Asking cause –
a. Anovulation
b. Endometriosis
c. Wrong time of intercourse

139. Suspecting endometriosis in a patient will reveal.

a. Uterosacral ligament densities
b. Tenderness on palpation of hypogastric area
c. Non tender abdomen
d. Adnexal tenderness
e. Normal pap smear
140. Endometriosis commonest site asked. Is it ovaries or fallopian tubes? or something else
#cause of dysmenorrhoea
a. Rertrovated UT
b. Adenomyosis 2nd cause
c. Endometriosis 1st cause
d. PID ( a major cause)

141. Pop safe to use a contraceptive method in all of the following situations except?
a. Previous pulmonary embolism
b. Endometriosis
c. Ovarian cysts
d. Hypertension
e. Biliary tract disease

By using mini pills, functional but asymptomatic ovarian cysts sometime develop.They usually
disappear spontaneously and surgery is not required.It is advised not to use progesterone only pills if a
female already has ovarian cysts.Mini-pills are safe to use in patients with previous history of
thromboembolism,endometriosis,hypertension and biliary tract disease. Other contraindications to use
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of the mini-pill include malabsorption syndromes, previous sex steroid-dependent cancers(breast
cancer), undiagnosed vaginal bleeding, previous ectopic pregnancy and severe active liver disease.

142. young girl has dysmenorrhea , typical scenario of endometriosis. Next inv?
a. Ultrasound
b. TVS
c. Laparoscopy—— gold-standard

143. Endometrial hyperplasia is most likely found in which of the following patients?
a.An ovulating woman
b.Obese diabetic woman more oestrogen
c.A woman on cyclic combined oral contraceptive pills
d.A woman on depo provera for endometriosis
e.A woman with intrauterine device

144. Young couple with infertility. Women has mild pain on sex.male semen analysis normal.women has one tubal
block on hystosalpingogram. What is the cause of infertility?
a. Tubal block
b. Endometriosis tissue any site

145. a 45 year old woman, a case of 2yr infertility , her children are 14, 15 and 20 years old, h/o endometriosis in
uterine lig , previous h/o pelvic operation, mid cycle sex. Which of the following is the cause of her infertility ,
partner never fathered a child.
a. increased maternal age
b. sperm abnormality
c. ovulation problems
d. endometriosis
e. tubal pathology

146. A 33 years old woman have been diagnosed with endometriosis, she is very worry and asked what is the least
common site for endometriosi
a. Ovary
b. Cervix
c. Uterine wall
d. Pouch of Douglas
e. Bladder
The following sites are, in descending order, the most common sites of involvement found during
laparoscopy:
o Ovaries
o Posterior cul-de-sac
o Broad ligament
o Uterosacral ligament
o Rectosigmoid colon
o Bladder
o Distal ureter

147. 17. 24 female amenorrhea 12 months, pain during sex, on examination uterus size normal, all examin. normal,
what will you suspect? (faulty ques)
a. Pregnancy
b. Endometriosis
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148. scenario of pain seems to be mid cyclic lasting for 3 days and happened from 4 weeks before pain cause:
a. ovulation
b. endometriosis

149. Q4) Which test is most sensitive in detecting pelvic inflammatory disease (PID) ?
a. Cell culture
b. Endocervical biopsy
c. Enzyme immunoassay
d. Microscopy
e. Nucleic acid amplification test

150. A lady came 6 days before for routine PAP smear. After that first 4 days she had no problem. Last 2 days she is
having lower abdominal pain, tenderness, fever. What to do for diagnosis?
a. High vaginal swab
b. Low vaginal swab
c. Blood culture
d. Endocervical swab

151. 37yr old woman with secondary amenorrhea normal BMI ,FHS- high OESTRADIOL low prolactin normal .USG-3
to 4 cyst in ovary. Doesn’r want to conceive and is not sexually active, What is the best treatment
A)POP
B)Menopause hormone therapy
C)OCP
D)Metformin

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152. 21 year old girl with bmi 15 came with amenorrhea n infertility progesteron test negative wt will help her to
conceive? ?
a. Correct her bmi will lead to conceive
b. Ivf
c. ICSI

our whole morning in one post...

Crack AMC - HRT and Menopause
================================
Menopause ==> age of 45 to 55 years
Symptoms? ==> Hot flushes, night sweats, vaginal dryness, mood swings, sleep disturbance and loss of self-
confidence.
Onset of symptoms? ==> often begin in perimenopausal period in women who still have a regular bleeding
pattern or in women with menstrual cycle disturbance or amenorrhoea.
Most effective treatment for the vasomotor symptoms of menopause ==> HRT
What’s HRT? ==> regimens contain oestrogen Dominantly to treat menopausal symptoms BUT would NOT
prevent Pregnancy (OCP contains Progestrone Dominantly and in high dose to prevent pregnancy)
===========
Advantages and Disadvantages of HRT? ===>
1- Relieving postmenopausal symptoms
2- Decreasing Osteoporosis Risks
3- Decreasing CV risks
4- Increasing Risk of Breast cancer (if used > 5 years)
5- DECREASES: LDL (estrogen effect)- (But OCP increases LDL Progesterone effect)
========
Types?
• cyclical (oestrogen daily and progestin for 10 to 14 days of the month)
• Continuous (oestrogen and progestin throughout the month).
• unopposed Oestrogen only HRT (continuous daily oestrogen without progestin) used only if no Uterus
(hysterectomy)
==========
MCQs about which types of HRT used to treat Hot Flushes?
1- If premenaupausal ? ==> Cyclical HRT
2- If < 24 months amenohrea? ==> Cyclical HRT
3- If ≥ 24 months amenohrea? ==> Continuous HRT
4- If with Endometriosis? ==> Continuous HRT Or OCP. Mirena best
5- If POF don’t want to conceive? ==> OCP
6- If with Liver Diseases or Gall stones? ==> Transdermal
7- If Obese? ==> Transdermal
8- If Varicosity? ==> Transdermal or Tibolone
9- Women with a history of VTE? ==> Transdermal
10- If patient with Hysterectomy? ==> unopposed Oestrogen only HRT (continuous daily oestrogen without
progestin) OR Tibolone
11- If patient with decreased libido (and NO uterus)? ==> Tibolone
12- With urinary frequency, dysuria? ==> Vaginal Oestrogen
13- With Sexual difficulties, Dyspareunia, vaginal atrophy? ==> Vaginal Oestrogen
14- If Vaginal Atrophy (Dryness) with Hx of Breast Cancer? ==> non-hormonal (eg Rep-lens, Sylk) before
using oestrogen intravaginally.
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NB: all Women with an intact uterus that will use transdermal oestrogen as above SHOULD ADD + cyclical
or continuous progestin
===========
Does we use it in treating Chronic disease as Osteoporosis ? ==> Nooo (even if has effective properties)
So MCQ of Osteoporosis prevention or Treatment ?===> Alendronate NOT HRT
===========
Don’t use HRT in uncontrolled HTN or PE/DVT or if > 60 years or in Oestrogen dependent cancer or in Liver
Diseases
Next? ==> Venlafaxine then SSRIs then Clonidine or Gabapentin as following:
1- 1st line non Hormonal? ==> SSRIs (e.g: Paroxtine)
2- If Faster action? ==> SSRIs (works in one week, in contrast to its action for depression that needs 4-6
weeks)
3- If hypertensive? ==> Clonidine
4- If main problem is Insomnia? ==> Clonidine
5- with Migraine? ==> Clonidine or Transdermal E&P
6- If with Depression? ==> SSRIs or Venlafaxine
7- If with Neuropathy? ==> Gabapentin
8- If Patient taking Tamoxifen for +ve HR breast cancer? ==> Clonidine
9- If After 5 years from HRT and flushes return back? ==> SSRIs or Clonidine
===========
1st symptoms to improve with HRT? ==> Vasomotor symptoms then Urogenital then Insomnia
Contraindication of Venlafaxine? ==> HTN, Electrolyte Imbalance and Heart Disease .. Next?==> Monitor BP
and tapered Cessation
Most common S/E of SSRIs ==> Dry mouth
S/E of Clonidine?==> dry mouth and drowsiness
============
How to Stop HRT? ((NEW recommendation)
tapering the dose was no better than stopping suddenly.
After 5 years Stop HRT no need for Tap-ring

Sexual health

153. A mother brought her 2 years old girl with history of blood stained vaginal discharge which regularly stained
the girl’s underwear. What would you do?
a. Parform Chlamydia and gonorrhea tests
b. Reassure the mother that is normal
c. Report to the child agency about sexual abuse
d. Foreign body
e. Crohn's disease

154. 80yr old lady has positive gonorrhea findings on pcr. She denied any sexual activities for up to ten years. What is
your next step of mgt?
A. Repeat test
B. Give im ceftriaxone single dose
C.Give IV penicillin
D. Refer for counselling about dx

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155. A 25 years old man is admitted to the hospital after sustaining head injuries in a motor vehicle accident.on his
2nd day in the hospital he shows you a sore in his penis that he developed a few days ago. He proudly admits to
numerous sexual encounters in the past 5 years and tells you that he has been tested for HIV every 6 months
and the last negative test only was about 3 months ago. He is otherwise healthy and not on any medication .he
denies any penile discharge in the past or present and no history of other STD . On phy.examination there in
painful Lymphadenopathy of the left groin region . On the distal penis there are 2 tender ragged ulcers that
appear punched out with surrounding Hyperemia.base of ulcer covered with purulent dirty exudate which bleed
easily during examination . This patient has most likely
a. Gonorrhoea ( discharge and prostitis)
Granuloma inguinale (small painess nodule)
b. Lymphogranuloma Venerum Chancroid is a bacterial sexually transmitted
c. Primary syphilitic chancre(painless ulcer) disease (STD) caused by infection with
d. Chancroid Haemophilus ducreyi. It is characterized by
painful necrotizing genital ulcers that may be
accompanied by inguinal lymphadenopathy. It
is a highly contagious but curable disease

Chancres are typically painless, whereas

chancroid are typically painful

chancres are typically single, whereas

chancroid are typically multiple..

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156. Women with menopause since 2yrs has bleeding 2 episodes what investigation next
A. Uterine US***
B. Hysteroscopy
C. Endometrial

157. An 18 yr old university student who had a suction curettage performed for an unwanted pregnancy which
occurred after a university party, present to u 4 days later with a temp of 38.4 degree
and a purulent vaginal discharge.which one of the following organisms is the most likely cause of her
symptoms?
a.mixed infection with clamydia trachomatis and vaginal pathogen
b.n.gonorrhoea
c.clamydia trachomatis alone
d.e coli alone
e.mycoplasma hominis alone

158. Female 69 yrs old wit c/os of vaginal discharge, pcr shows gonorrhea. PT said she has not had sex last few years .
Next?
A. IV ceftriaxone sgle dose
B. Repeat OCR
C. Give azithromycin
D. Hysteroscopy
E. Counselling her about treament

159. Young female after sex with new partner got soreness in vagina, dysuria n also discharge mild few
days,spontaneously resolved in a week and now asymptomatic came to u, cause?
• Chlamydia 1264
• Gonorrhoea
• HSV
• Candida

160. A young female sex worker present for normal check-up and on lab test you found she has gonorrhoea. Besides
treating her, what next will you do?
1. Trace contacts of her past one year
2. Ask her to avoid sex
3. Trace contacts of her for past 6 months
4. Trace contacts of her for past 2 months
5. Inform health department
Jm 1269

161. 69 yrs female with vaginal discharge PCR shows gonorrhea , pt. said she didn’t have any sexual activity last few
years , what is the best next ?
A) repeat PCR
B) give ceftriaxone single dose
C) Give azithromycine single dose
D) DO hysteroscopy
E) Counselling her about treatment

162. man complains of white discharge ,, culture show diplococci (he mentioned it but no microscopic pic) , dx ?
Gonorrhea – chlamydia
163. sexually active lady with foul smelling, greenish vaginal discharge , burning n itching. Most probable Dx? contro
a. Chlamydia
b. gardenilla
c. Candida
d. E.coli
e. Gonorrhoea if trichromonas option ..go for it I

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164. A lady has history of PID and endometriosis of
the uterosacral ligament surgery done 4 years
ago and she had chlamydia infection treated 2
years ago which of the following will lead to
future infertility
Surgery
Chlamydia
PID
Endometriosis

165. Indian student, 2 mths dysuria, hematuria, frequency. All urine test normal except RBCs and pus in urine.
Urine culture (-). Dx?
Cystoscopy. (Renal TB;next-cystoscopy to exclude bladder pathology best-renal biopsy)
Renal biopsy
Urogram
Repeat urinalysis
Chlamydia PCR

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166. woman with 3 sexual partner, last pap smear was 2 month ago and normal. Now coming for HPV vaccination,
what to do?
1. cervical swab for HPV
2. give vaccination
3. repeat pap smear
4. urine PCR for chlamydia

167. man with urethral discharge clear for 2 days asking investigation?
Urine re
Msu sample
First catch urine for chlamydia pcr
Urethral swab micro and culture

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168. Mother and daughter coming to your clinic for checkup and the daughter asked privately to be tested
for chlamydia ..you took a swab and the result was negative
Second day mother called and asked about the results of her daughter
a)You tell the mother that test for chlamydia was negative
b) You tell the mother that you will discuss the results of her daughter privately with her
c) Ask the mother to bring the daughter and come for meeting
d) You tell that you can not disclose the information

169. 52 year old woman to whom Pap test performed before 2 years and it was normal on examination she is healthy
woman with no evidence of family history. Apart from Pap smear. which is the most important screening test to
advise her at this age?
A-mammography
B-glaucoma screening
C-colonoscopy
D-chlamydia test
E-other non-relevant

170. 22 year old female presented through routine health examinations, her pap is normal and she has no history of
abnormal pap , she asked you about the main benefit of taking chlamydia test?
A-chlamydia is asymptomatic
B-infertility follows chlamydia infection
C-no need and advice safe sex

171. 32 year old female presented through

routine health examinations, her pap is
normal and she has no history of abnormal
pap , she asked you about the main benefit
of taking chlamydia test?
A-chlamydia is asymptomatic
B-infertility follows chlamydia infection
C-no need and advice safe sex

172. A young female sex worker present for

normal check-up and on lab test you found
she has gonorrhoea. Besides treating her,
what next will you do?
1. Trace contacts of her past one year
2. Ask her to avoid sex
3. Trace contacts of her for past 6 months
4. Trace contacts of her for past 2 months
5. Inform health department
Ref: racgp

173. Pregnant lady with measles presents within 24 hours of rash asking management options included
Do nothing
Administer immunoglobulin
Trace contacts
Termination of Pregnancy
found this
pregnant women might be at higher risk for severe measles and complications, intravenous IG (IGIV) should be
administered to pregnant women without evidence of measles immunity who have been exposed to measles.
People with severely compromised immune systems who are exposed to measles should receive IGIV regardless
of immunologic or vaccination status because they might not be protected by MMR vaccine

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http://emedicine.medscape.com/article/966220-treatment#d11

175. woman with post coital bleeding last pap normal 2 month.....advice pcr test***(chlamydia cervicitis)

176. 52 year old menopausal woman since 12 months, came with vaginal bleeding after 24 hours of having sex, her last pap
was normal , what’s the most propable diagnosis ??
a. Cancer endometrium
b. Cancer cervix (the most imp dx to eclude) jm 1129
c. Vaginal atrophy(most common)
d. Cervical polyp (young)

177. 25 year old on OCP with post coital bleeding, last pap 18 moths ago was normal What next

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a. Assure
b. Colposcopy
c. Repeat Pap
d. Do Thin Prep
e. Check for HPV
Cervical ectropion (or cervical eversion) is a condition in which the central (endocervical) columnar
epithelium protrudes out through the external os of the cervix and onto the vaginal portion of the
cervix, undergoes squamous metaplasia, and transforms to stratified squamous epithelium.[1]
Although not an abnormality, it is indistinguishable from early cervical cancer; therefore, further
diagnostic studies (e.g., Pap smear, biopsy) must be
performed for a differential diagnosis

178. Female with recurrent candidiasis 4 times in last 6 months.

Clotrimazole vaginal cream helped controlling the symptoms
last 3 times. What is the most appropriate next step?
a. Oral Nystatin
b. Oral Greisofulvin
c. Oral Ketoconazole
d. Oral Fluconazole****
e. Vaginal Nystatin

179. pregnant pt at 20 weeks with hsv infection on pcr. What is

treatment for this pt?
a. oral acyclovir****
b. iv acyclovir
c. oral famciclovir
d. topical antiviral

180. . A 50-year-old woman, who has recently been diagnosed with

hypertension, complains of pain in her knees. She feels tired
and her memory is poor. She has lost her appetite recently and
feels nauseated most of the time. Urinalysis is normal. Which is
the SINGLE MOST likely diagnosis?
A Chronic fatigue syndrome
B Chronic renal failure
C Coeliac disease
D Cushing’s syndrome
E Hyperparathyroidism***

181. A 70 year old lady with stress incontinence. Urodynamic studies done after Pelvic floor exercises what’s the best
management for her? (contro)

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a. Tension-free Vaginal Tape
b. Weighted cones in vagina —above 80
c. Burch's colposuspension
d. Local oestrogen cream
e. vaginal colposuspension

Line of management for stress incontinence

f. •Pelvic floor exercise (next)
g. •Weighted vaginal cones
h. •Burch colposuspension (gold standard/ best )

182. 68 years old lady with urinary incontinence on coughing and staining, she is obese with diet controlled DM. Her
urodynamic studies positive in low volume study. She has mild rectocele but no cystocele. She has been advised
to do pelvic floor exercise which she found to have some improvement but she feel socially embarrassed for
urinary incontinence. what would be your best next management?
a. weighted vaginal cones
b. weight reduction
c. colposuspension

183. An 85 year old lady with stress incontinence,whenever she laughs or sneezes presents with rectocele which is
reducible[KM3]. (not current problem)What is most important management in this patient after bladder exercise
has failed.
1.Weighted Vaginal cones
2.Imipramine
3.Surgery for rectocele
4.Bladder neck suspension surgery
5.Vaginal tape

184. 75 year old lady with severe incontinence. She manages to accidentally urinate 10 times during the day and cant make
it to the bathroom. She is annoyed by this. Urodynamic studies confirm detrusor instability. What is the best
treatment option?
a. Pelvic floor muscle exercise
b. Anticholinergic****
Jm 884 pg
185. Old woman with urgency and nocturia for a long time. Now having incontinence for like a month. She couldn't reach
the toilet downstairs. She also has bilateral knee OA. What is the best management for her?
a. Fluid restriction at night
b. Install a camode in her bedroom.
c. Oxybutynin**

186. A case of 45 y.o. woman having menorrhagia. was diagnosed of intramural fibroids, has enlarged uterus. What is the
management?

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a. low dose Oral contraceptive pill***
b. Oral oestrogen and progesterone hormone
replacement therapy.
c. norethisterone
d. Depo provera.

187. A lady lethargic anaemia .. mild icterus ... not a vegetarian no

menorrhagia .... macrocytosis n megaloblastic .. what is next
i think (pernicious Anemia)
A. red cell folate level (no menorrhagia)
B iron studies
C intrinsic factor antibodies *** best.
D vit b12 levels (less in vegetarians)next

Loss of appetite and weight loss can occur. Additional

signs are weakness, sore tongue, headaches, heart
palpitations, irritability, and behavioral disorders.[3]
In adults, anemia (macrocytic, megaloblastic
anemia) can be a sign of advanced folate deficiency.
• Situational
• Some situations that increase the need for
folate include the following:
• hemorrhage
• kidney dialysis
• liver disease
• malabsorption, including celiac disease and
fructose malabsorption
• pregnancy and lactation (breastfeeding)
• tobacco smoking
• alcohol consumption
• Medication

188. 32 yr old obese women with sec infertility BMI 32 FSH 2.2 LH 6.3 estradiol dec , TSH normal prolactin normal what you
advice next?
a) thyroid function test
b) endometrial sampling
c)ct abdomen
d) vaginal usg***

189. man with type 2 DM taking insulin complaints of severe night sweats . His present daily dosage is ISOPHANE 20 IU
(long acting) morning LISPRO 15 IU (not sure ) (short actinf) evening what changes will you make in his dosages?
So all options comprised of increase morning isophane dosage ,
reduce evening dosage of lispro****

190. A man with type 2 DM taking insulin complaints of severe night sweats. His present daily dosage is ISOPHANE
20IU morning LISPRO 15IU (not sure) evening what changes will you make in his dosages?
a. increase morning dosage of lispro
b. increase morning dosage of isophane
c. reduce evening dosage of lispro
d. reduce evening dosage of isophane

191. patient with DM , hba1c was 11 and FBs also raised asked cause .
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a. Metformin toxicity,
b. insulin resistance*** ,
c. insulin toxicity ,
d. renal failure

192. Women with secondary amenorrhea since 2yrs, BMI 23 well maintain goes to gym,periods previously regular and has
infertility too fsh 54, lh 55,prolactin 250 ,tsh 2.5 , estradiol 17 on us ovary has bilateral 2-3 cyst 40mm what's the
cause of infertility
a. Premature menopause
b. PCOS
c. Primary hypothyroidism
d. Prolactin secreting adenoma

193. Young girl with regular cycle.history of lower abdominal pain, bilateral cyst in ovaries 5cm and 6cm solid/cystic
appearance in usg no ascites dx?
a)mucinous cystadenoma
B)serous cystadenoma
c) corpus luteal cyst
d)germ cell tumor
e) dermoid cyst****

194. Female with hot flushes and disturbed sleep, she had breast cancer 5 years ago and treated with Chemo and
Radio , it was ER –ve , wut will u give her?
A) Paroxtine
B) Clonidine
C) Oestrogen
D) HRT

195. What's the diagnosis for 5 th Post op Day watery vaginal discharge with slight blood stain. Hysterectomy done
before -
(contro

)Vaginal cuff dehiscence

Vesico vaginal fistula
option missing==granulation tissue

196. 54 year old woman presents to your clinic with vaginal watery discharge with blood stained. She is 10 days post
op hysterectomy for fibroids and was subsequently discharged 4 days after a successful surgery. She has no
temperature and rest of exam is normal. What is your suspicion?
a. Granulation tissue
b. Vagina vault breakdown

197. 37 yrs. old woman with secondary amenorrhea, normal BMI, FSH: 55, LH: 54, estradiol: 77, Prolactin: normal, in
USG of ovaries: 3-4 cyst, she is sexually inactive and doesn’t want to conceive, what is the best treatment?
a. POP
b. menopause hormone therapy
c. OCP
d.. Metformin

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198. 16 year old female not menstruating yet comes to you because of abdominal pain every month for three days
for the last 6 months, her breasts started to develop 3 years ago , her secondary sexual characteristics are
normal and developed her weight and height are normal , no palpable abdominal mass vaginal examination is
impossible because she's still virgin what is the most probable Dx?
a. Imperforate hymen(with mass)
b. Turner syndrome
c. Premature ovarian failure
d. Delayed mullerian agenesis ( without mass)

199. 42 years female trying to conceive from 5 years, with family history of premature ovarian failure and she
had history of treated mild endometriosis and treated Chlamydia. What will affect her future
fertility?(question just written in this way):
A- Her age
B- Family history of POF
C- Endometriosis (PID thakle oita,otherwise endometriosis)
D- Chlamydia

200. Women 52 years taking HRT for 4 years for pre menopausal symptoms, but was having slight menstruation
regularly. She came to you today with amenorrhoea from last 6 months. What will you do?
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A.Continue same hrt. c. Stop hrt

201. A female with hot flushes and disturbed sleep, she had breast cancer 5 yr ago and treated with chemo nd was
ER –ve what is your appropriate management for this patient?
a. paroxetine
B) estrogen
C)HRT
D) clonidine
202. the woman with premenstrual symptoms affecting her marriage and daily life. she was worried that it will affect
her marriage cos of loss of libido. but she can go out and enjoy with friends.whats the best therapy option
available ?
a. Psychotherapy
b. Relationship therapy.
c. Distress management
d. Sexual therapy

203. Woman post hysterectomy ask for HRT what to give estrogen only or estrogen plus 12 days progesterone

204. Women has 5 min contractions at 26 wk gastation her examination is normal oss closed and no fluid in addition
to steroid what should be given,Paracetamol or antibiotics. (contro)
Ans: tocolytic

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205. pregnant women diagnosed with hepatitis C what investigations should be done further, liver enzymes or PCR.
protocol:ELIZA (IG,IM)>RNA PCR(to see viral load if IGM is positive) >liver marker

206. Then young lady did some investigation about chlamydia all result was negative ,but still she is worried what will
u advice? I was confused about 2 option one was u don’t have to worry until your bf has any penile discharge
and another was u can say don’t worry as all are negative, there was no option for asymptotic

207. 40yrs old woman on cocp for 8yr . She is a smoker and her BP is high. She doesn't want to get off pills. What is
your advise?
a. Stop pills and rely on condom
b. Copper IUD
c. Implanon
d. POP

208. 20 years old pregnant lady of 32wks ,h/o yellow vaginal dischage. has never had a pap smear before.what is
your management
A.antibiotic(
B.reassure
C.do the pap smear now
D.do pap smear after delivery
E.do pap smear close to the labour

209. A 53 year old woman has not been screened for the past 5 years. Sister diagnosed with colon cancer at 63 years.
Father and mother died of heart disease at 65 years. What screening will you do for her now?
a. Colonoscopy
b. stress ECG
c. Pap smear
d. Ultrasound breast exam

210. Girl came to clinic Cx just one genital ulcer.u did syphilis & other screening. she didn’t come to clinic for
2wk.now come for test result.Her viral culture is all negative but RPR test is 1:64 positive(syphilis). how will u do
for further Mx???
A.test for other STD
B.contact tracing
C.notify local public health
D.advice her to use condom
E.HIV testing
If the RPR is also positive (especially at > 1:8) and there
is
no history of treatment for syphilis, a diagnosis of
syphilis is made and the patient should receive
treatment.

211. Girl came to clinic complaint of just one genital ulcer, you
did syphilis & viral culture. She didn’t come to clinic for 2wk.
Now come for test result. Her viral culture is negative but
RPR test is 1:64 positive. How will u do for further Mx???
A. Test for other STD
B. Contact tracing
C. Notify local public health

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D. Advise her to use condom
E.IM penicillin

212. Excised BCC send to patho lab.what is the most prognosis value for this??
a. thickness of the lesion
b. no cancer cell all around the margin
c. inflammation of the lesion
d. amt Solar keratosis ????

213. A 33yo man presents with an itchy scaly annular rash on his thigh after a walk in the park. Which of the
following drugs will treat his condition?
a. Erythromycin
b. Doxycycline
c. Penicillin
d. Amoxicillin
dx: lyme disease

214. Pregnant female with genital herpes how to differentiate primary from recurrent herpes simplex:
a HSV Igm now
b.HSV specific serology now ( specific serology is done to identify Type one or 2 infection
c.PCR

215. 12 week old pregnant lady was brought to the emergency department with vomiting, abdominal pain and
severe bleeding for the past 4 hours. She also had 2 fainting attacks. Her blood pressure is 80/40.She was
normal till before this episode and USG at 11 weeks showed normal nuchal translucency. Which is the most
likely diagnosis?
a. Incomplete abortion
b. Complete abortion
c. Abruption placenta
d. Ectopic pregnancy rupture
e. Hydatidiform mole
As normal USG at 11wks so not ectopic or hydatidiform mole
AN-70

216. hep C how to dx in baby......

a.anti HCV at 18 months
b.Hep c PCR at birth
c anti HCV at birth
JM:
Hepatitis C
o HCV screening is recommended at the first antenatal visit for those from significant risk
groups. If positive, the transmission rate to fetus is 5% and much higher
o if there is maternal infection during pregnancy. 4
o Evidence is unclear whether HCV transmission occurs during breastfeeding. Screen
infants at risk at
o 12 months and treat positive cases accordingly under specialist care.
o HCV RNA PCR at 12-18months or ANTI HCV after 18 months.
o anti-HCV antibodies in the baby may be due to tranplacental maternal
antibodies.Antibody testing should be delayed up to 18 months post delivery.

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(ii)HCV RNA testing could be used.Undetectable levels(less than 100 copies/ml) at 3
months makes vertical transmission unlikely

217. To see prevalence of HCV in child born to HCV positive mother, which of the following can be used?
A. HCV PCR in neonate
B. HCV Ab just after birth
C. HCV AB at 18 month
D. HCV PCR in mother
218. . You want to know the Hep C in newborn baby born to Hep C positive mother. How to investigate?
A. Antibody of baby at birth
B. Antibody of baby at 18 months
C. Antibody of baby at 12 months ?
D. HCV PCR of mother

219. Pregnant HCV positive came in first trimester. Best advice to decrease vertical transmission
a. C/S at term
b. avoid scalp electrode
c. formula feeding of newborn

220. Q185302-Pregnant lady with Hepatitis C comes to you for advice. Which will reduce the risk of transmission to
her baby?
a. C section
b. Avoid Breastfeeding
c. fetal heart rate monitoring with scalp clip is avoided (exact word)
d. Baby should be screened between 12 and 18 years of age to determine whether they have been infected
e. Coexistance of HIV has no effect on HCV transmission

221. Lady primigravida HCV +ve comes to discuss risk to

fetus during delivery. What is the most important thing
to tell her about vertical transmission?
A-Vaginal delivery is contraindicated
B- She should not breastfeed her baby
C-delivery should be by caesarean section
D- Fetus will be checked for HCV at birth
E- Fetal scalp sampling should be avoided

222. A 25 years old primigravida presents for results of

antenatal screening tests. She is a drug injector in the
past. But has not get any drugs in the last 5 years. Her
results show Hep C Ab +ve, Hep C RNA –ve, HIV –ve,
Hep B Ab +ve. Which of the following will reduce the
risk of transmission of Hep C to her baby?
a. LSCS at term
b. Formula feeding of newborn
c. Avoid pH monitoring of fetal scalp
electrodes
d. Anti-retro viral therapy

Hep C RNA NEGATIVE Means spontaneous clearance if do nothing in option mark that! Bt if only hep c ab
positive thn avoid fetal scalp ph
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223. 24yrs old with dysmenorrhoea and menorrhagia asked to do investigation but she insist she wants medication
a. mefenamic acid
b. tranexamic acid
c. ocp
d. iucd

for ovulatory woman-

The agent of first choice is usually mefenamic acid, which reduces blood loss by 20–25%
as well as helping dysmenorrhoea. Bt tranexamic only for menorrhagia (50%)
JM-1126 AN-120

224. Young woman comes to you complaining of heavy menstrual bleeding with pain. She describes that clots of
blood are lost in the first few days of menses with severe back pain. You ask her for some investigations that
need to be performed. She gets irriated and says she just wants a treatment. Which of the following is the
appropriate next treatment ?
a. Tranexemic acid from day 1 of menses
b. Mefanimic acid from day 1 of menses
c. Mirena
d. Oral contraceptive pills

225. 45yrs old Patient with decreased Hb with cyclical menorrhagia. Hysteroscopy and D and C done. Both normal.
Whats most appropriate?
a. levonorgestral intrauterine system
b. progesterone from day 15-25 of cycle
c. oral tranexamic study
d. COCP

226. 40 years old woman with menorrhagia and hysteroscopy. She had a dilatation and curettage three months ago.
Which of the following is the MOST appropriate management plan?
a. nortestosterone
b. levonorgestrel IUCD
c. continuous medroxyprogesterone
d. Tranexamic acid during period
e. Mefanamic acid during period

227. 42yo woman who smokes 20 cigarettes/d presents with complains of heavy bleeding prolonged menstrual
period. What is the most appropriate treatment for her?
a. Tranexemic acid
b. COCP
c. Mefenemic acid
d. IUCD …take this one if says mirena
e. Norethisterone

228. Post hysterectomy patient with history of DVT post operative after hysterectomy. Now comes with hot flushes.
Which HRT is best?
a.Low dose Oral estradiol
b.Oral estrogen plus Progesterone
c.Oral Progesterone alone
d.Transdermal estradiol
AN-114
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229. 51 years old woman had her last menstruation 8 months back. She is complaining of host flushes and insomnia.
Which preparation is best for her?
a. Continuous HRT with oestrogen and 12 days progesterone
b. Continuous HRT with oestrogen and progesterone
c. OCP
d. Oestrogen patches
HB-3.217

230. infertile couple recall,what to ask in male

a.how much alcohol do u take
b.do u take ecstasy
c.do u take marijuana
d.parotitis history
AN-137 JM1251

231. . Young couple with infertility. Female with one child in previous marriage and female investigations were
normal, what in history you will ask the male patient that will be most useful to guide u to cause of infertility?
a. Do u drink alcohol so much?
b. Did u shave often?
c. Do you use Marijuana?
d. Do u have regular unprotected sex?
e. Do u often use ectasy and party drugs?

232. A 42yo woman who smokes 20 cigarettes/d presents with complains of heavy bleeding and prolonged menstrual
period. What is the most appropriate tx for her?
a. Tranexemic acid
b. COCP
c. Mefenemic acid
d. IUCD
e. Norethisterone /levonorgesterol IUCD

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233. women with 2 years after Filshie clip sterilization. Regular cycle with menorrhagia +, At this cycle, bleeding for 10
days with few clots. Pap smear normal 12 months ago. Initial investigation? (exact option)
a. pap smear
b. Full blood count
c. ultrasound
d. Thyroid function test
e. Endometrial Biopsy
JM 1137
234. 45 yr old lady smoker and htn uses ocps for many years now comes re prescription ,she says doesn't want to
come off because it has controlled her menorrhagia and also says doesn't want to concieve. What to do now
a. Tell her stop smoking then can give ocps
b. Use implanon
c. Use copper iud
d. Use progestogen only pill (as she doesn’t want to come off from oral medication)
e. mirena
AN 109

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235. Old lady 58yrs with urinary incontinence, when she makes some stress such as cough, laughing, urine flow out.
On examination she has only rectocele, no other cystocele. told
to do pelvic floor exercise and a little improved but still
incontinence and embarrassed. She is not satisfied. She had
DM and well controlled with diet. What is the next most
appropriate treatment in this patient?
A. Weighted vaginal cone
B. Bladder neck suspension
C. Imipramine
D. Oxybutyline
E. Surgery for rectocele
AN136 JM871

Whether you choose to have surgery will depend on how far

stress incontinence affects your daily life and what you feel
you can cope with.

https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/gynaecology/surgery-
for-stress-incontinence.pdf[KM4]

https://www.nhs.uk/conditions/urinary-incontinence/treatment/

http://www.aafp.org/afp/2013/0501/p634.html

https://www.medscape.com/viewarticle/516348_4Romana

236. An 85 year old lady with stress incontinence,whenever she laughs or sneezes presents with rectocele which is
reducible.What is most important management in this patient after bladder exercise has failed.
a. Vaginal cones
b. Imipramine
c. Surgery for rectocele
237. Elderly lady with stress incontinence... No rectocele.... Nor uterocele... What is next?
a. Urodynamic study
b. Ascending urethrogram
c. Surgery
d. Pelvic floor exercISE

238. Old lady 58yrs with urinary incontinence, when she makes some stress such as cough, urine will flow out. On
examination she has only rectocele, no other cystocele. Did urodynamic study (she passes urine at low detrusor
pressure?, don't remember), told to do pelvic floor exercise but still incontinence and embarrassed. She is not
satisfied. She had DM and well controlled with diet. What is the next most appropriate treatment in this patient?
a. Weighted vaginal cone
b. Bladder neck suspension (exact words)
c. Imipramine
d. Oxybutyline
e. Surgery for rectocele (colporraphy

239. Old woman came with incontinence. She is mother of 3 childern and on vaginal examination shows mild
cystocoele. Asking for the investigations?

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a. Urine culture (1st exclude UTI and drug cause)
b. Renal scan
c. Urodynamic studies
Initial tests Urinalysis
Bladder diary
Renal function
Bladder scan estimating post-void residual urine
Cough stress test
Follow-up tests Imaging of pelvic and urinary tract with plain films, ultrasound, computed tomography or magnetic
resonance imaging
Endoscopy
Urodynamic testing
If conservative management for SUI has failed, offer:
synthetic mid-urethral tape/sling
or • open colposuspension bruch best
autologous rectus fascial sling

Women whose primary surgical procedure for SUI has failed (including women whose symptoms have
returned) should be:
referred to tertiary care for assessment (such as repeat urodynamic testing including additional tests such
as imaging and urethral function studies) and discussion of treatment options by the MDT, or
offered advice as described in recommendation 51 if the woman does not want continued invasive SUI
procedures.

240. Stress incontinence scenario on cough or sneezing ....best next invest,

a. Ct
b. Urodynamic studies uti is urge incontinence
c. Urine analysis
d. Cystoscopy
241. 68 years old lady with urinary incontinence on coughing and staining, she is obese with diet controlled DM. Her
urodynamic studies positive in low volume study. She has mild rectocele but no cystocele. She has been advised
to do pelvic floor exercise which she found to have some improvement but she feel socially embarrassed for
urinary incontinence. what would be your best next management?
a. weighted vaginal cones
b. weight reduction?
c. colposuspension
242. A 70 year old lady with stress incontinence. Urodynamic studies done after Pelvic floor exercises what’s the best
management for her?
a. Tension-free Vaginal Tape
b. Weighted cones in vagina
c. Burch's colposuspension
d. Local oestrogen cream
e. vaginal colposuspension
1. The first one as it is written here does not mention failed treatment. If it mentions failure
then MUS. If not and the patient is responding to PELVIC floor ex3rcide then vaginal cones as
a complement may be considered. But as far as I know the original question is about failed
conservative management

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243. 72. Old woman with urgency and nocturia for a long time. Now having incontinence for like a month. She also
has bilateral knee OA. What is the best management for her?
a. Fluid restriction at night
b. Install a commode in her bedroom.
c. Oxybutynin
d. Paracetamol

244. Couple come for infertility problem for the last 12 months. On testing examination and tests of the female are
unremarkable. Male has azospermia. And bilateral absence of vas deferens. Which of the following is most
important test before the starting the treatment of infertility?
a. No testing required as they cannot have a child
b. Testing of both male and female for cystic fibrosis
c. Refer for IVF
d. Serum FSH and LH for male
Jm138

245. . Old lady presented few other features were given with narrow introitus. Biopsy showed lichen sclerosis
management.
a. 0.05% steroid (BETAMETHASON)
b. oestrogen cream
c. Surgical removal
JM1179
246. a case of young man who is presented with infertility. He had mumps when he was 6 years old. He was on
methotrexate before some months or years and he is taking sulfasalazine now his semen analysis showed
motility of 5% , sperm count 1 million /ml and abnormal sperms 90%. what is the cause of his infertility
a. methotrexate
b. sulfasalazine
c. mumps
methotrexate will dec spermatogenesis and reversible in 3months
sulphasalazine causes oligo (low sperm count) astheno (poor sperm mvmnt) terato(abnormal sperm)
reversible in 2 months

247. Young girl with menorrhagia regular cycle passing clots on 1st 2 days with heavy bleeding what initial
investigation
A. FBC
B. pelvic USG
C. hysteroscopy

248. 20 year old came for HPV examination ( pap smear). She is sexually active. On examination, yellowish exudates
obstructing the endocervical space. What best next?
249. do pap smear as requested
250. tell her it is not beneficial for her age
251. treat infection and perform pap smear after 3 months
JM-1089

252. female had mastalgia for the last 1 year. Conservative treatment has not worked. How would you
manage this patient? a) Bromocriptine b) Danazole c) Clomiphene d) OCP e) NSAID’s BROMCRIPTINE
ER THEKE DANAZOL AND TAMOXYPHANE VALO
AN100

253. Invasive intraductal carcinoma with no lymph node involvement, Mx asked-

a. Total mastectomy
b. Partial mastectomy
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c. Radiation
HB3.125 AN103

254. Female patient old age came to ER by sudden chest pain when they are preparing to make ECG they found that (
give picture with redness and swelling of RT Breast) diagnosis
1 invasive Breast carcinoma
2 cystasarcoma phylloides
3 chronic Breast abscess
4 intraductal carcinoma
5.inflammatory breast ca/mastitis carcinomatosis

255. Women underwent total hysterectomy and bilateral oophorectomy , her sister has ovarian cancer . when to give
HRT ?
a. Before operation
b. Immediately after operation
c. Only after symptoms of menopause arise
Answer will depend on age of the woman<35 - immediately
>35-45 - when symptoms appear then start
256. Women underwent total hysterectomy and bilateral oophorectomy , her sister has ovarian cancer . when to give
HRT ?
a. Before operation
b. Immediately after operation if <45yrs
c. Only after symptoms of menopause arise if >45yrs
d. 6 weeks post operative

https://www.menopause.org.au/.../756-surgical-menopause

257. Laproscopy pic of woman with PID given. She has done tubal insufflation test also. what is the most likely
associated findngs?((( most associated findings thy asked)))
a. -dyspareunia
b. -infertility
c. -pain
d. -discharge

PID will have discharge dyspareunia pain all! Bt here tubal insufflation test is for infertility
Pelvic pain less common in PID
Infertility is common in endometriosis.

258. 17 girl has dyspareunia, worry about endometriosis because sister has infertility because of this. Examination:
nodule on ligament on vaginal palpation and some other description, what is important to diagnose
endometriosis:

a. nodule on uterosacral ligament,

b. dyspareunia,
c. menorrhagia,
d. family history
an-129

259. A patient well controlled on carbamazepine wants to start OC pills.

A. A.Cease carbamazepine
B. B.Continue carbamazepine with low dose OC pills
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C. C.Continue carbamazepine with high dose OC pills (carbamazepine is enzyme inducer)

260. a young lady wants to conceive, she is well controlled on phenytoin for the last 2years, whats your next
appropriate management?
a-cease phenytoin,change to Na valporate
b-cease phenytoin,change to Carbamazapine
c-cease all anti-epileptics (cz after 2yrs can withdraw gradually for 6 months)
d-give high estrogen OCPS
e-do nothing

Epilepsy management before and after conception

Preconceptual management of women with epilepsy includes the following:

Attempt to decrease pharmacotherapy to monotherapy

Taper dosages of AEDs to the lowest possible dose
In women who have not had a seizure for 2-5 years, attempt complete withdrawal of
pharmacotherapy
Establish the level of total and free AEDs necessary for achieving good clinical control
Consider preconceptual genetic counseling
Supplement the diet with folate at 4 mg/d....
261. Gyn: 22 yo woman yellow greenish discharge. Etiology? Gonnorhea, Chlamydia, Trichomonas
AN124 JM1156
262. Menstruating woman are at risk of infection? Trichomonas, Group B streptococcus, candida

ANS- chlamydia
263. A 19 yr girl having 3 sexual partner came for HPV vaccine. What to do?
a. Give her
b. check HPV DNA
c. Do PAP
264. woman with 3 sexual partner, last pap smear was 2 month ago and normal. Now coming for HPV vaccination,
what to do?
a. cervical swab for HPV
b. give vaccination
c. repeat pap smear
d. urine PCR for chlamydia
https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-
MEDIA/Women's%20Health/Statement%20and%20guidelines/Clinical%20-%20Gynaecology/Guidelines-for-HPV-
Vaccine-(C-Gyn-18)-Review-July-2015.pdf?ext=.pdf

265. Migraine girl cam for contraception: best for her OCP, POP, Condom

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266. 18 years old lady never had period. For last 3 months she got pain in the lower abdomen for 3 days and become
iiritable before that. GP examine her, all development normal.what is cause of this?a) hidden ovulation
b)imperforated hymenc) pituitary disorder…hidden ovulation mane mullarerian
AN117

267. Woman 21 ys old came because of pain in her lower abdomen 12 days after LMP. O/E there is some tenderness
in her lower abdomen to the left side. U/S done show follicular cyst 1.8 cm in her left ovary what to do
a. reassure her
b. ask her to come back in 2 weeks for another U/S
c. laparoscopy to remove her ovarian cyst

268. A teenage girl,c/o abd pain -ultrasound done noted 4cm mass at the ovary ,what is ur mx
a. ( no option for tumour markers)
b. Review back in 4 weeks IF REASSURE IN OPTION THAT WILL BE THE ANS
c. Surgery- IF SEVERE PAIN, EXTERNAL BLEEDING ,>5CM
d. Review in 1 year
e. Review 2 year
AN 131 JM 1136

RMI = U x M x CA125

The ultrasound result is scored 1 point for each of the following characteristics: multilocular cysts, solid
areas, metastases, ascites and bilateral lesions. U = 0 (for an ultrasound score of 0), U = 1 (for an
ultrasound score of 1), U = 3 (for an ultrasound score of 2–5).

The menopausal status is scored as 1 = pre-menopausal and 3 = post-menopausal

The classification of 'post-menopausal' is a woman who has had no period for more than 1 year or a woman
over 50 who has had a hysterectomy.

Serum CA125 is measured in IU/ml and can vary between 0 and hundreds or even thousands of units

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Breast

269. Woman nipple one side discharge, blood stained from one duct. Management: excision of one duct
JM-1119 AN103

270. A 45 year old presents with bloody discharge from nipple. On examination, when nipple was squeezed blood was
expressed from only one duct. What is the most appropriate diagnostic tool?
a. FNAC
b. USG
c. Mammogram
d. Ductogram
e. Cytology of discharge

Imaging — Imaging studies are helpful because they may reveal an underlying abnormality in the
duct (or elsewhere in the breast) and help direct the surgical evaluation.

we recommend mammography and ultrasound examination as a starting point. Although the

sensitivity of mammography is low, it is the best modality for identifying suspicious lesions in the
breast. Ultrasound is especially useful for identifying lesions within the ducts that can be subjected
to core biopsy or localized for surgical biopsy. In addition, ductography is often used to delineate an
intraductal filling defect which may be causing the nipple discharge.

Cytology is rarely helpful and is not recommended. Other diagnostic testing, including breast
magnetic resonance imaging, magnetic resonance ductography, ductal lavage, and ductoscopy can
be helpful in selected women but are not always necessary for the work up of nipple discharge.

Imaging does not reliably identify all cancers or high risk lesions, such as papilloma or atypia.
Surgical evaluation of pathologic nipple discharge is required for diagnosis and treatment even if
imaging results are negative.

Mammography — Most experts recommend that a mammogram be performed in women with non-
lactational spontaneous discharge This is usually limited to women at least 30 years of age.
Mammograms may fail to show cancers or high risk lesions if they are small, lack calcifications, or
are entirely intraductal If an abnormality is detected, core biopsy with clip placement should be
performed.

Ultrasound — Ultrasound provides a useful tool for the diagnosis of ductal disease as it is directed
to the periareolar area and provides visualization of dilated ducts (image 1), and any nodules inside
them (image 2). It allows visualization of ductal pathology as small as 0.5 mm in diameter and can
be used for ultrasound guided percutaneous biopsy of lesions and ultrasound guided wire
localization for surgery. If core biopsy is performed, a clip should be placed to allow subsequent
localization if surgery is required.

##A ductogram can also help your doctor make a diagnosis. This is a type of X-ray that helps
determine the underlying cause of nipple discharge. During a ductogram, contrast dye is injected
into your breast ducts so your doctor can view them in the X-rays more easily. Though this test may
be used in some cases, it has largely been replaced by ultrasound.

271. History of orchidopexy, infertility, sperm count 1 million, what next?

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a. Scrotal US
2. Testosterone
3. FSH, LH
JM1254

272. #Woman present with constipation, wt loss of 4 kg, mass extending from pelvis to umbilicus.On physical
examination,mass is felt separated from uterus, a little beside right midline abdomen and asking management?
A.ovarian cancer
B.endometrial cancer
C.uterine leiomyoma

273. Bleeding from nipple in58 yr old lady: Intraductal papilloma, intraductal carcinoma
274. 39 year old female complaining if bleeding from nipple.3 cm mass is present.Diagnosis?
a. Intraductal carcinoma
b. Intraductal papilloma

275. 65 yrs old lady nulliparous comes with painless bleed from nipple ,her cousin had breast ca "they didnt comment
on any lumps or anything" ...Dx ??
A intraductal papilloma
B duct ectasia
C invasive cancer
D paget disease

The possible symptoms of breast cancer include:

A lump or thickening in an area of the breast-a change in the size, shape or feel of the breast dimpling of
the skin-a change in the shape of your nipple, particularly if it turns in, sinks into the breast, or has an
irregular shape-a blood stained discharge from the nipple-a rash on a nipple or surrounding area-a
swelling or lump in the arm. Invasive means that the cancer has “invaded” or spread to the surrounding
breast tissues

276.
.according to them hyperprolactinaemia due to drug <5000
If adenoma level will be usually >5000
Here they are asking cause so according to level we can reach for dx.but if in the qsn ask about inv in
that case without excluding pituitary adenoma in any case of hyperprolactinaemia we can’t
decide whether it’s drug or not.

277. got momography for 65 years old woman .she had a trauma in her breast last 10 years . She has not discharge .no
family hx for carcinoma of breast .what is your dx
a. calcinosis adenosis
b. adenocarcinoma
c. ductactesia
IF FAT NECROSIS IN OPTION THAT WILL BE THE ANS

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CALCINOSIS ADENOSIS:

278. A 35y woman presented with clear discharge from breast. Her small kid is 5y old. In the examination there is
no lump in the breast with presser of nipple clear discharge is obviously detected. Dx:
a. Benign duct papilloma
b. Intraductal carcinoma in-situ
c. Mammary duct ectasia
d. Paget disease

Intraductal papillomas are benign (non-cancerous), wart-like tumors that grow within the milk
ducts of the breast. They are made up of gland tissue along with fibrous tissue and blood vessels
(called fibrovascular tissue).

Solitary papillomas (solitary intraductal papillomas) are single tumors that often grow in the large
milk ducts near the nipple. They are a common cause of clear or bloody nipple discharge, especially
when it comes from only one breast. They may be felt as a small lump behind or next to the nipple.
Sometimes they cause pain
https://www.cancer.org/cancer/breast-cancer/non-cancerous-breast-conditions/intraductal-papillomas.html

279. Patient presnts with a breast lump, it was suspicious on Mammography and biopsy shows atypical ductal
hyperplasia
a. wide local excision
b. Watchful waiting
c. radiotherapy
280. .PT had mastectomy for CA breast 2 yr back. Had lesion on her rib. Wt investigation- to do?
a. total body bone scan
b. CT whole body
c. mri

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281. Mammogram of a breast …. an old women with normal breast examination. She had a history of trauma on chest
10 years ago with bruising in the breast ?What will u do?
a.reassure
b.Percutaneous core biopsy
c.FNAC
d.repeat mammo after 6 months

fat necrosis will be like carcinoma lump and skin change here normal breast exam so reassure otherwise
core biopsy
HB 3.127
Fat necrosis
Fat necrosis is usually the end result of a large bruise or trauma that may be subtle, such as protracted
breastfeeding. The mass that results is often accompanied by skin or nipple retraction and thus
closely resembles cancer. If untreated it usually disappears but the diagnosis can only be made on
excision biopsy. The full triple test is required.

282. traumatic fat necrosis, breast scenario, mammography given, what next?
a. percutaneous core biopsy HB
b. repeat mammography
c. C . excision JM

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283. An old postmenopausal pt. with bloody discharge from one nipple, most probable dx?
a. Benign duct papilloma
b. Ductal ca
c. Fat necrosis
d. abcess/Cyst
e. Paget’s dis

284. 68 year woman came with a 2 cm painful breast mass which she noticed a week ago, what’s the most common
dx ?
a. Breast cancer
b. Mammary duct ectesia
c. Fibroadenoma
d. Fat necrosis
e. Fibroadenosis
jm 1115

285. A female patient(~40 years)came for her routine breast checkup.clinical exam’normal.But on USG and
confirmation from mammography showed a calcified lesion in the upper outer quadrant in the right
breast.Diagnosis?
A.Ca breast common age depends on full que
B.Fibroadenoma…lump should be palpable
C.cyst
D.papilloma
JM 1115???
286. which one of the flowing is a condition where breastfeeding can be stoped
a. engorged breasts
b. inverted nipples
c. cracked nipples
d. breast abscess
e. mastitis
JM 1121
Amedex— d

287. Lady presents with mild temperature and redness of breast left….non fluctuant area +….what to do after giving

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antibiotics
a. Breast feed from left breast first
b. Express and discard
c. Aspirate
AN 102 jm-1108

288. Female with hot flushes and disturbed

sleep, she had breast cancer 5 years ago
and treated with chemo and radio. It was
ER negative. What will you give her?
a. Paroxetine 1st but not with
tamoxifen and if no insomnia
se
b. Clondine
c. Oestrogen
d. HRT

289. Woman presents with diagnosed retroverted uterus,she is unable to concieve for 6months with effective
intercourse.next step
1.give her a diary for temperature chart
2.pessary after mannual correction of uterus
3.surgical correction of retroversion
4.IVF

290. 16. year sold woman came for check up , speculum examination done
revealed cervical erosion. Her pap smear two years back and was
normal.

a. Refer her for colposcopy.

b. Treat her with local cream
c. Cauterization
d. Pap smear cause normaly 2 yrly

291. A 50 year old lady diagnosed with right ovarian tumor, which was found out to be a secondary cancer. where the
primary cancer most likely?
A Colon
B Liver
C Pancrease
D Breast
E Lungs
HB 3.221

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292. Old lady with high grade cervical cancer that cause bladder obstruction, she need surgery and seems she
understand her situation still refused.
a. Refer palliative care
b. Check her competency

293. 45 yr old female with menorragea and her consultation is due with a gynecologist in few weeks , so what can you
give her till that time?
a. NET
b. OCP
c. Mirena
d. Mydroxiprogesterone

HB Q p 532. Here if the pt has regular period, means still ovulating, with menorrhagia we give NET
throughout the whole cycle. marina is also an option but i would not use it since the pt will see her
gynecologist in few weeks. option A is the correct one. for MPA we can use as un alternative depends on
availability. but NET is choice # 1in practice if the pt has irregular period means none ovulating DUB,
then give progesterone either NET or MPA from day 15-25 for 3 months and check for her after that.

294. 20 years old female came for the ocp advise.Her BMI is 27. She is having the history of premenstrual headache
and GERD. Her mother diagnosed to have breast CA in her age of 50 and the girl smokes 20 cigerrates per day
and two standard drinks too. What is the absolute contraindication for the OCP.
a. BMI
b. family HX of Breast CA
c. Smoking….35 yr and 15 ciggeratte
d. Premenstrual headache
e. Drinking

295. Woman came with complaining of excessive bleeding during her period.She also lost her weight in last few
months, has 2/3 kids (forgot)telling that her relation with her husband is not going well, not
going for vacation for long time, having some financial crisis ans renting house.what to do next?
a. Send her to psychiatrist
b. Advice her to go for vacation
c. Send her to gynaecologist
d. Tell her to bring husband next time
st
1 rule out organic cause thn depression.

296. woman wants to try billing method for contraception when she can restore her sexual avctivity,
a. 17 days after ist day of mensturation
b. when vaginal mucous is moist
c. two days of raise of temperature
JM 1102

297. Billings ovulation method of anti contraception?

a. Abstain from sex until 17 days after period
b. Until a few days after peak mucus flow.
c. When mucus is heaviest
d. When mucus looks clear

298. A 16 year old female presents with Sickle cell anaemia and heavy menstrual bleeding. What is the best treatment
of choice?
a. Combined Oral Contraceptive Pill (COCP)

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b. Inj Depoprovera JM less thn 18 and more thn 45 not given but not CI
c. Mirena JM in young and nulliparous can be given
d. IUCD
e. Implanon
f. B depoprovera,

299. Young lady came with abdominal pain on USG uterine thickness 8cm? and ovaries normal except 1.5cm cyst in
left ovary.next app managemanet?
a.ca 125
b.review in 3wks
c.cyst aspiration
d.comence ocp
e.laparoscopy

300. 1)A 42yo woman who smokes 20 cigarettes/d presents with complains of heavy bleeding and prolonged
menstrual period. What is the most appropriate tx for her?
a. Tranexemic acid
b. COCP
c. Mefenemic acid
d. IUCD
e. Norethisterone
301. 2)A 17yo senior school girl with complain of prolonged irregular menstrual period and heavy blood losses. What
is the most appropriate tx for her?
a. Mefenemic acid
b. COCP oral progesterone is not effective in ovulatory DUB jm 1127
c. POP
d. IUCD
e. Mirena

302. 3)A 32yo presents with heavy blood loss, US: uterine thickness>14mm. What is the most appropriate tx for her?
a. Mefenemic acid
b. COCP
c. POP
d. IUCD
e. IU system (mirena)

303. 4.69 year old woman pap smear didn't show any abnormal cells but endocervical cells were absent, what to do?
a. i.Reassure that no further tests required anymore
b. ii.repeat pap smear now
Unsatisfactory. A diagnosis cannot be made because there are too few cells, there are no endocervical cells,
or the slide has been processed incorrectly. The smear should be repeated 4 weeks later

after menopause, the cervix may be less pliable and the transformation zone (the section of the
endocervical canal where squamous cells begin to change to columnar cells) moves higher up the cervical
canal, making it more difficult to routinely obtain endocervical cells. However, in a premenopausal woman,
the transformation zone is fairly close to the opening of the cervix, allowing the smear to capture both types
of cells easily.
Women whose Pap smears show no endocervical component but who have had otherwise normal results
and are not seeing abnormal bleeding or other symptoms generally do not need another Pap smear
performed until the next annual examination.

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At your next yearly exam, you could discuss with your ob-gyn your concern about prior Pap smears lacking
an endocervical component. He or she may be able to make a special effort to reach the endocervical canal
with the Pap instrument

304. 6.Postmenopausal woman with post coital bleeding, Pap smear was normal 1 year back but did not show
endocervical cells.. vagina atrophic, next
a.Pap smear
b.Vaginal estrogen
c.TVS
d.Hysteroscopy and curettage????
if mentioned atrophic vaginitis in the Q then next B or still we shud do a pap smear to rule
out cervical cancer.
next usg, best d

305. 8.20 years old pregnant lady of 32wks ,h/o yellow vaginal dischage.has never had a pap smeaR before.what is
your management
A.antibiotic
B.reassure
C.do the pap smear now
D.do pap smear after delivery
E.do pap smear close to the labour

306. A 24-year-old gravid 1 para 1 who is 2 weeks post partum complains of double vision, shortness of breath, and
almost dropping her baby while trying to hold her. She says her symptoms worsen as the day progresses. She has
no family history of neurologic or muscular illness. A physical examination is normal except for unilateral ptosis
and 4/5 proximal weakness of both arms. Breath sounds are generally decreased. Routine blood tests, including
TSH and creatine kinase levels, are normal. A chest radiograph and an MRI of the brain and cervical spine are also
normal. Of the following, this presentation is most consistent with

a. Fibromyalgia syndrome
b. Sheehan’s syndrome (postpartum hypopituitarism)
c. Polymyositis
d. Myasthenia gravis
e. Stroke

307. At the time of her annual examination, you find an 11-week-sized irregular uterus on an asymptomatic 40-year-
old woman. Her last exam 1 year prior was normal. Your next step in the management of this patient is:
a. Hysterectomy
b. Endometrial biopsy
c. Reexamination in 6 months
d. Fractional dilation and curettage
e. Gonadotropin releasing hormone agonist therapy

. Leiomyomas are a frequent finding in a reproductive age woman. If they are asymptotic (absence pf
pain, menorrhagia, urinary symptoms, gastrointestinal symptoms), and if they are small and not rapidly
changing in size, then they can be followed. Since her last exam 1 year ago was reportedly normal,
reexamination in less than 1 year would be appropriate.

308. A 24 year old female presents with abdominal pain. Beta-HCG is negative. Pelvic ultrasound shows a 5 cm right
ovarian cyst. You would

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a. Perform immediate laporotomy b) Perform immediate laproscopy
b. Aspirate the cyst under ultrasonographic guidance d) Order a CBC and a CA125
c. e) Expectant management with repeat ultrasound in 8 weeks

The management of ovarian cysts depends on a number of factors, including age of the woman, size
of the cyst, type of cyst as determined by ultrasound (simple or complex), level of CA-125 and the
presence or not of symptoms.

If ultrasound identifies that the cyst is simple, a wait-and-see plan ('expectant management') may
be appropriate, because many simple ovarian cysts resolve spontaneously.

With expectant management, the woman has a repeat ultrasound 6-8 weeks after the simple cyst
was first diagnosed. In the past, combined oral contraceptives were often prescribed to pre-
menopausal patients during this time, but it is now accepted that these agents only prevent the
development of functional cysts and do not suppress them. If the cyst has
persisted after the observation period, then the patient is usually referred for surgical evaluation.

309. Post hysterectomy – hrt, Answer were different kinds or progesterone preparation , (read the brands and kind)

310. 8.20 years old pregnant lady of 32wks ,h/o yellow vaginal dischage.has never had a pap smeaR before.what is
your management
A.antibiotic
B.reassure
C.do the pap smear now
D.do pap smear after delivery
E.do pap smear close to the labour
Jm1088

A yellow discharge from your vagina, especially while you are pregnant, could be an immediate signal
towards a possible infection.The neutrophils, which are a type of white blood cells, are present near
your vaginal area, and can result in the yellowish color that you may see in your vaginal discharge.

311. year sold woman came for check up , speculum examination done revealed cervical erosion, her pap smear two
years back and was normal.
a. Refer her for colposcopy.
b. Treat her with local cream
c. Cauterization
d. Pap smear AGE THN CAUTARIZATION
HB 3.200

312. 18.Pregnant lady comes to u for antenatal check up at 16 weeks , she never had pap smear , and no abnormality
now too.. what to do next:
a. pap now
b. pap after 6 weeks after delivery
c. no pap needed in pregnancy

313. Patient underwent Conization for abnormal pap smear 2-3 days back. Now presents with fever 39, pain lower
abdomen and tenderness. What’s the most appropriate place to take a swab?
a. Blood culture
b. Endocervical swab PID
c. High vaginal swab
d. Low vaginal swab
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e. Endometrial

314. 17, y.o girl with primary amenorrhea. Secondary sexual characteristic at stage 5. No abdominal pain. What is the
next ix?
a/ FSH
b/Pelvis ultrasound
c/ karyotype
AN 117
315. 18 year old girl presented with primary amenorrhea. Secondary sex characteristics not developed. Her height
and weight also below normal. What's your next inv?(contro)
a. Fsh and lh levels***
b. Pelvic usg
c. Karyotyping

316. . 2 yr old girl with vulval discharge, O/E labia red, whitish discharge. Culture reports enteric
organisms. Cause?
a) sexual abuse – RED DISCHARGE
b) poor perineal hygiene
c) UTI
d) chronic constipation

317. 20.cystocele in multigravida woman.with frequency urge incontinence and stress incontinance a few times. no
dysuria. investigation to diagnose?
a. cystoscopy
b. usg pelvis
c. urine culture
d. ivp
e. micturating cystourethrogram— ( its done in children for UTI reasons)

https://www.racgp.org.au/afp/2016/july/management-of-urinary-incontinence-in-residential-care/
https://www.racgp.org.au/afp/2012/november/overactive-bladder-syndrome/
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318. Perimenopausal woman on hrt with a typ of estrogen presents with hot flashes after hysterectomy she
underwent due to heavy menstural bleeding. what is nxt step
a. continue with same regimen
b. add progesterone
c. decreses the dose of current hrt
d. increase the dose
e. somthng else also about a type of progesterone

319. 25yo nulliparous woman at 6 weeks amenorrhea. her regular cycles are of 4 to 5 weeks. She had a home
pregnancy test which was positive. presents with bleed per vaginum and abdominal pain. what investigation
needs to b done
a. serial b hcg
b. urine pregnancy test
c. serum hcg levels
d. ultrasound

320. Lady wanting to conceive….she has regular 24 day cycle…presenting on 17th day….what hormone to check
for her today
a. FSH
b. LH
c. Progesterone MENS ER 5-10 DAYS AGE MORE THN 20 NG ASLE OVULATORY

Hormone levels in the normal menstrual cycle – considerable variations are compatible, however, with
normal menstrual function. Here, the inter-relationship of ovarian steroids and hypothalamic–pituitary
gonadotrophins is shown. After menstruation, rising levels of oestrogen exert a negative feedback,
reducing FSH release. Towards mid-cycle still higher oestrogen levels exert a positive feedback, causing
a sudden peak release of LH, which induces ovulation. An increased release in FSH also occurs.
Failure of this sequence will lead to an-ovulation and irregular cycles. In the luteal phase, LH levels must be
sufficiently high to maintain the corpus luteum until the conceptus has implanted and commenced
hCG secretion, which then maintains corpus luteum function. If conception fails to occur the corpus
luteum deteriorates after about 7 days, with the resulting falling levels of progesterone and oestrogen.
As a consequence menstruation occurs and FSH levels rise, initiating a new menstrual cycle. LLJ-14

321. Woman has regular menses from 4-6 wk interval , pain on left iliac fossa for 3 days ,aggravated while urination,
her lmp was 9 days back , she had similar episode 4 wks back which lasted for 3 days , cause ?
a. Ovulation
b. complicated ovarian cyst
c. dysmenorrhea
d. early PID

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e. ectopic preg

322. pt has urge incontinence..mx

a. Bladder training
b. Anticholinergic
c. Pelvic floor exercises

323. cystocele in multigravida woman.with frequency urge incontinence and stress incontinence a few times. no
dysuria. appropriate investigation to diagnose?
a. cystoscopy
b. usg pelvis
c. urine culture
d. ivp
e. micturating cystourethrogram

https://www.medscape.com/viewarticle/722323_4

324. Urge incontinence...next best invest.

a. Urine analysis
b. Urodynamic studies
c. Ct
d. Cystoscopy

325. Stress incontinence scenario....best next invest,

a. Ct
b. Urodynamic studies
c. Urine analysis
d. Cystoscopy
Next c, best b
326. 45 year female, incontinence, nocturia, uterus
prolapse, no abnormality in pelvic floor, bladder full
then did cough test, no dribbling , Dx?
a. Urge incontinence
b. Stress Incontinence
c. UTI

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327. Old man with urgency and nocturia for a long time. Now having incontinence for like a month. He couldn't reach
the toilet downstairs. He also has bilateral knee OA. What is the best management for him?
a. Fluid restriction at night
b. Install a camode in his bedroom.
c. Oxybutynin
d. Paracetamol

328. Old lady with hip osteoarthritis walks with 4 point stick... having nocturia and urge incontinence recall
a. Install comode in bedroom
b. Oxybutynin
c. Restrict drinking water at night

329. Young girl with regular cycle.history of lower abdominal pain,bilateral cyst in ovaries 5cm and 6cm solid/cystic
appearance in usg no ascites dx?
a)mucinous cystadenoma
B)serous cystadenoma
c) corpus luteal cyst
d)germ cell tumor
e) dermoid cyst an 131 llj 301 dutta 277

330. 25 yrs old..12 months previously pap done which showed LSIL..now u repeat pap smear(NOT HPV TEST)..what
will u tell her for HPV VACCINE?
a. it is indicted NOW..
b. -it is not indicated now
c. -it depends in the result of today’s pap smear
d. -it depend on HPV serology
e. -it depend upon HPV culture

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331. 37 years old with CIN-1 on pap smear. her last smear negative but 4 years ago genital warts Hx was positive.
what to do ?
1) Colposcopy jm
2) cone biopsy
3) hysterectomy
4) do nothing
5) LEEP

cin 1 is LSIL, so repeat HPV 12 months later

thats means present day CIN1. previusly smear negetiv and hx of genital wart

332. A 25 yr old lady came for her regular pap smear , all her previous pap smears were negative , the last of them
was 2 years ago.. this time her pap revealed a " LSIL " and u ordered a colposcopy now .. she asks about the HPV
vaccine , what is the most suitable advice ?
a ) wait the result of colposcopy
b ) give her the vaccine now
c ) she should receive it only if there is HSIL
d ) no need for the vaccine

HPV vaccination is recommended if a patient is sexually active, has a history of abnormal cytology, genital
warts, other sexually transmitted infections, or pregnancy. The vaccine may be less effective in some
populations, particularly women with a history of LSIL or HSIL, abnormal cervical cytology, or genital
warts, and immunocompromised men and women, but these individuals should still be vaccinated.

Keep in mind, the HPV vaccine is not a treatment for HPV infection, genital warts, LSIL, or HSIL.

http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-hpv

333. Old man with urinary incontinence. Not severe but it causes a problem when he goes out. First step of Mx?
a. Pelvic floor exercise
b. Bladder train
c. Prazosin
d. Anticholinergic agent

Treatment strategies
Initial management of male urinary incontinence usually consists of basic diagnostic investigations to
exclude any reversible conditions, such as a UTI (Figure 1). Conservative, non-invasive treatment
options include lifestyle interventions, pelvic floor muscle training (PFMT) with or without biofeedback,
and bladder retraining.9 Lifestyle interventions include caffeine reduction, weight loss and cessation of
smoking. While more recent literature supports PFMT to treat urge and stress incontinence, its long-
term efficacy remains uncertain.14,15 Pre-operative and early postoperative (immediately after
catheter removal) PFMT have been found to significantly improve and hasten the recovery of
continence rate,13–15 but there is limited evidence for preventive effects of pelvic floor rehabilitation.
In some patients with co-existing urinary symptoms that are suggestive of mixed incontinence, the use
of an antimuscarinic drug may be useful to eliminate potential detrusor overactivity.

https://www.racgp.org.au/afp/2017/september/adult-male-stress-and-urge-urinary-
incontinence/#download

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334. 21 years old female patient came to see you with a history of amenorrhea. Her lab investigation is as follow: FSH
slightly high LH slightly high Prolactin 400 (300-700) TSH 0.4 (0.5-4.0) Which of the following is the underlying
aetiology for her amenorrhea?
a) Hypothalamic dysfunction
b) Pituitary adenoma
c) Congenital hypothyroidism
d) Polycystic ovarian syndrome
e) Premature ovarian failure
AN118

335. Clinical pic of PID, what to do next?

A. -Cervical swab
B. -blood culture

336. Woman underwent ecg and incident finding of (breast pic - peau d orange, nipple inversion)
A. mastitis
B. breast abscess
C. ductal carcinoma in situ itz invasive

337. Old MAN with urinary incontinence when coming back home from shopping center asking cause
A.detrusor instability
B. BPH- there will be other symptoms
C. UTI

338. Case of septic abortion 8 months ago .. secondary amenorrhoea .. what to do

A. Bhcg level 1ST EXCLUDE PREGNANCY.
B. HSG
C. US

339. history of secondary amenorrhoea for 8 months after D and C. asking for inv
a. FSH LH
b. testosterone
c. usg
d. laparoscopy

340. young girl came to the clinic asking about contraception pills, she Is 19 years with normal examination, she said
that she recurrent attacks of headache that is associated with nausea and photophobia for which she takes
sumtriptan, what is the best for her ?
A mirena
B progesteron only pills
C estrogen patches
D combined oral (coc)

341. A woman with 20 year history of seizures controlled on sodium valproate now considering pregnancy.
A. Cease anticonvulsant
B. Continue valproate
C. Decrease dose of valproate

342. -PCOS scenario. Lh was twice as much as fsh. Asked what would support dx.
A. Ultrasound
B. Progesterone
C. Oestrogen level
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D. Testosterone level

343. -A 19 year old woman presents to the physician office for routine ph exam & pap smear.she has no complaints.
She has had 2 sexual partners in the past six months and takes ocpills. She has no significant past medical history
and takes no other medications. She has no known drug allergies. Her temperature is 37.2 C(98.9 F) & blood
pressure is 120/72 mm Hg. Complete pH exam including pelvic exam is unremarkable. Cervical swab is sent for
nucleic acid amplification of chlamydia trachomatis & Neisseria gonorrhea. One week later , the nucleic acid
amplification test returns positive for chlamydia infection. The patient is still asymptomatic. What is the most
appropriate next step in the management?
A. Repeat the test for confirmation
B. Reassurance and no treatment at this time
C. One dose of intramuscular ceftriaxone
D. Ceftriaxone and azithromycin
E. Single dose azithromycin

344. HRT risk per year; which is correct?

a) Breast CA 10% increase per year (2.3% per year)
b) Gall stones 2% decrease per year (increase)
c) Heart disease 1% increase per year
AN 114

Cognition: HT initiated after about 65 years of age increases risk of dementia (B)• Stroke: standard
dose oral HT may increase stroke risk in healthy women (B)• Ovarian: long term oestrogen therapy
(alone) is associated with a small risk of ovarian cancer• ET alone increases endometrial cancer and EPT
increases gallbladder disease.
https://www.racgp.org.au/afp/2011/may/hormone-therapy/

345. Which of the following is not transmitted during childbirth?

a. HIV
b. Gonorrhea
c. Herpes
d. Syphilis
e. Chlamydia

346. 11 month post menopause 3 days bleeding, no discomfort in intercourse. asking about the cause
a. Atrophic vaginitis
b. Cervical cancer
c. Ovarian Follicular activation
d. Endometrial cancer

347. 50 years old female with amenorrhoea for one year come with 24 hours bleeding
a-follicular activation
b-cervical erosion
c-cervical cancer
d-endometrial cancer
e-vaginal atrophy

348. 48 years old woman last menstruation was 8 month ago come with vaginal bleeding. what is the most common
cause?
a)endometrial cancer
b)cervical cancer
c)vaginal atrophy

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d)follicular activation
e)cervical glandular hyperplasia

349. After one year of post menopause, she has 3 days bleeding. What is the cause of her bleeding?
a. Atrophic vaginitis
b. Cervical cancer
c. Follicular activation
d. Endometrial cancer

350. Q185143- 17, y.o girl with primary amenorrhea.Secondary sexual chareteristic at stage 5. No abdominal pain.
What is the next ix? Dx:Mullarian agenesis.if Stage 2 theN USG
a/ FSH
b/Pelvis ultrasound
c/ karyotype

351. Q185156-Whats the minimum age for gillicks competence

12 or above can decide
Gillick competence is a term originating in England and is used in medical law to decide whether a child
(under 16 years of age) is able to consent to his or her own medical treatment, without the need for
parental permission or knowledge.

352. Q185157-Till how many weeks abortion is legally allowed in australia?

353. Woman has regular menses for 4-6 wk interval, pain

on left iliac fossa for 3 days, aggravated while
urination, her lmp was 9 days back, she had similar
episode 4 wks back, which lasted for 3 days, cause?
A. Ovulation
B. complicated ovarian cyst
C. dysmenorrhea
D. early PID

354. Patient who have performed IVF came for follow-up. How can know if it is successful? (sth like that)
A. Transvaginal USG
B. Perform APPA?
C. Measure B hcg

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A pregnancy test is performed approximately two weeks after your egg retrieval. Pregnancy symptoms are
not a reliable sign of pregnancy success or failure, because symptoms may come and go. Bleeding is
also more common following IVF. If you discover vaginal bleeding after the transfer, it does not mean
that the procedure was unsuccessful. We will ask you to get a blood pregnancy test (hCG level),
approximately 12 days after embryo transfer. You’ll take this test even if you’re bleeding,. When the
test is positive, you will return for a follow-up test two to three days later. The test is to confirm that
the level of hCG is rising appropriately

AMENORRHOEA
355. Q185183-37 y/o woman with bloody discharge from the nipple. painless and examination is non conclusive.
whats the dx
a.Fibroma
b.Cancer
c.Trauma
d.Cyst
e.Papilloma

356. 68 year old female have menopause at 55 , present with purulent brown-greenish vaginal discharge for 6 day ,
she is sexually active, what is the cause , previous pap smear normal
a. Chlamydia
b.endometrial Ca
c. gonorrhoea
d.ovarian ca

Here answer is be B endometrial ca. jm p1157

Vaginal discharge in the elderly
Vaginal discharge can occur in the elderly from a
variety of causes, including infective vaginitis,
atrophic vaginitis, foreign bodies, poor
hygiene and neoplasia. It is important to
exclude malignancy of the uterus, cervix and
vagina in the older patient.

357. A 36 year old lady with hypothyroidism who is

currently on thyroxine presents with intermittent
hot flushes and irregular menstruation. Which of
the following is the best investigation to make a
diagnosis in this patient?
A. Estrogen
B. FSH Premature ovarian failure
C. LH
D. TSH
E. Prolactin

358. 48 year old woman complains of heavy menstrual bleeding for last 4 months. She underwent a hysteroscopy
and D&C but the symptoms did not subside. She looks pale and Her haemoglobin is 8.5 g/dl(exact value). What
is the most appropriate management in this case?
A-oral tranexamic acid during the period
B-northisterone from 15-25 days of cycle
C-mirena
D-implanon
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E-COCP

359. Stress incontinence scenario on cough or sneezing ....best next invest,

Ct
Urodynamic studies
Urine analysis
Cystoscopy
1st investigations to order empty supine stress test ,urinalysis ,postvoid residual measurement (PVR),
cough stress test, Full details Investigations to consider pad tes,t urodynamic testing, Q-tip test
,cystourethroscopy Full details
360. You see a 17-year-old female for a routine visit. She tells you she has been sexually active for 3 years and that her
partners have used condoms, but not consistently. She has never had a Papanicolaou (Pap) test. You provide
counseling regarding contraception and sexually transmitted diseases, and perform a gynecologic examination,
including a Pap test. The results of the test are reported as atypical squamous cells of undetermined significance
(ASC-US). According to the guidelines for Colposcopy and Cervical Pathology, which one of the following would
be most appropriate with regard to the abnormal smear?
a. repeat Pap test in 6 months
b. A repeat Pap test in 12 months
c. HPV DNA testing
d. Colposcopy
e. Loop electrical excisional procedure

Atypical squamous cells of undetermined

significance (ASCUS). Squamous cells are thin
and flat and grow on the surface of a healthy
cervix. In the case of ASCUS, the Pap smear
reveals slightly abnormal squamous cells, but
the changes don't clearly suggest that
precancerous cells are present. With the liquid-
based test, your doctor can reanalyze the
sample to check for the presence of viruses
known to promote the development of cancer,
such as some types of human papillomavirus (HPV). If no high-risk viruses are present, the abnormal cells
found as a result of the test aren't of great concern. If worrisome viruses are present, you'll need further
testing

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361. PAP smear report: intermediate risk, HPV(not 16,18:mentioned) positive and LSIL present. What do to next?
a. PAP smear after 12 months
b. Colposcopy within 3 months
c. HPV after 12 months
d. Cone biopsy within 12 months
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JM 1092

362. -45 yr old lady complains of irregular menstrual bleeding. She has been treated for CIN-II previously and a Pap
smear done 6 months ago was found normal. WOF is the most appropriate investigation for her?
a. Colposcopy
b. USG to detect endometrial thickness (initial)
c. Cone biopsy
d. Endometrial curettage jm 1127
e. Repeat Pap smear
363. 5 yrs girl with blood stained discharge on underwear .on examination redness of vulva. Wts next
a. avoid bubble baths
b. STD screening
c. examination under anesthesia
jm 1167

364. 30-year-old obese white female comes to the physician with a six months history of oligomenorrhea. She never
had this problem before. She has no galactorrhea. She has gained significant weight over the past two years
despite a regular exercise program. She has also experienced hair loss during this time. She has had regular Pap
smears since the age of 20; pap smears have shown no abnormalities. She takes no medications. She does not
use tobacco, alcohol, or drugs. Her mother has a history of endometrial carcinoma and her grandmother had a
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history of ovarian carcinoma. Physical examination shows male pattern baldness. Abdominal and pelvic
examination shows no abnormalities. A urine pregnancy test is negative. Serum prolactin level and thyroid
function tests are normal. Which of the following is the most appropriate next step in management?
a. Screening mammogram
b. Oral glucose tolerance test —dx: pcod
c. CA- 125 levels, annually
d. Diagnostic laparoscopy
e. Iron studies

365. . A mother brings her two year old child who has genital warts. The mother had CIN 1 lesion 3 years ago. What
could be a possible cause for the warts in the child now
A. Swimming in the river
B. Sexual abuse
C. Acquired during birth through infected birth canal

Oaishy .. to ur ques ans is b only ... genital wat transmit by genital skin to skin contact ... nd baby of preg woman
with vaginal wart usualy present as resp warts nt genital wart in baby

366. 37 years old lady with CIN-1 on PAP smear, her last smear was negative but 4 years back genital warts history
what to do
a. do nothing
b. Colposcopy
c. Cone biopsy
d. Hysterectomy
e. LEEP
**should be repeat pap after 1 yr
367. 14 years old girl lives with family has now become sexually active comes to you for contraception advice and tells
you not to inform her parents. What will u do?
a. Give her prescription of contraception
b. Tell her she needs parents’ permission
c. Inform parents
d. Prescribe her OCP and Tell her to use condom to her partner
e. Inquire about the identity and age of the partner

368. Pop safe to use a contraceptive method in all of the following situations except?
a. Previous pulmonary embolism
b. Endometriosis
c. Ovarian cysts
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d. Hypertension
e. Biliary tract disease

By using mini pills,functional but asymptomatic ovarian cysts sometime develop.They usually disappear
spontaneously and surgery is not required.It is advised not to use progesterone only pills if a female
already has ovarian cysts.Mini-pills are safe to use in patients with previous history of
thromboembolism,endometriosis,hypertension and biliarytract disease.Other contraindications to use
of the mini-pill include malabsorption syndromes, previous sex steroid-dependent cancers(breast
cancer), undiagnosed vaginal bleeding, previous ectopic pregnancy and severe active liver disease

369. 14 yr live with parent come for contraceptive advice and don’t want to tell parent.beside giving contraceptive
what will u do?
a.tell her parent
b.ask age and identity of partner

370.

Ans A

371.

ANS c

372. A 25-year-old woman, who is taking the oral contraceptive pill {OCP), presents with a history of two episodes of
postcoital bleeding. She has never had an abnormal Pap smear and her last one was done about one year ago.
Which one of the following is the most likely cause of the postcoital bleeding?
A. A cervical ectropion.
B. Chlamydia cervicitis.
C. A cervical polyp.
D. Cervical intraepithelial neoplasia.
E. Cervical carcinoma

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373.
ANS B

374.
ANS B

375.

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376. A 41yo woman who has completed her family, has suffered from extremely heavy periods for many years. No
medical tx has worked. She admits that she would rather avoid open surgery. After discussion, you collectively
decide on a procedure that wouldn’t require open surgery or GA. Select the most appropriate management for
this case.?
a. Endometrial ablation
b. Hysterectomy
c. Fibroid resection
d. Myomectomy
e. Uterine artery embolization

377. A patient who has Factor V Laiden deficiency and a family history of DVT, comes for contraception. What will
you give beside condom?
a. Combined oral contraceptive pills
b. Progesterone only pills
c. Spermicidal gel
d. Transdermal estrogen patch
A: POP/ DEPO PROVERA

https://www.medscape.com/viewarticle/467129_2

378. 5th POD lady presents with watery vaginal discharge

slightly blood stained. Patient had undergone
hysterectomy before. What is the diagnosis?
a. Vesicovaginal fistula- WATERY
b. Vaginal cuff dehiscence
c. Vaginal abscess
d. Vaginal vault granulation- BLOODY
DISCHARGE NOT WATERY
e. Vaginal vault prolapse-

379. 54 year old woman presents to your clinic with

vaginal watery discharge with blood stained. She is
10 days post op hysterectomy for fibroids and was
subsequently discharged 4 days after a successful
surgery. She has no temperature and rest of exam is
normal. What is your suspicion?
a. Granulation tissue
b. Vagina vault breakdown

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380. Patient had amenorrhoea for past 12 months and wants to conceive. H/0 previous irregular menstruation with
5-6 times per year. Further hormonal details were given LH and FSH low, some other hormones mentioned all
normal. What will help you with the diagnosis?
a. MRI to diagnose pituitary atrophy CRANYOPHARYNGEOMA
b. Estrogen and Progesterone levels
c. Thyroid investigations

381. A 40 year old male presents with a decreased libido. His bloods reveal a low FSH, LH and testosterone level. His
free T4 is 12, TSH - 3 and his calcium 2.20 mmol/L. His prolactin level was 400 U/L. Which of the following is the
most likely diagnosis?
a. Langerhan's Cell Histiocytosis
b. Testicular germ cell tumour
c. Craniopharyngioma
d. Non functioning Pituitary Adenoma
e. Sarcoidosis

382. A lady presented with secondary amenorrhea. Prolactin,,, FSH, LH, and Testosterone all normal .estradiol (70
little bit low) normal value given (75).. U/S showed 3-4 ovarian cysts what is the cause
a. Primary Hypothyroidism
b. P.C.O
c. Hypothalamic pituitary dysfunction
d. ovarian failure
In pcos there should be 12cysts at least. In ovarian failure oestrogen level should low and
FSH should be high. But it takes time to set that level. If recently occurred may be Fsh
level can be normal.1..
383. a case of premature ovarian failure & don't want to conceive .. Mx ??
a. cocs
b. HRT
c. pops

384. 25 y/o female with no menstruation for 2 years, high FSH and LH, low oestrogen, USG shows 2-3 cysts in the
ovaries, she’s NOT sexually active and doesn’t want to get pregnant, how to manage:
a.HRT
b.Low dose POP
c.COC pills

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385. Q187266-Ductal hypertropy of breast what to do?

A-Excision…if its benign duct papilloma
B-Repeat mammography at 6 and 1 yr IF NEEDLE BIOPSY IN OPTION THAT WILL BE THE ANS

Atypical Ductal Hyperplasia (ADH)

Ø What is atypical ductal hyperplasia?

Atypical ductal hyperplasia (ADH) is not a form of breast cancer. Rather, it is a marker for women who may have a
risk factor for developing breast cancer in the future. If you have a biopsy that shows atypical ductal hyperplasia
in one of your breasts, your doctor will want to follow your breast health very carefully.

Armed with this knowledge, you will want to choose a comprehensive breast center. At the Johns Hopkins Breast
Center, our team of breast cancer specialists is recognized for their expertise in evaluating and treating breast
cancer. Further, our team of nurses, navigators and survivor volunteers are passionately committed to
preventing, fighting and treating breast cancer.
Women with ADH should never undergo a voluntary preventative/prophylactic mastectomy. Our physicians
and staff are specially trained to help women understand ADH and what their risks may be for developing breast
cancer.
2.

Ø How is a diagnosis made for atypical ductal hyperplasia?

After a core breast biopsy, an analysis will confirm the presence of atypical ductal hyperplasia cells in the breast
tissue. There is no way to determine the presence of ADH by reviewing a mammogram or other breast imaging
study. It also cannot be felt on a clinical breast exam. If ADH cells are found on a core biopsy, an excisional open
breast biopsy is often recommended so more tissue can be examined to look for an associated breast cancer.

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Ø What can I do if I'm diagnosed with atypical ductal hyperplasia?

First, there is no need to panic. If the pathology findings are limited to atypical ductal hyperplasia, you do not have
breast cancer – but you do have an increased risk of developing it in the future. Not all ADH cells need to be
removed, but your doctor should be aware of the findings. The most important thing to do now is find a breast
center where your breast health can be closely monitored.

Women with a diagnosis of ADH alone should not need to undergo a voluntary mastectomy. The risk of developing
breast cancer is higher than it is in the average population, but most women just need to be closely monitored.
Some can even take medication, such as Tamoxifen, to reduce the risk of developing breast cancer.
Our physicians and staff are specially trained to help women understand ADH and their risks for developing breast
cancer. If a woman has ADH cells found on biopsy, as well as other risk factors for breast cancer, further
evaluation can be done to calculate her risk of one day developing breast cancer and the appropriate
preventative steps can be recommended. This may include lifestyle changes, medications or surgery.

At the Johns Hopkins Breast Center, many of our patients with ADH benefit by joining our high-risk clinic program,
the Johns Hopkins Breast and Ovarian Surveillance Service (BOSS). The program focuses on ways to reduce the
risk of developing breast cancer and gives women tools to manage the knowledge that they are at higher risk.
A medical oncologist can assess your overall risk and recommend ways to reduce risk in the future, such
as hormonal therapy for breast cancer prevention.

386. Couple came with primary infertility for 2 years with regular sexual intercourse the female examination was
normal and her tests are normal , you found that the husband has a small testis what investigation you will
order?
- U/S
- Testosterone level
- Prolactin levels
- Karyotyping

http://www.racgp.org.au/afp/2012/october/andrology/

387. . 26year old female, with hair on face and hands, with irregular periods 3-4 times a year, What will you
investigate
Testosterone
Magnesium
Fsh
LH
Vaginal us

388. . Young male came for infertility , small testis, height 183 cm, what you going to do to reach diagnosis
Serum testosterone
Chromosome analysis average ht is 175.6cm
No FSH in option
Dx kleinfelter
389. A 46 years female presented with lower abdominal pain for 2 days. Her last menstrual cycle was normal n
three weeks ago. On examination there is mild tenderness n fullness in right adnexa. Usg shows cystic mass of 10
cm in right ovary whats the diagnosis??
A. Krukunberg tumor
B. Luteal cyst
C. Serous cystadenoma
D. Cystoadenosarcoma
E. Mucinous cyst

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390. woman came e amenorrhoea of 6 mths, she previously also had irregular cycles 4 times a year, wants to
conceive now, you ordered some investigations FSH low
LH, prolactin, thyroid all normal, what next
a. Serum progesterone
b. Serum testosterone
c. Pelvic ultrasound

391. 38 yrs old asking for COCP, she smokes 15 cigarettes, has family history of ovarian n breast cancer, she also has
history of premenstrual headaches what is most likely a contraindication/reason for not prescribing COCP to her
a. Her history of premenstrual headaches
b. family of ovarian cancer
c. Family ho breast cancer
d. Age
e. Smoking
https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-
criteria_508tagged.pdf

392. .patient taking ocp for very long period (time not mention) now complain of shoulder tip pain. What's the
diagnosis?

a.polymyalgia rheumatica
b.frozen shoulder
c.migraine
d. Cholestasis

Kehr's sign is the occurrence of acute pain in the tip of the shoulder due to the presence of blood or other
irritants in the peritoneal cavity when a person is lying down and the legs are elevated. Kehr's sign in
the left shoulder is considered a classic symptom of a ruptured spleen.[1] May result from
diaphragmatic or peridiaphragmatic lesions, renal calculi, splenic injury or ruptured ectopic pregnancy.

Kehr's sign is a classic example of referred pain: irritation of the diaphragm is signaled by the phrenic nerve
as pain in the area above the collarbone. This is because the supraclavicular nerves have the same
cervical nerves origin as the phrenic nerve, C3 and C4.

The discovery of this is often attributed to a German gall bladder surgeon named Hans Kehr, but extensive
studies into research he conducted during his life shows inconclusive evidence as to whether or not he
actually discovered it.

393. Q. Previous history of breast cancer . surgery done 10 years back. Now new mass on the breast . what could be
cause?
A. new mutation
B. .colon cancer
C. lung cancer
D. from opposite breast

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OBS RECALLS
1. A lady just presented for the first time for check up , she is about 19 weeks pregnant, she just relocated to
Australia and did not undergo antenatal care in her country. What is your advise?
⦁ Tell her to commence folinic acid
⦁ Tell her to book for antenatal program and follow the routine
⦁ Get her updated with needed immunizations
⦁ Refer her to tertiary hospital

2. 26 Yr old woman presented with slight lower abdominal pain on day 6 of her menstrual cycle.on examination
other than cervical excitation(cervical tenderness) there is no adnexal mass.what is your next inv to dx the
condition?
a. TVS
b. Cervical swab — pid or ectopic
c. Urine RE
d. TSH

3. pt postpartum with amenorrhea can’t breast fed her baby. Dx

a. pituitary adenoma
b. pituitary necrosis-sheehans syndr
c. asherman syndrome

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4. Helen Jones is a 19 year-old secretary who presents with a one year history of painless post-coital bleeding. She
takes a tri-sequential contraceptive pill. Clinical examination is normal except for a degree of cervical erosion.
Her Pap smear is reported as "inflammatory ". The MOST APPROPRIATE management is:-
a) Repeat smear after treatment with triple-sulpha cream
b) Change OCP to a more oestrogenic balance
c) Reassure, but review in six months
d) Refer for colposcopy
e) Change OCP to a more progestogenic balance (contro)
Jm 1088

The squamocolumnar junction, where the columnar secretory epithelium of the endocervical canal meets the
stratified squamous covering of the ectocervix, is located at the external os before puberty. As estrogen levels
rise during puberty, the cervical os opens, exposing the endocervical columnar epithelium onto the ectocervix.
This area of columnar cells on the ectocervix forms an area that is red and raw in appearance called an ectropion
(cervical erosion). It is then exposed to the acidic environment of the vagina and, through a process of squamous
metaplasia, transforms into stratified squamous epithelium.[1

5. Diabetic Pt with skin infections, staphylococcus detected.pt is on insulin, perindopril and combined ocp. going to
start rifampicin for 10 days. what to do
1)Increase insulin
2)increase perindopril
3)use alternate contraception

6. Fatty lady getting menopause. The vagina show

oestroginized.
a. peripheral conversion of androstenedione to oestrone.
b. Peripheral conversion of ---- to oestradiol
c. Exogenous oestrogen

in menopause there is no grafina follicle to produce

estradiol .... so the Adipose tissue convert Androgen to
Esterone

7. male patient with oligospermia, he had mumps during

childhood, he took cyclophosphamide for some reason and
stopped it, he’s currently on sulphasalazine. what’s
the cause of his infertility?
c. mumps
d. cyclphosphamide
e. sulphasalazine

sulphasalazine: All the 3 factors cause oligospermia

..in case of mumps ,oligospermia is common if
infection occurs after puberty or there mumps
induced orchitis.mumps infections in childhood rarely cause
infertility. cyclophosphamide also causes oligospermia but it
is temporary and reversible ..so after discontinuing the
drug, sperm count gets to normal , so that cant be the case
here, and as patient is currently taking sulphasalazine and oligospermia is a known side effect of the drug so this
seems more correct ans

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8. 65 yr old female comes to ur Gp clinic for
vulval pruritus and redness , her pap smear
was normal which was done 3 years back,
what will you rule out first in the management
of this patient..
a. Sexual abuse
b. DM
c. Candida
d. Vulval Ca in Situ
e. Oestrogen deficieny

The classic symptom is vulvar itching (pruritus),

reported in almost 90% of the women with
vulvar cancer. There can also be associated
pain, pain with intercourse, bleeding, vaginal
discharge, and/or painful urination (dysuria).
Pre-cancerous lesions or early vulvar cancers
may have mild or minimal symptoms.

9. A girl with acne and hirsutism.treatment?

a. Danazol
b. EE with cyproterone diane 35
c. EE with Yasmin
d. EE with progesterone
e. drosperinone
>1099

10. A girl with acne+hirsutism..initial mgmnt?

a- Anti androgens
b- isoretinoin for 20 weeks
c- isoretinoin for 6 weeks + tetracycline for 1st 2weeks
d- antiobiotics

11. Woman presents to clinic for recurrent vaginal herpes. She has had 5 such episodes by now. Earlier she was
treated with recurrent vaginal candidiasis. Now on examination you find a white plaque in the vagina when you
scrape it, it bleeds. Which of the following should you test in this woman?
a. Biopsy the lesion
b. HIV antibodies

candidiasis and recurrent herpes suggests immunocompromised status

12. Woman 3 hrs into labor, everything okay,

starts bleeding, bp drops, baby puls drops,
reason:
a. Placenta praevia,
b. amniotic embolist,
c. coagulation,
d. placenta accreta

An amniotic fluid embolism (AFE) is a rare childbirth (obstetric) emergency in which amniotic fluid, enters the
blood stream of the mother to trigger a serious reaction. This reaction then results in cardiorespiratory (heart and
lung) collapse and massive bleeding (coagulopathy).

Amniotic fluid embolism is suspected when a woman giving birth experiences very sudden insufficient oxygen to
body tissues, low blood pressure, and profuse bleeding due to defects in blood coagulation. Though symptoms

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 and signs can be profound, they also can be entirely absent. There is much variation in how each instance
progresses

13. women with 2 years after Filshie clip sterilization. Regular cycle with menorrhagia +, At this cycle, bleeding for 10
days with few clots. Pap smear normal 12 months
ago. Initial investigation? (exact option)
a. pap smear
b. Full blood count
c. ultrasound
d. Thyroid function test
e. Endometrial Biopsy

14. . primigravida delivered 3600gm baby spontaneously,

received oxytocin and placenta extracted 5 min after
delivery, uterus contracted, but she lost about 200 ml
blood vaginally mostly because of
a) retained placenta
b) lacerated delivery tract ?
c) coagulation disorder
d) uterine atony

15. A lady has just delivered a healthy 4.2 kg baby boy.

She has heavy bleeding of about 1000 ml soon after
delivery. On examination, the placenta is complete
and the uterus is well contracted. What is the cause
of the bleeding?
a. Amniotic fluid embolism
b. Laceration of genital tract
c. Uterine atony
d. Retained placenta

16. At the time of her annual examination, you find an

11-week-sized irregular uterus on an asymptomatic
40-year-old woman. Her last exam 1 year prior was
normal. Your next step in the management of this
patient is:

217
 a) Hysterectomy
b) Endometrial biopsy
c) Reexamination in 6 months
d) Fractional dilation and curettage
e) Gonadotropin releasing hormone agonist therapy(not
given<42)

17. 38 year old g1p0 38 weeks coming to ER after Spontaneous

rupture of membrane. After 3 hrs, no active contractions and
synto was commenced.. after 4 hrs assessment, uterine
contractions good but on continuous CTG monitoring there is 60
bpm with slow recovery to normal. On exam:LOA position, caput
1+ mould 1+? , cx dilated to 9 cm.What is your next appropriate
mx?
a. Add 1 L of NS
b. Stop synto
c. Forceps delivery
d. Vaccum delivery
e. Urgent CS

18. female had mastalgia for the last 1 year. Conservative

treatment has not worked. How would you manage this
patient?
a. Bromocriptine
b. Danazole or tamoxifen for severe mastalgia jm 1121
c. Clomiphene
d. OCP
e. NSAID’s (local is good)

19. lady with retroverted uterus, on examination the uterus is floating. Want to conceive . what to suggest?
a) do surgery for uterus
b)ICSI
c) wait for 12 months.

retroverted uterus does not appear to affect conception in any way(until complicated with PID or
endometriosis), and most women with retroverted uteruses will go on to experience healthy
pregnancies..

Rarely, a sharply tilted uterus is due to a disease such as endometriosis, an infection or prior
surgery. Although this may make it more challenging for the sperm to reach the egg, conception can
still occur. [2] A tipped uterus will usually right itself during the 10th to 12th week of pregnancy.
Rarely (1 in 3000 to 8000 pregnancies) a tipped uterus will cause painful and difficult urination, and
can cause severe urinary retention. Treatment for this condition (called "incarcerated uterus")
includes manual anteversion of the uterus, and usually requires intermittent or continuous catheter
drainage of the bladder until the problem is rectified or spontaneously resolves by the natural
enlargement of the uterus, which brings it out of the tipped position.[3] In addition to manual
anteversion and bladder drainage, treatment of urinary retention due to retroverted uterus can
require the use of a pessary, or even surgery, but often is as simple as having the pregnant mother
sleep on her stomach for a day or two, to allow the retroverted uterus to move forward.[4]
If a uterus does not right itself, it may be labeled persistent.

20. A lady was in Operation for hours and stayed in lithotomy position ( mentioned exactly)
After that she suffered of foot drop

218
 where the lesion
S1
neck of fibula
L5

21. scenario of nerve injury after lithotomy …which muscle is affected ???
Extensor Hallicus longus

Nerve Injuries in Lithotomy Position

Most Commmon: common peroneal (78%)
Etiology: compression
Risk Factors: low BMI, smoking, prolonged surgery
Manifestation: common peroneal is L4-S2, responsible for foot dorsiflextion and toe extension (thus leads to foot
drop)

22. patient 7 wk pregancy but uterus is 3cm palpable above pubic symphysis

a. molar pregnancy
b. polyhydramios-not in early pregnancy
c. Twin
d. Fibroid
e. E.Ectopic pregnancy

23. 35 yr old women, 40yr old man have no pregnant even though they try to it for 6 month. She has every 28-30day of
last 5 day menstruation. Initial m/m(not sure ,sorry)?
a. Semen analysis
b. Assessment of frequency and time of sexual intercourse*** coz only 6 months since trying.will investigate
after one year
c. Serum progesterone day 22 of next cycle

24. . Primipara woman in spontaneous labour. Membrane ruptured 1 hr ago. Head 2 cm above ischial spine, vagina
4cm dilated and fully effaced. 4 hrs later head is 1 cm above ischial spine and 5cm dilated. What is the best next
management?
a. Do another vag exam in 4 hours
b. Start oxytocin ans
c. C/S
d. Start lumbar epidural
e. Don’t remember other
**normal cervical dialation .5-10 cm/hr

25. Woman at 20 weeks gestation-presents with pain in lower abdomen, particularly when standing. Uterus is non
tender and soft. There is mild tenderness above pubic symphysis. Cause?
a. Pubic symphysis dysfunction ans
b. Ruptured uterus
c. Chorioamnionitis
d. UTI….. not in standing commonly

Symphysis pubis dysfunction (SPD) is a condition that causes excessive movement of the pubic symphysis,
either anterior or lateral, as well as associated pain, possibly because of a misalignment of the pelvis. Most
commonly associated with pregnancy and childbirth.
The severity of the pain can range from mild discomfort to extreme pain that interferes with routine
activities, family, social and professional life, and sleep.[2

26. Pregnant woman presenting with SOB and pain, SpO2 88%, nausea. Xray unremarkable (reported, no xray
shown). What is the best next step?
a. ECG….think about it as well cz there is pain

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 b. CTPA or lung scintigraphy if cxr is normal
c. US of leg
d. Heparin
Ans: vq
Its cause of Dvt

27. A primigravida lady 32 weeks of gestation smokes 30 cigarettes per day comes to your clinic with the complaints
of mild pedal edema and SOB.On examination lung is clear, O2 saturation is 90%. What will be your next step of
management?
a. V/Q ratio
b. CXR suspecting pul embolism
c. ECG
d. ECHO
e. CTPA-best

28. Uni Student female has been on OCP with 3 months of intermittent bleeding, informs GP she has had number of
different sexual partners recently. Last PAP test (recently) was normal. Best next management step?
a. Increase estrogen dose to 50mcg
b. Do a STD screening ans
c. Give progesterone only pill
d. IUD
e. Something else (there was no option to repeat PAP)

29. african lady had curcimsition now come for antenatal checkup.what to do?
a. Normal antenatal checkup
b. Vaginal dilator everyday
c. Reverse circumsition- aka deinfibulation…opd procedure…LA given…done to dilate vag opening

De-infibulation during pregnancy and labour

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 De-infibulation is a form of corrective surgery.
The available options should be discussed with the woman early in the pregnancy to facilitate appropriate
management.
If de-infibulation is requested by a pregnant woman, the procedure is best performed in the antenatal period
between 20 and 34 weeks gestation, to facilitate clinical care during pregnancy and labour.

30. Patient presented with increase vaginal bleeding

a. depot medroxy progesterone
b. progesterone in luteal phase
In menorrhagia
In ovulatory cycle(35-45 years)- 21 days progesterone
In anovulatory cycle(12-16 & 45-55 yrs) : 12 days(luteal phase) progesterone jm 1125

31. women from Africa. pregnant .have genital infibulation done in childhood. what advice u will give...
A.routine antenatal care
B. Regular use of vaginal dilator
C . c section

32. Women underwent total hysterectomy and bilateral oophorectomy , her sister has ovarian cancer . when to
give HRT ?
a. Before operation
b. Immediately after operation (young)
c. Only after symptoms of menopause arise (old)
d. 6 weeks post operative

If younger then immediately

If older then wait To symptoms come

Hrt is bad for ovarian and breast and endometrial ca

Good for bowel ca

33. A lady pregnant 37 weeks came with severe headache , see dots of light and her BP is 145/90. What will lead to
make an emergent intervention?
a. Increase knee reflex
b. Increase BP to 150/90 within 30 min
c. Leg edema

High blood pressure (Hypertension)

High blood pressure during pregnancy is one of the biggest red flags that preeclampsia may be developing. And
even if it's not a symptom of preeclampsia, it can still be a sign of a problem.
High blood pressure is traditionally defined as blood pressure of 140/90 or greater, measured on two separate
occasions six hours apart. During pregnancy, a rise in the lower number (diastolic) of 15 degrees or more, or a
rise in the upper number (systolic) of 30 degrees or more can also be a cause for concern.

Hyperreflexia is generally caused by an overreaction of the involuntary nervous system to stimulation.Deep

tendon reflexes are increased in many women prior to seizures, but seizures can also occur without hyperreflexia
Epigastric pain &headache &hyperrflexia are s&s of imminent eclampsia

34. 36 yrs old female migrates to Australia after living 6 yrs away from husband. In her country she was abducted
and raped by the militia. Now inv shows her to be syphilis positive but her husband RPR was negative 1 month
back. What to do to husband?
a. treat husband with ceftriaxone-rx is penicillin not ceftriaxone,but still can give
b. do nothing
c. repeat RPR after 3 months
d. do serial RPR for 3 months

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 According to sexual history and clinical stage of infection:
Primary syphilis: 3 months plus duration of symptoms
Secondary syphilis: 6 months plus duration of symptoms
Late latent syphilis: long term partners only
Presumptively treat all sexual contacts of patients with primary or secondary syphilis regardless of serology
with benzathine penicillin 1.8g IMI, stat

35. Mass extending from the iliac fossa to umbilicus, attached to internal structure but separate from the uterus and
rectum
a. Ovarian malignancy-hb
b. GIST
c. Uterine malignancy
A gastrointestinal stromal tumor (GIST) is a type of tumor that occurs in the gastrointestinal tract, most
commonly in the stomach or small intestine. The tumors are thought to grow from specialized cells found
in the gastrointestinal tract called interstitial cells of Cajal (ICCs) or precursors to these cells.Apr 28, 2020
Treatments: Imatinib
36. 32 weeks gravid woman , come with acute abd pain , she was suffering from cold and after repeated coughing
got the abd pain , fetal hr was good , dx?
a. rectus abdominis diastasis
b. placental abraption
37. 32 weeks gravid woman , come with acute abd pain , she was suffering from cold and after repeated coughing
got the abd pain , fetal hr 145 , dx?(no any bleeding
mention)
A. rectus sheath divarification
B. placental abruption
C. vasa previa
D. placenta previa
E. rectus muscle haematoma

38. Pcos senario given one was asking dx one about what u will
add beside weight reduction i opted metformin

39. . previously healthy woman came for AN 38 wk gestation

with 1L blood loss. Low lying placenta seen during 18 week
care and failed to follow up n USG check.
On exam: bp 100/70, Hb - slightly low. Which further
process will help u for dx?
Pain with bleeding-can be anythn
a. Fetal head high in position (placenta previea)
b. Uterus TENSENESS-ut soft and tender in pp
c. Absence fetal heart sound
d. Uterine contraction

40. 20 years old female came for the ocp advise.Her BMI is 27. She is having the history of premenstrual headache
and GERD. Her mother diagnosed to have breast CA in her age of 50 and the girl smokes 20 cigerrates per day
and two standard drinks too. What is the absolute contraindication for the OCP.
a. BMI-if >35=relative ci

222
 b. family HX of Breast CA- current h/o self cancer
c. Smoking- after age 35
d. Premenstrual headache migraine with focal
defecits(without aura)
e. Drinking
Jm1098

Absolute contraindications
• < 6 wks postpartum
• smoker over the age of 35 (>15 cigarettes per
day)
• hypertension (systolic > 160mmHg or
diastolic > 100mmHg)
• current of past histroy of venous
thromboembolism (VTE)
• ischemic heart disease
• history of cerebrovascular accident
• complicated valvular heart disease
(pulmonary hypertension, atrial fibrillation,
histroy of subacute bacterial endocarditis)
• migraine headache with focal neurological
symptoms
• breast cancer (current)
• diabetes with
retinopathy/nephropathy/neuropathy
• severe cirrhosis
• liver tumour (adenoma or hepatoma)
Relative contraindications
• smoker over the age of 35 (< 15 cigarettes per day)
• adequately controlled hypertension
• hypertension (systolic 140 -
159mmHg or diastolic 90 -
99mmHg)
• migrain headache over the
age of 35
• currently symptomatic
gallbladder disease
• mild cirrhosis
• history of combined OCP-
related cholestasis
• users of medications that
may interfere with OCP
metabolism

41. IOL planned due to pre-eclampsia...

Bishop score 2...what to do next..
A. Arm nd oxytocin
B. Elective lscs
C. Induce nd arm at 4 or 24 hrs
https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/diagnosis-and-management-
of-pre-eclampsia-and-eclampsia.pdf

42. 39 weeks pregnant female with Mild Preeclampsia With Bishop score 2. Best MX-
a.PGE2and amniotomy in 6 hr.
b.PGf2 and amniotomy in 12 hrs

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 c.Syntocinon
d.CS

43. 4 Women has 5 min contractions at 26 wk gastation her examination is normal os closed and no fluid in vagina in
addition to steroid what should be given,
a. Paracetamol
b. Antibiotics-first choice is nifedepine-ccb given in premature labour
c. Similar qs previously in old recalls –same scenario, qs itself states other than nifedepine wat to give-ans
is steroids

44. 17 girl has dyspareunia, worry about endometriosis because sister has infertility because of this. Examination:
nodule on ligament on vaginal palpation and some other description, what is important to diagnose
endometriosis:
a. nodule on ligament, specific to uterosacral ligament endometriosis
b. dyspareunia,-can be other causes too
c. menorrhagia,
d. family history

45. A lady presents at about 32 weeks GA, her last menstrual period was 11th April, she is not sure of her expected
date of delivery due to conflicting infos. She had usg during her 19th week GA which says that her EDD is 20th
jan, shr had another usg which states that her EDD is 28th jan. which is most reliable?
A) her last LMP
B) usg at 19th week GA-best is usg in 1st trimester
C) usg at 28th week GA
D) rest not reliable

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46. pregnant women at 37 weeks og gestation presented with pain RIF ..u admit and give antibiotics after few hours
she developed rebound tenderness temp 37.8 what will u do
Laparotomy-if confirmed
Laparoscopy-is suspected
Iv fluids
Induce labour

When the diagnosis is not clear, we recommend performing a laparoscopic exploration. During the third trimester
we recommend a conversion to an open appendectomy once the intra-operative diagnosis of appendicitis has
been made.

47. A pregnant lady with multiple gallstones came to a GP. He advised her cholecystectomy after delivery. Why?
a. risk of Ca gallbladder
b. increased risk of CHOLESTATIC jaundice in next pregnancy ANS
c. increased risk of Ca pancreas
d. increased risk for primary biliary cirrhosis

https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/RCOG-Obstetric-
Cholestasis.pdf?ext=.pdf

48. Women asks for Ogtt at her first antenatal...all results normal wat nxt
Do glucose tolerance at 28 weeks
Do glucose chalange test at 28 week-done previously now not preferred
Do hb a1c
No need

225
49. Preg lady developed pain lower abdomen
after cough followed by urti..on exam
tenderness on uterus..ctg norml showing fhr
of 160 pr mint
rectal sheath hematoma?

Diverticarin recti?
Ruptured uterus?

50. 32 weeks gravid woman , come with acute

abd pain , she was suffering from cold and
after repeated coughing got the abd pain ,
fetal hr was good , dx?
a. rectus abdominis diastasis
b.placental abruption
c. vasa previa
d. placenta previa

51. PPH Scenerio with 1000 ml blood loss after placenta spontaneous deliver in 5 min and synto given at time of
delivery now pt bleeding what is your first step in management?
a. Inspect vulva and vagina
b. Coagulation profile check
c. Inspect placenta
d. Massage of Fundus
e. Give morphine

52. couple trying to conceive. Female everything normal. Male azoospermia and small testes of 3ml size. Cause
a. Gonadotrophin deficeincy
b. Pituitary adenoma
C. Obstruction in vas deference
D. Klienfelter**** xxy

in gonadotrophin deficiency...testosterone level is decreased but testis will not be small

lanky(thin) man+small testes + infertility= Klinefelter

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53. Scenario of POF and the woman does not want to conceive. Management?
A- OCP****
B- HRT

As HRT is not contraceptive, counselling regarding

contraceptive options is important for women not
desiring pregnancy. COCP can provide both hormone
replacement and contraception and, if prescribed,
women should be advised to take it continuously or
long cycle, without the inactive pills, to avoid
intermittent periods of symptomatic oestrogen
deprivation.1 Other forms of contraception (eg
Implanon, progesterone-only pills, depot
medroxyprogesterone, intrauterine devices [IUDs])
provide contraception but not oestrogen replacement.
An option would be to use transdermal oestrogen with
the levonorgestrel IUD, thereby providing
contraception, symptom management and prevention
of long-term sequelae
https://www.racgp.org.au/afp/2017/june/premature-
ovarian-insufficiency-in-general-practice-meeting-the-
needs-of-women/

54. Pts 41 yr old, was trying to conceive form last 2 year,

after getting pregnant, there was spontaneous
abortion at 12 week. Now whats next.
a.. tell her to conceive as soon as possible
b.. ivf****-wont work without good eggs
C. egg donation

C Since she concieved after two years and that ended

up in a misscarriage. Due to advanced maternal age,
conception and retaining the fetus gets tougher due to
the quality of oocytes.
I think eveb if ivf is done with hr own egg it night result in the same problem. Probably a donated egg is the
answer to a successful conception.
https://www.babycenter.com/0_age-and-fertility-getting-pregnant-in-your-40s_1494699.bc

55. A 33 years old woman have been diagnosed with endometriosis, she is very worry and asked what is the least
common site for endometriosis
Ovary
Cervix****
Uterine wall
Pouch of Douglas
Bladder
The following sites are, in descending order, the most common sites of involvement found during
laparoscopy:
Ovaries>Posterior cul-de-sac>Broad ligament>Uterosacral ligament>Rectosigmoid colon>Bladder
>Distal ureter

56. 39 weeks pregnant female with Mild Preeclampsia With Bishop score 2. Best MX-
a.PGE2and amniotomy in 6 hr.
b.PGf2 and amniotomy in 12 hrs**

227
 c.Syntocinon
d.CS

57. Which test is most sensitive in detecting pelvic inflammatory disease (PID) ?
a) Cell culture
b) Endocervical biopsy
c) Enzyme immunoassay
d) Microscopy
e) Nucleic acid amplification test****

58. 18 39week gestation comes in for labour, bishop score 2, how to mx?
• iv oxytocin,
• give PEG1 and recheck in 4 hours.
• Give PGE2****
• C/s

228
59. A preg lady at 41 weeks and 3 days came with bishop score of 2 .What is the appropriate management?
Emergency LSCS
Admit and observe
Induction by oxytocin
Induction by prostaglandin***

60. 24 female amenorrhea 12 months, pain during sex, on examination uterus size normal, all examin. normal, what
will you suspect?
A. Pregnancy
B. Endometriosis
C.PID

61. what if the patient with RA trying to conceive?? We can give paracetamol,corticosteroids(best) and
hydroxychloroquine

62. Postpartum fever, Ampicillin started. Allergic rash started. Mother is breast feeding. What to give mother?
Vancomycin plus Ampicillin

229
 Ceftriaxone plus Gentamycin
Cephalexin plus metronidazole
Vancomycin+metronidazole +cefatriaxone****(metronidazole+ceftrioxone)

Endometritis
For more severe cases requiring empiric IV antibiotics
Amoxicillin 2g IV 6 hourly
+
Gentamicin as per the KEMH
Gentamicin Guideline
+
Metronidazole 500mg IV 12 hourly
For patients with non-type 1 hypersensitivity penicillin reactions or where
gentamicin is contraindicated
Ceftriaxone 2g IV daily
+
Metronidazole 500mg IV 12 hourly

For patients with type 1 hypersensitivity reactions to penicillin use

Clindamycin 600mg IV 8 hourly + Gentamicin as per the
KEMH Clinical Guideline

63. Postpartum fever in a lady allergic to amoxicillin:

a- Vancomycin + metronidazole + gentamycin
b- Flucloxacilin+vancomycin
c- Cefatrexoine + vancomycin
d- Metronidazole +vancomycin
e- Gentamycin + metronidazole**

64. 0.45 year old woman, a case of 2yr infertility , her children are 14, 15 and 20 years old, h/o endometriosis in
uterine lig , previous h/o pelvic operation, mid cycle sex. Which of the following is the cause of her infertility,
partner never fathered a child.

increased maternal age*****

sperm abnormality
ovulation problems
endometriosis
tubal pathology

65. Women came with infertility.has irregular period of avg 48days. Sex 3 times weekly. Asking cause –
1. Anovulation****
2. Endometriosis
3. Wrong time of intercourse

66. Suspecting endometriosis in a patient will reveal.

A. Uterosacral ligament densities*****
B. Tenderness on palpation of hypogastric area
C. Non tender abdomen
D. Adnexal tenderness
E. Normal Pap smear

A.Examination
Most women with endometriosis exhibit no abnormalityor minimal findings on physical
examination. Cluesto the diagnosis include uterine, adnexal or pouch of
Douglas tenderness, a tender fixed adnexal mass or a fixed retroverted uterus. The most suggestive

230
 sign is tenderness and nodularity in the pouch of Douglas or
uterosacral ligaments. In any pelvic examination where
endometriosis is suspected, a conscious effort should be
made to palpate this area by running the vaginal fingers
behind the cervix and onto the pouch of Douglas. The
palpation should then continue laterally to define the
bordering uterosacral ligaments. Nodularity in this area is
highly suggestive of endometriosis.
Positive findings are often are associated with more
severe disease and should increase clinical suspicion. This
may prompt more immediate recourse to specialist opinion
or surgery. They may also influence preoperative planning,
counselling and the use of bowel preparation

67. Pop safe to use a contraceptive method in all of the following situations except?
a. Previous pulmonary embolism
b. Endometriosis
c. Ovarian cysts****(qbank question)
d. Hypertension
e. Biliary tract disease

.It is advised not to use progesterone only pills if a female already has ovarian cysts Other
contraindications to use of the mini-pill include malabsorption syndromes, previous sex steroid-
dependent cancers(breast cancer), undiagnosed vaginal bleeding, previous ectopic pregnancy and
severe active liver disease.

68. Couple try to conceive last 12 mo. , female had all examinations normal , male SFA shows 35% motile(40 normal)
%, 45% normal morphology(>4% normal forms) , count 19 *10^6(> 15million) , asking your advice?
A) spontaneous pregnancy could be occur in the next 12 mo jm 1257
B) spontaneous pregnancy will not occur???
C) advice them to do IVF**
D) they need seminal donation

Motility – At least 50% of sperm must be motile in order for the sample to be normal. However,
progressive motility > 20% is usually sufficient for intrauterine insemination, provided that the
sperm count is adequate. Progressive motility < 10% usually requires IVF with ICSI. Sperm motility is
a critical factor.

69. 68 year old female have menopause at 55 , present with purulent brown-greenish vaginal discharge for 6 day ,
she is sexually active, what is the cause , previous pap smear normal jm 1156
a. Chlamydia
b.endometrial Ca*******
c.gonnorHea
d.ovarrain ca

70. Primigravida got abortion at 12 wks & want to conceive again. ask ur advice when to conceive??
a. she can start as soon as possible***need to wait atlst 6 months-12 mnths is for molar
b. take ocps for 12 months

71. 28yr old lady lst childbirth 3yrs back, regular cycles, trying for the second one, intercourse timed around
ovulation .. no tubal pathologies- confirmed, what's the reason for difficulty to conceive ?
A antibodies to semen
B. male infertility- abnormality of semen*** ** (secondary male infertility)
c shortened luteal phase

231
 D inappropriate timing

The symptoms of shortened luteal phase include:

spotting between periods
miscarriage
not being able to become pregnant
early menstrual cycles

72. A 28 year old married female complains of difficulty conceiving. Normal PE.
FSH –low Estrogen- normal
TSH-low
LH-low
Prolactin-normal
All blood chemistry normal
A. Pituitary macroadenoma
B. Pituitary microadenoma
C. Hypothalamic axis dysfunction**** jm 1254
D. PCOS

73. .female using 30mg ocp. presents with continuing painful periods. want to conceive after 12 to 15 months.
whatll u advise?
A- coninue same ocp
B- pop injectable.
C- use 50mg ocp.
D- use condoms and nsaids***
#gynobs

74. A 16 year old female presents with Sickle cell anaemia and heavy menstrual bleeding. What is the best treatment
of choice?
A. Combined Oral Contraceptive Pill (COCP)
B. Inj Depo Provera**
C. Mirena
D. IUCD
E. Implanon
http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/modernmedicine/modern-
medicine-feature-articles/bleeding-disorders-impact-re

232
233
https://www.aafp.org/afp/2010/0915/p621.html

234
75. Pt is on low dose OCP, complaining of breakthrough bleeding, what to give…
increase estrogen****…
b. increase progesterone…
c. advice high dose of both…

76. Mother has twins wants to breastfeed for contraception and she only wants to get pregnant after that. What
would be the factor that increases her risk for conception
1. Period like discharge
2. Unliateral mastitis
3. Multiple sex a week
4. One twin doesnt breast feed
5.Twins only breastfed at night

77. Newborn baby born to a diabetic mother at 36/40. Weight 4240g, APGAR 7/10, found to be cyanosed on his
hands and feet, also jittery. Axillary temperature was 37.2. He improved after aspiration and 100 % O2. The most
likely diagnosis is:
A. Hypoglycemia
B. Meconium aspiration
C. Heart disease
D. Lung disease(hyaline membrane disease or respiratory distress syndrome)
E.hypoxia??
Ans: transient tachypnea of newborn hb 187

78. Commonest cause for unsuccessful breastfeeding ?

a. Tired mother
b. Not keeping for long in each feed
c. Not feeding frequently-no breastmilk
d. Poor positioning****

79. Mother of twins. Does not want contraception other than breastfeed. What will indicate that she needs OCP?
-She has her period
-One twin doesn’t eat
-Twins only breastfed at night
-other options about twins breastfeeding less frequently

It can be A if bleeding occurs for any two consecutive days after 2 months of delivery ... And c is also
right as breast feeding is not done on continuous basis ..

80. 22 year-old primigravida complains of headaches, restlessness, sweating, and tachycardia. She is 16 week
pregnant and her blood pressure is 180/110 mmHg.
What is the best investigation for her?
a. Exploratory laparotomy
b. Mesenteric angiography
c. Head CT scan-sub arachnoid hemorrhage
d. Abdominal CT scan
e. Abdominal ultrasonogram-pheochromocytoma-best mri, next lap surgery before 24 weeks of pregnancy

235
 Pathway Diagram

he signs and symptoms of a pheochromocytoma are those of sympathetic nervous system

hyperactivity,[3] including:
Skin sensations
Flank pain
Elevated heart rate
Elevated blood pressure, including paroxysmal (sporadic, episodic) high blood pressure, which
sometimes can be more difficult to detect; another clue to the presence of pheochromocytoma is
orthostatic hypotension (a fall in systolic blood pressure greater than 20 mmHg or a fall in diastolic
blood pressure greater than 10 mmHg upon standing)
Palpitations
Anxiety often resembling that of a panic attack
Diaphoresis (excessive sweating)
Headaches – most common symptom
Pallor
Weight loss
Localized amyloid deposits found microscopically
Elevated blood glucose level (due primarily to catecholamine stimulation of lipolysis (breakdown of
stored fat) leading to high levels of free fatty acids and the subsequent inhibition of glucose uptake by
muscle cells. Further, stimulation of beta-adrenergic receptors leads to glycogenolysis and
gluconeogenesis and thus elevation of blood glucose levels).

81. lady with 4 cm dilatatation of cervix came to hospital.on examination cervix was 5 cm dilated, fetal head at ischial
spine,LOT position and ctg was of early deceleration.what to do now
a.immediate delivery
b.fetal scalp sampling
c.continuous ctg

236
 d.tocolytics

82. A preg lady at 39 weeks with no foetal movement or 24 hours .CTG picture with early deceleration (as I
understood) with normal foetal heart beat.Management
1-Admit and observe
2-Continious CTG
3-Ask her to come after 24 hrs for CTG
4-Ask her to dring juice and repeat CTG

237
83. A female came with complains of dysuria and multiple vulval ulcers. Asking for treatment?
Doxycycline
Vancyclovir
Ceftriaxone
Azithromycin
Benzylpenicillin

84. Contra indication of ocp

a. Strong family h/o epithelial ovarian Ca jm 1098
b. Family h/o breast Ca
c. Family h/o a DVT following a pelvic surgery
d. Hep A 3 years ago
e. Homozygous hemophilia

http://www.wnhs.health.wa.gov.au/development/manuals/O&G_guidelines/sectiona/9/a9.3.2.pdf

85. Vegetarian pregnant lady. In addition to folic acid she needs

1 iron and thiamine b1
2 iron and zinc

238
 3iron and vit c
4vit c and vitamin d
5 vit k and iron— jm 1177

86. A pregnant lady in 2nd trimester developed DVT. Was treated with Enoxaparin for 7 days. What to give till the
end of pregnancy?
a. Continue enoxaparin **cont till 6 weeks aft delivery
b. Warfarin
c. Give nothing

87. woman h/o recurrent genital herpes, last episode 8 months ago. Best way to prevent transmission to partner?
a. avoid sex when lesions
b. tell partner always use condom
c. prophylactic antiviral partner
d. prophylactic antiviral for woman

88. woman 7 weeks amennorhoea, vaginal bleeding episode. obese so pelvic examination difficult, home preg test
was positive, USG shows no gestational sac in uterus, no fluid in pouch of Douglass, cant exactly remember but
there was an apparent follicular ovarian cyst/corpus luteal cyst . how to manage?
a. serial beta hcg
b. ultrasound review in 2 weeks
c. repeat pelvic examination in 2 weeks
d. laparoscopy jm 1134

239
89. Women with secondary amenorrhea since 2yrs, BMI 23 well maintain goes to gym, periods previously regular
and has infertility too fsh 54, lh 55, prolactin 250 ,tsh 2.5 , estradiol 17 on us ovary has bilateral 2-3 cyst 40mm
what's the cause of infertility
a. Premature menopause — — bfr 40 yrs-fsh high(>40)-estrogen low-prolactin high
b. PCOS lh:fsh ratio high
c. Primary hypothyroidism-tsh normal range - 0.4 to 4
d. Prolactin secreting adenoma-fsh and lh and testosterone(in males) low

FSH stimulates the ovaries to produce estrogen, so levels of this hormone rise when estrogen levels
drop. FSH levels that are higher than 40 mIU/ml are considered diagnostic of the menopause. Levels
of ovarian hormones, such as estradiol, may be also measured, as low levels (levels less than 32
pg/ml) are suggestive of menopause.so A is the answer

240
90. A lady of 42 years comes with a breast lump. On exam she has a 2 or 4 cm cyst. Next
a. Usg
b. Fnac
c. <35 bil usg
d. 35-50 bil usg and mammo
e. >50 bil mammo

91. Invasive intraductal carcinoma with no lymph node involvement, Mx asked-

a. Total mastectomy
b. Partial mastectomy
c. Radiation

92. A pregnant woman came with urinary retention. When you tried to insert catheter, you find painful vesicles and
diagnosis is confirmed as herpes simplex. What to give?
a. Oral acyclovir
b. IV acyclovir
c. IV famcyclovir
d. Topical acyclovir
http://www.sahealth.sa.gov.au/wps/wcm/connect/91b9ab004ee4825781368dd150ce4f37/Genital+Herpes+Sim
plex+Virus+%28HSV%29+Infection+in+Pregnancy_PPG_v5.0.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-
91b9ab004ee4825781368dd150ce4f37-lNRZxle

93. A 50 year old lady diagnosed with rt ovarian tumor .which was find out to be secondary cancer.where the
primary cancer most likely?
a. 1-liver
b. 2-pancrease
c. 3-breast
d. 4-lungs
Hb 3.221-pg308-in underdeveloped countries-breast, in japan-stomach, in oz-colon

94. pregnant mid trimester with condylomata acuminata , all on the left labia majora , she did cryo but it increased
in number spreading more , what should you do
Topical antiviral
Surgical excision of the whole left labia majora

241
Operative cryotherapy
Ignore till after delivery

http://sti.guidelines.org.au

242
95. 65 year old lady nulliparous comes with painless bleed from the breast , her cousin had breast Ca , very short
stem. what is the diagnosis ?
Intraductal papilloma
Ductal ectasia
Invasive cancer
Paget disease
96. A 32 year old woman has increasing white vaginal discharge. She is 7 weeks pregnant. Her Chlamydia swab is
positive. All other tests are normal. What is the single most appropriate treatment?
a. Amoxicillin –first choice azithromycin
b. Clindamycin
c. Doxicycline -
d. Erythromycin -
e. Metronidazole

97. A women had to undergo laproscopy for the investigation of her infertility. Which of the following is not the
complication of laproscopy?
a. Hypercapnia
b. Emphysema to the peritoneal skin
c. Injury to common iliac vessels
d. Injury to posterior division of lumbosacral plexus
e. Hematoma formation

243
98. 33 year old female, in 3rd trimester, came with an injury which occurred due to the use of garden implements.
Her last DTPa was at 26 years. What is the most appropriate thing to do?
a) No immunization
b) Vaccine now***
c) Vaccine after birth
d) Vaccine and immunoglobulin now
e) Vaccine at 36 years of age

99. a woman came to your office with her 8 year old girl and ask your advice about HPV vaccine . what will you do ?
a. give her now**
b. advice after 10 years of age best recommended-12-14 yrs
c. needs to get it while he enters to college
d. need it when she begins her sexual relationship
http://www.hpvvaccine.org.au/the-hpv-vaccine/how-when-where-vaccine-given.aspx

Two doses are now recommended for those

aged 14 and under
Data now support the routine use of two doses
of HPV vaccine delivered 6–12 months apart in
people aged 14 and under at first dose.

Gardasil®9 (Seqirus/Merck & Co Inc) is a 9-

valent HPV vaccine (9vHPV; types 6, 11, 16, 18,
31, 33, 45, 52 and 58) registered in Australia for
use in females aged 9–45 years and males aged
9–26 years. From 2018 Gardasil®9 is the HPV
vaccine used in Australia's National HPV Vaccination Program

244
100. 39 weeks pregnant lady came with labour pain..she was put in left lateral position having oxygen mask in
place.iv fluids with syntocinon is running. Ctg was done which shows heart rate of 140 which dropped to 70 and
came back to 140 in 4 min. asking next appropriate treatment.
a. Fetal scalp sampling
b. Continuuous ctg monitoring
c. Stop syntocinon
d. C section ( <80bpm for >3min=severe bradycardia leading to hypoxia so immed delivery)

101. 39 weeks pregnant lady came with labour pain..she was put in left lateral position having oxygen mask in
place.iv fluids with syntocinon is running. Ctg was done which shows heart rate of 140 which dropped to 70 and
came back to 140 in 2min.asking next appropriate treatment.
a. Fetal scalp sampling Monitoring
b. Continuous ctg
c. Stop syntocinon
d. C section

102. 39 weeks pregnant lady came with labour pain..she was put in left lateral position having oxygen mask in
place.iv fluids with syntocinon is running 5 unit in 500 ml of Ringer lactate. Ctg was done which shows heart rate
of 140 which dropped to 70 and came back to 140 in 2min.asking next appropriate treatment.
A. Fetal scalp sampling
B. stop syntocinon bcos RX is asked snd only 2 mins ctg is done.
C. C section
D. Give 1 L of ringer lactate
E. Titrate to increase

103. 39 weeks pregnant lady came with labour pain…on iv fluids with syntocinon is running 5 unit in 500 ml of
Ringer lactate. .with irregular uterine contractions. Ctg was done which shows heart rate of 140, which dropped
to 70 and came back to 140 in 2min.what is the most appropriate next step.
A. give oxygen to mother via face mask
B. stop syntocinon
C. C section
D. fetal scalp sampling
E. Titrate to increase dose of syntocinon

104. mother Hep C positive. What to avoid during pregnancy to avoid transmission in infant?
a. breastfeeding
b. vaginal delivery
c. Antivirals in pregnancy
d. Fetal scalp sample

105. Young couple wz infertility, female Ix were normal, what in history’ll u ask the male pt 'll be most useful to
guide u to cause of infertility ?
a. Do u drink alcohol so much?
b. Did u get chicken pox infection for once while u were young?

106. 51 years old woman had her last menstruation 4 months back. She is complaining of host flushes and
insomnia. Which preparation is best for her?
a. Continuous HRT with oestrogen and progesterone
b. Cyclical HRT with oestrogen and 12 days progesterone (since its not been 1-2 years since her last period
continuous therapy is not given due to risk of breakthrough bleeding thus only cyclical is given.)
c. OCP
d. Oestrogen patches

107. A 30 years old woman comes to your clinic asking you for the best contraception for her.She doesn’t smoke,
and she has negative family and personal history of breast cancer. But she has one episode of DVT few months
ago, what will be your best contraception advice for her:
a. Use condoms

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 b. Use natural methods of contraception
c. Use low dose combined oral contraceptive pills
d. Use progesterone only pills-estrogen not given in dvt risk pts.
e. Trasdermal estrogen patch-can be chosen if postmenopausal for HRT, see nxt qs.

108. Post hysterectomy patient with history of DVT post operative after hysterectomy. Now comes with hot
flushes. Which HRT is best?
a. Low dose Oral estradiol
b. Oral estrogen plus Progesterone
c. Oral Progesterone alone
d. Transdermal estrogen patch ( because it has lesser risk for DVT otherwise chose oral estrogen)

109. A patient who has Factor V Laiden deficiency and a family history of DVT, comes for contraception. What will
you give beside condom?
a. Combined oral contraceptive pills
b. Progesterone only pills
c. Spermicidal gel
d. Transdermal estrogen patch
110. 18 years old girl come to clinic for HPV vaccination. Her Pap test last 6 months ago is normal. She has regular
three sexual partners. What will you recommend for her?
A. Do Pap test now
B. Give HPV vaccine as she request
C. Tell her that HPV vaccine is not effective for her
D. Check STD screenings and then give HPV vaccine- red book page 38,8th edition.

111. mother hc vpositive what will b best indicator of

child status
a. Hcv pcr at birth
b. Pcr at 18 months
c. Antibodies at 18 month

112. 4 w gestation hep C positive mother asking what

to do on next antenatal
a) Chlamydia PCR
b) Hep C PCR*** All hepatitis C antibody positive
women require confirmation of active infection by
hepatitis C RNA PCR on a further sample
c) Some other Hep C investigations

246
113. patient in labour, amniotomy done, Irregular contraction..CTG given BHR DROP to 80..for few min.Diagnosis
asked
1:amniotic fluid embolism
2:Placenta abruption
3:cord prolapsed (common in women who have had rupture of membranes and all others have bleeding
vaginally)
4:vasa previa

114. pregnant height 150 cm(5ft) , weight 45 kg , at 36 weeks , fundal hight 33. What dx is relevant with the
examination findings?
- constitutional small baby
- hypothyroidism
- membrane rupture

247
115. . 36 week pregnant lady present with pain in RUQ and fever, OE
mild tenderness in RUQ. After 24 hours, pain become severe and there
is abd tenderness and rigidity. Mx?
a. laparoscopy ( can be done in all trimester but preferable 2nd tri)
b. USG
c. urine culture
d. CTG
(for normal people)

116. 35 year old pregnant woman presented at 15 weeks gestation

asking you for a diagnostic screening of down, what is the diagnostic
screening test you should do for this woman?
A-nuchal translucency ultrasound
B-maternal serum and ultrasound
C-maternal serum
D-amniocentesis ****
E-chorionic villous sampling
Down syndrome diagnostic test in second trimester
screening tests in 1st tri: MSST(HCG and PAPP-A) and NT
Screening in 2nd tri :Quad screen testing blood- afp, estriol,
HCG, inhibin A
Diagnostic tests if positive: in 1st rti=chorionic villus
In 2nd tri=amniocentesis

117. A 32 primi came at 28 weeks having contractions , her examination 3 weeks ago was pretty normal so as the
baby too , u did a CTG , What is the best test to be done to reveal the problem of the baby and give a clue about
early intervention to save it
a. Fetal blood sampling
b. Mother serum for Ig anti D titration
c. B HCG
d. Ultrasound ***
e. Amniocentesis

248
 DHB

118. question of HELLP syndrome scenario one asking which clinical feature will help to dx?

249
 a. RUQ pain
b. fever
c. reduced fetal movements
d. bleeding PV

119. . another question of HELLP scenario asking for investigation

a. platelet count
b. CTG
c. USG
d. blood culture
e. urine culture

120. history of secondary amenorrhoea for 8 months after D and C. asking

for inv
a. FSH LH
b. testosterone
c. usg-asherman syndr
d. laparoscopy

121. 18 yrs old girl, BMI 17, slim, amenorrhoea and growth of fine hair. What will you check?
a. Fsh lh ratio
b. Prolactin

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122. Pregnant female with 12 weeks gestation (2nd pregnancy),
anti D antibodies present. What to do
a. Offer termination of pregnancy
b. USG
monitor ab titre

**In an alloimmunised rh pregnancy(second pregnancy

with anti d antibodies) first check for hydrops fetalis
second check for anemia in baby-by middle cerebral
artery peak systolic velocity MCA PSV or serial
amniocentesis.if anemia present then give blood
transfusions before birth and before 34 weeks bcoz
after this more disadvantages than benefits.

123. Middle aged lady 28 wks pregnant presents with vaginal

discharge this morning and continue discharging until now. Had
intercourse last night. H/O antepartum hemorrhage previously.
No abdominal tenderness. No fever. Fetal HR 140/min, regular.
Speculum examination shows straw color fluid. What is the
cause?
a. Serum from previous APH
b. Post coital fluid
c. Rupture of membrane???? (amniotic is pale yellow to
straw or amber colored)
d. Urinary incontinence

124. 26 year old woman complains of mild increase in her

menstrual flow for last 3 months.She also feels irritable during
menses.She believes that her decreased libido affecting her marriage. What is the appropriate management for
this patient?
a. High dose OCP without pill free week
b. Sertraline 100mg (ssri-antidepressant-given in this
case)
c. Evening primrose oil

125. woman with 3 sexual partner, last pap smear was 2

month ago and normal. Now coming for HPV vaccination,
what to do?
a. cervical swab for HPV
b. give vaccination
c. repeat pap smear
d. urine PCR for Chlamydia
126. 18 18 years pregnant woman with smoking. What will be
the most possible outcome if continued smoking in
pregnancy?
a. increased risk of preterm labour
b. IUGR????? (even preterm labour is right but IUGR %
is higher)
c. gestational diabetes
d. pre-eclampsia

127. Risk factor of Ca endometrium

a. Smoking
b. Cervical dysplasia
c. Obesity

251
 d. COC pills

128. Woman in post partum post perineal wound suture dehescience 1cm wide, 2cm long, 0.5 cm deep. What to
do
Leave the wound cleanly
Resuture in local anesthesia
Antibiotics

252
129. Patient with decreased Hb with cyclical menorrhagia. Hysteroscopy and D
and C done. Both normal.symptoms not improving,Wts next
a. levonorgestral releasing IUCD-needs permanent rx bcoz not stopping.
b. progesterone from day 15-25 of cycle
c. oral tranexamic study
d. COCP

130. young girl Came with menorrhagia. Absent from work because of menses
pain & heavy flow. From history & Xm, cannot find cause. You ordered
several lab investigations but she insists to give medication.Her cycles were
regular
A- OCP
B- Oestrogen patches
C- Mefenamic acid during period***NSAID first choice
D-tranexamic acid during period-does not relieve period pain

131. 13year girl come to your practice saying she wants ocp for
contraception,what will you do?
a. Give ocp
b. Tell parents
c. U can give after telling parents
d. Give ocp and tell her to say her boyfriend to use condom also

132. A 30year old lady comes for pap, asking she can get sti screening or not,in
councelling her wat will you tell about why we do Chlamydia screening?
A. It can be asymptomatic.
B. It causes infertility.
C. Because partners could be asymptomatic.
D. No need for screening-no indicators-and screening less than 30 yrs

Test for chlamydia in the following situations:

o <30 years and sexually active
o more than 2 partners in last year
o have had an STI in past 12 months
o have had a sexual partner with an STI
o at increased risk of complications of an STI e.g. termination of pregnancy (TOP) or
intrauterine device (IUD) insertion
o signs or symptoms suggestive of chlamydia
o patient requests a sexual health check

Seminoma investigation:
133. Alpha feto protein done. What next to do?
a. Testonsteron
b. Beta HCG-present in both but afp present only in NSGCT

134. Women after delivery, argometrin given, placenta delivered, heavy bleeding due to what:
a. Atonicity of uterus — common cause of postpartum hemorrhage is atonicity but its Rx is
ergometrine(causes contractions) which is alrdy given and still bleeding is not stoping so maybe
retained placenta
b. Retained Placent

135. Boy with mother complain was left testis is lower and larger than right and worried. What next:(contro)
a. Reassurance
b. USG of testis-usually left testis is lower but if larger than test

253
136. Woman using anti epilepsy drug. Want to contraception—
a. Continue Carbamazepine and increase dose of oestrogen

137. if woman on enzyme inducing anti epileptic(EI AEDs) (ex carbamazepine,phenytoin,phenobarbitone) drugs
the ocps are:
coc with high dose estogen on continuous therapy
second and more effective and lesser side effects are with depot medroxyprogestogen acetate(MPA)
injections or iud. Best levonorgestrol releasing IUCD.

138. A patient well controlled on carbamazepine wants to start OC pills.

A.Cease carbamazepine
B.Continue carbamazepine with low dose OC pills
C.Continue carbamazepine with high dose OC pills

139. Pregnant mother in her 28th week of gestation, diagnosed by Usg and hydrops fetalis was found.What
investigation will help you treat the hydrops?
a. Fetal blood sample for HB
b. Fetal heart usg
c. Fetal blood sample for CMV IgM
d. Maternal Coombs test — to check if it is immune hydrops(rh incompatibility) or non immune hydrops
(infectious causes like cmv thalassemia etc) ( to rule out Rh incompatibility JM 1193)

140. Patient underwent Conization for abnormal pap smear 2-3 days back. Now presents with fever 39, pain
lower abdomen and tenderness. What’s the most appropriate place to take a swab?
a. Blood culture
b. Endocervical swab
c. High vaginal swab
d. Low vaginal swab
e. Endometrial (don’t remember this one exactly)

254
141. woman is planning to do the IVF..she is well controlled on lithium..she takes 1000mg of lithium per day.what
to do now?
a) reduce the dose
b)cease lithium
c) check the blood lithium level.(for now)

142. . Husband doesnt want wife to take ocp, wife comes for ocp recall... what to say
a. Tell her it’s her wish give her choice of ocp
b. Go to local doc who will not bother husband’s wish

143. Pt in labour baby well.now no heart beat usg confirm baby dead. Cx 4 cm.. head 2 cm above ischial spine.
Along with mental support what to do
a. Amniotomy-to hasten the second stage of labour (cus she is already in labour)
b. Wait for spontaneous delivery (or womans choice while not in labour)
c. Cs
d. oxytocin

255
144. 38yr old women smokes 15 cig per day, has history of benign breast disease, has f/h of breast n ovarian ca
asking for ocp. What is the most imp contraindication for ocp
a. age
b. Smoking
c. F/h of breast ca
d. F/h of ovarian ca

145. Breastfeeding mom wants contraception but wishes to conceive once breastfeeding complete..
a. Pop-immediately
b. ocp
c. Iucd — wait 4 weeks aft birth
d. Depot — wait aft stopping to conceive
e. Implant — immediately aft birth
f. First line is implant,IUD,inj,mini pill,don’t give
http://www.fpv.org.au/for-you/contraception/postnatal-contraception

146. . 6 wk postpartum come for contraception. She is now on Breastfeeding & plan to give BF till 1 yr & want to
conceive immediately after she stopped contraception. .What to give ?
a. Cont. BF
b. OCP
c. low dose POP
d. Levonogestrol IUCD
e. Condoms

147. Lady thrombophilia heterozygous positive asking for contraception recall-GO FOR PROGESTOGEN ONLY
CONTRACEPTIVE PILL-LEVONORGESTREL

148. Strong f/h of dvt and pt with factor v laiden def comes for
contraception. What to give beside condom
a. Ocp
b. Pop
c. Spermicidal gel
d. transdermal estor/progesto

149. 20yrs breast lump recall...non tender mobile.inv?

a. Review in ....
b. Mamo
c. Usg
d. Fnac

150. Cyclical pain each month for 3 days in a teenage girl.. no

mass in abd, tanner stage 5, vaginal xm not done, asked cause
of pain
a. Torsion ovarian cyst
b. Corpus luteal cyst
c. Started ovulation

151. 38 yrs pregnant lady for hpv vx.

a. Indicated after delivery can be given upto 45 yrs in females,26 in males
b. Indicated now
c. Not indicated

People who should not have the HPV vaccine are:

o people with a yeast allergy
o pregnant women: however research has shown no significant effect on you or your baby if
you have the vaccine and later find out you are pregnant

256
 people with a bleeding disorder: they should talk to their doctor before having any vaccine
people with previous anaphylaxis (serious allergy) to a previous dose of the vaccine or any of the
vaccine ingredients.Not recommended in pregnancy, if dose has started then delay next dose till
pregnancy is completed

152. 24 yr sexually active woman now with post coital bleeding pap done 2m ago normal what next
a. Repeat pap
b. Urine pcr for chlamydia

153. 28 year old lady with post coital bleeding one-two separate occasions.Pap smear normal 2 months ago.What
next?
a. HPV serology
Chlamydia PCR
Pap smear
Thin Prep Pap test
Repeat Pap smear
154. 25 year old on OCP with post coital bleeding, last pap 18 months ago was normal. what next
A. Assure
B. Colposcopy
C. Repeat Pap
D. Do Thin Prep
E. Check for HPV
Jm 1088
In post coital bleeding if recent pap not done: do co test
In post coital bleeding if recent pap done: chlamydia pcr

155. lady 42 yrs sexually active with severe hot flush, mens irregular, 2 in last 6 months, on xm fsh and lh
increased, what to give
a. Cyclical hrt
b. Ocp
c. With uterus — give both
d. Without uterus — give ONLY ESTROGEN

156. lady with cyclical hrt had light vaginal bleeding now comes as she had no vag bleeding last 5 months what to
do
a. Change hrt
b. Continue same

157. One partogram and he asked management based on the partogram

257
https://www.ranzcog.edu.au/RANZCOG_SITE/media/DOCMAN-ARCHIVE/Partogram%20or%20instagram.pdf

258
158. .pregnant lady her friends told her take precautions in ur
usual diet.what she should not eat??
a..tinned salmon
b..coffee
c..soft cheese
d..fresh veg
e..Iodine

159. Woman has regular menses from 4-6 wk interval , pain on

left iliac fossa for 3 days ,aggravated while urination, her lmp
was 9 days back , she had similar episode 4 wks back which
lasted for 3 days , cause ?
a. Ovulation
b. complicated ovarian cyst — as with difficulty in urination, if
endometriosis present chose that
c. dysmenorrhea
d. early PID

Signs and symptoms of pelvic inflammatory

disease might include:
o Pain in your lower abdomen and pelvis
o Heavy vaginal discharge with an unpleasant odor
o Abnormal uterine bleeding, especially during or after intercourse, or between menstrual
cycles
o Pain or bleeding during intercourse
o Fever, sometimes with chills
o Painful or difficult urination

160. Young man, palpable smooth scrotal mass on left side.Palpable testicles Thickened cords. Dx?
a. Epididymal cyst more like epidydimitis but if only two go for this
b. Hydrocele

161. Women with amenorrhoea, previous D&C. What is the next investigation?
a. Laparoscopy
b. Hysteroscopy (best)
c. US
If menorrhagia then for sure nxt step is hysteroscopy for sure!!!

Foul smelling, green color vaginal discharge. Asked which drug to give
Dx trichomonas vaginalis Rx oral metronidazole or tinidazole and use vag tablets clotrimazole
during pregnancy and treat partner simultaneously.

259
162. A lady after 5 days(as I remember the days) postpartum,
not allow anyone to touch baby.. so concern about everyone,
even nurses. She thinks someone will take her baby. Ask Dx?
a. Postpartum psychosis
b. Depression
c. Schizophrenia

Best longterm contraception with complaints of

menorrhagia and dysmenorrhea
Is Mirena

163. 42 week term woman, Amniotomy done, clear liquor . Now

cervix is 8cm dilated and head at ischial spine.syntocin drip, CTG
shows heart dropping to 70 for 4 minutes with baseline heart
rate 110bpm. What next?
a.Fetal scalp ph
b. Immed CS
c.Ventous delivery

260
261
164. 48 year old woman complains of heavy menstrual bleeding for last 4 months. She underwent a hysteroscopy
and D&C but the symptoms did not subside. She looks pale and Her hemoglobin is 8.5 g/dl. What is the most
appropriate management in this case?
A-oral tranexamic acid during the period
B-northisterone from 15-25 days of cycle
C-mirena
D-implanon
E-COC

165. Woman, 39-40 years, taking OCP for 15 years, now high BP and doctors suggests to stop OCP now. She
doesn’t want to change the pill which works for her for a long time. She doesn’t want to conceive.
A- POP-bcos she is refusing other methods plus reliable for htn
B-Copper
C-IUCD
D-Implanon

166. Old lady taking HRT for 5 years, now her menopausal symptoms (hot flushes and some others) are
completely cured and she’s fine otherwise. What’s your management?
A- continue HRT-
B-stop HRT

167. .Woman with prescription of HRT.She has been taking HRT for 6 years now and no complaints.What will you
do?
Trial of ceasing HRT
REDUCE HRT
CONTINUE HRT
168. Woman around 40-45 years having heavy painful menstrual loss. With anemia which was corrected with iron
therapy. Her D&C and hysteroscopy is normal. What to give?-
A- Mirena-
B-copper
C-IUCD-
D-OCP-
E-implant
169. 35 year old lady comes to you regarding screening for breast cancer screening. She says her paternal aunt was
diagnosed with breast and ovarian cancer at the age of 60 years which was diagnosed as being associated with
BRCA1.Which of the following is the most appropriate advice?
A-Genetic counselling assessment –for brca h/o and h/o familial
brca and ovarian ca
B-refer for BRCA 1 screening
C-screen now
D-tell her to look at her breast
E-annual mammography
170. A woman is on HRT therapy. She suddenly felt intermittent
of blurred vision affected
her right eyes. Investigation shows right carotid stenosis 40 –
50% and left carotid stenosis
50 – 60%. Which is the most likely factor that can reduce risk of
stroke?
a) Cease HRT therapy.
b) Carotid endarectomy.
c) Start Transdermal Oestrogen

262
 171. 64
yrs old
lady came with dyspareunia. Usually uses lubricant while intercourse. Does not take any HTR. Cervix atrophied.
Vaginal wall red no discharge. Nxt mx
a) Vaginal oestrogen
b) Colposcopy.
c) Pap smear.
d) HRT.
e) Antifungal.
172. A 55 year old woman complained of vaginal dryness,vaginal burning and irritation which results in
dysparenia. Pelvic examination confirms the presence of atrophic vaginitis. No other abnormality is noted. She
has h/o breast ca and is on tamoxifen. What is the most appropiate management?
a. Non hormonal vaginal lubricants
b. vaginal oestrogen therapy
c. oral oestrogen replacement
d. COC pills
e. POP
173. 50 year old male comes to you for consultation due to decrease libido. He has decreased libido and hardly any
erections during masturbating and also complains of occasional early morning headaches on awakening. He has led a
good life and has 2 children aged 15 and 17. His BMI is 38 and his BP is 130/80 mm Hg. Lab investigation values for
tests done to evaluate his problems are as follows
FSH – 3 (1-18)
LH – 1.8 (2-20)
Prolactin 11 (<20)
Testosterone 200 (280 – 800)*
TSH 2.0 (0.5 – 4.0)
What further investigation would you advise to this patient ?
a. Sleep Studies
b. MRI
c) Karyotyping
d) USG testis
e) Thyroid scan

This patient has probably obstructive sleep apnea. His BMI is high with Headache and eractile dysfunction.
Apnea can causedecrease in testosterone as well
Causes of low testa-restless leg syndrome,stress,depression,ageing 60-65 and OSA

174. Patient BMI 32. Everything normal. Amenorrhoea for 12 month. Previously irregular (5-6 times yr). Now
came for infertility
Fsh 2 (normal <3)
LH normal
Prolactin 450 ( upto 700)
TSH Normal range
Oestradiol normal range
What inv to confirm
a. S.testosterone
b. Usg
c. CT scan
d. Endometrial biopsy
https://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=12&cad=rja&uact=8&ved=0ahUKEwig
xaHW1cvWAhUDwLwKHVbgAygQFghZMAs&url=http%3A%2F%2Fcontemporaryobgyn.modernmedicine.com%2F
contemporary-obgyn%2Fnews%2Fhormone-levels-and-pcos&usg=AOvVaw2sYb-9CtPFo8vL1DW3_Lcb

263
175. A32 yr old obese women with sec infertility BMI 32 FSH 2.2 LH 6.3 estradiol dec (sorry value not remember)
TSH normsl prolsctin normal what you advice next?
a. thyroid function test
b. endometrial sampling
c. ct abdomen
d. vaginal usg-PCOS-LH surge 2 -3 times
176. young lady with BMI 15 comes with secondary amenorrhoea.cycles were regular always. lanugo hair
present. all physical exam normal. cause?
a. PCOS
b. POF
c. Hypothelamic amenorrhoea

177. Couple come for infertility problem for the last 12 months. On testing examination and tests of the female
are unremarkable. Male has azospermia. And bilateral absence of vas deferens. Which of the following is most
appropriate before the starting the treatment of infertility?
a. No testing required as they can not have a child
b. Testing of both male and female for cystic fibrosis(same wording , no option of testing the male only)
c. Refer for IVF
d. D.serum fsh and lh for male
Absence of vas def is mostly ass e cystic fibrosis but can have kids with ivf

178. A woman 33 weeks of gestation comes to your clinic with increased BP 145/105, blurring of vision, headache and
some other symptom which I cannot recall, what to check that will require an immediate response?
a. presence of 5 jerks of clonus at ankle-late stage pre eclampsia
b. tenderness at left costal margin
c. bilateral hand edema
d. Increase in blood pressure in the next 30 minutes
(I forgot the last option)
Q42)
179. 30 weeks pregnant with UTI. Hx of facial rash and swelling with oral flucloxacillin. What to give?
a) Cephalexin –safe-broad spectrum
b) Nitrofurantoin –safe but contraindicated in 3rd trimester-
JM
c) Trimthorpim-not safe
d) Gentamicin-not safe

180. A woman came three days after abortion at 7 weeks

gestation. She got pregnant bcz she missed several
contraceptive pills. No children before. She and her boyfriend
dont want children for three years n want contraception will
you recommend for her at this vary moment?
a. IUD
b. COP
c. Depo provera
d. POP
e. OCP
Note: It’s completely safe to give IUD following abortion

181. 32 year old female , BMI 32, smoker, on

OCP, grandmother had breast ca at age 63 . Asks her risk of
getting breast ca. What will you advise?
a. Lose weight
b. Stop smoking
c. Change to low dose estrogen
d. Mammography
e. Regular breast self-exam
risk factor first is fam h/o

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182. Pregnant 10 weeks gestation presented with history of
contact with child known to have chicken pox, she has no hx of
chicken pox infection nor and unvaccinated for VZV. asking you
if she might be affected, her tests showed that she is
seropositive for VZV. What is your most appropriate next step?
A-reassure her that she is immunized
B-give her VZV vaccine
C-give her VZV immunoglobulin within 5 days
D-wait for further 1 month to see if she was affected
E-give her acyclovir

Depending on what seropositive meaning

If seropositive meaning that she is immunized igG +ve then

reassure

If meaning that igM +ve then give her acyclovir

If meaning igG -ve and igM -ve then immunoglobulins

From the stem im thinking she is infected so E based on her

saying not infected nor immunized

Within 96 hours from exposure > Zoster immunoglobulin

(ZIG) should be given to all seronegative women within
96 hrs-4 days
183. . 20 week pregnant lady came with pain full vesicles in the groin with dysuria, serology positive for chicken
pox mx
a. O. acyclovir
b. IV. Famicyclovir
c. IV. Acyclovir
d. O. Prednisolone

184. female px took rubella vaccine and came to you saying she is pregnant. what to do?
A. abortion
b. reassure that nothing will happen
c. do usg and see
d.start rubella treatment
185. 45 years old patient who has been treated for CA breast last 5 years ago. Amenorrhoea for 8 months and now
comes with complaints of hot flushed and insomnia. What is the best treatment to describe to her?
a) Paroxetine
b) Estrogen+ Progesterone
c) Alprazolam
d) Oestrogen
186. Young lady in 26wks of pregnancy came with PROM, cervix closed and baby is okay. There is no contractions.
There wer a hospital at 50km and other tertiary hospital at 150km. After giving antibiotic and glucocorticoids, what
should you do next?
a) send her to tertiary hospital 150km away
b) send her home
c) send her to primary hospital 50km away
d) give tocolytic
e) Send her to speciality hospital to treat the baby accordingly if it is born premature

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187. Female presents with oral ulcers, malise, lymphadenopathy and fever. When history is taken, she is sexually
active with her partner who is presently asymptomatic, what is the most likely diagnosis
a. HIV
b. EBV
c. CMV
d. (unable to remember the other options)

188. HIV screening for two partners, the male partner is positive and does not want the wife to know and said he will
use condom and you should not tell the partner, what to do?
a. Report to health authority for contact tracing
b. Tell both partner the results
c. Don’t tell the partner

189. Patient presnts with a breast lump, it was suspicious on Mammography and biopsy shows atypical ductal
hyperplasia
wide local excision or lumpectomy
Watchful waiting
c) radiotherapy

190. Women with history of hyperthyroidism taking carbamazipine, now euthyroid...comes to u for OCP advice
a) decrese carbamZipine and high dose OCP
b)stop carbamazipin and start OCP
c) increase carbamazipine,give OCP
d) increase carbamazipine with high dose OCP
e) decrese carbamazipine and low dose OCP

Therefore, if a women is on one of the AEDs and wishes to take the oral contraceptive pill, she will need to take a
preparation containing at least 50 microg of ethinylestradiol. Levonorgestrel implants are contraindicated in
women receiving these AEDs because of cases of contraceptive failure. It is recommended that
medroxyprogesterone injections be given every 10 rather than 12 weeks to women who are receiving AEDs

191. .lady on carbimazole for thyroid, now going to be pregnant.what to do?

A) continue carbimazole
b) stop carbimazole
c)decrease the dose
Proper method is to stop carbimazol;e and replace with propylthiouracil

192. 15 year old girl comes to u for OCP advice...few days later her mother also ur patient comes to u and ask
about her daughter's health issue....what to do
1,make an appointment with daughter again
2,tell mother that u cant tell anything
3,ask mother to discuss this with her daughter

A frequently faced problem is the request from a sexually active teenage girl for
advice on contraception, where the teenager makes it clear that her parents are not
to be informed of her attendance. Each case should be judged on its merits, but for
practical purposes it is generally permissible for doctors to treat teenagers who are
16 years or over, provided they are mature and appear to understand the proposed
treatment. If they meet these criteria, they are also entitled to have their medical
information kept confidential from their parents. When the teenager is under 16
or where doubt exists as to the maturity of a teenager over 16 years, greater care
must be taken and the doctor should endeavour to explain to the teenager the
need to obtain the consent of the parent or guardian as well, unless the minor
clearly objects. The doctor is not necessarily obliged to provide treatment to such
a minor, other than in an emergency.

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193. 12 week old pregnant lady was brought to the emergency department with vomiting, abdominal pain and
severe bleeding for the past 4 hours. She also had 2 fainitng attacks. Her bp is 80/40/ She was normal till before
this episode and usg at 11 weeks showed normal nuchal translucency. What is the most likely diagnosis?
A-Incomplete abortion
B-Complete abortion
C-Abruption placenta-aft 20 weeks
D-Ectopic pregnancy rupture
E-H. mole

Normal U/s finding exclude H.mole and ectopic pregnancy

Placental abruption occur in late pregnancy
So if she presented now At ER with severe vaginal bleeding its incomplete abortion
If at ER there is No vaginal bleeding and closed Os and No POC its complete abortion

194. 1)a female came to u asking after delivery of her child she intends to breastfeed her child for 12 months but
she want a reliable contraception method and she want to get pregnant after 1 year what will u advice :
a. COCP
b. POP
c. Depo provera
d. Merina
e. condom
Any of the above can be given
First choice; intradermal implant-immediately aft birth
IUCD-aft 4 weeks
Injection-waiat 6 weeks
Mini pill –after 4 wk
Coc-cant give estrogen until baby is 6 months old
condoms

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195. .32 year old woman with her mother recently diagnosed as breast cancer at 60 year age, worried if she got
breast cancer and asking advice , what is your most appropriate action?
a. reassure her that no further action is required
b. recommend and teach her
the systematic ways of
breast self-examination
c. annual mammography
with 6 monthly clinical
review
d. refer for genetic screening
e. ultrasound and
mammography now

196. 55yr woman came to ED with

dysparunia & vaginal atrophy.
Menopause at 50yrs of age & now
have vaginal stenosis & Dx is
lichen sclerosis. What will u give
her?
a. Hydrocortisone cream
b. Oestrogen cream
c. Antifungal
d. Topical Antibiotic
e. Conization

197. Pregnant lady at 16 weeks

comes to you for check up. She is
hepatitis C positive. What will you
check next?
a. HCV PCR
b. Chlamydia

It is recommended that individuals who are HCV positive have a

PCR test for HCV RNA, as the risk of perinatal transmission is
dependent on the presence of HCV RNA. Liver function tests
should be performed at the time of checking HCV RNA status.
As HIV co-infection increases the risk of transmission, HIV
status should be ascertained if not already performed

198. Gynecomastia photo, young man, bilateral parotid

swelling, came to you for scrotal swelling. You can get above
the swelling, alcoholic, smoker. What is the diagnosis?
a. Teratoma
b. Ledwig cell tumour
c. Alcoholic liver disesse-

199. Pregnant at 8 weeks antenatal visit, asking regarding

Influenza vaccine. What to tell her?
a. She should take it now-can take at any stage
b. She should take it at 12 weeks and never before it
c. No vaccination during pregnanc

200. .30-year-old lady presents at your clinic at 26 weeks of gestation.She is worried as she came in contact with a
child having chicken pox 24 hours ago.You checked her pre-pregnancy IgG level for chicken pox which was

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 negative.She missed to get vaccinated for chicken pox before pregnancy.She has no symptoms otherwise. What
is next best step in her management?
a. Check IgM level
b. Give vaccine for chicken pox
c. Check IgG level-if was not checked prebiously
d. Give varicella zoster immunuglobulins-within 5 days
e. No action needed as she is asymptomatic

if in contact first check IgG level to see if previously immunized or not….if seropositive no need
for immunization,if sero neg then immediately give IgG varicella zoster within 48hours ,also give
to immunocompromised pts.
Refer 1181 JM

201. 18 yrs girl three sexual partners and previous pap normal,Now Pregnant..asking about HPV vaccination –
a. Give Vaccine
b. Its Contraindicated

202. Lady going to be grandmother asks which vaccine is necessary to protect her grandchild.
Influenza-
DPT-
Typhoid

203. BMI 32 , Amenorrhoea 12 mths , come with infertility , FSH LH

are within normal range but LH:FSH ration is 3:1 ( LH 3 times
greater ) what will you do to know the cause of Amenorrhoea ?
a. Serum testerone
b. Vaginal USG

204. Pregnant lady with cord prolapse presentation and doc

decided to go for vaginal delivery what's in the ctg will change the
plan.
a. A: early decelerations..head compression
b. B: late decelerations….fetal distress
c. C: variable deceleration****

205. Variable deceleration pic for patient in Labour 4 cm. First step?
Observe
knee chest position***
Tocolytics

O2 mask>Lateral position>stop oxytocin>start tocolytics

Variable decelerations may be managed by placing oxygen via face-mask on the patient, positioning the
patient in a lateral position to improve uterine perfusion and reposition the fetus, and maximizing
intravenous fluid administration. If the patient is undergoing oxytocin infusion, the oxytocin
infusion may be temporarily stopped or decreased to allowing for fewer contractions, thus
reducing cord compression between the contracting uterine wall and cord. Tocolytics such as
terbutaline may also be considered if variable decelerations are present in areas of the fetal heart
tracing where hyper-stimulation is observed. Lastly, amnioinfusion is recommended for recurrent
moderate to severe variables.

206. . Placenta previa on ultrasound findings, patient with a normal progress delivery, what is consistent on CTG
findings

270
 A. Tachycardia
B. Early acceleration
C. late acceleration
D. late deceleration—— late deceleration is due to utero placental insufficiency
E. variable deceleration

207. 4th day puerperium with bright red bleeding and treatment
started with cephalosporin..what to add next
a.Gentamycin —— usually given along with
clindamycin….in cases where there is penicillin or
cephalosporin allergy
b.metronidazole***
c.amoxicillin

208. A lady with history of breast cancer, presented by severe

osteoporosis. What to give?
A. Bisphosphonate***
B. Paracetamol
C. HRT (combined estrogen and progesterone)

209. Only menorrhagia, no dysmenorrhea:

a. Mefenamic acid during menstrual cycle
b. Tranexamic acid during menstrual cycle****
c. NET from day 15-25
d. Cocp

210. A mother brought her 2 years old girl with history of blood stained vaginal discharge which regularly stained
the girl’s underwear. What would you do?
a. Parform Chlamydia and gonorrhea tests
b. Reassure the mother that is normal
c. Report to the child agency about sexual abuse****
d. Foreign body
e. Crohn's disease
Ø If there is redness in vaginal area it is vulvovaginitis
Ø If there is pure red discharge or any STI symptoms or
indications go for child abuse
Ø If there is offensive discharge than go for foreign body

211. old lady with some gyane procedure now with lower
abdominal pain, tenderness (PID) what is the treatment
a. Amoxy+metronidazole+Gentamicin***jm 1141
b. Doxycycline

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212. 32 weeks pregnant woman with previous minor bleeding(PP), presents with a breech presentation. Which of
the following is the management?
A- ECve now
B- ECV at 37 weeks –contraindicated bcoz of bleeding otherwise can do.
C- C.S at 35 weeks-if massive bleeding
D- C.S at 39 weeks**** jm 1196
E- Vaginal breech delivery
Ideally, ECV is done for breech presentations @36 weeks since
fetal repositioning after 36 weeks is unlikely, however, ECV can
still be done before 39 weeks.If at 39weeks after ECV
presentation is still mal presentation then it becomes an
indication for elective C/S.
if past history of bleeding was known to be massive, elective
C/S could have been planned earlier at 35 weeks when fetal
lung maturity is assured and plan for prematurity care.

213. some ECV Scenario 28 yrs old woman at 39 weeks

pregnancy is found to have a transverse lie.she is not in labour,
there is no other abnormalities, next step?
1.immediate us
2.external cephalic version
3.LSCS******…jm 1196
4.Tell her to come to see u in 2 weeks

214. 41 wk 3 days pregnancy with prev h/o CS..with complete

breech presentation, mild uterine contraction,bishop score 2 &
CTG is completely normal…wht will u do next??
a.CS**
b.induction by oxytocin
c.induction by prostaglandin
d.AROM
e.wait

215. Indication of Internal cephalic version?

A- first breech twin
B- second twin in transverse lie after delivery of first*******
C- failed ECV
D- shoulder dystocia
216. 35 weeks gestation with breech presentation what to do
a. A.External cephalic version
b. B.LUCS
@ 36 week go for ECV

217. 54 yr lady came for pap smear and all are fine ..but has slight heavy period…what next important? Already
given iron therapy.whats next ??
A iron studies
B monogram
C colonoscopy
D usg***
E CT

218. 22 yr old lady coming for breast cancer..usg done all normal…no family history… no mass…breast r all
fine.what next?
A reassure and no follow up****
B rs and 6 month fu
C rs and 12 month fu

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 D mammogram
E self breast examination

219. 17 yr old girls complaints of dyspareunia 3 months ago after she started sexual activity.had history of painful
menstruation since 11yr.on ve there is mass extending from just above hymenal remnant upto cervix os on the
right side.she didn’t use any contraception method.no fever.what dx?
A bartholin abscess
B wolffian duct cyst******
C right side ectopic pregnancy
D acute pelvic infection
A Gartner's duct cyst (sometimes incorrectly referred to as vaginal inclusion cyst) is a benign vaginal
cyst that originates from the Gartner's duct, which is a vestigial remnant of the mesonephric duct
(wolffian duct) in females.[1][2] They are typically small asymptomatic cysts that occur along the
lateral walls of the vagina, following the course of the duct. They can present in adolescence with
painful menstruation (Dysmenorrhea) or difficulty inserting a tampon. They can also enlarge to
substantial proportions and be mistaken for urethral diverticulum or cystocele.[3][4] In some rare
instances, they can be congenital.[2]
There is a small association between Gartner's duct cysts and metanephric urinary anomalies, such
as ectopic ureter & ipsilateral renal hypoplasia.[5] Symptoms of a Gartner's duct cyst include:
infections, bladder dysfunction, abdominal pain, vaginal discharge, and urinary incontinence

220. .Lady with dyspareunia and discomfort urinating, noted with a cystic mass from hymen to cervix on vaginal
examination, no fever, asking dx:
A. Bartolin abscess
B. Wolfian duct cyst***
C.Mullerian cyst

A Bartholin's cyst occurs when

Bartholin's gland, within the labia,
becomes blocked.[1] Small cysts may
result in few symptoms.[1] Large cysts
may result in swelling of one side of
the vagina, and pain with sex or
walking.[1] If the cyst becomes infected
an abscess occurs.[2] These are typically
red and very painful.

221. partograph q---.fetal heart rate was plotted on partograph ,,it was 120 b/min then dropped to 70 b/min.per
vaginal bleeding was nill, ARM(AMNIOTOY) was done,syntocinon was given what was the cause of this condition:
a)placenta previa
b)vasa previa
c)amniotic fluid embolism
d)umbilical cord prolapse.*** Obstetric interventions, such as amniotomy, induction of labour, external cephalic
version
o if cx fully dilated do operative del
o if not fully dil do cs
o first stop synto then air mask then ctg and then examine

222. Woman with 2 episodes of eclampsia and CTG shows bradycardia of 90 bpm. Wha is causing the bradycardia
a) Maternal hypoxia***
b) cord prolapse
c) uterine contractions on the head

223. 34 years female...mother got breast cancer at 60 years...now anxious...advice

1.reassure

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 2.recommend self breast examination
3. Look and feel for her breast

224. 32 year old woman with her mother recently diagnosed as breast cancer at 60 year age, worried if she got
breast cancer and asking advice , what is your most appropriate action?
A-reassure her that no further action is required—— in red book
B-recommend and teach her the systematic ways of breast self-examination
C-annual mammography with 6 monthly clinical review
D-refer for genetic screening
E-ultrasound and mammography now

225. Female...35..grandmother got breast and ovarian cancer and BRCA 1 positive
Ans.Genetic risk assessment
226. a pregnant lady 12 weeks with cramping pain came .abortion was done.on jehovah's witness she doesn't
want to take the anti d injection .what to do??
a)tell her anti d isn’t a blood product
b)tell her if she refuses thee will b problem in future baby
c)don’t give but take a signed copy of refusal case

227. An Rh –ve woman who is a Jehovah’s Witness, is

refusing to take anti-D immunoglobulin. Her baby is
found to be Rh +ve. What will you do next?
• Tell her to discuss this matter with her priest
• Try to convince her during review next week
• Tell her it's essential
• Tell her she may not get pregnant again
• Let her sign a letter of refusal
**take discuss and explain if in option

Jehovah's Witnesses believe that the Bible

prohibits ingesting blood and that Christians
should not accept blood transfusions or
donate or store their own blood for
transfusion. The belief is based on an
interpretation of scripture that differs from
that of other Christian denominations

228. pregnant woman at 34 weeks gestation presented at 32 weeks for antenatal care where her first USG was
done. Everything was normal. She has returned today with complaint that someone had told her she looks small.
What will you do to confirm with her that her progress is normal?
a) Repeat abdominal USG
b) symphysio-fundal height of 34cm at 35 weeks
c) examine her on next visit
d) If fundal height has been shown continuous linear growth, not to worry**** (if it is exactly the question)

because linear growth means the same rate of growth; for example 1cm per week and it is a
fixed rate whereas FH doesnt have a fixed rate of growth it might change on time or even
sometimes fixed.Linear growth means that it grows by the same amount in each time step. For
example you might have something that is 5 inches long on Monday morning and then 8 inches
long on Tuesday morning and then 11 inches long on Wednesday morning and so on

274
229. Laparoscopy pic of woman with PID given. She has done tubal insufflation test also.what is the most likely
associated findings?((( most associated findings thy
asked)))
-dyspareunia
-infertility..( complication)if asked what lead to
doing tubal insufflations
-discharge
-pain

230. Young couple with infertility. Women has mild

pain on sex.male semen analysis normal.women
has one tubal block on hysterosalpingogram. wht is
the cause of infertility?
Tubal block
Endometriosis****
-pain***Symptom-common symptom of PID
-discharge

231. Another case of PID. Commonest organism asked

a.N. Gonorrhoeae. (if chlamydia not in option)
b.E. Coli
c.Bacterial vaginosis
d.Trichomonas

Commonest: mixed vaginal pathogen

232. 24 yr old man with h/o undescendent testis and treated at 12 months age.now sperm count
1million/cumm.and decrease motility and abnormal morphology.next inv
a.fsh,lh****(lh more,fsh is low in male)in this pt it is high.
b testosterone
c.usg
d.karyotyping
Scrotal ultrasonography
Scrotal ultrasonography is indicated in patients with infertility and risk factors for testicular cancer (eg
cryptorchidism, atrophic testis, first-degree relative with testicular neoplasm), and can be useful in
clarifying physical examination findings. While it should not be a substitute for a physical examination,
a low threshold for requesting is appropriate.

233. 22.15 yr came with swelling in rt testis has dragging pain.otherwise normal.on examination testis r palpable
but there is a swelling over testis with only seen when standing and strain(most probably).what is appropriate
a.no inv
b.usg***
c.tumor marker
d.fnac
Dx: varicocele

234. female presented with left abdominal pain on 12 day of cycle.on usg 1.8 cm ovarian cyst. And endometrium
8mm. what will u do next
a.repeat usg after 3wks**** hb 200
B.cystectomy ( if > 3cm)

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 Rmi: risk of malignancy index

235. 16 yr come for contraceptive.stays either woman refugee shelter or on road.sometimes abuses sociality with
her friends.wat to give.(exact these are the lines)
a.ocp
b pop
c.depot medroxyprogesterone****
d.condom???
236. woman with h/o smoking.has family h/0 breast and ovarian cancer. Risk of endometrial cancer
a) smoking, (prevents endo ca)
b) obesity***,
c) cyclical HRT,
d) alcohol,
e) cervical dysplasia

276
237. 32 weeks gravida came to you she had pain for 4 hour in rt upper quandrant .she was well till 1 hour after
eating a hamburger.all examinations are normal only bp145/95.what will you do next?
a.ct abdomen
b.laparatomy***
c.obstetric usg
d.urinary creatine/protein ratio

238. a baby was delivered by foceps.apgar score 3 and

8 repectively.baby had excessive moulding of head
after delivery.on examination his left hand doesn’t
move.wats da cause-
a.early cerebral palsy
b.left brachial plexus injury****
c.hemiplegic paralysis

239. A 20 years old woman with type I DM with mild

renal failure, wants to conceive, what will be the risk
in her baby?
a. macrosomia
b. IUGR**

240. A woman with incontinence on laughing, sneezing, what investigation will u do to get the diagnosis?
a. bladder scan for overflow
b. urodynamic studies****
c. Urine Analysis
d.urine C & S
#GYNOBS

241. middle aged Australian woman,multipara, c/o inability to control her bladder past 3 months. She is afebrile.
Coughing , sneezing and laughing causes dribbling of urine.How do you define the exact cause of her
incontinence?

277
 Urine Analysis
Urine C&S
Urodynamic Studies****
Voiding Cystourethrogram

primary amenorrhea
242. 18 year old girl presented with primary amenorrhea. Secondary sex characteristics not developed. Her
height and weight also below normal. What's your next inv?(contro)
a. Fsh and lh levels***
b. Pelvic usg
c. Karyotyping

278
243. Billings ovulation method of contraception?
a. Abstain from sex until 17 days after period
b. Until a few days after peak mucus flow ****
c. When mucus is heaviest
d. When mucus looks clear

279
 fertile mucus – clear, watery, stringy, incr. in amount, feels lubricative
§ on ovulation – highest secretion
• ovum survives for 2 days + 1-2 days extra for safety => safe = 4 days after maximal mucus secretion (ovulation

244. patient planing for pregnancy and now for

prepregnancy counselling , patient has only one boy friend , no other sexual partner, what to ask to test
rubella***
CMV
Toxoplasmosis

245. 49 year old female lumbar progressive back pain. Past H/o Breast ca, OA. (L5-T1 pain) What amongst the
following clinical features will help you decide what investigation to do?
A.past history breast ca***
b. past history of OsteoArthritis
c.pain in back without trauma
d. high BP
e. radiculopathy(pain radiating to buttock)

246. Patient 32 weeks of pregnancy presented with headache . BP 160/ 94 protein 1+. After resting of thirty mins
, recheck BP 130 /70. . no protein in urine .normal blood pressure in previous clinic
A normal pregnancy
B. preeclampsia
C. pregnancy induced hypertension****(if normal pregnancy not in option, then choose pih)
Hypertension in pregnancy
1. Systolic blood pressure greater than or equal to 140 mmHg and/or
2. Diastolic blood pressure greater than or equal to 90 mmHg (Korotkoff 5)
These measurements should be confirmed by repeated readings over several hours.

247. 12 week pregnancy presented with right lower qudrant pain examination non tender , no rigidity , cause?
Round ligament strain ****
Acute appendicitis
Red degenation of fibroid
Torsion ovary
248. 24 yrs old female menorrhagia and dysmenorrhea . asked to do investigation but she resist for medication
Mefenamic****
Tranexamic
OC pill
IUCD

249. Pregnant woman at 32 week of gestation comes with back pain after lifting her child. Restricted in flexion
and extension and pain is radiated down to leg. What to give?
Observation
Paracetamol**** treat ist than keep her in observation
ibuprofen
diclofenac

250. A lady has history of PID and endometriosis of the uterosacral ligament surgery done 4 years ago and she
had chlamydia infection treated 2 years ago which of the following will lead to future infertility (contro)
Surgery
a. Chlamydia****JM 1252
b. PID
Endometriosis
https://yourfertility.org.au/resource/sexually-transmitted-infections-and-reproductive-outcomes/

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251. Female 32 weeks pregnant. Uterus 34 weeks, no tender. RUQ pain, headache, N&V, HT< Vitals stable. Lung
crepitations. BP increased. Liver normal size.Diagnosis?
A. Biliary colic.
B. Placental abruption(uterus tender)
c.HELLP ****
d. pneumonia

252. CMV related.

Q) Pregnant lady contacted with CMV affected person. Her blood results came are CMV IgM. Next important
step
1- terminate pregnancy
2- check her past history previous serology
3- repeat serology ( IgM and IgG) in the next 2 weeks.****
4- give antiviral Tx

253. A G2P1 came at 12 weeks of pregnancy for the second time. The first visit was at 4 weeks of pregnancy, now
in her lab tests: CMV IgM (+). What is the appropriate management?
a. Check her previous sample for Ig G and Ig M
b. Do amniocentesis
c. Do blood test again for Ig G****
d. USG in 18 weeks

254. Q.Lady came with CMV IgM positive at 16 week pregnancy how will you manage?
1) Offer termination
2)Take foetal blood sample
3) Repeat serology test for mother after 3 weeks****

255. Lady with symptoms of CMV infection and is also positive for IgM antibodies. Next step:
A. Offer termination of pregnancy
B. Vaccination
C. Immunoglobulin
D. Do nothing****

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256. 32 years old lady , 39 weeks pregnant presents with complaint of did not feel fetal for past 12 hours .She
was seen 2 weeks ago and everything was normal. what do you do?
A. CTG
B. USG***
C. Reassure
D. Review in 24 hours
E. Admit and observe

257. 39 wk pregnant lady comes to you because she did ’t feel fetal movement for 2 days, general condition good.
No pain and no loss per vagina. A CTG was given showing normal pattern. How will you advice her?
a. Come back in 24hr******* -if no fetal movement still
b. Come back in next routine followup
c. Admit and induce(near term and cervix favourable)
d. Admit and observ
e. Continuous CTG
https://www.racgp.org.au/afp/2014/november/decreased-fetal-movements-a-practical-approach-in-a-primary-
care-setting/
258. A pregnant of 37 weeks gestation comes with complains of reduced fetal movements for the last 24hrs..CTG
done it was normal and pt was sent home with reassurance…she now comes again after 3 days that she is not
feeling any baby movements..what’s the most appropriate next step?
a-immediate CTG***
b-obstetric USG
c- reassure that its normal at this gestation
d-Amniotomy
e-induction with prostaglandins hb page 69-70

259. man complains of white discharge ,, culture show diplococci (he mentioned it but no microscopic pic) , dx ?
Gonorrhea**** – chlamydia

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260. Young women with Hx of past 3 early miscarriage.She works as a nurse in the renal unit where there was
many cases of CMV..Most likely cause of Miscarriage?
A. CMV infection
B.Chromosomal abnormality**** (1 or 2 abortion, old age)
C.Maternal anticardiolipin Ab
The gestational age at the time of the SAB can provide clues about the cause. For instance,
nearly 70% of SABs in the first 12 weeks are due to chromosomal anomalies. However, losses
due to antiphospholipid syndrome (APS) and cervical incompetence tend to occur after the first
trimester.

261. 16 week primi came for antenatal check up.maternal screening done for congenital defects showed
following results 1:250 for FNTD 1:1000 for Down's syndrome.Next step in mx
Amniocentesis( Dx confirm)
US****(mx)
CVB
Reassure
Intermediate-risk women were divided into two subgroups for further analysis:
high-intermediate risk (1/101-1/250) and
low-intermediate risk (1/251-1/1000).
Low risk 1:1000
Medium risk 1: 50 to 1000
High risk 1: <5

262. female with bleeding 200 ml in her 39 weeks of gestation, she had stable vital signs, stable baby, uterus is
soft, on speculum exam there was no blood but the cervix was dilated 3 cm and membranes are clearly visible,
Ultrasound was done revealed placenta in fundus in posterior part of uterus. whats is your management :-
a. admission for observation****
b. send her home
c. urgent C/S
d. Artificial rupture of membrane
If the woman presents after 37+0 weeks of gestation, it is important to establish if the bleeding
is an APH or blood stained ‘show’; if the APH is spotting or the blood is streaked through mucus
it is unlikely to require active intervention. However, in the event of a minor or major APH,
induction of labour with the aim of achieving a vaginal delivery should be considered in order to
avoid adverse consequences potentially associated with a placental abruption.
Placenta praevia is when the placenta attaches inside the uterus but near or over the cervical
opening

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263. Pregnant female 18 weeks pregnancy .. presenting with sudden severe headache .. mild blurring of vision ..
drowsiness .. exam revealed normal
abdomen .. no uterine tenderness .. HTN
don’t remember the exact number .. you
take blood sample for lab .. what to do
next
A) Abd. US
😎 Fundus exam
C) CT brain
D) Urine culrure and sensitivity

264. A 41 year old lady with increasing

dyspareunia and burning sensation in
vagina not responding to clotrimazole
came to you. On examination you found
redness of vulva with a painless small

284
 ulcer on labia. What to do next?
A) VDRL****(painles ulcer >chancre)
B Vaginal Cytology
C) Vaginal swab for bacterial culture
D) PCR for Herpes simplex (painful)

265. In women of reproductive age the most common causes of vaginal irritation and discharge in DESCENDING
order of occurrence are:
1. Bacterial vaginosis, candidiasis, trichomoniasis****
2. Bacterial vaginosis, candidiasis, herpes simplex
3. Candidiasis, bacterial vaginosis, Chlamydia
4. Candidiasis, Chlamydia, herpes simplex
5. Chlamydia, bacterial vaginosis, trichomonas

266. A 25 yr old woman no history of diabetes or history of previous congenital malformed babies( spina bifida).
She is not on any anti epileptic drug or teratogenic drug. She asked for preconception advice on folic acid
therapy bcos a friend is taking them
a. Tell her its not important
b. B. Give her 5mg folic acid daily- only for high risk-on medications for epilepsy/seizures,type 1 DM or
previous h/o neural tube defects
c. Give her multivitamins
d. Give her low dose folate therapy***- daily supplement containing 0.5 mg of folic acid.
e. 5 another forgotten option

267. A 21 weeks nulliparous patient treated for ivf came with an inevitable abortion. usg done for fetus 270 g .
husband claims you should do your possible best to save the child. what arrangements will your delivery team
make
a. adequate resuscitation ****
b. arrange with a neonatal register for urgent referral
c. do not resuscitate

285
268. Patient 21 weeks pregnant after IVF. couple had been trying for 3 yrs but couldn’t conceive. now delivery
expected in 1 hr. fetal weight in previous 20 wks scan was 270 gms. mother and father both insisting on doing

286
 everything for the newborn. now the labour ward team gather up for devising a management plan. What should
be the appropriate management plan?
A-Advice against active resuscitation
B-Call neonatal retrieval unit for urgent transfer of neonate after birth
C-Provide full cardiopulmonary resuscitation
D-Bag and mask ventilation and cardiac massage of neonate after birth
E-transfer mother to a tertiary care hospital before birth

269. Pregnant woman who did not receive Hepatitis B vaccine before getting pregnant, gets exposed to Hep B
infection. How will you manage her?
a.Give Hep B vaccine and Immunoglobulin now
b.Give Hep B Ig now
c.Give the vaccine and Immunoglobulin after delivery****-for child
HBV unvaccinated women exposed to HBV should be offered (preferably within 24 hours)(2): •
Hepatitis B immunoglobulin HBIG (note: for sexual exposure, HBIG should not be administered
more than 2 weeks after exposure) • Hepatitis B vaccination(2)

270. A 36 year old woman with 3 children and BTL done, presents with some vaginal bleeds after intercourse. PAP
smear shows a CIN 3, her last PAP 2 years ago was normal. What is next in management?
a. Excision biopsy
b. Repeat Paps
c. Hysterectomy***
If colposcopy with biopsy present choose that otherwise biopsy.

271. A pregnant woman with CIN 3 lesion wht will u do

A. Cone biopsy
B. colposcopy
C. Observe
D. LEEP
JM 1092

287
272. A 36 year old woman with 3 children and BTL done, presents with some vaginal bleeds after intercourse. PAP
smear shows a CIN 3, her last PAP 2 years ago was normal. What is next in management?
a. Excision biopsy
b. Repeat Pap smear
c. Hysterectomy
d. Hysteriscopy and biopsy
e. Cone biopsy

273. An old woman came to the ED with vulvar erythema and vaginal pain. She had some symptoms of
candidiasis which was confirmed by labs. How will you treat this woman?jm 1157-58
a. Oral Nystatin-given vaginally
b. Oral Fluconazole—— actually given wen resistant and chronic cases and if vaginal therapy not tolerant by pt.
c. HRT
d. Topical estrogen***
e. Oral Clotrimazole –available only vaginally-first choice

274. 42 female with recurrent candidiasis from 12 months.Rx

topical miconazole
topical nystatin
oral ketoconazole
oral fluconazole

275. Female with recurrent candidiasis 4 times in last 6 months. Clotrimazole vaginal cream helped controlling
the symptoms last 3 times. What is the most
appropriate next step?
a. Oral Nystatin b. Oral Greisofulvin c. Oral Ketoconazole
d. Oral Fluconazole**** e. Vaginal Nystatin

276. A woman with a previous Caesarian section done

for a breech presentation, had her 2nd delivery few
hours ago vaginally. Ergometrine and Oxytocin were
given after delivery. She was found to bleeding per
vaginum ; uterus was soft and non-tender. What is
cause of the vaginal bleeding?
a. Uterine rupture
b. Accreta
c. Uterine atony***

277. A 42 year old woman presented with breast lump

which is diagnosed as intraductal carcinoma. What is
your next step in management?
a. Core biopsy
b. Hook wire excision
c. USG***

278. Patient is found to have calcified lesion on

screening. She had trauma to the breast some years
ago. The lesion is not palpable and is non-tender. What
is the most probable diagnosis? (contro)
a. Fibroadenoma
b. Breast cancer***(most common cause)
c. Ductal ectasia
d. Fatty necrosis( young lady)

279. A case of breast discharge with blood. Diagnosis asked

a. Fibroadenoma

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 b. Ductal ectasia(toothpaste like discharge)
c. Papilloma*** jm 1212
280. 39 weeks pregnant lady came with labour pain. Synto was given appropriately. Ctg was done which shows
heart rate of 140 which dropped to 70 and came back to 140 in 2min. asking next appropriate treatment. (Que
does not include any basic measure given for her like Left
lateral position, Oxygen, Fluid)
A. Stop syntocinon
B. Fetal scalp sampling
C. C section
D. Titrate to increase dose of syntocinon
E. Give O2 to mother via face mask
281. A lady having amenorrhea; FSH is slightly low. She is put on combined oral contraceptives pills. At what level
will these medications act?
a. Hypothalamus***
b. Pituitary
c. Ovary
d. uterus

The clinical literature now agrees that the inhibition of pituitary gonadotropin secretion is the most
important mode of action of OCs.

282. . A female with hot flushes and disturbed sleep, she had breast cancer 5 yr ago and treated with chemo nd
was ER –ve what is your appropriate management for this patient?
a. Paroxetine—— in h/o BrCa, tamoxifen for ER +ve
b. estrogen
c. HRT
d. clonidine

283. .pt conceived after IvF at is at 22 week gestation , preprom, going to deliver in one hour you are a gp at rural
area. Pts husband is anxious wt of baby is 270 g what is your next step in management of this pt?
a. arrange a neonatal retrival for successful referral after delivery
b. no active resuscitation
c. refer her to tertiary care >23 weeks, no need if not resuscitating
d. arrange for active resuscitation if >23 weeks
e. conticosteroids-if > 23 weekis

https://www.health.qld.gov.au/__data/assets/pdf_file/0023/142259/g-viability.pdf

284. .pregnant pt at 20 weeks with hsv infection on pcr. What is treatment for this pt?
a. oral acyclovir-
b. iv acyclovir
c. oral famciclovir
d. topical antiviral

285. old female pt, obese with mild rectocele, no cystocele, c/o stress incontinence, improve with pelvic floor
exercises but she feel socially embarrass. Next step in her management?
a. weighted vaginal cones
b. bladder suspension surgery
c. c)reduce weight

286. A 70 year old lady with stress incontinence. Urodynamic studies done after Pelvic floor exercises what’s the
best management for her?
a) Tension-free Vaginal Tape
b) Weighted cones in vagina
c) Burch's colposuspension
d) Local oestrogen cream
A, as this can be done under LA as well

289
287. 45 years old aged female , BMI 30 , urine incontinence when coughing or laughing....asking next appropriate:
A)Lose weight
B)vaginal cones
C)Vaginal tape

290
288. Pt.on ocp with sever abdominal pain during cycle?
1 fibrosis

291
 2endometriosis
3ovarian cycle
289. what causes most teratogenicity? Heroin/ marijuana/ alcohol / 2 more recreational drugs

290. A young lady complains of abdominal pain while urinating, she had menstrual period 8 days ago. She says
she also has this kind of pain 4 weeks ago and it lasted for 3 days. What is the cause?
a. Ectopic pregnancy
b. Ovulation pain
c. Complex ovarian cyst—— can be endometriosis (choc cyst),caused due to endometriosis
d. Endometriosis—— can cause painful urination as well as ovulation pain, other symptoms=more
bleeding during periods, pain during sex. INX: usg but lap definitive,Rx: lifestyle, ocps ,gnrh agonists,
progestins ,lap and hysterectomy.

291. . Female with recurrent candidiasis 4 times in last 6 months. Clotrimazole vaginal cream helped controlling
the symptoms last 3 times. What is the most appropriate next step?
a. Oral Nystatin-for recurrent cases given as vag pessaries in candidiasis
b. Oral Greisofulvin
c. Oral Ketoconazole
d. Oral Fluconazole
e. Vaginal Nystatin

292. 6th post partum day, presents with seizure GTCS, no previous episode or h/o seizure.3 episodes after
reaching ER controlled with Midazolam. next
a.Magnesium,—— first choice before ruling out eclampsia, give mg then do ct or eeg then if no t
eclampsia changer to phenytoin
b.phenytoin,
c. phenobarbitone,
d.valproate,

The treatment of eclampsia or any others seizure before, during, or after delivery is similar. MgSO4 and
intravenous anti-epileptic drug infusion are the first choices. Organic lesions should be ruled out by EEG
and brain computed tomography if medication fails after 24 hours. MgSO4 should be discontinued 24
hours after delivery to prevent overdose intoxication effects, such as respiratory deterioration. Because
eclampsia is frightening, there is a tendency to try and stop the convulsion. However, drugs such as
diazepam (valium) should not be given in an attempt to stop or shorten the convulsion, especially if the
patient does not have an intravenous line in place and if nobody skilled in intubation is available. If
diazepam is used, no more than 5 mg should be given over a 60-second period. Rapid administration of
diazepam may lead to apnea and/or cardiac arrest

293. . woman want to be pregnant on Na valproate for epilepsy, well controlled what to do
a. dec the dose of Na valp
b. change to phenytoin Na
c. stop the medication as she became good
d. leave her on the same dose of Na valp
Sodium valproate is the only effective treatment of juvenile myoclonic seizure.

Sodium valproate is generally avoided in pregnancy due to high risk of spina bifida, malformations
and coagulopathies if there is alternative treatment option is available.

Carbamazepine and phenytoin may worsen the seizure in juvenile myoclonic epilepsy and thus
should be avoided.Reducing the dose of sodium valproate should be considered if possible.

Lamotrigine is not as effective as valproate for treatment of juvenile myoclonic epilepsy and thus
not the appropriate option.

292
 So educate the patient about the risk of teratogenicity and then it would be her decision to whether
to conceive or not. The decision to conceive should be fully informed.

294. A 30-year-old lady at 36-weeks of pregnancy presents with blood pressure 140/95 mmHg, proteinuria,
headache and mild upper abdominal pain. What is the most appropriate management?
a. Give magnesium sulphate(next)-
b. Observe until full term
c. Full bed rest
d. Follow up in 1 week
e. Immediate vaginal delivery

295. A preg lady came at 30 wk her dates were confirmed on 10th week u/s and her 19th wk scan was fine her
ogtt at 28wk was normal but on exam her fundal height is 34 wk wat is reason for this
a) wrong dates
b) fibroid
c) ovarian tumor
d) full bladder
e) polyhydraminos****

296. on combined OCP, presents now with scenario of

migraine with aura asking what is appropriate
continue cocp b. its contraindicated c.review if has another
episode.
The combined contraceptive pill and the risk of
stroke. If you suffer from migraine with aura you
should not take the combined oral contraceptive
Pill. This is because the combined pill is associated
with a very small increased risk of ischaemic stroke.
... So progestogen-only contraceptives are a safer
alternative

297. sexually active young male,urethral discharge ,lab g-ve

diplococci,asking management??
a. Gonorrhea-ceftrixone, c tracing: 2month
b. Chlamydia-azithromycin, c tracing: 6 month
c. Syphilis-penicillin, c tracing: 3 month

298. A 32 year-old woman presented with increasingly severe

headache and two generalized fits 36 hours after the normal
vaginal delivery of her first baby at 40 weeks’ gestation. She
had been treated with epidural analgesia during labour.
On examination, her temperature was 37.6°C, she was
drowsy, there was a mild left hemiparesis and both plantar
responses were extensor. What is the most likely diagnosis?
A bacterial meningitis
B cortical thrombophlebitis
C pre-eclamptic toxemia
D subarachnoid haemorrhage
E viral encephalitis
299. Pregnant Lady at 8 wk gestation present with nausea and severe vomiting. On exam , she is dehydrated and
urine ketone +++. Her husband has GE.What to do to reveal the cause?
a. Pelvic ultrasound
b. Stool culture and microscopy
c. Urine culture and microscopy

293
 d. Blood culture
The missing option should be serum electrolytes urea and creatine.. As she os highly dehydrated and
ketonuria is positive so we should do serum electrolytes first... See hb question 3.318
e. R/o molar first

CVS ADULT
1. A 70-year-old male presented with left sided chest pain for last one hour and is found to have unstable angina on
further assessment. He has history of ischemic heart disease, type 2 diabetes mellitus and hypertension. You started
him on aspirin, clopidogrel, heparin and glyceryl trinitrate. Because of the ongoing chest pain, the cardiologist advised
you to start him on tirofiban. Which ONE of the following is not contraindication to use tirofiban? (anti platelet)
a. History of intracranial neoplasm
b. Acute pericarditis
c. Aortic dissection
d. Non-STEMI answer
e. History of vasculitis

STEMI AND NSTEMI both are indications pf tirofiban

294
2. years old girl presented with fever during examination ejection systolic murmur(3/6) was foundedat left sternal
border ur immediate step
a. Refer to cardiologist
b. Review after 2 weeks (innocent murmur) answer

(Rch.org.au )if doctor suspects innocent murmur then he may call the patient after the illness or after an appropriate
interval

3. systolic murmur was found in a girl who was collapsed in school and was brought to emergency a while ago , now
regain her consciousness ,her father died at age of 28 suddenly, what to do now as she want to go home :
a. discharge with opd refral to cardiologist (HOCM) answer
b. refer to gp in opd follow up
c. start bb
d. iv fluid

295
4. 1 yr old child growing well , good feeding , stand with assistance , sits unsupported , say some some sound like BABA ,
on exam. He had a systolic murmur, whats next?
A) refer hem to pediatric cardiologist ??
B) reassure her innocent murmur (innocent murmur) ??
C) send for urgent echo???
D) tell her that he could have a cong. Heart disease(????)
JM 1007

5. .A 45-year-old male presented to the emergency department with left sided chest pain radiating to the left arm and
jaw. There is no ECG changes and troponin is negative 4 hours since the onset of chest pain. He has been on sildenafil
for erectile dysfunction, metformin for type 2 diabetes mellitus, and ramipril for hypertension. What would be the
most appropriate treatment?
a. Nitrates(sildenafil so cant give)
b. Heparin
c. Morphin (reduce pain, unstable angina) answer
d. Beta blocker (we can choose this one if no pain)
e. Paracetamol
JM 444

6. A-72-year-old male presented with severe chest pain radiating to his back. On cardiac examination you notice diastolic
murmur. Chest X-ray shows wide mediastinum. ECG shows acute inferior myocardial infarction.
What is the most appropriate management
a. Give alteplase
b. Give aspirin and intravenous morphine
c. Give morphine, B-blocker and arrange for trans-oesophageal echocardiogram (aortic dissection) answer
d. Refer the patient to cardiology clinic
e. Consider urgent MRI of the cervical and thoracic spine
jm457 aortic dissection

296
7. A 65-year-old schizophrenic patient needs coronary angiography because of suspected myocardial infarction.
Cardiologist explained the procedure to the patient who did no understand the procedure. Who can give the consent
on behalf of the patient
1. The patient’s relative (guardianship court)
2. Mental health tribunal (can give consent only for mental illness) (ANS)
3. The patient
4. The court

* Operations and Treatment other than Emergency Treatment A medical superintendent may apply to the
Mental Health Review Tribunal, or to an authorised officer, for consent to perform a surgical operation or
special medical treatment (see below) on 18 a temporary patient, continued treatment patient, forensic
patient (suffering from mental illness) or any other patient detained in a hospital if, the patient is incapable
of giving consent, or is capable of giving consent and refuses to do so, or neither gives nor refuses consent
and the medical superintendent is of the opinion that the surgery or special treatment is desirable, having
regard to the patient’s interests. A medical superintendent may apply to the Mental Health Review Tribunal
or to an authorised officer, for consent to perform a surgical operation or special medical treatment on an
informal patient or a forensic patient (not suffering from mental illness), if in the medical superintendent’s
opinion, the patient is incapable of giving consent, and the medical superintendent is of the opinion that the
surgery or special treatment is desirable, having regard to the patient’s interests.

297
8. A 17 year old male was running a race and suddenly collapses on the floor. Luckily someone was there and performed
CPR as patient did not have a palpable pulse and resuscitated him. Upon arrival to the ED it is revealed that his father
died at age 28. He is now alert, asymptomatic, ECG was non eventful and he is anxious to go home. What would you
do next?
A. Send him home and arrange an outpatient consult with a cardiologist
B. Send him home.
C. Admit and refer for cardiologist team consult ANSWER
Because already an episode of sudden collapse so if you send him home he may die

298
9. a young athlete presents with history of sudden syncope and dyspnea. ecg shows Left ventricular hypertrophy.
patient's father had sudden death at very young age. initial treatment?
a. verapamil INITIAL ANSWER
b. septal myomectomy(most definite)
c. defibrillator
d. LMWH
e. adenosine
First cacium channel blocker and beta blocker in cardiomyopathy kaplan141

https://www.racgp.org.au/afp/2017/august/hypertrophic-cardiomyopathy-in-the-adolescent/

10. A young girl 15 yr collapsed at excercise,her father had HOCM,after ecg and echo u find no abnormality,next step
a)holter monitoring
b) stress echo for LVOTO ANSWER
Echo now
c)repeat echo after 3 year

11. A 9 year old male was running playing football and suddenly collapses
on the floor. Upon arrival to the ED it is revealed that his father died at
age 28. He is now alert, asymptomatic. What would you do next
a)holter monitoring
b)stress echo
c)repeat echo after 3 year
d) ECG ANSWER
E)ECHO
Jm 170 KAPLAN 144

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12. A teacher 30 yrs old, collapsed in school after exercise. Now presents wid SOB. A harsh systolic murmur is found in
right sternal area, radiating to neck
A. PDA
B. AS ANSWER
C. HOCM
D. VSD

13. Upon auscultation of a young child with fever for 5 days, a loud systolic murmur can be heard all over the
pericardium. He had fever. What to do regarding this murmur?
Refer to pediatrician
Refer to cardiologist
Review and auscultate the heart after fever is gone******
AS ITS SO LOUD THAT HEARD ALL OVER THE PRECORDIUM SO PAEDIATRICIAN WILL ASSESS

Often a Paediatrician will examine the child and may be able to confirm that the murmur is 'innocent', in which case
no further checks may be needed. If there is any continuing uncertainty, or if the doctor or the parents are anxious
about the issue, then a consultation with a paediatric cardiologist (childrenís heart specialist) may be helpful. – RCH

14. PT with Complete Heart block, but I was at a SUBURBAN hospital, asking the most appropriate Mx300??
A- refer by ambulance.
B- Refer Cardiologist.
C- Insert pacemaker (temporary pm) ANSWER

15. A baby delivered by normal vaginal delivery, is well after birth. On the 4th day, the baby is found collapsed in the cot,
breathless and floppy. On examination there are no murmurs. Possible cause could be--
a) TOF
b) PDA
c) TGA with VSD
d) Pulmonary stenosis
e) L. Ventricular Hypertrophy(COULDN’T EXCLUDE IT) ANSWER hypoplastic heart disease
IN SEVERE PS THERE IS NO MURMUR

300
Uptodate ref: above

TGA É VSD

16. You are in emergency department, you see patient with electric shock, he is alert, his pulse is regular, ECG normal, the
inlet was on the left hand, and the exit on the RT shoulder, what is your management?
a.Discharge him home, and if he has chest pain to com to the hospital.
b.Do cardiac enzymes, if normal discharge him.
c.Admit him in intensive care
d.Call cardiologist on call.

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JM1416

302
17. old lady presents with chest pain. She was on
nitroglycerine, diltiazem 60mg, digoxin 0.125mg, enalapril
xxx. On examination she is found with biventricular
enlargement. ECG: (seem to be grade II A-V block & T wave
inversions, ventricular entopic, HR: 50-65/ min). what is the
best management?
a. Stop all medications and review in 12 hours?
b. Increase the dose of digoxinc.
c. Commence of cardivolol.
d.Infusion of potassiume.
e. Commence on frusemide

18. girl collapsed in marathon. Father died at 27 yrs.

Resuscitation done and now girl is conscious and alert.
What to do next:-
- discharge with appointment of cardiologist
- admit under cardiologist ANSWER hocm
- discharge as she is ok now

19. Young kid with fever of 5 days .. mother give him paracetamol
.. exam revealed loud systolic murmur all over the pericardium
.. all other exam is normal .. no cyanosis .. chest X-ray is
normal , What is the diagnosis
a. TGA
b. Fallot 4
c. Innocent murmur
d. Pda
Other irrelevant options

20. Typical scenario .. asking what to do regarding this murmur

Refer to cardiologist
Refer to pediatrician (if low suspicion of innocent)
Review and auscultate the heart after fever is gone (if
innocent)
Other irrelevant options .. No option for echo are expected to
see one murmur question in AMC from cardiology. dont forget
to read ECG(5 ECG atleast). Eventually common ECG are given
.15 different diseases are enough for ECG example
MI,RBBB,SVT,VT,AF. But you need to familiar with those .
#let's see this topic given below regarding murmur

The combination of this patient's exertional dyspnea, dry

cough, and holosystolic murmur on auscultation are most suggestive of mitral regurgitation (MR).

303
 Now lets see this question,
Dont forget to check the previous notes by many seniors in this group searching with #note_this.
#Another tips from my side, discuss + memorize.People often forget to memorize after discussion. Write your own note in
small words after healthy discussion in amedex. Otherwise there will be no benefir.

21. Q.A 62-year-old Caucasian female is being evaluated after she had an episode of syncope. She complains of having
progressive exertional dyspnea over the last two months with an occasional dry cough. Cardiac auscultation findings
over the apex is holosystolic murmur. Which of the following best explains the physical findings in this patient?
A. Ascending aortic aneurysm
B. Constrictive pericarditis
C. Mitral regurgitation
D. Tricuspid valve stenosis
Mitral regurgitation can occur as a result of primary mitral valve disease (e.g. rheumatic heart disease,
infective endocarditis, or trauma) or may be associated with other cardiac conditions (e.g. ischemic heart
disease or hypertrophic cardiomyopathy).
(Choice A) An ascending aortic aneurysm can be associated with aortic regurgitation, which would result
in a diastolic murmur.
(Choice B) Although patients with constrictive pericarditis often present with exertional dyspnea, physical
findings such as elevated jugular venous pressure, pulsatile hepatomegaly, and signs of fluid overload are
often present as well.
(Choice D) Tricuspid stenosis would cause a diastolic murmur, not systolic. Rheumatic heart disease is
the most common cause of tricuspid stenosis.
Educational objective:
Mitral regurgitation classically results in a holosystolic murmur heard best at the apex with radiation to
the axilla. Common clinical features of MR include exertional dyspnea, fatigue, atrial fibrillation, and
signs of heart failure.

22. Patient with h/o chest pain 2 months ago..bp is

170/90...cholesterol is 8.5...smoker 30 pack year
history.Which one is the most important factor for
major cardiac event within 2 years?
BP
Smoking
Cholesterol
Angina ANS
Jm 443 951

23. Patient came with h/o dizziness on thiazide and

dioxin.bp while standing 90/60 and lying
130/80.S.Creatinine and urea raised.What to do
next? (contro)
Stop dioxin
Stop thiazide (drug induced orthostatic
hypotension)…Dr Tonmoy chose this as pt presents
with s/s of postural hypotension
Give dopamine
Give dobutamine

First stop dig treat toxicity then stop thiazide(we

don’t give in renal deranged functions) and add
loop plus spironolactone
Orthostatic hypotension indicates that maybe dose was higher than needed
patient on Digoxin and Thiazide diuretic for heart disease. Electrolytes were given, all normal except for K+

304
24. Atrial rate was 220 and there was variable AV dissociation with ventricular rate 100. Most appropriate next step:
a. Stop Thiazide and give potassium supplement
b. Give potassium supplement
c. Stop Digoxin and give potassium supplement

25. ECG bradycardia with hyperacute Twave only one strip….Middle age pt c/o light headache and syncopal attack 3
episode in one month, bp 100/60 0r 90/60 ??he is on multiple drugs.which drug combination will be the cause of his
problem? Actually confusing scenario not that simple….
A.Amiodarone +Aspirin
B.frusimide+Aspirin
C.Amlodipin+Amiodaron ans
D.Aspirin+ Nitrtriglycerite

Furosemide has an acute venodilator effect preceding its diuretic action, which is blocked by nonsteroidal
anti-inflammatory drugs. The ability of therapeutic doses of aspirin to block this effect of furosemide in
patients with CHF has not been studied. For comparison, the venodilator response to nitroglycerin (NTG)
was also studied.
Amiodarone causes brady and amlodipine causes hypotension. nitrates cause tachy.A and B has no potent
antihypertensive

26. ecg given..(some ectopics but didn’t understand well) of 65years old man on hypertensive treatment &history of MI
3yrs ago ,now all examination is normal except of soft blowing precordial murmur on the left border of sternum ..
what to do ?
a.cease metaprolol
b.cease metaprolol & commence verapamil
c. add warfarin
d/d
1.mi+murmur=valvopathy leading to embolism

305
2.IDCMP leading to MR leading to increased AF
3.Left ventricular aneurysm???
27. Post MI after 4 years cane to your clinic for follow up visit, the
patient is doing well. Still on diet and regular exercise with complete
normal lab work provided. He is on ace and aspirin only
a. reinforce diet and exercise
b. stop aspirin
c. add statin
d. complete in regular follow up
e. tell him he don't need any more follow up
JM448 and 449
28. old man coming from travel presents with increasing chest pain and
sweating with hypotension and ECG done it showed ST elevation in
lead 2 3 and avf with rbbb (rsR pattern) (can be previous one) is the
diagnosis ?
a- Acute inferior MI
b- PE
C lbbb
D pericarditis

29. male attack of angina and hypertensive, 170/? ,s.cholesterol 5.5, most risk factor for IHD?
A-Angina
B-BP
C-Cholesterol
JM 443 951
30. ECG wide complex , slow af biventricular failure, basal crepitation, E.F=40% on digoxin,lisnopril,verapamil ?
A. increase digoxin
B. stop all drug and check in 12 hours
C. decrease verapamil
D. Add lasix 20ml/day

CCF
31. svt ecg with a 50yr old with palpitation dizziness after morning
jogging.he is taking b blocker,frusemide acei digoxin some other
drug asking what should do in his management
a.serrum TSH
b.holter monitor
c.stop digoxin
SSS jm 808 AAFP
If arrhythmia then stop digoxin

306
32. Elderly man with multiple falls during the day especially in the morning after waking up. ECG found LVH and
multiple ventricular ectopics. Orthostatic hypotension was also noted. Hypertension is well controlled and so is
diabetes. How will investigate further?
A Repeated measure of BP in supine and prone positions
B 24 hour ECG holter ans
C Serum electrolytes. (HYPOKALAEMIA LEADING TO ARRHYTHMIAS BUT HERE FALLS CAUSE IS ORTHOSTSTATIC
HYPERTENSION MAILY SO FIX THE DOSE OF DIURETIC FIRST)

33. Ist degree heart block ECG in one old lady and told frequent dizziness complaint. Asked ix
a.Echo
b. Troponin Cardiac enzymes
c.Thyroid function tests
d. Holter monitoring

34. A young pt has got often light headness, dizziness, his clinical features are
normal, CXR, ECG normal, Holter monitor reveals ventricular ectopics:
a) reassure
b) ETT
c) /Dobutamine indeced echo/
d) plain echo answer …mitral valve prolapse jm 823

35. ECG of SVT..middle aged man presented to ER with breathlessness,

palpitation and dizziness after running for some time..he has travelled
from abroad 5 days back..ecg given..what wud u do next?..
a. troponin (no chest pain and no ecg findings)
b. holter
c. ctpa (ecg is of no use in Pe)

307
PE 445 JM .NORMALLY sinus tachy occurs with rbbb.but
rarely svt can also be there.few case reports on internet
shows.
36. Ecg of wpw in a 2yr old child.. bp not measurable.
what nxt
Dc cardioversion
Adenosin
Amiodarone
KAPLAN 155
37. Pt become Hypertensive after dialysis. Which drug will
you choose
A. Losartan
B. Amlodipine…
C. Frusemide
D. CarvideloL

308
38. a 50 year old man present with hypertension with asthma and
reflux nephropathy .lab inv were given.there was high
urea,high creatinine and proteiuria 900 mg/day.what is the
choice of anti HTN?
1.amlodipine
2.losartan
3.perindropil
4.indapamide
5.BB
Ref:Uptodate and Australian doctor

39. ECG of hypokalemia.Patient in

digoxin,furosemide,amlodipine(and some other
drugs.Which drug is the cause of this presentation?

a)Amlpodipine and Amiadarone

b)Furosemide and amlodipine
c)furosemide and amiadarone both causes hypokalemia
Amlodipine no effect on potassium
Jm 241 pg
40. Ecg of bradydia simple bradycardia not block as I noticed for pt
with multi pharmacy taking amlodipine frusemide amiodarone
digoxin and furosemide asking about the cause that may
produce light headedness dizziness and syncope
A. Furosemide amiodarone (torsade pointes cause tachycardia)
B.Amlodipine amiodarone(amlodipine more associated with
hypotension so can also be the answer,but no mention of
hypotension in the scenario)
C.Frusimide and digoxine

Confused between a and b..furosemide cause hypokalemia which

will lead to digitoxin toxicity.

41. Hyperkalemia ECG in pt with many medication which interaction

cause this ecg:

309
 A.amlodipine and amiodaron
B.amiodarone and aspirin
C.aspirin and fruesamide answer
D.amlopdepine and furosemide

42. Pt. with CHF taking b-blocker , furosemide , perindopril ,

K supplement , metformin for DM , start amiodarone due
to arrythmic problems , now complain of lightheadednes
and palpitation & feeling like syncope , what id the cause
?
A) perindopril + lasix
B)b blocker + lasix
c) K supplement + b blocker
d)amiodarone + furosemide
43. A patient on multiple drugs perindopril,atorvastatin, amlodipine,warfarin ,amiloride. On inv. he is found to b
diabetic and was put on glicazide. He presented after 24 hours with three episodes of hypoglycemia. Which drug
is responsible for enhanced effect of glicazide?????

******PERINDOPRIL(if warfarin not in option)

ATROVIASTATIN
AMLODIPINE
WARFARIN
AMILORIDE
http://www.medscape.com/viewarticle/856263

44. patient on amlodipine, amiodarone, furosemide, aspirine ,had

intermittent falls,reason? Ecg given.looked like hyperkalaemia.
A- amlodipine and furo(nothing and hypokalaemia done only by
frusemide)
B- amlodipin and amiodarone (amiodarone causing bradycardia
AND INCREASED AMLOPDIPINE CAUSE HYPTENSION, FALL)
C- aspirine and amlodipine. (HTN)
D- aspirin and furosemide answer(Hyperkalaemia)
Refernce mentioned above

310
45. 23yr old woman come to clinic for pre employment check up.she got type 1 DM since age of 13..
u perform a full physical xamination.her temp was 37.1,bp 146/89, pulse 54/min,rr 12/min.her skin is warm and
dry.cvs xam normal. she returns to d clinic several times and her bp remains high.. what is appropriate for her initial
treatment
ATENOLOL
AMLODIPINE
ENALAPRIL ans…as pt is diabetic and <55(another choice is arb)
FRUSEMIDE
HYDROCHLOROTHIAZIDE

46. Man with history of hemochromatosis. He is in intensive care unit. Has flapping tremors. He is confused and restless.
He also has ascites with shifting dullness. Ascites tap done which shows
Cells – 300
LDH –
Which of the following is the most appropriate immediate management?
A) Amlodipine
B) Albumin
C) Lactulose
D) Cefotaxime answer

SBP.do paracentasis and if pmn leuco greater than 250 in ascitic fluid start empiric antibiotic(cefotaxime)
before culture results

47. Hyperkalemia ecg, poly pharmacy patient,onamidarone, amilodipine, fruesmide, aspirin

a.aspirin+amlodipine answer
b.frusimide+ amidarone
c.frusimide+amilodipne
d.amidaron+amlodipine
e. Aspirin + amiodarone

Asprin causes hyperkalemia.A and E both can be.but choosing A because amio causes hypokalemia.
48. long scenario about multiple drug including : ramipril amlodipine , hydrochlorothiazide,
celecoxib, asking about which combination making muscle weakness without tenderness
?
A. ramipril and HCT
B. amiloride and ramipril [side effect-muscle weakness]..both causing hyperkalemia
C. celecoxib and HCT[ cz muscle pain]

311
49. ECG given of an old female on polypharmacy haloperidol,methadone,amlodipine found unconscious on the floor of
her home with a succide note and empty packets of pills. Dx asked
a. long QT answer haloperidil n methadone cause long qt syndrome n torsade de pointis
b. AF
c. ST T wave changes
d. inferolateral MI
haloperidol toxicity

50. pt With u/l renal atery stenosis with hypertension... Drug of choice..
Metoprolol
Hydrochlothiazide
Perindopril answer
Spironolactone
Amlodipine pg 970 jm

51. Known HTN pt presented with muscle weakness. K 6.5. What could be the cause?
A. Enalapril answer
B. Amiloride
C. Simvastatin
D. Thiazide
E. Amlodipine

52. #CARDIOPatient with polypharma presented with repeated syncope, ECG strip was given and asked about
combination responsible about that
a. Amlodipine + amiodarone BRADY CARDIA N SYNCOPE !!answer
b. Frusemide + amiodarone… HYPOKALEMIA .. LONG QT !
c. Aspirin + amoidarone
d. Frusemide + amlodipine

312
53. Patient with CHF taking B-blocker , furosemide , perindopril , K supplement , Metformin for DM , started
Amiodarone due to arrythmic problems , now complain of lightheadedness and palpitation & feeling like
syncope. Potassium level was given about 6.5 and other lab values were within normal range
A.Metformin & amiodarone
B.Metformin & K supplement
C.Frusemide & Perindopril
D.Frusemide & Metformin
E. Amiodarone +Perindopril (ans)

54. An old man with congestive heart failure and hypothyroidism. On levothyroxine, digoxin, and other medications
came with light headedness and palpitations. His Hr was 140 regular. The ECG picture was given very close to the
below one. Wt should you do:
1 Cease thyroxine (reduces tachycardia)
2 . Stop digoxin (reduces tachycardia)
3. Decrease digoxin
4 . Add metoprolol. (My answer) ecg finding svt...
5. Cease both drugs

NORMAL FETAL CIRCULATION

https://en.wikipedia.org/wiki/Fetal_circulation

313
Structure
Blood from the placenta is carried to the fetus by the umbilical vein. In humans, less than a third of this enters the
fetal ductus venosus and is carried to the inferior vena cava,[2] while the rest enters the liver proper from the inferior
border of the liver. The branch of the umbilical vein that supplies the right lobe of the liver first joins with the portal
vein. The blood then moves to the right atrium of the heart. In the fetus, there is an opening between the right and
left atrium (the (foramen ovale), and most of the blood flows through this hole directly into the left atrium from the
right atrium, thus bypassing pulmonary circulation. The continuation of this blood flow is into the left ventricle, and
from there it is pumped through the aorta into the body. Some of the blood moves from the aorta through the
internal iliac arteries to the umbilical arteries, and re-enters the placenta, where carbon dioxide and other waste
products from the fetus are taken up and enter the maternal circulation.[1]
Some of the blood entering the right atrium does not pass directly to the left atrium through the (foramen ovale, but
enters the right ventricle and is pumped into the pulmonary artery. In the fetus, there is a special connection
between the pulmonary artery and the aorta, called the ductus arteriosus, which directs most of this blood away
from the lungs (which are not being used for (respiration at this point as the fetus is suspended in amniotic fluid).[1]

Placenta
The circulatory system of the mother is not directly connected to that of the fetus, so the placenta functions as the
respiratory center for the fetus as well as a site of filtration for plasma nutrients and wastes. Water, glucose, amino
acids, vitamins, and inorganic salts freely diffuse across the placenta along with oxygen. The uterine arteries carry
blood to the placenta, and the blood permeates the sponge-like material there. Oxygen then diffuses from the
placenta to the chorionic villus, an alveolus-like structure, where it is then carried to the umbilical vein.

After birth
Main article: Adaptation to extrauterine life
At birth, when the infant breathes for the first time, there is a decrease in the resistance in the pulmonary
vasculature, which causes the pressure in the left atrium to increase relative to the pressure in the right atrium. This
leads to the closure of the (foramen ovale, which is then referred to as the (fossa ovalis. Additionally, the increase in
the concentration of oxygen in the blood leads to a decrease in prostaglandins, causing closure of the ductus
arteriosus. These closures prevent blood from bypassing pulmonary circulation, and therefore allow the neonate's
blood to become oxygenated in the newly operational lungs.[3]
Sometimes these postnatal closures are incomplete or absent. The vessels or cross-connections remain open
(patent), leading to the following conditions:

Patent foramen ovale in the heart

Patent ductus arteriosus in the great vessels

Patent ductus venosus in the great vessels

INNOCENT MURMURS

Kaplan 111
JM 1007

55. A child 5 days old brought by mother complaining that child is crying excessively . otherwise child is growing
normally, gaining wt. on examination everything normal and child is having systolic murmur
a. reassurance
b. urgent referral to paediatrician (ans)

The majority of murmurs in infants and children are innocent murmurs, also referred to as functional
murmurs specially in an Asymptomatic child.

314
Innocent murmurs
Sensitive (changes with child's position or
with respiration)
Short duration (not holosystolic)
Single (no associated clicks or gallops)
Small (murmur limited to a small area and
not radiating)
Soft (low amplitude)
Sweet (not harsh-sounding)
Systolic (occurs and is limited to systole.

Pathologic murmurs:
Harsh systolic ejection murmur at the upper
left or right sternal border
Harsh pansystolic murmur at the left sternal
border
Continuous murmur
Blowing, high-pitched systolic murmur at the
apex

https://www.rch.org.au/cardiology/parent_info/Innocent_Murmur/
https://pediatricheartspecialists.com/blog/66-3-common-innocent-murmurs-in-children
http://www.aafp.org/afp/2011/1001/p793.html

56. What is the most likely persentation of venous hum & innocent murmur in a new born? > A.the murmur
disappers on change in postion > B.the intensity of murmur is 4/6 > C.The presence of cyanosis >

AAAA

57. Young child with fever for 5 days. Mother gave him Tab Paracetamol. Examination revealed loud systolic murmur
all over the pericardium. All other exams are normal. No cyanosis. C x ray is normal. What is the diagnosis?
TGA
TOF
INNOCENT MURMUR (ANS)

58. A baby cries a lot ,10 days old,on paediatric examination he has systolic murmur otherwise well and growing
well.
A.reassure because it is normal
B.admit hospital
C.immediate ecg
D.refer to paediatrician (ANS)

315
59. On examining Child (aged 18 months), whom you are seeing for the first time, you hear a heart murmur. Which
of the following clinical findings would suggest that this is an innocent heart murmur? a) The murmur is diastolic
b) The murmur is associated with a thrill c) The murmur is pansystolic > d) The murmur disappears when the
child lies down > e) The murmur is associated with reduced exercise tolerance >
DDDDD

60. 1 yr old child growing well , good feeding , stand with assistance , sits unsupported , say some some sound like
BABA , on exam. He had a systolic murmur ,whats next ?
A)refer hem to pediatric cardiologist
B) reassure her 316
C) send for urgent echo
D) tell her that he could have a cong. Heart dis

61. a young boy presents with his father c/o URTI.on exm doctor found a murmur which is grade 2/6,change in
position,no other abnormal finding.dx? > a.pathological murmur > b.physiological murmur > c.VSD >

BBBB

62. A 4 yrs old girl is found on medical examination to have murmur, which is not changing with position. What is
your management? > a- Observation > b- Reassuring the parents > c- It should be explained that she needs
further investigation

Cccc
63. 3 years old girl presented with fever during examination
ejection systolic murmur(3/6) was founded at left sternal
border ur immediate step
Refer to cardiologist
Review after 2 weeks (ANS)

64. 10 year old boy on examination u found murmur.What next?

Urgent referral to pediatrician (ANS)
Reassure it's innocent

65. Upon auscultation of a young child with fever for 5 days, a loud systolic murmur can be heard all over the
pericardium. He had fever. What to do regarding this murmur?
Refer to pediatrician
Refer to cardiologist
Review and auscultate the heart after fever is gone (ANS)

316
VSD
66. 6 months old female child found to have a heart murmur at
the routine checkup. She has been healthy previously
weight + height normal. Not cyanosed + has no chest
deformity. There is a palpable thrill at the Lt sternal edge.
Apex beat palpable in the 5th ICS on the MCL. She has a
grade 4/6 systolic cardiac murmur max in the let sternal
edge radiate to the axilla + back. No variation with
respiration on postural change. Which is the most likely
diagnosis?

A-TOF

B-Mitral Stenosis

C -ASD

D –VSD

E-Benign cardiac murmur

DDDD hb q 2.143

317
67. A 6 months old infant with a systolic murmur and failure to thrive has a cardiac catheterisation for possible CHD.
The following O2 saturation were obtained with the infant breathing air..
RA - 67% (67)
RV- 80% ( 69)
PA- 80% (69)
LA- 96% (>95)
LV- 97% ( >95)
Aorta- 96% (>95)
based on these catheter findings, which one of the following is the most likely diagnosis?
A.TOF
B.ASD
C.PDA
D.VSD (ANS)
E.TGA

68. Child, normal delivery, presents to GP for a checkup. On exam acyanotic and found systolic murmur on left lower
sternum edge. Whats Dx?

A-Tetralogy of Fallot

B -ASD …systolic ,left 2nd 3rd intercostal space

C -VSD

D -TGA

69. A 6 yrs old boy during routine school medical examination was found to have a high pansystolic murmur loudest
at the left sternal border. He was not cyanosed. CXR showed mild cardiomegaly and pulmonary plethora. What
will be your advice to his mother?

a- That he has atrial septal defect –ejection systolic left middle to upper sternal border
b- That he needs further investigations
c- That the murmur most probably will disappear when he grow older
d- That he has patent ductus arteriosus
e- That he has patent pulmonary stenosis –systolic ejection murmur and left ics 2 space

Needs echo to rule out further complications of large VSD. On CXR there is cardiomegaly (left/biventricular
hypertrophy) large defect causes dysnpea and feeding difficulties, poor growth, sweating, pulmonary infection, HF
Harsh holosystolic murmur over lower left sternal border and thrill

318
70. Which one of the following CHD close spontaneously?
Small VSD in 12 month old baby (ans)
b- ASD in 3 year old
c- PDA in a 3 month old
d- Large VSD in 1 year old
e- PDA in a 1 year old

71. Which of the following conditions usually resolves spontaneously?

Congenital heart block

Patent ductus in 15 yrs boy

c-Atrial septal defect

d- Small ventricular septal defect

Dddd

72. 10 day old child develop dyspnea,he`s pale and dusky.On auscultation systolic murmur heard on the left sternal
border,diagnosis? > A. ASD > B. VSD > C. TOF > D. PDA >

BBB

Lower murmur: vsd

Upper murmur: TOF

73. A 4 yo child has loud pansystolic murmurs at left sternal border and all over the precardium. Chest Xray showed
pulmonary plethora and the apex extended to axilla. The diagnosis is:
a) VSD (ANS)
b) PDA
c) ASD
d) transposition of great vessels
e)MR

74. 3 years old child previously well was seen for viral infection
on exam ejection systolic murmur was heard at upper left
eternal border chest clear no displacement
Innocent murmur
Asd (ANS)
Vsd
PDA
Tof

( after a long scenario ) ..

319
75. of a 16 yrs old male who presentes with ejection murmur in second left intercostal space , which of the following
is likely to be the diagnosis :?
A- ASD with aortic stenosis...as should be in rt side 127 kaplan 1021 jm
B- ASD with mitral stenosis
C- ASD with pulmonary HTN
D-ASD with aortic regurgitation

76. 21 years old lady has exertion dyspnea, wide split 2nd heart sound, murmur on 2nd leftintercostal area. What’s the
diagnosis?
a) ASD…wide and fixed spliting
b) VSD.....
c) MS...........
d) Pulmonary stenosis…only wide

77. cardio Female pregnant of 18 wks. On examination diastolic murmur found on left sternumand systolic murmur
on tricuspid area, S2 wide splitting. What will be the Dx: CONTRO(recaller reversed the location of murmur)

320
a.ASD
b.VSD
c.pda
d.tof

Midsystolic Murmurs
Midsystolic murmurs — also known as systolic ejection murmurs, or SEM — include the murmurs of aortic stenosis,
pulmonic stenosis, hypertrophic obstructive cardiomyopathy and atrial septal defects. A midsystolic murmur begins
just after the S1 heart sound and terminates just before the P2 heart sound, thus S1 and S2 will be distinctly audible.
The term midsystolic is preferred to SEM because many lesions that produce midsystolic murmurs are unrelated to
systolic ejection.

321
Next topic:

HEART FAILURE

78. Which of the following will be the best sign of cardiac failure in a 6 months old child?
Increased
Cyanosis
Dysponea
Ankle oedema
e- Hepatomegaly > jm 1071
EEE

How is a heart condition diagnosed?

About one third of affected babies develop symptoms in the early weeks of life. The abnormalities which are present
in some babies lead to mixing of dark (blue) blood from the veins with the bright (red) blood from the lungs. The
blood then flowing to the body and its organs is dark instead of being bright. This produces a bluish colour of the lips
and skin (called cyanosis), hence the term 'blue baby'.

322
In other children, even if blueness is
not present, the heart may not be
able to perform the extra work
caused by the abnormality. Such
children may develop symptoms,
such as marked shortness of breath
and difficulty with feeding. This is
usually due to build up of fluid
(congestion) in the lungs or other
organs such as the liver. Doctors
refer to this congestion as 'heart
failure'.

In at least half of the children with

heart abnormalities, there are no
symptoms and the disorder is
recognised when the child has an
illness, or during a routine
examination. The condition is
usually recognised by the presence
of a heart murmur, heard with the
doctor's stethoscope while
examining the heart. These
murmurs result from turbulence in
the flow of blood as the heart
beats. Many heart abnormalities
lead to greatly increased turbulence
and hence produce quite loud
murmurs. However, murmurs are
not always due to heart defects and
may have no significance. About
50% of children with normal hearts
have faint heart murmurs. These
'innocent murmurs' tend to be
more apparent during illnesses
associated with fever, and this is
when they are often detected.

79. WOF is helpful sign of congestive heart failure? > a- Enlarged liver…if child > b- Increased jugular venous
pressure…if adult > c- Splenomegaly > d- Oedema > e- Dyspnea >
Aaaaa
PDA

Kaplan 114

80. child has a continous murmur on the left parasternal region and radiating to the left axilla,the child is
acynotic.CXR shows plethora Ds
a-VSD
b-PDA
BBB

Patent ductus arteriosus (PDA) describes a preservation of the connection between the pulmonary artery and the
aorta that exists in the fetus (see Figure 8). Since aortic diastolic pressure is higher than pulmonary artery systolic
pressure, there is continuous flow into the pulmonary circulation, creating the characteristic continuous
("machinery") murmur, heard best just below the left clavicle. In hemodynamically insignificant lesions (>50% of

323
cases), patients are asymptomatic. Patients with bigger shunts develop cardiac failure at an age that depends on the
severity of the lesion. Treatment is surgical closure of the duct; this can be carried out percutaneously.

81. Which of the following statements about patent ductus arteriosus is

INCORRECT?
a) It occurs frequently as an isolated phenomenon
b) Cyanosis is usually present
c) It causes a pansystolic 'machinery' murmur at the upper left sternal
edge
d) there is a wide pulse pressure
e)treatment is by surgical closure
BBB

82. 1 month old female child brought by her mother to ask for her vaccination schedule, baby is alert and feeding is
ok.you find a loud systolic murmur below the left clavicle.what condition you think is responsible for this finding.
A) Innocent murmur
b) Pulmonary Hypertension
c) TOF
D) PDA (ANS)page 128 kaplan paeds..
E) TGA
Pda... Common in girls
If small... Possibly no symptoms

324
83. just after birth all feature of cardiac disease except cyanosis.diagnosis ask.
a.pda (ANS)
b.vsd
c.asd

Patients are asymptomatic when the ductus is small. With increasing size, newborns present with signs of increased
pulmonary blood flow, a wide pulse pressure, and "bounding" pulses. Eisenmenger's physiology, secondary to
pulmonary vascular obstructive disease and shunt reversal, may occur if the PDA is large and long standing, and
results in cyanosis only in the lower half of the body.

HOCM topic

Jm 126

84. A young guy while playing cricket suddenly had

syncopal attack without any convulsive features.
Soon he spontaneously recovered and started
fielding and continue playing rest of the
game.What was the cause?
a)Vasovagal syncope
b)cardiac issue (ans)jm 858
c)Epilepsy
cardiogenic: the patient drops down suddenly and
regains consciousness in seconds. Neurogenic: goes
suddenly and come backs in minutes (vasovagal ,
seizure , etc) Metabolic: the patient goes gradually
and come backs gradually.

325
. if there is post ictal state then SEIZURE otherwise
SYNCOPE. If there is prodromal signs then more with
Vasovagal if no prodromal sign and recover
immediately(seconds) more with cariogenic (there could
be murmur), no murmur arrhythmic syncope. But there is
some rare once too.

85. a young girl 14 yr collapsed at excercise,her father

had HOCM,after ecg and echo u find no
abnormality,next step
a)holter monitoring
b)stress echo (ans)
c)repeat echo after 3 year

86. Young man with syncope after exertion on exam u

find a systolic murmur at right 2nd intercostal space.
Dx?
a.HOCM…lt lowervsternal border
b.AS
c.PS
d.ASD

Physical Examination – HOCM

The murmur of HOCM is important to detect due to its clinical implications. The murmur is a high-pitched,
crescendo-decrescendo, midsystolic murmur heard best at the left lower sternal border. The murmur of HOCM does
not radiate to the carotids like that of aortic stenosis. The important auscultatory features of HOCM that distinguish
it from AS relate to dynamic auscultation.

HOCM- young,sudden syncope goes with HOCM.....the murmur will sound similar to the murmur of aortic stenosis.
However, a murmur due to HCM will increase in intensity with any maneuver that decreases the volume of blood in
the left ventricle (such as standing abruptly or the strain phase of a Valsalva maneuver)....
Page 143 kaplan

Systolic ejection murmur.. At left sternal edge and apex... Increase after exercise n valsalva

326
Dilated cardiomyopathy

HTN

82. 82 (mcq from kaplan) A 5 year old girl is noted to have BP above 95th % on routine physical examination. The rest
of physical examination is unremarkable. Her bp remains elevated on repeat measurement over the next few
weeks. Past history is unremarkable for treated UTI 1 year ago. CBC normal. Urinalysis normal. BUN is 24 mg/dl
and creatinine is 1.8mg/dl.
Essential HTN
Secondary HTN ( ANS)

Kaplan paeds 146

JM 968
Most common is secondary HTN n MOST COMMON causes are UTI, kidney parenchymal disease, kidney artery
stenosis
Treatment: ACE inhibitors or CCB (1ST line)
Diuretics (2nd line)

PERICARDITIS
Inflammation leading to accumulation of fluid in pericardial space
Most common Initial finding is precordial pain (sharp, stabbing, over precordium and left shoulder and back, worse
supine, relief with sitting and leaning forward. other s/s are cough, dyspnea, abd pain, vomiting.

327
Small amount of fluid (FRICTION RUB is variable) ;if large amount (muffled heart sounds, narrow pulse pressure,
tachy,neck vein distension, PULSES PARADOXIS : A drop in bp > 20mg Hg during inspiration in a child with pericarditis
indicates cardiac temponade.)
Most common cause is VIRAL (coxsackie, adeno, influenza, echo)
Other causes are bacterial inf, acute RF, SLE,Uremia, neoplasm
If CONSTRICTIVE: pericardiectomy
Chest Xray; Water Bottle appearance
Echo: most sensitive

KAPLAN 127

83. ECG Of STEMI asking next investigation

1 troponin
2 echo
3.cxr
4.thallium scan
84. had 1 ecg. Will upload if i find a similar pic online. Pt with 2 hours chest pain palpitations. Given oxygen morphine
aspirin already. BP hypotensive unstable (like SBP below 90). Asked wat next initial treatment
a. BB
b. adenosine
c. Lignocaine
d. DC cardioversion(AF, ptnt unstable)
e. Transfer to catheter unit (if mi ecg)

85. . An ECG came with Atrial fibrillation. It was very prominent. The patient came with complains of palpitation.
Heart rate was I think in 70s. He was hypertensive. Asking for treatment?
a) Digoxin
b) Beta blockers***
c) Adenosine
d) Amiodarone
No calcium channel blocker in options. IF Asprin in option give asprin.

86. ECG given. A 65 yrs old lady has emphysema for many years and presents with dyspnoea and chest pain. ECG
shows: bradycardia with variable rates (40-70 beats/minute), no p waves, normal axis, raised ST segment in leads
II and AVF, with ST segment depression in leads I and AVL, V2-V4 with slopping S waves and inverted T waves.
QRS complex normal, right bundle branch block (RSR in V1 and V2). WOF statements is true?

a. She has ischaemic heart disease***

b. She has right ventricular hypertrophy

c. Right bundle branch block is diagnostic of emphysema

d. She has evidence of digoxin toxicity

e. She has WPW syndrome

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87. Patient present with sudden severe abdomen pain and pulsatile mass.after giving iv fluid and cross match Next
FAST ultrasound aortic aneyurism
CT abd
USD
Admit to ccu
Aortic stent or shunt

88. ECG of an adult presented with chest pain cardiac enzymes and 1st ECG normal BP was 120/70 , After 8 hrs of
observation his BP goes down 89/50 ,And ECG is showing SVT with HR 150 ,What would you do ?
Adenosine
Flecainamide
Atropine
Synchronized cardioversion
defibrillation

89. Pt on Digoxin, Bisoprolol, thiazide (one more med I can't remember at the moment) Longterm pt of HTN and CHF
& AF. stopped taking meds for 3 weeks while on vacations.
Now presents with edema upto his knees & a raised JVP of 4 cm but with clear chest sounds. BP 145/90, pulse
irregular. What would u do as initial management of this pt?
1- commence furosemide mane
2- commence spironolactone
3- commence metoprolol
4- commence digoxin, bisoprolol, (one more med I don't remember but it's not a diuretic)
5-recommence all medication

90. Given ECG showing “M” spike QRS complex in all leads and given long lead II. Also on long lead II, all QRS are “M”
spike and irregularly irregular. HR calculate is 150.
Scenario gives patient with hypertension and BP-150/90.
Patient is taking only atorvastatin. Not given chest pain
clinical features.
Metoprolol. dx-AF with RBBB
Apizaban
Other anticoagulant
Verapamil
Adenosine

91. Old man brought to emergency dept with history of sudden

loss of consciousness for 20 seconds and was able to get full
consciousness. Vitals given and were normal He is htn,
diabetic and on ramipril sulphonylurea and statin, what is
the diagnosis ?
A. Postural hypotension
B. Ischemic heart disease
C. Stroke
D. TIA

92. 2-ECG given ,I interpreted as AF , scenario was

A middle aged man known hypertensive started feeling dizziness & he feels his heart is racing.it occurred after
running.there was also travel history few days ago.he is on Irbesartan-Hydrochlorothiazide, & well controlled. No
mention of diabetes.BP was around 138/78 with no postural change.asked what is most appropriate next
investigation?
1-CTPA
2-D-diamer (IF ECG SHOWS SINUS TACHYCARDIA)
3-TSH(if ecg shows AF)
4-TROPONIN

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(24 hour ECG monitoring or holter......first ecg...most appropriate to find out the cause of arrythmia...so Holter is the
most appropriate test here......if you find arrhythmia then you can do TSH...to rule out thyroid cause...but with this
little information about "Racing heart" Holter is the most appropriate test)sir answered

93. 60 yrs. old male, 10 yrs history of hypertension, feeling dizzy and light headache from this morning when he was
doing exercise. smoke 20 cigarettes per day, drinks 2-3 glass of wine most of the night. BP 138/80 sitting 120/75
on lying. Currently on ibesertan-thiazide 150/12.5 Mg and ASA 100 mg. here they mention he got these
symptoms for abut 2 hrs . ECG was given (SVT) HR around 150/min. Cause of his presentation
A) dehydration –
B ischemic heart disease –
C) hypertension
D alcoholic cardiomyopathy

94. 74 yr old man with exertional dyspnoea with many drugs Lisinopril, digoxin ,pulse irregular ,jvp 3cm above ,basically a
scenario of RVF
What's investigation you would do
A. BNP nxt
B. Echo***bst
C ecg
D. Troponin

95. Aboriginal lady has mitral stenosis and dyspnea. On chest auscultation bilateral basal crests . Chest X-ray given

a. LVF****- Left-sided valvular heart disease, such as mitral valve or aortic valve disease
b. Pulmonary hypertension-
c. TB

96. Patient on ramipril and h/o syncope came to a&e and ecg normal was done and high potassium 5,5
a. Cease ramipril***if no ecg changes,if ecg changes + give calcium iv
b. Insert pacemaker
c. Insuilin and glucose

97. A women on multiple drugs one of them was digoxin , she presented with central abdominal pain and
tenderness, her pulse was irregular . Apart from ct what is most appropriate next investigation?
A. Abdomen USG
B. Serum Lipase
C. Serum lactate (mesenteric ischaemia)
D. Digoxin level

98. 1 ECG with bradycardia and prolong QT or sth like that, In scenario patient came with chest pain for 15 min and
relieve by rest. Troponin normal. Pulse – normal and regular. BP normal. What to do next?
1.repeat troponin
2. echo
3. coronary angiography
4. repeat ecg
**repeat Trop I 6,12,24 and 48 hr
**repeat ecg 3 ecg and 30 min interval

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99. A man comes to you following an episode of rectal bleeding which has stopped spontaneously. You are planning
to do colonoscopy. He had a drug eluting stent placed 2 months ago and was started on clopidogrel and aspirin).
Which of the following is the appropriate mode of action?
a. Stop clopidogrel and do colonoscopy
b. Stop clop for 7 days, give LMWH and do colonoscopy
c. continue clop and do colonoscopy ( since stent is present antiplatelet drugs should not be stopped for 2 years
post stent insertion thus continue and do procedure, if no stent present then stop 1 week prior procedure)

100. . mitral valve prolapse, taking colonoscopy, what prophylaxis to give

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A)Ampicillin Oral six hourly
b) Ampicillin IV before procedure (if no regurgitation-no tx,if regurgitation-drug)
c) Oral ampicillin + metronidazole before procedure
d) no prophylaxis.

If MVP only No need prophylaxis, if MR present need IV Ampicillin

101. ventricular ectopics recall they put many drugs in stem and asked what to give now
102. ecg ventricular ectopics , of 65years old man on hypertensive treatment &history of MI 3yrs ago ,now all
examination is normal except of soft blowing precordial murmur on the left border of sternum .. what to do ?
a.cease metaprolol
b.cease metaprolol & commence verapamil
c. add warfarin ???-otherwise this

103. Indeginous women mitral stenosis + edema +

raised JVP + bilateral basal crepts + xray
HIV
Lymphoma
LVHF (left side failure leading to right side symptoms as
well)
TB
Pulmonary fiborisis
treatment

104. Patient on multiple drugs. Patient not taking

drugs for 5 days. Jvp 4 cm raised and oedema. no
crackles or anything lungs clear-(When a subject is sitting at 45 degrees, the JVP is normally less than 3cm above
the angle of);/ the sternum and thus is not visible above the clavicle.What to give
a. Digoxin
b. Mannitol
c. ACEI****

105. ECG hyperkalemia

Pr prlonged, K 5.5, what is your action?
Cease Ramipril (ramipril causes hyperkalemia, main side effects are dizziness,cough and angioodema. Serious side
effects are hyperkamlemia,dry mouth,oliguria,dark urine,confusion,jaundice,fever)
b.Caclcium carbonate –if arrhythmia + first calcium
then insulin
c.Insulin glucouse –if no arrhythmia give this
first,then calcium
D. Pacemaker

106. one case of hyperkalemia ,patient on ramipril

, presented with lethargy about immediate
management?
a. insulin and glucose
b. haemodialysis
c. rectal resonium
d. Cease ramipril****
e. Calcium gluconate

if pt symptomatic+no ecg
changes=insulin and glucose
if pt unstable+ECG changes=iv calcium

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and if pt asymp but k more than 7=still iv calcium
if asymp+normal ecg=then stop offending drug

and imp is we give ca gluconate or ca cholride

Digital infacrction + p2
PHTN and interstitial disease
Signs of pulmonary htn

o ECGs
o Bradycardia à atropine
o VF àdefib again
o Atrial flutter àfirst dc cardioversion…and in medicine amiodrone and then digoxin and beta blocker
o ECG – SVT – bp 80/50, Rx?CARDIOV

107. Old man with recurrent falls in nursing home, he is found to have many bruises in head, ECG showed sinus
tachy, multiple ventricular ectopics and ventricular hypertrophy (written), on enam/thiazide combination, BP
standing 150/90 standing and systolic 90 in sitting, what invx for diagnosis?
1. 24 hr ECG
2. 24 hr BP
3. Repeated BP measurements with postural change
4. CT head

If if question stem postural bp not measured, measure if first cus it might be due to dehydration as getting
thiazide

108. Mitral stenosis where murmur is found:

a) Systolic murmur
b) Diastolic murmur at apex
c) Diastolic murmur at left lower sternal border

109. young man with dizziness and fainting attack during exercise in school but otherwise normal during the day ,
no family history of such findings. What is the most relevant to see on examination?
A-Heart rate less than 50
B- BP 90/50
C-Continuous machinery murmur (Patent ductus arteriosus)
D-Systolic murmur on right upper sternum-AS

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E-Presence of S3 murmur – CHF

110. A baby with all normal physical examination having a murmur all over his chest.

A. Physiological
B. Patnt ductus art-machin ery murmur
C. TOF
D. Pulmonary stenosis-systolic ejection murmur

physiologic murmurs tend to be located between the apex

and left lower sternal border

. PDA Typically, the murmur is loudest at the left upper chest.

AT BIRTH
cyanosis plus murmer: TOF
cyanosis , no murmer : TGV
2-7 DAYS
cyanosis plus murmer : TOF
cyanosis , no murmer : HLH

111. Pt with SOB, raised jvp, leg edema... worsening symptom... SaO2 is low...after giving oxygen what to do next
Intubation
echo
Cxr
Diuretics-

112. Ecg with tall peak t.. with multiple drugs for dm htn and bla bla.what to do
Stop verapamil
Stop enalapril-ace

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Stop metfo

Due to hyperkalemia, drugs causing it-

• Potassium-sparing diuretics (eg, spironolactone, triamterene, amiloride)
• NSAIDs
• ACE inhibitors
• Angiotensin-receptor blockers (ARBs)
• Cyclosporine or tacrolimus
• Pentamidine
• Trimethoprim-sulfamethoxazole
• Heparin
• Ketoconazole

113. old lady presents with chest pain. She was on nitroglycerine, diltiazem 60mg, digoxin 0.125mg, enalapril xxx.
On examination she is found with biventricular enlargement. ECG: (seem to be grade II A-V block & T wave
inversions, ventricular entopic, HR: 50-65/ min). what is the best management?
a. Stop all medications and review in 12 hoursdx-digoxin toxicity
b. Increase the dose of digoxin
c. Commence of colvexin
d. Infusion of potassium
e. Commence on frusemide

114. . A 23 yrs man comes for follow up. His bilateral arm BP 140-160 / 100-110 range on several occasion. Occasional
headaches, rest of physical exams and urinalysis is normal. Heart rate 75/min with mild left ventricular
hypertrophy.BB , hydrochlorothiazide , captopril was used and
BP now is 150/100. Next appropriate step .
A , duplex ultrasound of renal arteries***
, B. Echo ,
c.repeat ECG
, D. Prescribe triamterene .
E, do ophthalmoscopy or so

The famous 2 min and four minute CTG I got them ECG of
hyperkalemia asking treatment
The ans calcium gluconate Methotrexate hepatitis toxicities
Yes one more new question just remembered

115. A person took methotrexate for RA, he took other drugs

for heart disease but he came in with dyspneao , x-ray shows
diffuse lung fibrosis

The answer was again methotrexate induce, amiodarone

116. Which one of the following causes of lung fibrosis

predominately affect the upper zones?
A - Bleomycin
B - Rheumatoid arthritis
C - Cryptogenic fibrosis alveolitis
D - Methotrexate
E - Extrinsic allergic alveolitis

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117. Distal amputated finger cause
a. Chronic asthma
b. Bronchiectasis
c. Empyema
d. Pulmonary fibrosis
e. Pulmonary hypertension

118. Ecg of wpw in a 2yr old child.. bp not measurable.what nxt

Dc cardioversion
Adenosin-1st line
Amiodarone-2nd line
Same like svt

119. -rch of wpw with rate of 280 ask rx....a.amiodarone-if wide qrs b.adenosine.if narrow
complex....c.verapamil
120. Atrial fibrillation ecg
121. Scenerio of variable heart block with hypo k using multi drugs...
I chose stop digoxin and give k
122. almost like this ecg(pretty sure was first degree heart block) young pt took many white tablets used by his
grandmother, which from below u suspect cause this change
a digoxin(heart block)
b-TCA(wide qrs complex)
c-bb
d-aspirin

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123. And old man taking digoxin and hydrochlorothiazide presents with palpitation and ECG was given. What is
the cause of his problem?
Digoxin toxicity
Hypokalemia
Hyperkalemia

124. One scenario with HF, raised JVP, dullness on lung

percussion. On digoxin, thiazides all lots of other medication. ECG was
there with HF. Asked what to do next. Digoxin level was 1.5 (normal
was 2.5).
Increase digoxin dose
Stop all medications and review after 3 days
Increase thiazide

125. EcG of biventricular cardiac failure,with features of lbbb and

tall T waves, patient was on digoxin,enalapril,carvedolil,what next?
1)increase dose of digoxin,
2)increase carvedolil,
3)increase enalapril,
4)start furosemide,
5)stop all drugs and reassess in 12 hour

Hyperkalemia can cause LBBB patients with heart failure

who are taking spironolactone and ACE inhibitorscan
develope severe hyperkalaemia

What can possibly cause digoxin toxicity here? He is not on

diuretics which would cause hypokalemia and lead to

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toxicity......if we give loop diuretics it would dec his k level too and protect his heart since we dont
hv calcium gluconate in options. But assuming this is digoxin toxicity (dont know the reason-
similar ecg changes can be due to hyperkalemia as well) loop diuretics can be hazardous then e
would b a better option. I am having difficulty understandung if its due to k or digoxin

126. 5.pt on many medication metoprolol, digoxin, frusemide, ecg was given mobitz type 1 and nausea, vomoting
and abd pain was there, digoxin level was given and it was normal. what to do?
A. cease digoxin
B. cease metoprolol
C. tempory pacemaker
D. angiography
E. cease metoprolol and commerce verapamil

127. 10 days baby well no prob feed well, weight gain well... now with murmur in left lower sternal edge which
radiates to all over precordium. Dx?
Ps
vsd
Pda
Physiological

128. Q of innocent murmur after urti.... intensity 2/6 asking dx

129. ECG features in hyperkalaemia?
Flat T
Inverted T
Wide QRS

130. ECG of myocardial infarction, I think morphine was given and asks what is the best Management ?

Figure 1 STEMI, similar to my ECG in the exam

a) Coronary angiography –Preferably angioplasty then stent

b) rTPA (streptokinase )
c) Troponin levels examination

131. ECG Of STEMI asking next investigation

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1 troponin
2 echo
3.cxr
4thallium scan

132. A 25 year old man came after MVA with hoarseness of voice, loss of aortic knuckle,
and widening of mediastinum, BP stable.
a) Echo
b) CXR
c) CT angiogram
d) MRI
e) Fast USG

133. Ecg of wpw HR 280, systolic pressure 105....

A- Verapamil
B.Adenosine
C.Amiodarone
D.Digoxin
E.Lidocaine

Treatment may involve the use of medication or a

procedure known as ablation. In rare instances, an
electric shock may be used to restore a normal rhythm
Verapamil and diltiazem (calcium channel blockers),
metoprolol and atenolol (beta-blockers), and digitalis
all prolong conduction time and refractoriness in the
AV node.
Depend on ECG as WPW present with both narrow
complex and broad complex tachycardia
If u consider narrow complex like SVT ur choice B if CI to adenosine then A
If broad complex then C with hemodynamically stable

134. Ecg of wpw in a 2yr old child.. bp not measurable. what nxt
Dc cardioversion
Adenosin
Amiodarone
135. CXR showing cardiomegaly and ??bilateral hilar opacities , pt come with dyspnea and palpitation
,cardiomegaly confirmed again in the Q( exactly saying pt did CXR and show cardiomegaly) , JVP 3 cm raised , no
mentioned about leg edema , , what is next appropriate mx?
A , Echo
B , ACEi
C . beta blocker

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136. Patient come with feeling palpitation ECG showing bradycardia 50/min , BP good , Mx
Atropine-drug of choice

Forgot other options

137. 60 yr old PT,presented with palpitations and lightheadedness,has history of hypothyroidism and heart
failure... Already taking thyroxine, ACEI, diuretic ECG shows At.fibrillation... What is the next step in
management?
a. A...start digoxin
b. B...stop thyroxine
c. C...start beta blocker****
d. D ...start verapamil

138. An ECG came with Atrial fibrillation. It was very prominent. The patient came with complains of palpitation.
Heart rate was I think in 70s. He was hypertensive. Asking for treatment?
a. Digoxin
b. Beta blockers if palpitation
c. Adenosine
d. Amiadrone- if irregular pulse

139. patient taking ACE inhibitor Beta blocker Digoxin and ectopic beats in ECG .. what he s next management
Ans-cease digoxin than go for stop digoxin option cause it induce atrial fibrillation and ectopic beats

140. old pt with c/o light headachness and recurrent falls specially in morning when he get from bed, having a
long list of drugs ( sorry not remember) ECG shows ectopic beats what is ur next plan regaring its management?
a) echo
b)ct chest
c)24 hr bp
d) holter

141. Heart failure case man with AF on Ramipril, metoprolol, digoxin. Went on trip for 2 weeks and stopped his
medication. Now with bilateral oedema up to knee in legs. And ankle swellings Lungs is clear. And the patient is
not dyspneic, What is the most appropriate management?
A- Frusemide - asked a dr working in emergency med. He said to recommence his medication as when we will start
tge treatment the fluid will redistribute itself. Furosimide wont work alone
B- Recommence all his medications****jm says clearly even in severe overload always start with ace then diuretic.
And add spironolactone in severe congestion
C- Ramipril
D- Digoxin

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142. patient with heart failure on AcE inhibitor and digoxin and on some other drugs went on trip for 2 days and
come back with oedema..chest X-ray and ecg have done .. what next ?
Ans- Echo

143. Pt presented by acute chest pain, light headedness and SOB, ECG (Inferior STEMI), what’s the diagnosis?
A. Acute MI***
Heart block
C. Hyperkalaemia
D. ???

144. A 65 years old Pt presented by light headedness, and palpitation, Examination was clinically free, he’s on
perindopril, Eltroxin, verapamil, antidiabetic medications. ECG (1st degree heart block). What’s the next
appropriate treatment?
A. Increase Eltroxin
B. Stop verapamil***(sinus bradycardia,pulmonary edema, severe hypotension,second degree atrioventricular
block)
C. Stop perindopril
D. Add digoxin

145. old recall….pharma men to u for new drug,what u will ask from him:
a: which country
B. which journal published
c. when conducted
d.both group recived equal dose****
e.WAS THERE ANY CROSSOVER BETWEEN GROUPS

146. Q85) one ecg was stemi , 27 yrs old man , what best ?
a) coronary angiography with angioplasty**
b) thrombolysis
147. #cardio ecg pic with chest pain, STEMI, ix asked?
CT Angiogram***
Temporary pacing
Depends on the time,
148. ECG of SVT in a 58 year old with chest pain and difficulty breathing, presented with progressive 150,bp
80/50.What will you do next?
a)Iv metoprolol
Iv adenosine***
b)Iv verapamil
c)DC cardioversion (done first In unstable pt)
d)Defibrillation
(in stable pt, IF vagal stimulation is in the option go for that as its tried first and if it fails then we give adenosine
and if it also fails then verapamil)

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149. treatment of heart block asked

Dealing with cardiac arrest ...

First step..................CPR
First drug to be give............IV adrenaline
Shockable rhythm.............V.Tac and V.fibrillation, Non-shockable rhytm........... asystole and pulseless
electrical activity
Once V.fibrillation............DC shock ( defibrillator) Step has the best long term effect after cardiac
arrest.....defibrillator.....vvvvvvvvvvvvvv imp
TTT of asystole and pulseless electrical activity......CPR and epinephrine
Best step to maintain the airway......head lift jaw thrust Best way to asses line for fluid in pediatrics in
shock.....intraosseous
Drug of choice for supraventricular tachycardia....adenosine
To have the best neurological recovery after cardiac arrest....induced hypothermia
Most imp in myocardial infarction......angioplasty

150. Aboriginal scenario . X-ray was given. no cardiomegaly . almost normal. some perihilar haze. options.
a. pulmonary HTN**
b. LVhF
c. PE (irrelevant)

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151. child with URTI treated.... infective endocarditis. blood cultures taken. treated with penicillins but murmur
persists. was to do ?
a. give antibiotic for 4 weeks with blood culture weekly
b. echo****
JM 283- (Golden rule is culture the blood of every patient who has a fever and a heart murmur)

152. Patient with spiking fever, SOB. History of prosthetic aortic valve 3 months ago. Culture done and Staph
aureus is grown. Was given flucloxacillin and furosemide. SOB is subsided. But there is persistent diastolic
murmur at left sternal edge. What investigation will you do?
A. CXR
B. Aortic valve replacement
C. Recheck blood culture every week
Troponin
E. Transthoracic echo****

153. pregnant woman at 36weeks of gestation present with dyspnoea and orthopnea. X-ray shows bibasal
effusion and cardiomegaly. Exam: crept. Next appropriate investigation?
a. ECG
b. Echo ****
c. d-dimer
d. CTPA

154. A 60yrs of age man was found fallen on bathroom floor with dizziness but was conscious with a history of
poor stream urine and difficulty in micturition and brought by his wife to ER.He has a history of HTN and DM..his
BP is 165/85 and pulse is irregular.ECG showed AF (complication of mi).what investigation will you do as next
most appropriate?
A.blood glucose
B.troponin***(suspecting myocardial infarction)
C.holter monitoring(if ecg normal)
D.echo

155. A hypertensive and diabetic presented with histories of numbness, nausea and sweating. He developed
dizziness while urinating.Pulse is irregular and ECG shows atrial fibrillation. Other things said. Diagnosis asked
a. Myocardial infarction*******
b. Micturition syncope
c. Vasovagal syncope

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156. ECG bradicardia asking for managment
a) Holter
b) Stress EKG
c) Pacemaker***-only after medications fail or if it is due to some arrhythmias like sinus node /av node problem
If atropine available choose that

157. ECG bradycardia asking for management

a) Holter
b) Stress EKG
c) Pacemaker
d.Atropine***
158. Patient with features of heart failure Worsening SOB increase JVP bilateral basal crept . cxray give. Asked
next investigation
Troponin
ECG( next) if chest X-ray has given so depend on X-ray
Echo****( best)

159. Pacemaker syndrome with difficulty in breathing with faint heart sounds,spo2 96%, bp-90/60mmhg,jvp-6
with no ECG given. investigation of choice needed.
A. Chest xray.
B. CTPA.
C. ECG

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D. ECHOCARDIOGRAM
E. SERUM TROPONIN

160. Patient was just shifted from icu after pacemaker insertion. Patient Suddenly complains of chest pain and
difficult breathing. Pulse 88 bpm ,oxygen 98% heart sounds very faint on auscultation . what next ?
a) chest xray (to rule out hemo and pneumothorax)
b) ctpa
c) ct
d) troponin
e) Echocardiogram (best as dx is cardiac tamponade)

Delayed cardiac tamponade after pacemaker insertion.

Signs of classical cardiac tamponade include three signs, known as Beck's triad. Low blood pressure occurs
because of decreased stroke volume, jugular-venous distension due to impaired venous return to the heart,
and muffled heart sounds due to fluid buildup inside the pericardium.

161. Guy who had a pacemaker and had a complication recall don't remember the duration but I think it was right
after and he was in ICU. Jvp raised, distant heart sounds and low bp (all pointing towards tamponade I guess)
and asking for invx----
A. echo**** B. cxr C. ctpa

162. A hypertensive and diabetic presented with histories of numbness, nausea and sweating. He developed dizziness
while urinating. Pulse is irregular and ECG shows atrial fibrillation. Other things said. Diagnosis asked
a. Myocardial infarction*******(Pulse is irregular A.F causes M.I).
b. Micturition syncope
c. Vasovagal syncope
163. A 53 year old man with a VF cardiac arrest is undergoing advanced cardiopulmonary resuscitation in the ED. He
has received adrenaline 1 mg (1 minute ago), and has just received the 3rd DC shock 200J (biphasic). He remains in VF.
What is the next step in his management?
a. Recommence cardiac compressions and ventilation at a ratio of 5:1
b. Recommence cardiac compressions and ventilation at a ratio of 30:2
c. Electrical cardioversion.
d. Adrenaline 1 mg.
e. Amiodarone 300 mg.

164. ECG with VF, patient unresponsive, no pulse, started cpr and gave one 200j shock , rytm still the same, what to do
next
A 2 minute compression
B- defibrillate again patients with a shockable rythmn (ventricular fibrillation and pulseless ventricular tachycardia), the

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 first action would be to defibrillate as soon as possible followed by 2 minutes of CPR and the second defibrillation, after
which adrenaline should be started and repeated every second cycle.
C adrenaline-1mg aft 2nd shock in shockable nd immediately in non shosckable
D amiodarone-300 mg aft 3rd shock

if non shockable-pulseless electrical activity and asystole, give epi

165. Picture of atrial fibrillation ecg with the ff scenario pt with hypertension ,DM, well controlled congestive heart
failure presents with palpitation and irregular pulse which one is appropriate first
a. digoxin****(as pt is diabetic cant give bb)
b. verapamil
c. metoprolol
d. Ramipril
e. Amlodipine

166. Patient was just shifted from icu after pacemaker insertion. Patient Suddenly complains of chest pain and difficult
breathing. Pulse 88 bpm ,oxygen 98% heart sounds very faint on auscultation . what next ?
a) chest x ray.
b) ctpa.
c) ct
d) troponin
e) Echocardiogram-maybe tanponade-best choice

167. . Baby well postpartum , sudden central cyanosis, no murmur, I chose Ventricular hypoplasia,
Fallot-cyanosis+ but murmur also +
VSD,-no cyanosis
PDA-no cyanosis
ASD-no cyanosis
No Transpose of GA in options

168. Almost similar thought as AF.55 yr old Developed sudden loss of consciousness.. Previously healthy.most
appropriate investigation
1)Transthoracic Echo if …pre existing af …may be ventricular ectopic
2)D dimer
3)troponin… if new af may be due to post mi complication

169. Patient presented with diplopia for 1 day. On examination there was diplopia on the right eye when
looking towards the right side. his glucose is normal. ECG has
occasional verntricular ectopics. Whats the most appropriate
management

A. Warfarin-suspecting TIA - giving anticoagulants etc

B. Peridropnil
c. Metformin
d. Observation dx :6th nerve palsy. s/s :double vision, pain around
eye and headache

170. Pacemaker syndrome with difficulty in breathing with faint heart

sounds,spo2 96%, bp-90/60mmhg,jvp-6 with no ECG given. investigation of choice needed.
A. Chest xray.
B. CTPA.
C. ECG.
D. ECHOCARDIOGRAM.
E. SERUM TROPONIN

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171. 7- ecg- bradycardia with u wave , asked what u cease? Metformin, verapamil , cant remember more options
Both beta-adrenergic receptor antagonist drugs (beta-blockers) and non-dihydropyridine calcium-
channel blockers (non-DHP CCBs), ie, diltiazem andverapamil, can cause sinus arrest or severe
sinus bradycardia, and when drugs from the two classes are used together, these effects may be
more than additive

172. -pt with CHF complaining from intermittent palpitation what to give .....atenolol(ans). B.statin

173. Chf Rx
1.ACEI
2. Beta blocker
3. diuretics

174. 70 y old pt. with hx of intermittent palpitation..ECG AF (rate not mentioned but not elevated after calculation
)..pt. stable...cholesterol about 5...wt to give?
A.atenolol
B.atrovastatin
C.verapamil
D.apixaban

175. Ecg next inv

Troponin
Ctpa
D dimer
echo

176. small child collapsed in bed 4th day after delivery with cyanosis and dyspnea, no mumers heard
a) hypoplastic left heart –present at birth, congenital, symptoms start within first week aft birth, aft closure of ductus
begings,same symptoms,Rx-norwoods,fontans operation,transplant
b) TOF
c) PE
177. A 67 y old male presented with history of aaa, us of the abdomen showed gallstones and an incidental finding of
3.8 cm aaa. What is the recommended management 3.8 cm abdominal aortic aneurysm?

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A. Us every 12 m
B..ct every 12 m
C. Us every 24 m
D. Ct every 24 m
E. Any of the above

178. Man came in for motor vehicular accident with multiple rib
fractures, widened mediastinum, ___aortic knob (cant remember
the term used) what do do next –
a. pericardiocentesis
b. Intubation and mechanical
ventilation…haemodynamicamically unstable
c. 2d echo-if dx asked

179. old woman, brought after fall, confused, on warfarin ,bruises on both thighs and buttocks, troponin,
0.08,(troponin increased only in MI and stays increased even days after MI after other markers come back to normal)
ck 1000(N=60-220), whats dx.
a. recent MI less than 12hrs
b. MI in 4 hrs
c. rhabdomyolysis,— ck increased, ldh ,crp,ast alt all increased!!

Troponin normal level 0.04 to 0.4 ng/ml

180. .Patient on medications for HTN (perindopril+indapamide).She feels dizzy when get out of the bed.. happenining
for a while.. she also had some falls. BP 160/100, Has AF. Next Ix
A echo B xray C holter monitoring D 24 hour BP monitoring E repeate for postural BP measuring

181. Old man with recurrent falls in nursing home, he is found to have many
bruises in head, ECG showed sinus tachy, multiple ventricular ectopics and
ventricular hypertrophy (written), on enam/thiazide combination, BP standing 150/90 standing and systolic 90 in
sitting, what invx for diagnosis?
D) 24 hr ECG
E) 24 hr BP
F) Repeated BP measurements with postural change-orthostatic hypertension due to essential htn or dm, here
essential htn
G) CT head

182. A 60yrs of age man was found fallen on bathroom floor with dizziness but was conscious with a history of poor
stream urine and difficulty in micturition and brought by his wife to ER.He has a history of HTN and DM..his BP is

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 165/85 and pulse is irregular.ECG showed AF.what investigation will you do as next most appropriate
A.blood glucose
B.troponin
C.holter monitoring
D.echo

183. 70+ year old man on Ramipril 5mg for hypertension. On Examination Bp- 150/?, pulse – normal Cholesterol
6.?(normal range given around 2). Rest investigation with in normal limit. Which one will reduce his risk of stroke?
A. Low dose Aspirin
B. Clopid
C. Increase Ramipril
D. Atova

jm-965

184. a man with ht on ramipril 5mgbpr= 130/80 , he is diabetic Hba1c= 7.1, serum cholesterol = 5 he has heart failure.
what is the best next step ?
a. add simvastatin
b. increase ramipril dose (if no lung sign)
c. add diuretics (if sign of fluid overload)
d. add aspirin
e. commence insulin

185. 40 year old Mother Had MI and now on Aspirin, father has DM. His BP found 160/100 mmHg. His Bp normally
varies from 170/? To 120/70. What will you do?
A. Echo
B. 24 hour BP
C. Ecg
D. anti HTN
186. 57 yr Man complain of anorexia and weakness....known case of CCF on digoxin .25 ,
frusemide/hydrochlorothiazide...lab value cbc-normal..Na -131, K- 3.1

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 Ecg (not given)....atrial rate 180...ventricular rate 110
A. Increase frusemide
B. Stop hydrochlorothiazide
C. Stop Digoxin and add K
D.defibrillation
E. Cardioversion

187. DM qs. On metformin. HbA1c 6.9%. Normal was given upto 6.4. Bp was 130/80. Trace of protein in urine.
Cholesterol 4
A. add simvastatin
B. increase metformin
C. Continue treatmen
D.add ramipril

188. A diabetic patient in metformin 500 mg BD comes to you for

follow up. His random blood glucose is 5.6 (4.4 -7.5)and his
HbA1C is 6.9 (upto 6.6 was give as normal)
What would be the best advise to give to this patient ?
a. Add Insulin
b. Decrease metformin
c. Increase metformin
d. Continue same treatmen(tIn dm bp should be 130 80 rbs
should be 10 fbs n hba1c sshould be 7 so A) JM 192.correct ans
Add simvastatin
189. .ecg---MI & want tx ?? the scenario focused about severe
chest pain
options was
a.aspirin
b.morphine
c.thrombolytic therapy
d.aspirin+thrombolytic therapy
no option about 02,angioplasty or thrombolytic therapy with LMWH

190. ecg---AF & scenario was about pt has already AF, HTN & DM &taking anti HTN,metformin,now present an
irregular pulse HR around 200 ,so whats next most appropriate??
Ans.warrfarin check the ques carefully…if acute case choose rate controller like bb or verapamil

191. Old man come for dyspnoe and H/O hypertension and DM. No h/o stroke. HR 80 irregular. Hypertension is
treated with losartan and DM witg metformin. ECG AF. Next appropriate rx?
A. Warfarin ???
B. Metoprolol
C. Digoxin
D. Verapamil
E. Atropine

192. .bacterial endocarditis scenario,asking tx?

350
Ans.crftriaxone+vancomycine+gentamycine

193. Aboroginal female has mitral stenosis. she presented with dyspnoea. C xray given. it had bilateral
middle LOBE OPACITY. Whats is the diagnosis.
A. Pulmonary Hypertension.
B. Pulmonary Fibrosis
C. LVF
194. 2)25 yr indigenous lady presented with sob and cough since 3 weeks..o/e temp 37.8,pr,rr,bp,saturation all
are within normal limits,mitral stenosis with bilateral basal crepts ..x ray given with features likeblateral
symmetrical mid lobe pulmonary infiltrate especially perihilar area..diagnosis?
a.pulmonary edema????
b.pulmonary hypertension
c.rheumatic fever
d.peumocystis pneumonia
195. A scenario of an aboriginal woman presents with mitral
stenosis, shortness of breath, low grade fever, malaise for 6
weeks. Bilateral basal crackles
a) TB
b) LVH
c) Pulmonary HTN
196. )xray quite abnormal.. left sided pleural effusion but no
heart borders not dilated.. 6 weeks of cough and dyspnea
aboriginal lady with bibasal crepts and also left sided
decreased breath sounds systolic murmur over apex
Rheumatoid heart disease
Left heart failure
Pulmonary hypertension
Pneumonia
197. 5)Aboriginal lady has mitral stenosis and dyspnea. On chest
auscultation bilateral basal crepts. No fever cough sputum.
Chest xray given with bilateral peri hilar opacities coin like
lesions Asked diagnosis.
A.pulmonary hypertension,
B.TB
C.Lymphoma
D. Left ventricular failure
E. Sarcoidosis

198. Lady 75 years old has HTN, DM, well controlled on drugs.
She has an episode of chest pain during walking for 15 mins
which is relived after rest. Her current medications include
ramipril, metformin, metoprolol. Now the b.p is 130/85, Heart
rate is 54bpm. Which of the following inveatigations will you consider next?
a. Serum Troponin
b. Thalium scan
c. Holter monitoring
d. CT angiogram

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199. bacterial endocarditis scenario,asking tx?
Ans.ceftriaxone+vancomycin+gentamicin

AF recalls
200. A patient with history of AF ..htn .. hypercholestremia .. dm .. on many drugs with long labs and long history
Most raised in his labs is cholesterol Asking what drug u give to pt in the long run will cause decrease incidence
of stroke? A)low dose aspirin B)warfarin C)clopedogrel D) statin

201. ECG showing AF in a 55 yrs old pt . Developed sudden loss of consciousness.. Previously healthy. Most
appropriate investigation : A)Transthoracic Echo B)D dimer C)troponin

202. Heart failure case man with AF on Ramipril, metoprolol, digoxin. Went on trip for 2 weeks and stopped his
medication. Now with bilateral oedema up to knee in legs. And ankle swellings Lungs is clear. And the patient is
not dyspneic, What is the most appropriate management? A- Frusemide B- Recommence all his medications C-
Ramipril D- Digoxin

203. An ecg with pt on multiple drug taken with history of dm,hypertension asking cause of AF a.dehydration
b.ischaemic heart disease (15% jm813) c.hypertensive heart disease (20% hb435)d.high cholesterol

204. Again Heart failure with AF , what to give Bb Digoxin

205. Pt with heart failure, AF. on digoxin, ACEI, metformin etc.. develop severe abdominpain, vomiting. Pulse
irregular. A. S. Lactate B. S. lipase C. CTPA

206. S patient with AF... pain in legs.. right leg is pallor absent pulses... ix A ct angiogram B uss veins C uss leg (if
colour Doppler choose this one) D d dimer #FEB…femoral art embolism

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207. A male pt AF..whitish lesion in ct brain?? A.Echo B.CT angio C.MRI

208. An ECG od AF,old age man come for dyapnoea and H/O of
Hypertension and DM but no H/O of Stroke.HR is 80/min irregular and
hypertension is treated with losartan and DM for metformin,next
appropriate Rx? A.warfarin (by exclusion)B.metoprolol C.digoxin
D.verapamil E.Atropine

209. Patient on medications for HTN. she feels dizzy when get out of the bed..
happenining for a while.. she also had some falls. BP 160/100, Has AF. Next Ix

A echo
B xray
C holter monitoring***
D 24 hour BP monitoring
E check BP again in supine

210. Which one the following is not an initial pharmacological therapy used in a
pt presenting with a non ST elevation MI?
A - IV heparin
B - oral clopidogrel hb3.083 as pt may undergo angiography
C - oral aspirin
D - oral Bblocker
E - IV or oral morphine

211. Patient with a fracture managed on Fentanyl infusion for pain. He complains of continuous nausea but the pain is
well controlled on Fentanlyl. Most appropriate next step :
a. Reduce dose of Fentanyl
b. Add IV Metoclopramide along with Fentanyl infusion
c. Replace Fentanyl with Morphine
d. Something metioned about giving Tramadol
e. Continue same dose of Fentanyl
1st B then E

212. 20 yrs old boy with h/o adhd was on

353
methylphenidate. Stop drugs 2yrs ago, now wants to take drug again ans symptom assess

213. Alzheimer pt present diagnosed 4 yrs ago became increasingly annoying to live wife. Wakes up early, goes through
drawers & blames everyone for stealing her things. Dx:
a) Worsening AD ***ANS
b) Frontal lobe lesion
c) Delirium
d) Hallucination

214. A psychiatric patient (Alzheimer), being taken care of by a carer was brought to you. It was reported that she had
been normal until 2 weeks ago when her colleagues started complaining of her strange behaviour. She wanders in the
room and accuses her mates of attempts to hurt her. She also repeatedly fidgets with the drawers. What is the likely
cause?
a) Worsening Alzheimer's**** ANS
b) schizophrenia
c) drug effect

215. 72 years old man is admitted with a 5 day history of confusion, lethargy and fecal incontinence. He has a
dense hemiplegia as a result of a stroke 3 years earlier and is using hydrochlorothiazide and amiloride for
hypertension. He stopped smoking 5 years earlier when he presented wjth a squamous cell carcinoma of the
lung which was successfully treated. His supine BP is 155/85. A CT brain scan revealed evidence of past infarction
and chest film revealed no evidence of recurrence of malignancy. Initial biochemistry results show sodium 115,
potassium 3.6, urea 8 and creatinine 0.11. Plasma osmolality 256 (n 280-295) and urine osmolality 366 Urinary
sodium is 52. Which of the following is correct?
A. The BP indicates that he is not hypovolemic.
B. The urinary sodium indicates that he is not hypovolemic.
C. He has SIADH
D. He has diuretic-induced hyponatremia
E. He should have a water deprivation test

354
216. some scenarios with hyponatremia stems totally diff from handbook
a.adrenal failure , b. salt loss ,
c. inadequate secretion of ADH (carbamazepine causes SIADH also head trauma)
d. Addisons
SIADH caused by head trauma.

217. Qs pt feeling dizziness on lateral eye movement esp when turning eye to Rt. It said had CT scan which was normal,
BP normal ,also RBS normal with occasional ventricular ectopic beats . (All these mentioned verbally)Now what to do
A. Observation*** B. Perindopril
C. Warfarin D. Metformin

218. Female with history of sinusitis now presenting with symptoms of meningitis and asked diagnosis Investigation
showed sinuses thickened options were
a. meningococcal meningitis
b. Sinusitis
c.pneumococcal meningitis**** ANS strepto pneumonae

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219. Bp measurement in 32 yr old male in
routine screening , what to do next ?
a) 24 hrs bp
b) repeat bp after 1 week ??
c) echo
d) ecg

220. 65years old man on hypertensive

treatment & history of MI 3yrs ago ,now all
examination is normal except of soft
blowing precordial murmur on the left
border of sternum .. what to do ?
a.cease metaprolol
b.cease metaprolol & commence verapamil
c. add warfarin ***

221. 60 yrs old lady with ecg showing

anterior septal wall mi already oxygen ,
morphine , aspirin given what is the next ,
patient presents with in 2 hrs ?
a. alteplase
b.reteplase
c. angiogram**…..should be
thrombolysis cz pt presented within 2
hr

222. Scenario of man with multiple drugs

now has developed urinary retention and
also pedal edema He was in af too I think
A. Urinalysis*** B. USG bladder C.
Digoxin level
D. Echo (Looks like right ventricular
failure)

223. .1ecg questionVentricular fribrillation ,Pt

unconscious low BP (shock) 1shock given
next
A. Chest compression for 2mins***
B. Iv adrenaline
C. Iv amoidarone

224. Young male long scenario came for

health check up, found elevate bp 150/90
and in the last month his Bp fluctuate bt
180/100 and 130/90
What to do ?
a, asses cvs chart risk
b. 24 bp monitoring
d. Start ace inhibitor

225. Post MI after 4 years came to your

clinic for follow up visit, the patient is doing well. Still on diet and regular exercise with complete normal lab work
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 provided. He is on ace and aspirin only
a. reinforce diet and exercise
b. stop aspirin
c. add statin
d. complete in regular follow up
e. till him he don't need any more follow up

226. ecg of inferior wall mi patient presented after 2 hrs of chest pain.whats the best mx? Not initial but best Tx....??
a.tpa
b.angiography and angioplasty
c.iv heparin
d.gtn patch
E. Aspirin
227. Pt with attack of MI, u started heparin and 12 hrs later abdominal swelling developed, u suspect hematoma, what
to do
A. Stop heparin
B. Reassure (injection site hematoma..tx-change the site or give IV)
C. Stop heparin and give aspirin
D. Give FFP
E. Give platelet

228. -middle age female with hx of mi come for follow up with normal ecg what to do
A-follow up after 3month (if pt is already getting all medication)…ans
B-give metoprolol (if not given earlier cz we add it after acute mx)
C-give thrombolitc

229. Patient had inf mi two days back. Today in hospital has bradycardia ,pulse 35/min
Adenosine
Atropine
Adrenaline

230. 70 yrs ant wall mi on ekg one hr since pain next

a.oxygen
b.aspirin
c.ntg
4.morphine
5.angioplasty
231. A 50 year old women had a mitral valve replacement surgery after rheumatic infection. After 24 hours she starts
developing a swelling in the femoral region which is increasing in size every hour, the swelling is pulsatile on palpation.
What would be your immediate next step?
A. Perform USG… usg guided compression
B. Perform CT angio
C. Put pressure on the swelling D. MRI

232. a young kid ingested his grandmother’s white tablets ( unknown quantity ) he presents with an ECG showing
bradycardia around 50 , wide QRS complex , peaked T waves , what did he take ?
a- Digoxin
b- Potassium tablets

digitalis toxicity
Bradycardia
hyperkalemia
arrhythmia (any type with the exception of rapidly conducted atrial arrhythmias)
Gastrointestinal: anorexia, nausea, vomiting, and abdominal pain
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neurologic signs: confusion and weakness
Renal dysfunction

233. ECG tachycardia, paent has controlled heart failure on thyroxine. What’s the next management?
. Beta Blocker
. Digitalis
. Stop Thyroxin
. Decrease Thyroxin

234. ecg of biventricular cardiac failure,with features of lbbb and tall T waves(so many features)….patient was on
digoxin,enalapril,carvedolil,what next?
increase dose of digoxin,
increase carvedolil,
increase enalapril,
start furosemide,
stop all drugs and reassess in 12 hours.

(Treatment of Acute HF is directed towards the cause 1st before deciding to give furesemide.. if giving
symptomatic treatment while not treating the cause .. Acute HF will continue to disaster.If ECG done
and shows Arrythmia then next will be directed to treat arrythmia not giving furesemide.Also when we
have a clear case like digoxin tixicity .. then we have to address toxicity 1sr.The choices could be strange
.. but this is a clear case of Digitalis toxicity.Hypokalemia causes digoxin toxicity .. and digoxin toxicity if
sever will cause hyperkalemia and Cardiac problems.Now we have hyperkalemia with CHF ==> it is a
must to stop digitalis .. also to stop ACEIs as it causes also hyperkalemia.. untill later on we add ACEIs
back after stabilization.ACEIs causes hyperkalemia .. BB Is not given in acute HF .. Untill stabilization ..
furesemide will increase digitalis toxicity .. Here i will go with treating the cause of HF and stop all drugs
1st.)

235. Patient on Digitalis and Thiazides for 2 weeks, comes with bradycardia and drowsiness.ECG was given >>
bradycardia with Bigeminy.What’s the cause?A. Hypokalemia B. Digoxin effect
common dysrhythmias associated with digoxin toxicity include: Frequent PVCs (the most common abnormality),
including ventricular bigeminy and trigeminy Sinus bradycardia

358
236. Child was bought to the ED after consuming some white tablets which belonged to his grandmother, she has
ischemic heart disease and taking medications for pain aswell. Which of the following medications will cause
such an ECG? ecg shows tall T wave
a.Potassium tablets
B.digitalis
C.analgesics
237. A young man comes for routine medical check up for insurance . All
examinations are normal but urine dipstick protein 1+ but no
hematuria. What is your next appropriate management? 1) 24 hour
urinary protein 2) serum electrolytes and urea creatinine 3) repeat
urine check in early morning 4) Intavenous pyelography 5) CT abdomen

238. Acute pericarditis scenario treatment asked==nsaid

case of pericarditis, chest pain aggravates during inspiration.
Treatmenta.Naproxen b.LMW c.iv heparin

239. Ventricular tachycardia e fibrillation BP 90/40 mx==defib.

240. A 45-year-old male presented to the emergency department with

left sided chest pain radiating to the left arm and jaw. There is no ECG
changes and troponin is negative 4 hours since the onset of chest pain.
He has been on sildenafil for erectile dysfunction, metformin for type 2
diabetes mellitus, and ramipril for hypertension. What would be the
most appropriate treatment?
a. Nitrates
b. Heparin
c. Morphin
d. Beta blocker
e. Paracetamol

241. Patient was just shifted from icu after pacemaker insertion. Patient
Suddenly complains of chest pain and difficult breathing. Pulse 88 bpm
,oxygen 98% heart sounds very faint on auscultation . what next ?
a) chest xray (next). cardiac temponade
b) ctpa
c) ct
d) troponin
e) Echocardiogram (best)

242. old pt with c/o light headachness and recurrent falls specially in morning when he get from bed, having a
long list of drugs ( sorry not remember) ECG shows ectopic beats what is ur next plan regaring its management?
a) echo
b)ct chest
c)24 hr bp
d) holter

243. Heart failure case man with AF on Ramipril, metoprolol, digoxin. Went on trip for 2 weeks and stopped his
medication. Now with bilateral oedema up to knee in legs. And ankle swellings Lungs is clear. And the patient is
not dyspneic, What is the most appropriate management?
A- Frusemide
B- Recommence all his medications
C- Ramipril

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244. patient presented with diplopia for 1 day. On examination there was diplopia on the right eye when looking
towards the right side. his glucose is normal. ECG has occasional verntricular ectopics. Whats the most
appropriate management.
A. Warfarin
B. Peridropnil
c. Metformin
d. Observation
245. #cardio pt on many medications , indapamide, verapamil, perindopril , aspirin….. present wth light
headedness and mobitz type 2 ecg given wt to do next
1.valsalva manover
2.cease verapamil
3.temporary pace maker
4.ceaseindapamide

246. 6 weeks baby for check up. Pan-systolic murmur left sternal edge. Wat inv- echo

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247. an obese man with type 2 diabetes on metformin for 2 yrs, bp
within normal range come for f/u, lab test ; - hba1c (high than
normal value ), glucose level high , wt to give ?
a. ramipril
b.insulin
c.gliclazid…causes wt gain, take dpp4 if in option

248. .svt ecg with a 50yr old with palpitation dizziness after morning
jogging.he is taking b blocker,frusemide acei digoxin some other
drug asking what should do in his management
a.serrum TSH…if af on ecg
b.holter monitor
c.stop digoxin
249. ECG of a 60 yr man show ? Atrial flutter 4:1 , with HT & DM , pt
has no complaint of dyspnea.. Mx ?
Add Metoprolol
Add aspilet
Add warfarin
DC cardiovertion

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250. New born baby،fuLLy cyanosed، in 100% o2 box No dstrress, no
murmur, 100% sat Hr normal, everything normal except cyanosis Not
reduced with o2, Wat next-
Pge2 infusion (TGA)
Atrial ostostomy
…..in tga and hypoplastic lt heart we use pg and in pda
use aspirin
surgery is arterial switch operation

251. 10 years old girl with type 1 DM come to your clinic for follow up.
She is using her own glucometer and check twice a day. She said her
average blood sugar between 5-9, but her HbA1C is 15%. What is the
problem here?
She is taking high glycaemic index foods
She is not taking her insulin
She is using expired blood strip ( can use upto 6 months)
She didn’t exercise
Cannot trust the HbA1C

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DERMA
1. A man was diagnosed of melanoma and was treated seeking advice for his children
A) children should put on sunscreen before going out
B) children should not go out between 10am and 3am…should be avoided…not stopped (if avoid take it)
C) cant remember other options
. sk

2. A lady had melanoma 0.3mm Breslow thickness and surgery done. She has 3 yr and 5 yr old children. She ask you
for her children at risk of melanoma. What is the most appropriate advice you give her?
A. They absolutely get melanoma if there is CT2----- ( Long gene name)
B. Apply sun cream when they go outside
C. Avoid going outside between 10am to 2pm
D. Recommend removal of dysplastic naevi
E. Skin check 6 monthly

3. skin Condition COMMONLY responsible for persistent dandruff

a) Irritant dermatitis
b) Seborrhoeic dermatitis
c) Tinea capitis
d) Lichen planus
e) Pityriasis versicolor

4. ..Excised BCC send to patho lab

what is the most prognosis value for this??
A. thickness of the lesion-for melanoma
B. no cancer cell all around the margin
C. inflammation of the lesion
D. amt Solar keratosis ????

5. pic of shingles lesion is there for 1 week.what is the best management of this patient
a.oral steroids
b.regular oral analgesia
c.acyclovir
d.topical steroids

6. 80 kg man came with 15 % burn how much IVF needed

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A. 3L hartman +2 L 5 % D/W
B. 2L N/S +2 L 5% D/W
C.3 L hartman + 2L blood
D. 3L NS + 1L hartman

Parkland formula of burns= 4ml x %of burns(15)xBody weight = Quantity in 24 hr(3L Hartman+rest DW)
Give half in first 8 hour
http://www.vicburns.org.au/severe-burns/early-management/fluid-resuscitation/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038406/

7. Melanoma patients did surgery now asking u about giving risk of his 5 and 3 years of old child ?One option like
don’t go out 10 am and 3 pm another one was looks appropriate for me if having dysplastic Navi

Risk factor for melanoma:

Table 9.4.1.1. Melanocytic skin cancer: Identifying risk

Who is at risk? What should be done? How often?

Average risk
Medium/dark skin colour and no Primary preventive advice (III, B) Opportunistically60
other risk factors

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 Increased risk
• Family history of melanoma in first- Primary preventive advice and Opportunistically 60, 65
degree relative risk [RR] = 1.7) examination of skin (III, B)
• Fair complexion, a tendency to burn
rather than tan, the presence of
freckles, high naevus count ( 100),
light eye colour, light or red hair
colour
• Presence of actinic damage (RR = 2)
• Past history of non-melanocytic skin
cancer (NMSC) (<40 years of age
higher risk)
• People with childhood high levels of
ultraviolet (UV) exposure and
episodes of sunburn in childhood (RR
= 2)

High risk (Risk 6 times normal)

• Previous history of melanoma (RR Preventive advice, examination of Every 6–12 months (Practice Point)
10) skin (with or without
photography) and advice on Frequency of follow-up
• 5 atypical (dysplastic) naevi (RR = 6)
self-examination (III, C) examinations for people who have
had melanoma is based on disease
stage 66-64

RR, relative risk; NMSC, non-melanocytic skin cancer; UV, ultraviolet

8. Man with rash on hand of sun exposed areas. Rashes are more severe when exposed to the sunlight. And he’s
just started taking amiodarone for a few weeks. What is the cause of the rashes?

1. Pseudoporphyria
2. Other options don’t remember.
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9. Picture showing rashes on hands of a man. Patient on amiodarone and many drugs. Developed maculopapular
skin rash on hands and face after 2-3 days of started on amiodarone. Asking cause?
a. Fixed drug eruption
b. Pseudoporphyrin
c. photo-toxicity
d. pemphigus
10.PIC of hands with rash.patient was started on amiodarone 2 weeks back and this rash developed on face and
hands for 1 week.rash gets aggravated when he goes to sun .what is the cause
. a.phototoxicity
b. pseudoporphyria
Ref: racgp

11.pic of SLE face(butterfly rash), what to dx

ANA (for suspected SLE- recommended approach is first ANA then if + then do dsDNA and ENA-Anti Sm)
Anti smith

12.Picture of facial rash (butterfly wings), woman, young with mouth ulcers asks for exam to make Diagnosis
A ana
B anti smith***

13.Pics of erythematous rash in both legs, after taking amoxicillin, complaint of joint pain, rash is non blanching,
palpable
1. Henosch schonlein purpuric — non blanching palpable rash on legs and buttocks and h/o previous infection.
2.E. nodosum
3.Hypersensitivity vasculitis —— amox rash presents all over the body and not symmetrical.

14.last 2years,on examination there was red, painful, lumpy lesion on leg with bilateral ankle swelling, no pic was
there, serum ACEI was high, was asking what will you do next
a. ANA
b. Skin biopsy –Dx is sarcoidosis in which ACEI high ,painful lumps and Dx is CXR,CT,MRI,Biopsies of lesions
c. Blood culture

15.Pic of a toe nail with granulation tissue . He has had this infection several times in 2 years. Has taken full two
courses of antibiotics. No help . what to do now?
a- wedge excision of nail bed
b- Steroids
c- another course of antibiotics
d- half resection with nail bed.
e-wedge resection of extra nail— pg 805 jm
proper response is wedge removal of nail and nail bed

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16.. Pic of molluscum contagiosum... asking for school exclusion
a. -no exclusion Isolation of the case is not required. Infected children should either avoid contact sports or ensure
that lesions are adequately covered during play. No school or childcare exclusion is required
b. -exclusion after 2 days of commencement of penicillin
c. impetigo school exclusion required.-until antibiotics started

17.An an old Australian male, came with the following complaint as in the picture below, what is the most appropriate
action?
a. local excision
b. Excision with 2cm margin..should be 2mm
c. Topical podophyllin
d. Topical imiquimods

18.Patient came for biopsy result . he did excision of pigmented lesion with
2 mm margin and result showing malignant malenoma grade 2 . best
advice to pt ?
Reexcision ***JM1370
Observation

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19. Psoriasis was described but no image was given and the question asked for the most appropriate treatment?
a. Topical triamconolone -cortico
b. Emollient creams
c. Apply coal tar — frst
d. Ketoconazole
first line : anthralin aka dithranol
second corticosteroids but not use alone preferred to use with tar or calcipotriol
systemic methotrexate or cyclosporine(only in hosp)

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20. Psoriasis pic asking treatment –
a. Bactroban
b. Chloramphenicol
c. Betnovate-cs betamethasone

21. SLE PIC(left one from anthrology)..Asked Long term Rx?

CORTICOSTEROIDS MAINSTAY Rx
hcq
22.pic of psoriasis asked about treatment
a) oral steroids — given topical
b) ultraviolet rays
c) local antibiotics
d) local calcipotriol cream***

23. Fever ,joint pain and rash with history of scab at the tick bite area with regional Lymphadenopathy after visiting South
Queensland, what is your likely diagnosis?
a) Scrub typhus-causative org is rickettsia tsutsugamushi
b) Ross river fever viral-in NSW-spread by mosquitos-symptomatic Rx
c) Q fever-in shephards, animal rearing places etc

r australis aka queensland tick typhus=QLD=aka spotted typhus

r honei=flinders island=Tasmania aka spotted typhus
r tsuttsugamushi=scrub typhys=QLD and north aus
r typhi=murine typhus=all over aus

looks like queensland tick typhus causative org rickettsia australis

Rx doxycycline

24.Pic of Hutchison(lentigo) melanoma in an old Australian male. What is the most appropriate action?
a. local excision
b. Excision with 2cm margin
c. Topical podophyllin
d. Topical imiquimod

25.a young female came with rash all over her body she has a history a sore throat from two weeks and take
ampicillin the rash developed from 2 days ?
a.henoch schonlen purpura
B.hypersensitivity vasculitis

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With this picture answer would be allergic vasculitis

26.pic of leg(h/o dvt in the past and melanoma but a long time ago..5-15 years) what could be the cause of this?
a. Spread of melanoma
b. Hemosiderin deposits

hemosiderin deposits hemosiderin deposits

27.Hand pic RH vasculitis( necrosis of finger tips) DX by

A. ANA
B. ANCA
**RA+RV=ANCA
RA+Antiphospholipid syndrome=anticardiolipin ab

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28.buttock pic given... similar to
this but more reddish and
without central clearance or
raised edges and neither was
psoriasis.... no silverfish scales
no plaques at all... just plain red
surface.. no clinical features
mention just written a pt
presented with this rash . how
will u treat ? (DX: psoriasis)
a. calcipotriol
b. UV- B
c. triamcinolone –since no
definitive pic given
d. Tar
e. Ketoconazole***-depending
on pic

29.pt with red raised nodules on

leg.(sarcoidosis)
Acei inhibitor raised. most app Ix
asked?
a. skin biopsy****
some others in option i don't rem.
but not CT chest
Serum ACE levels are elevated in
60% of patients at the time of
diagnosis. Serum ACE levels may
correlate with total body
granuloma load.
Routine chest CT scanning adds
little to diagnosis. High-
resolution CT (HRCT) scanning of
the chest may identify active
alveolitis or fibrosis and
correlates with yield of biopsy.
Pulmonary function tests and a
carbon monoxide diffusion
capacity test of the lungs for
carbon monoxide (DLCO) may
be performed-decreased

30.Child had history of URTI , now pin point rash on trunk , non blanchable, afebrile .platelet give 35x10-9 . seems
like ITP asking what is most approp at this stage ?
a- iV immunoglobin
b- strict bed rest
C- Prednisolone
**if simple rest that’s fine…but not strict bed rest. If review platelet present go for it but.if no review in option but ‘no
treatment’ present go for that

31.A 24 yrs old male presented with fever, malaise, and sore throat for last 12 days. Examination showed white
tonsillar exudates, generalized lymphadenopathy, maculopapular rash (not vesicular), rash on palms and soles
and excoriating lesions around anus. Which of the following is the likely diagnosis?
a. Glandular fever-EBV-rash starts on trunk and upper arm then spreads to forearm and face , no genital rashes
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 b. Secondary syphilis***-
c. Pemphigus-can be oral and body-shoulders and trunk etc, no lymphedenopathy sore throat etc
d. Steven Johnson’s syndrome-no lymphedenopathy,fever,sore throat
e. Herpes simplex infection-rashes on face ,mouth etc and body, not genital ulcers.-vesicular

32. Pt come with complain of tongue ulcer heavy smoker o/e indurated area and whitish surrounding area not
vanished by scraping. Hx of previous gonococcal infection. Dx
Ca tongue
Leukoplakia***
Syphilis lesion

33.Picture of a penis with papulo nodular lesions on the glans and three same lesions on the corona. Diagnosis?
a) scabies
b)lymphogranuloma venereum**** -caused by Chlamydia, more in men to men sex
c)flea
d)HIV
e)Syphilis

34.Picture of necrosis on 3 fingers, patient with rheumatoid arthritis, nonsmoker, can't remember the rest of the
description, but asks for diagnosis
A ana*****(secondary Raynaud's)-rheumatoid vasculitius-in longstanding ra
B ena——SLE
C anti ssa—— for SLE,SSB-sjogrens
D anti citrulline-for rheumatoid arthritis-alrdy diagnosed
**if no anca take ana

35.7-year-old boy with a history of atopic eczema is brought to the surgery. Overnight he has developed a painful
blistering rash affecting his face and neck. His temperature is 38. 1deg.Which one of the following is most likely to
be responsible for this presentation?
a. Varicella zoster virus
b. Streptococcus pneumoniae
c. Pox virus
d. Staphylococcus aureus-not painful
e. Herpes simplex virus****(atopic eczema with rash eczema herpeticum) -painful

36.child with fever, conjunctivitis, rash lymphadenopathy, abdominal pain . Initial Investigation (Kawasaki
disease).dd: TSS, SJS, measles,Scarlet fever
a. Aso titre****
b. ESR—-initial to rule out other diseases then blood tests then echo(if asked best)
c. Echo
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D. Ana
E. Urinalysis.-i
http://www.mayoclinic.org/diseases-conditions/kawasaki-disease/home/ovc-20259782

37.Malignant melanoma , excision done about 2cm dept. Asking what to do next for the patient ?
A. Chemotherapy
B. CT
C. USG
D. Wide excision
E. Review in 3months —1371 jm

38.pic of Malar rash give lab show Ana &anti ddna positive. Anticcp negative ask long term rx......hydroxychloroquine

39.scenario of sle best inv......anti smith(ans) there was no antidsdna in opt.

40.hand pic of raunaud phenomenon in woman improved by nifedipine also give lab with Ana and antidsdna positive
.reumatoid factor positive but anticcp negative ask long term rx of condition.....hydroxychloroquine -sle

41.Pic of left hand who didn't have distal phalanges in all fingers, petechial rash on foot dorsum has cough dyspnea
loud P2 along the rt-sternal border. asking about the cause
a. Pulmonary HTN (ans)-can occur in scleroderma
b. Bronchiectasis

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 c. Chronic asthma
d. interestial lung dis g.

42.HY:a pt presented with c/o dry eyes. He has history of seasonal allergic conjunctivitis c/o dry mouth as well as
positive anti Ro and La antibodies what is ur next step in her management?

1.Hydroxychloroquine
2. Artificial tear drops-sjogrens
3. Methotrexate
4. Topical prednisolone

43.Patient with known Waldenström's macroglobulinemia is admitted with fever. He has a history of glandular fever
infection and varicella infection in childhood. He is given ampicillin and azythromycin. The next day he develops
rash. Picture: rash is on the abdomen and chest. It doesn’t look like erythema multiforme at all. Most of the
elements are raised papules, but couples of them are pustules. What is the initial next step to identify cause of
rash?
a. swab from the lesion
b. biopsy of the lesion —— since rash is not itchy or painful cant be varicella related
c. bone marrow biopsy
d. drug allergy test
https://www.dermnetnz.org/topics/waldenstroem-macroglobulinaemia/

44.which one of the following is the risk for familial hypercolesterolomia?

Ans.tendon xanthelesma

45. a farmer presents with rash on back with elevated margin+fever Tx?
A steroids
B Penicillin….lyme disease..donut shape rash
C acyclovir
46. DERMA A pic of a man with really bad herpes zoster on left flank area. What is the management?
1. Acyclovir…if within 72 hr
2. Oral antibiotics
3. Oral analgesics
4. Topical antibiotic

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47. Picture showing red patches of rashes in legs à psoriasis??? Treatment
a) prednisolone (didnt remember it was given oral prednisolone or just prednisolone)
b) calcipotriol cream
c) antifungal
48. Venous ulcer on medial malleolus.
Many method of
Dry
Wet
Local ab
49. Anterior triangle neck lump in smoker with history of melanoma. Diagnosis?
Primary SCC
Metastatic melanoma
Nasopharyngeal carcinoma
50. Cracking of the skin behind the ears in an infant, along with itching of the scalp is most suggestive
of which skin condition?
A.Atopic eczema
B.Cradle cap
C.Seborrhoeic dermatitis
D.Psoriasis
51. condymalata in genital area with pregnancy.
laser cautarization done but relapse, mx?
-pap,
ebv pcr,
diathermic removal
**leave small and asymptomatic wart until delivery
**if symptomatic or large do cryotherapy or ablation
with TCA/BCA,or imiquimod (cat b)after informing the
woman…if it reccurs use the previous method which
worked earlier
52. Pt on lithium then he put on resperidone. He
developed acne and wt gain. Cause? a) lithium b)
resperidone c) both
**side effect of lithium is acne and wt gain, side
effect of resperidone is wt gain..so answer is lithium

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53. An old scenario of ulcer on tongue. Asking for
diagnosis
a. Squamous cell carcinoma
b. Apathous ulcer
c. Basal cell carcinoma
d. Lichen planus
54. #DERMA severe persistant pain infront of the ear
with redness
a-herpes simlex
b-trigeminal neuralgia
c-herpes zoster….pre-eruptic phase
55. an obese lady with hirsutism and acne came for
contraception she has hx of migrane
A. Ocp contain ciproteron …cant give bcz of migrane
B. Ocp
C. Injection medroxy progestron every 3 mon.
D. Barrier method….cause progesterone causes acne
56. A young boy (cant remember age) has received treatment with tetracycline for his acne, he says it
somehow looks like cysts to him. Whats the next treatment you will offer?
A. Topical retinoid acid
B. Oral retiniod
C. Benzyl Peroxide
D. Tetracycline
**if pt is continuing tetracycline dont give oral retinoid cause it causes BIH but if he is not continuing
tetra then take oral retinoid

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57. Lady on anti depressant ; now replace it with resperidone and lithium but have acne and weight
gain what the cause
a) Lithium( if only asking for acne side effect)
b) Resperidone (leads to metabolic syndrome)
c) Reaction between litium and respeidone

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58. Pt wid scabies treated wid permethrin. After 1 month symp again developed. What next tt option ?
a) repeat permethrin b) corticosteroids #derma
59. Scab on child’s face not responding to antiseptic. Treatment: a) bactroban b) acyclovir c) antibiotics
Dx??
60. 14 year old woman on tetracycline for acne presents with a three month history of headaches and
fleeting episodes of blurred vision.On examination she is obese and has severe papilledema but no
other neurological signs.A CT scan is normal.most appropriate next initial investigation?
A.MRI brain scan
B.cerebral angiogram
C.Hypercoagulability screen
D.Overnight dexamethasone suppression test
E. Lumber puncture

61. Most common skin cancer in australia?

BCC is 80% most common among skin cancer

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 ANS A

62. you are invited to give lecture in 13 year old girls school. sex education is covered by school
curriculum. Whats ur concern? a) Acne b) Alcohol… c) Skin cancer d) Pap smear
63. Diabetic patient with ulcer on right foot (2 pics given....2 deep ulcers at medial malleolus and foot
with skin necrosis and inflammation. Glycated hemoglobin 6.5.He was admitted and antibiotic was
given, takes swabs and sent for C/S. What will you do after that?
a.X ray b.MRI c.Bone scan d. Doppler e.CBC

64. psoriasis whole legs since 6 mons treatment

Uv therapy
Calcipotriol
Prednisolone

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65. #derma You are taking care of a patient in the internal medicine clinic. She’s 61, and five years ago
she had a biopsy-proven basal cell carcinoma on her nose that was treated with imiquimod. In the past
6 months, she’s noticed a new pink papule in the same spot that won’t heal. What is the next
appropriate action?
A.cryotherapy
b.excision with 5 mm margins

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 c. Repeat application of imiquimod 5 nights a week
for 6 weeks
d. Referral for Mohs micrographic surgery
e. Referral for radiation therapy

66. Psoriasis pic on the buttock of a man for 6

weeks. What is the most appropriate plan?
a. apply coal tar
b. Emollient creams
c. Topical triamconolone
d. Ketoconazole
67. Identify this disease? 1) Haemangioma 2) Purpura 3) psoriasis 4) pityriasis rosea 5) Kaposi sarcoma

68. derma You are taking care of a patient in the internal medicine clinic. She’s 61, and five years ago
she had a biopsy-proven basal cell carcinoma on her nose that was treated with imiquimod. In the past
6 months, she’s noticed a new pink papule in the same spot that won’t heal. What is the next

381
 appropriate action? A.cryotherapy b.excision with 5 mm margins c. Repeat application of imiquimod 5
nights a week for 6 weeks d. Referral for Mohs micrographic surgery e. Referral for radiation therapy

69. A young woman has two black spots on her lower limb with no change for last one year What is it
A. Benign junctional naevus B. HSP purpura C. Seborrhic keratosis

Junctional • Usually <5 mm • Circular-shaped macules • May be slightly elevated • Colour usually brown to black
• May be ‘fuzzy’ border Most naevi of the palms, soles and genitals are junctional but there is no evidence to
support the traditional view that naevi in these sites have more malignant potential. JM 1355 6th

70. A 67 year old man with a history of Parkinson’s disease presents due to the development of an
itchy, red rash on his neck, behind his ears and around the nasolabial folds. He had a similar flare up last
winter but did not seek medical attention. What is the most likely diagnosis?
A) Levodopa associated dermatitis
Seborrhoeic dermatitis
C) Flexural psoriasis
D) Acne rosacea
E) Fixed drug reaction to ropinirole

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71. 40-year-old female presents with a six month history of pruritic papules, vesicles and excoriations
on the elbows, knees, buttocks and scalp. Her GP has prescribed topical betamethasone therapy which
has been unhelpful. What is the most likely diagnosis?
Atopic dermatitis (eczema)
Dermatitis herpetiformis (DH) jm 1294
Henoch-Schönlein purpura (HSP)
Psoriasis
Scabies

** herpes simplex-like vesicles, errupt at dermatoepidermal junction

extremely itchy

mainly over extensor surfaces of elbows, knees, trunk, shoulders

MC asoc. with coeliac dis.

skin biopsy is diagnostic

Rx

gluten-free diet

dapsone 100 mg / day

72. Child with history of eczema and asthma asking prevention therapy. Both parent smoke cigarette
and history of hay fever in mother A. cromolyn B. budesonide C. fluticasone

73. year-old female presents with a six month history of pruritic papules, vesicles and excoriations on
the elbows, knees, buttocks and scalp. Her GP has prescribed topical betamethasone therapy which has
been unhelpful. What is the most likely diagnosis? Atopic dermatitis (eczema) Dermatitis herpetiformis
(DH) Henoch-Schönlein purpura (HSP) Psoriasis Scabies

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74. Young man who has travel around asia, he spends 3 months in Berma. Has patches of loss of hair on
his head & Rashes on palm & sole & feet. Whats is dx- JM-.1385 a. Syphilis b. Zinc allergy c- eczema

75. mother has goat milk allergy and other family members has atopic eczema she is pregnant now and
she want to know what be effect on her child and ask for advice pre and post term A. Don't drink goat
milk during pregnancy b.. Don't give child goat milk C.keep away child from dust pollen

76. A 6-year-old child is brought for assessment of his skin problems by his parents. You suspect atopic
dermatitis as a possible diagnosis and advise topical corticosteroids. Parents of the child are not willing
to use steroids for their child. What will you do next? a) Request a court order b) Notify police c) Notify
child protection services d) Cancel the steroid prescription 0 e. Cancel the steroid prescription

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77. Many children in a school got scabies. After appropriate management of the children with scabies,
what would do next?
A. Exclude them from schoool
B. Keep swimming pool closed until no new cases found
C. Treat household of family members of kids having scabies with TOPICAl scabies agent

78. Q. A child came to GP with the arthralgia , purpuric rash, abdominal pain alongwith URTI :
Investigations: Urine; spun specimen.
A. ITP
B. HSP
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 C. vWD
D. Haemophilia A

79. homeless middle aged female, picture of rash over wrist , this rash on both wrists and groin , ttt: a-
cortisone cream b- tar c- benzyl benzoate
80. h/o rash after penicillin injection..asked what next antibiotic?
1,cephalexin
2.ciprofloxacin
3.roxithrtomycin
4.ticarcillin
81. flu like symptoms body ache, high fever, rash, vomiting diarrhea Bp 80/50 diagnosis? a.malaria b
dengue c hepatitis d. toxic shock syndrome
82. 40 yo alcoholic and smoker complains of a 2 cm painless lump on the left tonsil. No other signs and
symptoms described. What is the most likely dx?
a. Squamous cell carcinoma
b. nasopharyngeal cancer
c. body/aneurism on the carotid artery
d. mts from some place
e.Hodgkin
83. A 53yo man presents with a longstanding history of a 1cm lesion on his arm. It has started bleeding
on touch. What is the most likely diagnosis?
a. Basal cell carcinoma
b. Kaposi’s sarcoma
c. Malignant melanoma
d. Squamous cell carcinoma
e. Kerathoacanthoma
84. Patient with cellulitis in left leg,treated with cefazolin and got relieved but after 3 days later
developed rash, in future which drug will be considered safe for this patient?
A. Cefazoline
B. No cephalosporin
C. Neither penicillin nor cephalosporin***
D. Any cefalosporin except cefazolin
E. Need serum test before any antibiotic
85. One 30 year female patient for last 2 and half years suffering from joint pain ( hand- metacarpo
phalangeal joint, elbow joint), Skin lesion in back of the trunk and also in scalp, external ear cavity. Her
ESR is 75 mm in 1st hour. Hb% 11. RF - negative, mantoux test also negative . So , what could be the
provisional diagnosis here and Mx

386
 **Dx:psoriatic arthritis
MX: mainly NSAID+DMARD
Although traditional therapy has consisted of nonsteroidal anti-inflammatory drugs (NSAIDs) and local
corticosteroid injections, with disease-modifying antirheunatic drugs (DMARDs) being reserved for NSAID-resistant
cases, the finding that 40% of patients may develop erosive and deforming arthritis has led to recommendations
of early treatment with DMARDs in patients with active disease (see Guidelines). In addition to older DMARDs,
several biologic agents and targeted synthetic agents have become available for use in psoriatic arthritis

Derma recalls:

86.Treatment of Lichen planus

A. Penicillin

B. Steroid

C. E.mycin

Jm 1294

87.A 35 year old woman develops extremely pruritic, purple, polygonal papules on her wrists. In association with
these skin findings, she is likely to have:
a. Herpes labial on the lips

b. Candidiasis on the vulva

c. Lacy white patches on the buccal mucosa

d. Ulcerations on the conjunctiva

e. Anal fissures

LICHEN PLANUS

• **idiopathic inflam. condition

• occasionaly triggered by drugs or hep. C inf.
• can affect skin, hair, nails, oral and genital mucosa

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 • violaceous polygonal flat topped papules that show lacy white lines (Wickham’s striae)
• can form ulcers
• risk of malignant transformation of oral l.p. needs to be considered, especially in patients with chronic
ulcers and Hx of tobacco use
• Mx
– skin eruptions resolve in 6-9 mths, but leave discolored marks and no scarring
– moderately potent topical C/S ointment
– if not improved, oral prednisolon

88.skin condition COMMONLY responsible for persistent dandruff

a) Irritant dermatitis

b) Seborrhoeic dermatitis

c) Tinea capitis

d) Lichen planus

e) Pityriasis versicolor

89.Picture of a penis.papulo nodular lesions on the glans and three same lesions on the corona.diagnosis?
A)scabies

b)lymphogranuloma venereum

c)flea

d)HIV

e)syphilis

90.24 year old male came up for follow up regarding 6 weeks history of pruritus and rash on his genitalia. Pic as
shown (very very similar but not this picture). What is the diagnosis?
a. Syphilis

b. Lymphogranuloma venereum

c. Scabies
388
d. Genital warts

91.A man with numerous painful vesicles on penile shaft. A test done showed multi segmented giants cells. What is
the possible organism or diagnosis
A. Tzanck prep for viral organism

B. Syphilis

C. Lymphogranuloma

D. Shingles

E. Haemophilus ducreyi

92.Picture of a man with 4-5 pruritic spots on gfans penis and shaft. What's the diagnosis?
a) Scabies

b) Syphilis

c) Herpes

93.A 6 month old infant had itchy erythematous papules and exudative lesions on the scalp, face, groins and
axillae for one month. She also had vesicular lesions on the palms. The most likely diagnosis is:
A. Congenital shypilis

B. Seborrheic dermatitis

C. Scabies

D. Psoriasis

94.65 yr old female comes to ur Gp clinic for vulval pruritus and redness,her pap smear was normal which was done
3 years back,what will you rule out first in the management of this patient..
a. Sexual abuse
b. DM
c. Candida
d. Vulval Ca in Situ
e. Oestrogen deficieny
jm1165

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95.8 months pregnant female wants to know about how to protect the child from familial atopy.her first child has
flexural eczema
a. breast feeding for 1 yr
b. breast feeding for 6 months
c. house mite control
Fa Iqbal There is evidence that exclusive breastfeeding and avoidance of complementary feeds in the first 3–4
months of life is associated with a reduced risk for developing allergic disease in early childhood, particularly
atopic dermatitis during infancy and childhood asthma.

There is no evidence that exclusive breastfeeding for longer periods (6+ months) has a protective effect against
allergic disease and some studies have found an increased risk for asthma, eczema or atopy at 5 years of age.

The long term effects of breastfeeding on the development of allergic disease in later childhood and adulthood is also
uncertain, with longitudinal studies reporting a small increased risk for allergic disease and sensitization with
exclusive breastfeeding for 3–6 months or prolonged for 6 months or more.

96.Which of the following is aggravated by topical steroids. A)psoriasis b)atopic eczema c)discoid eczema d)perioral
dermatitis e)SLE
97. Out of theses option, where u cant use steroids—1. SLE 2. Perioral dermatitis
perioral dermatitis

discrete erythematous micro papules that often become confluent

lower face, around mouth and chin

commonly symmetrical, rim of sparing around vermilion border of lips

due to cosmetics, pregnancy, OCP, C/S

Rx

tetracycline, doxycycline

avoid topical C/S

98.A 3 year old child has a scaly itchy rash on the extensor of the arms and applications of the moisturizer applied by
mum do not help. What is the most likely cause?
a. A. Herpes zoster
b. B. Atopic dermatitis
C. Pityriasis rosae
**Hx of atopy

location

infants: cheeks, folds of the neck and scalp, extensor surfaces

chilfood: flexural surfaces (cubital and popliteal fossae), hands, feet

if inf. treat:
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on the outside, clean it

on the inside – treat. staph.

Cephalexin

avoid iritants – fabric, heat, drying of the skin, known allergen, soap, baths not to long or hot

can be

dry – avoid dryness - moisturise with creams

weeping (with crusts)

depending on the area

face, genital – go easy 1% hydro cortisone

99.6 year old boy was brought by mother because of fever. The patient is a known case of atopic dermatitis then
lately developed crusting of lesion on his legs some with erythema and some with purulent discharge. Suddenly
developed a systolic murmur on the sternal area. What is the next step to arrive at
the Dx?

a. FBE
b. Lumbar Tap
c. ECG

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d. Echocardiogram
dx infective endocarditis

100. A 3 year old child has eczematous dermatitis on extensor surfaces, His mother has a history of
Bronchial asthma. Diagnosis should be
a. Atopic dermatitis
b. Contact dermatitis
c. Seborrhic demiatitis
d. lnfantile eczematous dermatitis

Ø 1% hydrocortisone + ketoconazole cream ,medical t/m of which nappy rash?

e. A.irritant dermatitis b.seborrhoeic dermatitis c.Atopic dermatitis d.monilia nappy rash e.psoraitic rash
Jm1323

101. Non-scaly eruption, demarcated edge of rash,usually have family history ?

a. A.irritant dermatitis b.seborrhoeic dermatitis c.Atopic dermatitis d.monilia nappy rash e.psoraitic rash

102. Erythematous nappy rash,flexures spared.suprious diarrhea with constipation ?

A.irritant dermatitis b.seborrhoeic dermatitis c.Atopic dermatitis d.monilia nappy rash e.psoraitic rash

Jm1322

103. Red,shiny nappy rash involving felxures,satellite lesions ?

a. A.irritant dermatitis
b.seborrhoeic dermatitis

c.Atopic dermatitis

d.candidiasis

e.psoraitic rash

104. Picture of Psoriasis Anthology book and ask about the RX

a. 1 topical steroid
b. 2 oral steroid
c. Erythromycin
d. 4intralesional steroid

105. In which of the following conditions are nails MOST COMMONLY affected?
a) Systemic lupus erythematosis (SLE)

b) Psoriasis

c) Iron deficiency

d) Infective endocarditis (IE)

e) Hypoalbuminaemia.
392
106. Picture of psoriasis treatment option
a. A UVB
b. B Corticosteroid
c. C Calcitriol
d. D Moistoiturer

107. A pic of psoriasis of the leg plaques extending from thigh to leg,red and extensive lesions,what's the
treatment of choice?
A.UVB

B.Calcipotriol

C.Steroids

393
108. Extensive psoriatic lesions on hand and legs. Treatment?
a. UV-B
b. diathranol
c. steroids
d. erythromycin

109. psoriasis asked about appropriate treatment.

a. moisturizer

b.steriods

c)sulphasalazine

110. Pic of psoriasis skin patches, (NO ITCH) what is the best initial Rx:
A. Prednisolone

B.B UV

C.Calcipotriol

394
111. A patient presented to your clinic with an erythematous scaly lesion. Your differentials include tinea,
psoriasis and pitiryasis rosea. Which of the following tests will help you to reach a definitive diagnosis?
a. Wood’s lamp
b. Skin scrapings
c. Dermatoscopic examination
**B is correct i think .Pityriasis rosea Diagnosis based primarily on clinical observation .

KOH preparation/skin scraping confirmatory by ruling out fungal infection.

Skin biopsy indicated if lesions do not resolve within a month .

Wood's light you can detect remember 3PET(pityriasis,porphyria,pseuddomonas,Erythalsma, Tinea capitis)

JM p1294 edi 6th.

395
Dermatoscopic examination is mainly used to detect.ion of melanoma and other skin
cancers.scabies,,warts,fungal infection,alopecia.

From dermatological point of view Pityriasis and Psoriasis can be detectable clinically quite easily. So, as a
earlier investigation Skin scraping/KOH preparation is more appropriate here i think. So, B is probable
answer
112. Mx OF PSORIASIS?
a. UV
b. oral prednisolone
c. cotrimazole
d. no options of TAR, calcipotriol...

113. which one cant cause keratin scaling?

a. psoriasis
b. pitiryasis rosea
c. scc
d. bcc
e. solar keratosis

114. The only definite indication for giving systemic corticosteroids in pustular psoriasis is:
A. Psoriatic enythroderma with pregnancy

B. Psoriasis in a patient with alcoholic cirrhosis

C. Moderate arthritis

D. Extensive lesions (erythrodermic psoriasis)

115. Similar picture given, Numerous, Large, Red colour patches/plaques on both shins,
treatment?(psoriasis )
a. Anti-Fungal
b. Ultraviolet B
c. Oral Steriods

116. WOF factors would be least likely to provoke a worsening of Psoriasis

a. Beta-blockers
b. lithium
c. Penicillin
d. stress
e. antimalarial

117. Photograph 1: Shows a skin lesion on the forearm. Slightly raised, red plaque, slightly scaly. What is the
diagnosis?
a) Lichen planus

b) Discoid eczema

c) Squamous cell carcinoma

396
d) Psoriasis

e) Contact Dermatits

118. Which of the following is characteristic of psoriasis? a- Silver scales b- Wickham’s striae(lichen planus) c-
Koebner’s phenomenon d- Mucosal lesions e- Pruritis

119. Rashes similar to syphilis except

a. Roseola
b. Discoid eczema
c. Tinea coporis
d. Guttae psoriasis
e. Atopic eczema

120. A girl with acne and hirsutism.treatment?

a)danazol
b)EE with cyproterone
c)EE with Yasmin drosperinone

121. A girl with acne+hirsutism..initial mgmnt?

a-Anti androgens
b-isoretinoin for 20 weeks
c-isoretinoin for 6 weeks + tetracycline for 1st 2weeks
d-antiobiotics

122. A 40-year old woman presents with a 2 year history of erythematous papulopustular lesions on the
convexities of the face. There is a background of erythema and telangiectasia. The most likely diagnosis in the
patient is:
a. A. Acne vulgaris
b. B. Rosacea
c. C. Systemic lupus erythematosus
d. D. Polymorphic light eruption
**acneiform lesions on forehead, cheeks, nose, chin - with papules, pustules

differentiated from acne by the absence of comedones

flushing and blushing precedes the rash

telangiectasia, erythema

123. Lady has positive pregnancy test. She is taking OCP, treatment of diabetes and treatment for Acne. What
drug likely to cause teratogenic effect on her baby?
A.Metformin

B.OCP

C.ISOTRETINOIN

124. A 25-year-old man presents with a well-defined patch of hair loss on his scalp surrounded by
‘exclamation mark’ broken hairs. There is nail pitting, hypopigmented skin but no scarring. What
397
 is the most likely diagnosis?
a. Alopecia areata..it is associated with nail pitting and vitiligo

b. Discoid lupus

c. Telogen effluvium

d. Trichotillomania

e. Tinea capitis

Driving Questions
https://www.commerce.wa.gov.au/sites/default/files/atoms/files/assessing_fitness_to_drive_2013.pdf

builder 48 yr,weekness in left side of body for few minutes.past same episode for 5 times.advice after giving aspirin
and discharge with follow up by local doctor
More antiplatelet
Can’t drive 6months
No strenuous work
Can’t go to work without local doctor’s permission (ans)

398
https://strokefoundation.org.au/About-Stroke/Help-after-stroke/Stroke-resources-and-fact-sheets/Driving-fact-
sheet

PRIVATE :

• You must not drive for at least two weeks after (TIA).

• You must not drive for at least four weeks after a stroke.

COMMERCIAL :

• four weeks after a TIA

• three months after a stroke.

• Before you start driving again, you need medical clearance from your doctor.

• You may need an occupational therapy driving assessment.

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

55 year old builder came with weakness of his left hand and leg not lasting for 12 minutes, same complaints couple
of weeks back. he is taking only Aspirin, no other drug, what will youadvice him other than usual Mx (October 16
recalls)

a)Do not do strenuous exercise

b) Do not drive for 6 months

c) Add warfarin

d) Add more anti coagulation

e)don’t go 2 work unless allowed by urgp

Raza Khan Kochai and they had written in question " what you will advise him, other then usual mX" so doctor have
to do his management, advise is here for him, to stop the work.

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Lady with type 1 DM. She had hypoglycaemic crisis and was recently hospitalised. She asks about driving her kids to
school. What will you advise?
-no restrictions
-she can drive after having breakfast in the morning if option to check glucose then go for that
-she should not drive 6 months
drivers are required to perform a blood glucose check before they drive and again during the journey if driving for
more than two hours.

insulin= 2 yearly review

metformin= 5yearly review

https://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/bee30f0d-9b45-49f0-9800-5d66ee1f49d9.pdf

399
https://www.racgp.org.au/your-practice/guidelines/diabetes/14-management-of-other-impacts-of-diabetes/143-
driving/

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

74…Pt with seizures on carbamazepine,controlled on phenytoin for last three months.how long he can't drive?
(contro)
a)three months acc to racgp
b)six months
c)one year …our ans
d)2 years
e)never drive

only 1 time seizure= private= 6months and commercial = 5years

recurrent epilepsy= private = 1 year and commercial 10 years

dawalerhahai and seizure agya private= 1 year no drive and dawa nae lerha and seizure agya toe phr private 1 month

commercial always 10 years

ACCORDING TO RACGP GUIDELINES THE PATIENT SHOULD BE SEIZURE FREE FOR 6 MONTHS ONLY THEN HE IS
CONSIDERED FIT TO DRIVE

National standards governing medical fitness to drive were revised in March 2012. In most cases, patients with
epilepsy on AEDs and patients after first epileptic seizure will be judged fit to return to driving after being seizure-
free for 6 months

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

57…A man who had epilepsy advised for 6months to avoid driving but in 2 weekcz he is working in a company what
to tell him
to accompany a partner when drive

tell the driving board will be notified

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

32…A man 25 yrs had one episode of seizure. He experienced having muscle jerks in his right arm few months ago.
He asks you advise regarding driving ?(contro)
Can drive after 6 months
Can drive after 3 months
Can drive after 12 months
Can drive after 24 months

400
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

.taxi driver came with TIA, he want to go work what ur mx

let him go …..but this will be against medical advice
Cant drive until his neurologist check him- if 4weeks mark that
ban for 6 mn

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

A man with h/o epilepsy on treatment with valproate had h/o intermittent
seizures every month for past 5 years. Since 1 month he is on carbamazepine
and well controlled. What would you advise him on driving?
a) He can only drive after 2 years of seizure free period
b) He can drive after 6 months
c) He can never drive.
A in this one

https://epilepsycentre.org.au/driving/

A young woman comes with first time seizure. She had history of sudden spasms and twitching of muscles in past
few years. What is your advice about driving?
a. no driving for 6 months
b. no driving for 3 months
c. no driving for 1 months
d. can not drive any more.
A here.

401
402
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

403
…An interstate truck driver 60 yrs ,vision 6/6o in his left eye and vision 6/36 in his right eye,wants you to issue a
certificate for driving .You refuse to issue him ,therefore he visits another doctor and gets a certificate to drive.Later
he visits you saying he is driving.What will you do ? (normally upto 6/12 error is accepted)
Call the police
Tell him that he cannot drive
Call the GP and discuss the matter
Tell him that he can drive only if someone is with him
Report to RTA/VIC Roads

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

6) A nursing home bus driver had a grand mal epilepsy(generalized tonic clonic)still driving …with no trigger factors.
What will you advise him?
A) drive after 6 months
B) never drive
C) report to the authorities ====still driving

D) something else, specify...

Advice cant drive 10 years==recurrent

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Commercial driver had seizure and was adequately treated .. You told him that he souldn't drive ..however he came
back after 3 weeks telling you that his work needs made him drive yesterday and was no problems at all in that ..he
thinks he is totally fit now and can drive …..Management
1. Talk to him and tell him how dangerous is that to drive now
2. Call his boss and tell him about the disease
404
3. Tell him that you have to report what he did for the official driving agency for safety
4. Ask him to give you his license

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

A 38-year-old man is complaining of slowly progressive visual problems that make him ‘bump into objects’ on both
sides. He also reports that, while driving, he has trouble switching lanes because he needs to turn his head all the
way backward to look for other cars. Ocular exam shows bitemporal field loss with preserved visual acuity.
Examination of the fundus is unremarkable. WOF is the most likely diagnosis?

1. Pituitary adenoma

2. Occipital lobe meningioma

3. Optic glioma

4. Optic nerve atrophy

5. Optic neuritis

6. Retinal detachment

Bitemporal hemianopia occurs when optic chiasma has pressure symptoms from adjacent structures

Most commonly pituatary tumour

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

. A 14 year old presents to the ED following a car accident in a car which was stolen and was driven by her 16 year
old boyfriend. She requests her parents not to be informed. What is the next step? (contro)
a. Inform her parents
b. Inform the police
c. Convince the boyfriend to inform her parents
d. Tell her to inform her parents
405
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Lady with type 1 DM. She had hypoglycaemic crisis and was recently hospitalised. She asks about driving her kids to
school. What will you advise?
-no restrictions
-she can drive after having breakfast in the morning
-she should not drive 6 months

"The minimum period of time before returning to drive is generally SIX WEEKS because it often takes many weeks for
patterns of glucose control and behaviour to be re-established and for any temporary ‘reduced awareness of
hypoglycaemia’ to resolve." Reference: Assessing Fitness to Drive 2016

she cant drive 6 week chose this option if in Q

Diabetes and Driving

you must inform the Driver Licensing Authorities in your state or territory. In most cases if you manage your
diabetes by
> insulin you will require a medical certificate every two years
> tablet every five years.
> diet and exercise alone you are still required to inform them.
If you are required to notify the authorities but don’t, you could be charged with driving offences if you have a
driving accident.
>An HbA1c level of ≥75 mmol/mol (≥9.0%) should not be used administratively by licensing authorities to deny
eligibility for a licence in the absence of a medical review. There is no strong evidence of high average blood glucose
levels and driving risk.

https://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/bee30f0d-9b45-49f0-9800-5d66ee1f49d9.pdf
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
406
82 yrpt came with numbness ,heaviness of the rt hand & leg together with left homoanyomous hemianopia .Her
hand & foot state resloved after 2 weeks but her visual field defect is still present 6 wklater.wht would u do?
Cannot drive for 2wks
Cant drive for 2 months
Cant drive for 6 months
Cant drive forever

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

75 yr old lady came to you after MVA. she has a wrist fracture and irregular pupil with mild cataract.wht advice shd u
give her?

she should not drive at all

she can drive safely
she can drive after 6 weeks
she can drive in daylight only
she shd have an urgent CT of brain

causes:concussion bleeding infection meningitis

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

70 y.o woman complains that she feel a sudden weakness in her right hand and found it difficult to manage the
steering wheel when she was about to drive. She also said that her face felt funny during the episode. Now she's
fine. What will you do next? (dx TIA)
a. Urgent admission and do EEG
b. doppler of carotid arteries

407
c. Let her go home
d. Emergency surgery

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

)Pt with stroke 2 d ago us on carotid done, aspirin given, wt should u tell him
a) have some Rest ,
b)u need anticoagulant,
c)ban from driving for a 6 m

4wk for stroke for private 3month for commercial

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

38yo lady Blur vision after car accident. Ask about driving.(contro)
Continous driving
3m Stop
Not drive (ans from amedex)

e In Australia the last degree to permit for drive is 12/6

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

A 18yr old lady is on ocp and presents for the first time with seizure . she had early morning
muscle twitches for the past 4 years .now she is started on sodium valproate. She is planning to apply
for a learners license . what is your advice about her driving? (condititonal licence)
a. Cant drive for 6 monthsans
b. Cant drive for 3 months
c. Cant drive for 1 year
d. Cant drive for 24 months
e. Can apply for the license right away

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

A 24 y.o. lady has one episode of seizure. She experienced of having muscle jerks in her right arm few months ago.
She asks you on advice for driving?

a. can drive after 6 monthsans

b. can drive after 3 months

c. can drive after 12 months can drive after 24 months

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

bus driver who is 25y,experinceda fit for the first time in his life,he use to drive bus for nursing home pt, under aus
law as a gp what are your responsibilities ?
a.encourage him to continue driving
b.inform his employing agency

408
c.advice him to dont drive for few weeks
d.you can contact licenicing authority

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

15. “Ecstasy” is very popular in Australia, commonly used by young people; it's properties similar to:

A. Cocaine

B. LSD

C. Amphetamines (ans)

D. Diazepam

E. Cannabis

2. In Australia, the legal limit for drinking and driving for most people is

A. 0.1

B. 0.01

C. 0.02 commercial

D. 0.05(ans) private

E. 0.07

For learner :0

84 years old man come for his regular driving license assessment. He is independent and living together with his
wife. MMSE 23/30,reduce scorings d/t impaired memory. Can arrange his whole house affairs with support. No
accident during last 12months. Patient is very confident and safe during day light driving. What appropriate advice
for driving license department?
A- Cease his license
B- Practical driving test
C- Non-conditional license with annual assessment
D- Conditional license limited to 2km radius and day time driving only
E- Driving assessment by approved occupational therapist

409
18year old patient comes to you for driving licence clearance certificate. You know that the patient is having
type 1 dm and his blood sugar level was not well controlled. What is necessary for the clearance? A- fbs less
than 12 B- hba1c less than 9 C-dietitian referral D- attend the dm group program

410
411
DVT WARFARIN HEPARIN MCQS

24. CT scan of hematoma, patient was on drug,

Most appropriate management is:

a) Cease warfarin

412
C stop warfarin is needed but it will take many days to be effective as (((((( Because the effect of warfarin
on the INR is dependent on the clearance of preformed coagulation factors, the maximum effect of a dose
occurs up to 48 hours after administration, and the effect lasts for the next five days.. .The full effect of
vitamin K1 in reducing the INR takes up to 24 hours to develop, even when given in larger doses with the
intention of complete reversal. For immediate reversal of clinically significant bleeding, the combination of
prothrombin complex concentrate (PCC) and fresh frozen plasma (FFP) covers the period before vitamin
K1 has reached its full effect.

Vitamin K1 is essential for sustaining the reversal achieved by a PCC and FFP.27

A 65 years old man in on warfarin for 2 months. He is on regular check-up for INR, which is within the
required range of 2.5. He travelled to Bali 2 weeks ago and came back with bloody diarrhoea diagnosed
with amebiasis. And he was treated with Metronidazole. You checked his INR you found it to be 4.5. What
will be your next step in management?
A- Reassure as his INR is within an acceptable range
B- Stop warfarin and change to heparin
C- Skip today’s dose and measure INR tomorrow(inr jodi 3-5 thake with no bleeding, then skip dose)
D- Give vitamin K
E- Stop warfarin and give fresh frozen plasma

pic of cancer colon , patient on warfarin after cardiac stent for 6 month Came to u in ER,, what initial
a.Change warfarin to clopigrol and after 10 d proceed to operation
b.Stop warfarin and give vit k and proceed now c.Stop warfarin and give ffp and proceed now
d.Stop warfarin for 10 d and proceed to operation

Perioperative management of antiplatelet therapy

Dual antiplatelet therapy (DAPT) following percutaneous coronary stenting and acute coronary syndrome (ACS) is
common. Antiplatelet medications that are used commonly in Australia include, aspirin, clopidogrel, prasugrel and
ticagrelor. Management of patients on DAPT who are referred for surgical procedures depends on the level of
emergency and the thrombotic and bleeding risk of the individual patient.

Current recommendations for DAPT range from 4 weeks in patients undergoing elective stenting with bare metal
stents (BMS) to up to 12 months in patients with drug-eluting stents (DES) or for patients undergoing coronary
stenting for acute coronary syndrome.13 In some cases of complex stenting (eg bifurcation stenting), continuation of
DAPT for longer than 1 year may be necessary. Premature cessation of DAPT is thought to be one of the most
important causes of stent thrombosis, which can have fatal consequences.14

The current guidelines recommend that elective non-cardiac surgeries be postponed for at least 6 weeks (ideally 3
months) following angioplasty with BMS and for 12 months after DES,15 as the risk of thrombosis is highest within 6
weeks after the placement of a bare-metal stent and within 3–6 months after the placement of a DES.16

Perioperative continuation of aspirin increases bleeding risk slightly but does not increase the risk for bleeding that
requires medical or other interventions and therefore can usually be continued.17,18 On the other hand, perioperative
interruption of aspirin confers a 3-fold increased risk for adverse cardiovascular events.19 If a patient is to undergo
surgery with a high risk of bleeding and an antiplatelet effect is not desired, clopidogrel, prasugrel and ticagrelor
should be discontinued 5–7 days prior to the procedure.13,20 Good communication with the treating cardiologist and, in
some cases, individualised treatment plans may be necessary in managing such patients in the perioperative periods.
413
Pt with attack of MI, u started heparin and 12 hrs later abdominal swelling developed, u suspect hematoma,
what to do

A. Stop heparin

B. Reassure

C. Stop heparin and give aspirin

D. Give FFPE.
E.Give platelet

old lady after long flight developed red,tender,painful swelling on calf vein.taking warfarin and SC
enoxaperin . 5 days after pt comes with same problem (symptoms not subsided)
INR 1.8 .what will you do?
A. Continue same treatment
B.Increase enoxaperin ,same warferin
C.Increase warferin,same enoxaperin
D.increase enoxaperin and increase warferin.

414
recall of infected hematoma. Pt on warfarin with fever. Swelling in thigh. What investigation to do
d dimer
ct angio
Doppler (to exclude dvt)

ans: should be inr

A 55 year old builder came with weakness of his left hand and leg not lasting for 12 minutes, same
complaints couple of weeks back. he is taking only Aspirin, no other drug, what will you advice him other
than usual Mx (October 16 recalls)
a)Do not do strenuous exercise
b) Do not drive for 6 months
c) Add warferin
d) Add more anti coagulation
e)don’t go 2 work unless allowed by ur gp

According to Assessing fitness to drive of AUstralia ;

If it was only STROKE( cerebral infraction or interacerebral haemorrage ) ::

1) private driver >>> should not drive at least 4 week following a stroke
2) public driver >>>> should not drive at least 3 month following a stroke
------------------------------------------------------
If it was only TIA ::

1) private driver >>> should not to drive at least 2 weeks following a TIA
2) public driver >>> shoul not to drive at least 4 weeks following a TIA

Patient on Warfarin,came with rectal bleeding,his INR became 9.what to do next?

Give vitamin K…if minor bleeding
Give ffp….if clinically significant
Cease Warfarin

415
80 yr old woman fall from a low high chair and intramedullary nail is given for her femoral fracture.what is
next advice
during discharge??
1.alendronate ..as low trauma #
2.bone scan
3.warfarin for 6 mnth
4.heparin…already started 12 hr post surgery for 10-14 days

Post-procedure VTE prophylaxis

For certain procedures pharmacological VTE prophylaxis is recommended for all patients, using one of the
following:
dabigatran, started 14 hours after surgery
fondaparinux, started 6 hours after surgery
LMWH, started 6-12 hours after surgery
rivaroxaban, started 6-10 hours after surgery.
apixaban

Procedure Length of prophylaxis

Elective hip 28-35 days
Elective knee 10-14 days
Hip fracture 28-35 days

80 yr old woman fall from a low high chair and intramedullary nail is given for her femoral fracture. how you
will
manage the patient
.alendronate
2.bone scan
3.warfarin for 6 mnth
4.heparin

past history of dvt pt on UFH perioopertively n switch to lmw heparin after 5 days undergone rt hip surgery
develop dvt after 10 days that what to do
In investigation only platelets r decreased
A- ffps
B- vit k
C- cease heparin and switch to other anticoagulant
D- platelets infusion

Heparin-induced thrombocytopenia (HIT) is the development of thrombocytopenia (a low platelet count), due to
the administration of various forms of heparin, an anticoagulant. Given the fact that HIT predisposes strongly to new
episodes of thrombosis, it is not sufficient to simply discontinue the heparin administration. Generally, an alternative

416
anticoagulant is needed to suppress the thrombotic tendency while the generation of antibodies stops and the
platelet count recovers.

60 years old man with history of TI a year ago and controlled hypertension and DM. Three months ago, he
had an episode of DVT and has been warfarnized since then. He has been recently diagnosed with
cholecystitis after stabilization with fluid and antibiotics he will have his elective surgery in 5 days, what will
be your plan of management of warfarin pre operatively?
A- Change to heparin until two days before surgery then check INR
B- Cease warfarin today until the day of surgery
C- Measure the INR, if it’s less than 5 continue warfarin
D- Cease warfarin and change to LMWH from the 4th day until the 12 hours before surgery
E- Cease warfarin and change to heparin now

Table 5. Perioperative
management

Anticoagulants7–10
1 Evaluate the thromboembolic risk and hemorrhagic risk of the individual patients
2 Consider temporary cessation of the drug in procedures that carry a significant risk of
bleeding
3 Low thromboembolism and bleeding risk
Warfarin may be continued with relatively low INR 1.5–1.8 for minor procedures
4 For high bleeding risk with low-thromboembolism-risk group
Warfarin can be withheld for 5 days before surgery without any bridging anticoagulation
with unfractionated or low molecular weight heparin
5 High-thromboembolism-risk patients
Generally such patients should be considered for a more aggressive
perioperative management strategy with bridging therapy
6 As compared with warfarin, patients on NOACs are less likely to require bridging therapy
due to their short half-life

When bridging therapy is needed for patients at high risk, unfractionated heparin is preferred when the CrCl <30. In
procedures when bridging therapy is required, the usual protocol is to stop warfarin 5 days before the procedure
and start low molecular weight heparin at a therapeutic dose once the INR <2.10 The INR is usually checked on the
morning of the procedure while enoxaparin should be last given 24 hours prior to the procedure. Unfractionated
heparin on the other hand is usually stopped 4–6 hours before high-risk procedures.7

https://www.nps.org.au/australian-prescriber/articles/the-perioperative-management-of-anticoagulation

417
418
 A woman with HTN, DM on ACEI, Biguanide and other medicine develop calf pain. Ultrasound calf DVT.
You commenced Heparin. How will you continue to treat this patient?
a. Heparin for 3 week
b. Warfarin for 3 weeks
c. warfarin for 6 months
d. clopidogrel and aspirin for 6months

In most instances (

Table 2

), pharmacological treatment for VTE

consists of:

• initiating

immediate

acting

subcutaneous

419
LMWH

or

unfractionated

heparin(intravenousorsubcutaneous)orfondaparinux

(subcutaneous) with oral warfarin, and

• continuing

the

injected

drug

for

at least

5 days

and

until

international normalised ratio (INR) is therapeutic (2.5±0.5).

The therapeutic effectiveness and safety of warfarin relies on

maintaining the INR in the therapeutic range.

27

Key recommendations

on when to cease warfarin and how to proceed when INR goes above

the therapeutic range are provided in

Table 3

. A high variability in

dose response between patients and significant interactions with

drugs and diet means that warfarin therapy is difficult and time

consuming to manage.

27

Nonetheless, it remains the most effective

and cost efficient drug currently available for the treatment of the

majority of patients with VTE.

10,28
420
Low molecular weight heparins may be preferred to warfarin in

some patients, including cancer patients for whom treatment with

warfarin is associated with an increased risk of bleeding and VTE

recurrence; monotherapy with LMWH instead of warfarin can halve

VTE recurrence in these patients.

29

Low molecular weight heparins

are also recommended over warfarin for long term therapy in pregnant

women (due to the teratogenic effects associated with warfarin), and

as bridging therapy in patients scheduled to undergo surgery (due to

LMWH’s shorter half life therapeutic anticoagulation can continue

closer to surgery time).

Patient on CVP line for long time. When u remove CVP line she develops dusky discoloration and swelling
of face and neck. What is next Invx?

a. Duplex Doppler of neck veins

b. cervical spine X ray
c. CT angiogram of neck veins

Superior vena cava syndrome (SVCS), is a group of symptoms caused by obstruction of the superior vena cava (a
short, wide vessel carrying circulating blood into the heart). More than 80% of cases of SVCS are caused by
compression of the vessel wall by malignant tumors in the mediastinum, the vast majority of which are either lung
cancer or non-Hodgkin's lymphoma. Non-malignant causes include benign mediastinal tumors, aortic aneurysm,
infections, thrombosis due to central venous catheter placement, and fibrosing mediastinitis.[1]

Characteristic features are edema (swelling due to excess fluid) of the face and arms and development of swollen
collateral veins on the front of the chest wall. Shortness of breath and coughing are quite common symptoms;
difficulty swallowing is reported in 11% of cases, headache in 6% and stridor (a high-pitched wheeze) in 4%. The
symptoms are rarely life-threatening, though edema of the epiglottis can make breathing difficult, edema of the brain
can cause reduced alertness, and in less than 5% of cases of SVCO, severe neurological symptoms or airway
compromise are reported. However the underlying cancer is nearly always fatal.[2]

Diagnosis

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A CXR of a person with lung cancer which was causing superior vena cava syndrome.

Thrombosis of the superior vena cava caused by an indwelling central venous catheter which caused superior vena
cava syndrome

The main techniques of diagnosing SVCS are with chest X-rays (CXR), CT scans, transbronchial needle aspiration at
bronchoscopy and mediastinoscopy.[4] CXRs often provide the ability to show mediastinal widening and may show the
presenting primary cause of SVCS.[4] However, 16% of people with SVC syndrome have a normal chest X-ray. CT
scans should be contrast enhanced and be taken on the neck, chest, lower abdomen, and pelvis.[4] They may also show
the underlying cause and the extent to which the disease has progressed.[4]

a lady with18 weeks gestation and previous DVT, present with sudden dyspnea and
shortness of breath. What's the initial investigation in this pt?
A) D-dimer
B) V/Q scan
C) ECG
D) CTPA
E) Doppler –US

422
423
424
dvt senario doppler showed thrombus extending from popliteal to femoral .. asking immediat MX
a.IV heparin
b.LMWH
c.warfarin

A known type 2 diabetic man with a previous history of DVT, now presents with painful leg, on examination
he has a temperature of 38.2 and calf redness, what's your initial investigation? Dx: cellulitis.
�A. Blood culture.
�B. Fasting blood sugar.
�C. Doppler ultrasound of the affected leg.
�D. Chest xray....
�E. D-dimer

A lady was admitted for radiation to breast cancer. She received her radiotherapy and was placed a central
line during her hospital stay. After her chemo/radio her central line was removed. The next day she noticed
some dyspnea and facial edema which worsened in 24 hours. Which of the following tests will accurately
define the lesion?
a. Duplex Doppler vascular studies�b. CT scan of neck�c. Chest x-ray�d. ECG�e. D-dimer

A 22 years old woman came to your surgery for contraception advice. Her mother and sister had DVT
episodes. Which one of the following is best step in the care of this patient?
A- Ask for family history of breast or ovarian cancer
B- Do thrombophilia screening
C- Prescribe combine oral contraceptive pill
D- Prescribe low dose combine oral contraceptive pill
E- Do lower limb Doppler ultrasound

425
Factor V Leiden (rs6025) is a variant (mutated form) of human factor V (one of several substances that helps blood
clot), which causes an increase in blood clotting (hypercoagulability). With this mutation, protein C, an anticoagulant
protein (which normally inhibits the pro-clotting activity of factor V), is not able to bind normally to Factor V, leading
to a hypercoagulable state, i.e., an increased tendency for the patient to form abnormal and potentially harmful blood
clots.[1] Factor V Leiden is the most common hereditary hypercoagulability (prone to clotting) disorder amongst ethnic
Europeans.[2][3][4] It is named after the Dutch city Leiden, where it was first identified in 1994 by Prof R. Bertina et
al.[5]

Signs and symptoms

Abnormal, recurrent venous thromboses.

A man with chronic kidney disease poor GFR, had dyspnea+tachycardia +chest pain. Xray showed
peripheral wedge-shaped opacity. What’s next investigation?
A.Doppler U/S lower limbs
B.D-dimer
C.CTPA
D.Arterial blood gas
E. V/Q scan

Xray pulmonary embolism

Old pt on multiple medications BB,statin and warfarin developed pain and swelling in left thigh , on
examination you found the left thigh swollen hot tender and 4 cm larger the right thigh what the most
appropriate next step?
- INR
- Angioplasty
- X ray
- US doppler

DX: warfarin hyperactivity

** Statins may, for example, raise blood levels of the clot-preventing drug warfarin, which could increase
the risk of internal bleeding

Pt can develop new onset of dvt inspite of being on warfarin.This is called warfarin failure. It usually occurs
in cancer or SLE pt. If new dvt is suspected us Doppler should be done to diagnose. INR of preceding
426
weeks should be checked to assess the warfarin activity but in SLE INR could be in therapeutic range
though there is warfarin failure.

• Including results for hematoma symptom.

Do you want results only for heamtoma symptom?

• Clinical signs

• Uninterested in the foal.

• Tachycardia (often over 100 bpm).
• Tachypnea.
• Pale mucous membranes with prolonged capillary refill time.
• Cool extremities.
• Weak pulse.
• Sweating.

40 years old lady come to your clinic with complain of acute dyspnea. She did chemotherapy 3 weeks ago
and at that time her chest was normal. You assessed her and you found her Clinical wells score is 4.
What's the investigation of choice in this pt?
A) D-dimer
😎 CTPA
C) CX-Ray
D) Doppler -USG
E) V/Q….according to amedex q bank

427
Well score:

Clinical probability (3 levels) Total

Low 0–1

Intermediate 2–6

428
High ≥7

Table 2. Some risk factors for VTE4

Strong risk factors (odds ratio >10)

Major surgery
Major trauma (including hip or leg fracture)
Spinal injury
Hip or knee replacement

Moderate risk factors (odds radio 2–9)

Knee arthroscopy
Central venous lines
Chemotherapy
Congestive heart failure or respiratory failure
Hormone-replacement therapy
Oral contraceptive therapy
Stroke
Pregnancy and puerperium
Previous VTE
Thrombophilia

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 Table 2. Some risk factors for VTE4

Strong risk factors (odds ratio >10)

Weak risk factors (odds ratio <2)

Bed rest >3 days

Immobility due to sitting (eg. travel)
Increasing age
Laparoscopic surgery
Obesity
Varicose veins

8 days after elective cholecystectomy , a 75 yrs man collapses complaining of sudden onset of chest pain
and shortness of breath. Wof diagnostic is likely to be most helpful?
A. Vq scan
B . Cxr
C. ECG
D. Calf and thigh venography.
E. Doppler duplex USS of thigh veins

what's the initial investigation in a pt who suspicious with PE ?

A) CX-Ray
😎 CTPA
C) Doppler-USG
D) D-dimer
E) V/Q

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HD unstable: ctpa, if not available then echo

26 years old woman who is suspected to PE. She has a family Hx of thrombophilia. What's the investigation
of choice in this pt?
A) Doppler- USG
😎 chest x-Ray
C) V/Q scan
D) CTPA
E) D-dimer

431
45 years old man who had a hip replacement 2 weeks ago, present with sudden chest pain and Hypoxia.
O2saturation is 89%. He has a Hx of renal disease. What's the appropriate investigation in this pt
A) CTPA
😎 V/q scan
C) ECG
D) CX-Ray
E) D-dimer

A 69-year-old woman has been in the intensive care unit for 7 days following complicated hip replacement
surgery. The patient is currently receiving heparin and wears intermittent pneumatic compression devices
on her lower extremities bilaterally. The patient has developed new-onset right calf pain, oedema,
tenderness, and a positive Homans’ sign. ADoppler ultrasound revealed a deep vein thrombosis. Her
platelet count is 78,000/mm³, and there has been no evidence of spontaneous bleeding. Which of the
following is the next step in management?

Begin warfarin therapy

Discontinue bilateral pneumatic compression devices
Discontinue heparin(heparin induced thrombocytopenia.stop hheparin & give warfarin)
Perform venography
Transfuse platelets

432
433
doppler showing plaque from tibial to popliteal vein , Pt RFts
were very dearranged
a. warfarin
b. i v heparin ==ufh as renal impairement
c. SC enoxparine
d. LMWH

Indication of unfractionated heparin: early reversal, renal

impairment.

No DVT hx, completely mobile patient, diverticular resection

surgery, enoxaperin for how long,
A. No need
B. From surgery to day 3
C. From surgery to day 10
D. From surgery to discharge
E. From surgery to day 40

**if patient was over > age 40..then C (5-10 days) , if age not
>40, then A no need cause its only low risk (with no
additional VTE risk factors)

Pt with a history of DVT when young.. Undergoing gastric plication surgery. During surgery they will be
using electric blankets for calf Muscle stimulation. Which of the following would you recommend for the
patient.
1. Nothing
2. Enoxaparin from before surgery to after surgery.
3. Enoxaparin from after surgery till discharge.
4. Enoxaparin from after surgery till 10 days
5. Enoxaparin from before surgery till 10 days after surgery.

**in the ques there is nothing mention about warfarin…and though he is young but has h/o of dvt

434
435
pt was stable after mi had thigh Hematoma enoxaparin and
clopirodgel taken asked how ill u manage next

a.compress hematoma (wound site hematoma)ans

b. stop enoxaparin & clopidogrel

c. inject anti thrombin in thigh

4. give ffp

Incomplete stem they will mention what kind of swelling it is

Haematoma - compress
PseudoAneurysm- thrombin inject

old patients with MI and stent 2months ago. Now he is on

clopidogrel now falls and has a fracture of neck femur FBC and
platelet morphology normal,INR-1.5, but has bruises on the body
what should be done?

A. stop clopidogrel immediately and do surgery in 1 week if there is no stent

B. give FFP and do surgery now

C. give platelet and do surgery now

d, do surgery now

. History of DVT, HTN with DM patient on Warfarin ,

metformin, and Statin suddenly got swelling at right
thigh for 2 days ,became painful and got high grade
fever 38.5 degrees Celsius . Right thigh size is 4 cm
larger than left thigh . Asking possible Diagnosis?

A)Rhabdomylosis

B) hematoma

C) DVT

D) Cellulitis

E) Drug reaction

Middle aged man come with calf muscle pain, by examination you find an infalmmed cord with firm nodules under
the skin what to do:

A. Heparin ….lmwh

436
B. Analgesic and mobilization

C. Corticisteroid and rest

D. Warfarin

Superficial thrombophlebitis:

Signs and symptoms

Findings of tenderness, induration, pain and/or erythema along the course of a superficial vein usually establish a
clinical diagnosis, especially in patients with known risk factors. In addition, there is often a palpable, sometimes
nodular cord, due to thrombus within the affected vein. Persistence of this cord when the extremity is raised suggests
the presence of thrombus.[6]

Treatment

Treatment with compression stockings should be offered to patients with lower extremity superficial phlebitis, if not
contraindicated (e.g., peripheral artery disease). Patients may find them helpful for reducing swelling and pain once
the acute inflammation subsides.

Nonsteroidal anti-inflammatory drugs (NSAID) are effective in relieving the pain associated with venous
inflammation and were found in a randomized trial to significantly decrease extension and/or recurrence of superficial
vein thrombosis.[12]

Anticoagulation for patients with lower extremity superficial thrombophlebitis at increased risk for thromboembolism
(affected venous segment of ≥5 cm, in proximity to deep venous system, positive medical risk factors).[13]

437
#aboriginal 156. An aboriginal old man who is a heavy drinker, 20 cigarettes aday. His BMI is 28 his abdominal
circumference is 118. How to manage :

1. Fat restricted diet will decrease your weight.

2. Do regular exercise to loose some weight.

3. Attend to environmental and cultural issues

4. Give him a strict lowering limit to reduce his abdominal circumference to 108 within a certain time

97) 14yrs old boy,One of your long term patient since birth,presents to you at your surgery after Dog bite
at home,when he was playing with it , accidentally fell over the animal and provoked it. O/E There were
Two deep puncture wounds. No deep structural injury.His last immunization for tetanus was at 4 yrs of
age according to his File.You advise him to get the wounds cleaned and apply non-Adherent , absorbent
plaster by the Office nurse and give him prophylactic antibiotics for 5 days. As the bytes are deep
puncture wounds you decided to give him tetanus injections as well.

Which one is the BEST vaccination?. 1.DTPa(Diptheria,Tetanus,Pertussis acellular)

2.Tetanus Toxiod

3.Adult Tetanus and Diptheria Toxoid

4.Tetanus immunoglobulin + Tetanus toxoid

438
5.Diptheria toxoid +whole cell pertussis +Tetanus toxoid (DPT) booster.

*A combination vaccine should be used in order to boost community protection against pertussis:

• < 10 years old: DTPa or DTPa combinations

• ≥ 10 years old: dTpa (Boostrix®)

https://www.rch.org.au/clinicalguide/guideline_index/Management_of_tetanusprone_wounds/

A scenario of patient that was recently discharged from hospital from CCU for fainting attacks and they
added to him Amiodarone. He’s DM,

HTN, IHD, Af on many medications ACEi, Glibenclamide, Nitrates, Warfarin.Then he

developed acute painful thigh swelling, what to check for him?

A. INR

B. US

C. MRI

D. LAB Investigation

E. drug interaction.

439
A known type 2 diabetic man with a previous history of DVT. Now presents with painful leg. O/E he has a
temperature of 38.2 and calf redness. What is your initial investigation?
1.Blood culture
2.Fasting blood glucose
3.Doppler US of the affected leg

4.Chest X-ray
5.D-dimer

Dvt from one wk on warfarine, developed perforated PU, wt next:

A-stop warfrine and operate after 2 days
b-stop warfarine, IVC filter, oprate
c-stop warfarin, start heparine , operate

d-stop warfarine, give FFP, operate

**D. Key Recommendations • Warfarin discontinuation prior to invasive procedures is necessary for all
interventional procedures except for minor skin procedures, routine dental work, cataract surgery,
endoscopies without biopsy, and percutaneous venous access. • For elective procedures, warfarin should
be stopped for 5 to 6 days prior to the procedure to allow gradual normalization of the international
normalized ratio (INR). • For urgent procedures, use of prothrombin complex concentrate is highly
effective in rapidly reversing warfarin anticoagulant activity and has a duration of action of ~ 6 hours. • The
use of bridging heparin therapy is dependent on the risk of thrombosis. • Discuss the risk of bleeding with
the surgeon and anesthesiologist to determine optimal timing for resuming warfarin and bridging heparin
therapy after surgery

H/o DVT 15 yrs back, lap cholecystectomy, enoxa for how long
a.no need
b.3 days
c.7 days
d.10 day

440
84. past history of dvt pt on UFH perioopertively n switch to lmw heparin after 5 days undergone rt hip surgery
develop dvt after 10 days that what to do In investigation only platelets r decreased

A- ffps

B- vit k

C- cease heparin and switch to other anticoagulant

D- platelets infusion

Pt was stable after mi had thigh Hematoma enoxaparin and clopirodgel taken asked how ill u manage next

a.compress haematoma

b. stop enoxaparin clopidogrel

441
c. inject anti thrombin in thigh

4. give ffp

56. Middle age man WITH pain in buttock and thigh during 100 m walk on ground. He can walk 20 m uphill but his
femoral pulses are not palpable however his dorsalis pedis is palpable. which appropriate investigation will you
request
A. Arterial Doppler
B. Digital subtraction arteriography
C. CT angiogram
d. femoral ultrasound scan

A case of recurrent herpes zoster infection. Tzanck prep done showed multi nucleated giant cells. which treatment
is best for resistant viral infections
A. High dose acyclovir -single
B. foscarnet
C. valaciclovir -recurrent
D. Ganaciclovir

if lesions persist or recur in a patient receiving antiviral treatment, HSV resistance should be suspected and
a viral isolate obtained for sensitivity testing (367). Such persons should be managed in consultation with
an infectious-disease specialist, and alternate therapy should be administered. All acyclovir-resistant
strains are also resistant to valacyclovir, and most are resistant to famciclovir. Foscarnet (40–80 mg/kg IV
every 8 hours until clinical resolution is attained) is often effective for treatment of acyclovir-resistant genital
herpes (368,369).

Q97. A case of chronic back pain in an old man with radiating pain and tenderness at L5 disc, He has problems
passing urine when lying down, but can void urine easily on standing. Which of the following symptoms indicate a
need for an urgent MRI?
a. urine problems

b. radiculopathy
c. chronic back pain
d. disc herniation

Urine problem could be due to cauda equina compression which is an emergency and needs to be ruled
out by MRI urgently. And compression if present has to be released within a certain period ( golden time )
before the patient develops irreversible injury to nerves

Q98. 45 yr old man is to have surgery for fundoplication on account of a long standing Hiatus hernia. on examination,
no abnormal findings except a previous history of DVT at age 25 due to a leg injury. What will be your plan for anti
coagulation therapy?
A)Enoxaparin before and after surgery till discharge.
B)Enoxaparin before and after surgery till 10 days.

C)Enoxaparin after surgery till discharge

D)Enoxaparin after surgery till 10 days

E)No anticoagulation
442
A Nissen fundoplication, or laparoscopic Nissen fundoplication when performed via laparoscopic surgery, is a
surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia.

Pt with 2 ulcers, one on leg above medial melleolus and other on plantar surface of foot over the head of 2nd
metatarsal. Burger test positive of that limb. H/O claudication while walking, and rest pain as well. And pulses and
not palpable for this limb. Asked reason behind the pain?

a) Ulcer
b) positive Burger test
c) Osteomyelitis

A scenario of a patient admitted for DVT and was started on Heparin and Warfarin. Then he developed bleeding per
rectum, BP 80/50, HB: 8.5 (was 15 at admission), and INR became 9. What to do?
A. Give Vitamin K
B. Give FFP alone
C. FFP + platelets
D. Fresh whole bloood

SMA:The condition primarily affects the muscles that control chewing and swallowing, chest wall muscles, and arm
and leg muscles. Symptoms are typically severe and may include hypotonia or diminished muscle tone, muscle
weakness, respiratory problems, pneumonia, and swallowing and feeding difficulties.

Pradar willi syndrome :newborn with PWS tends to weigh less than normal, has weak muscles, known as hypotonia,
and they may find sucking difficult. Between the ages of 2 and 5 years, but sometimes later, individuals start
developing a strong appetite, called hyperphagia.

CP:Low muscle tone (baby feels ‘floppy’ when picked up)

Unable to hold up his/her own head while lying on their stomach or in a supported sitting position

Muscle spasms or feeling stiff

Poor muscle control, reflexes and posture

Delayed development (can’t sit up or independently roll over by 6 months)

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Feeding or swallowing difficulties

Prefers to use one side of their body

past history of dvt pt on UFH perioopertively n switch to lmw heparin after 5 days undergone rt hip surgery develop
dvt after 10 days that what to do

In investigation only platelets r decreased

A- ffps

B- vit k

C- cease heparin and switch to other anticoagulant (heparin induced thrombocytopenia)

D- platelets infusion

5-Man with PCI and stent 3 months ago and taking clopidogrel aspirin. Now having blood mixed with stool .for inv
what's appropriate one?
a. CT colonoscopy
b. Stop both drugs and do colonscopy
c. Continue drugs and do colonoscopy …for diagnostic colonoscopy
d. Stop clopidogrel , take aspirin and do colonoscopy….for therapeutic colonoscopy

86-patient with AF... pain in legs.. right leg is pallor absent pulses... ix

A ct angiogram
B uss veins
C uss leg
D d dimer
Dx :acute limb ischaemia: cta
Chronic limb ischaemia: duplex usg then cta

Pain pallor pulseless paraesthesia all indicate towards embolectomy if in between 4 hr after that amputation
so A

A Doppler evaluation is used to show the extent and severity of the ischaemia by showing flow in smaller arteries.
Other diagnostical tools are duplex ultrasonography, computed tomography angiography (CTA), and magnetic
resonance angiography (MRA). The CTA and MRA are used most often because the duplex ultrasonography although
non-invasive is not precise in planning revascularization. CTA uses radiation and may not pick up on vessels for
revascularization that are distal to the occlusion, but it is much quicker than MRA.[1] In treating acute limb ischaemia
time is everything.

One leg pain cold, AF, looks like ischaemic symptoms. Best management
A) heparin-initial
B)embolectomy-best
C) Aspirin
heparin then embolectomy and life long warfarin

The primary intervention in acute limb ischaemia is emergency embolectomy using a Fogarty Catheter

444
A legally competent, terminally ill 70-year-old patient on life support asks her physician to turn off the machines and
let her die. The physician follows the patient’s wishes and discontinues life support. The physician’s action is best
described as

(A) unethical and illegal

(B) ethical and legal

(C) unethical but legal

(D) ethical but illegal

Biostatistics and Epidemiology

3.196 3.339 3.386 3.387 3.389 hb qzz, 2.084

1. Which one of the following can be used for data analysis in Cross sectional?

a. Odds ratio
b. Relative risk
c. Chi square test
d. Attributable risk and Chi square test
e. odds ratio and attributable risk
cross sectional: use CHI SQUARE
Cohort: use RR or AR
Case control: use ODD's RATIO

2. Which is the best study to find out the

state of Vitamin D deficiency in
Australia?

A. Cohort
B. Case control
C. Case study
D. Cross--sectional study.

To check Prevalence è Cross Sectional Study

To check incidence è Cohort

445
446
cohort study ===ans

3. Two groups are being studied for risk reduction for some disease with aspirin use. Tables are given
as follows. Calculate Number needed to treat (NNT)?

Aspirin Placebo
With Disease 10 20
Disease free 990 980
A. 1
B. 10

447
C. 100
D. 1000

NNT=1/ARR

Absolute Risk Reduction (ARR) = CER – EER

Control event rate (CER) = 20/1000
Experimental event rate (EER) = 10/1000

ARR = 0.02 – 0.01

= 0.01

NNT = 1/ ARR = 1/0.01 =1/1×100=100

448
4. P value of effectiveness with drug

Type 1 error kaplan 149

Type 2 error
Effectiveness in less than 0.05
Effectiveness > 0.1

Reality true ==type 1error

Reality false==type 2 error

449
 - It is the figure frequently quoted as being “statistically significant”,
i.e. unlikely to have happened by chance and therefore important
- If we look at 20 studies, even if none of the treatments work, one
of the studies is likely to have a P value of 0.05 and so appear
significant
- The lower the P value, the less likely it is that the difference
happened by chance and so the higher the significance of the
finding
- P = 0.01 is often considered to be “highly significant”. It means
that the difference will only have happened by chance 1 in 100
times. This is unlikely, but still possible
- P = 0.001 means the difference will have happened by chance 1 in
1000 times, even less likely, but still just possible. It is usually
considered to be “very highly significant”.

C ANSWER

450
5. In a village of 3000 people, 500 get Congo Hemorrhagic fever. 450 eventually recover from
the disease in the next 4 weeks while 50 died. What is the case fatility rate for this disease?
a. 10
b. 20
c. 35
d. 50
e. 200

Case fatality rate = Total number of deaths from disease/ Total number of cases
= 50 /500*100
= 10

Ans is E

6. You are a doctor in a town, where 6 people out of 100 are non-smoker.,which is also the chances of stroke
among them. The chances of stroke in smoker is 50%more than non-smoker. Now
the pharmaceutical company is introducing a medicine which reduces the chances of
stroke up to 1/3rd in smoker population. What is the percentage of the smoker population
will get stroke
A. 3%
B. 6%
C. 9%
D. 12%
E. 20%

451
No. Of non smoker = 6 out of total 100 ppl
Chances of stroke in non-smoker = 6/100
Chances of stroke in smoker = 6 + 50% of 6
50% of 6 = 3
So, chances of stroke in smoker = (6 + 3)/100 = 9/100
The medicine reduces the chances of stroke in smokers by 1/3
1/3rd of 9/100 = 3/100
That reduces percentage of stroke = 9 – 3/ 100 = 0.06 = 6%

7. Which one of the following can be used for data analysis in Cross sectional?
A. Odds ratio
B. Relative risk
C. Chi square test
D. Attributable risk and Chi square test
E. odds ratio and attributable risk
cross sectional: use CHI SQUARE
Cohort: use RR or AR
Case control: use ODD's RATIO
Kaplan pg 121

8. Which is the best study to find out the state of Vitamin D deficiency in Australia?
A. Cohort
B. Case control
C. Case study
D. Cross--sectional study.
To check Prevalence Cross Sectional Study
To check incidence Cohort

Kaplan 118

9. 3. Two groups are being studied for risk reduction for some disease with aspirin use. Tables are given
as follows. Calculate Number needed to treat (NNT)?
Aspirin Placebo
With Disease 10 20
Disease free 990 980
a. 1
b. 10
c. 100
d. 1000

Absolute Risk Reduction (ARR) = CER – EER

Control event rate (CER) = 20/1000
Experimental event rate (EVR) = 10/1000

ARR = 0.02 – 0.01

= 0.01

NNT = 1/ ARR = 1/0.01 = 100

10. 4. P value of effectiveness with drug

A. Type 1 error
B. Type 2 error
C. Effectiveness in greater than 0.5
D. Effectiveness > 0.1

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Kaplan 135

Type I error (α error): rejecting the null hypothesis when it is really true, i.e.,
assuming a statistically significant effect on the basis of the sample when there is none
in the population or asserting that the drug works when it does not.
–– The chance of a type I error is given by the p-value. If p (or a) = 0.05, then the
chance of a Type I error is 5 in 100, or 1 in 20.
• Type II error (β error): failing to reject the null hypothesis when it is really false, i.e.,
declaring no significant effect on the basis of the sample when there really is one in
the population or asserting the drug does not work when it really does.
–– The chance of a Type II error cannot be directly estimated from the p-value.

11. 5. In a village of 3000 people, 500 get Congo Hemorrhagic fever. 450 eventually recover from
the disease in the next 4 weeks while 50 died. What is the case fatility rate for this disease?
1. 10
2. 20
3. 35
4. 50
5. 200

Case fatality rate = Total number of deaths from disease/ Total number of cases
= 50 /500
= 10
12. You are a doctor in a town, where 6 people out of 100 are non-smoker. What are the
chances of stroke. The chances of stroke in smoker is 50%more than non-smoker. Now
the pharmaceutical company is introducing a medicine which reduces the chances of
stroke up to 1/3rd in smoker population. What is the percentage of the stroke population
will get stroke
a. 3%
b. 6%
c. 9%
d. 12%
e. 20%

Chances of stroke in non-smoker = 6/100

Chances of stroke in smoker = (6 + 50% of 6)/100 = 9/100
The medicine reduces the chances by 1/3 = 9/3 = 3
That reduces percentage of stroke = 9 – 3/ 100 = 0.06 = 6%

13. In a small village of North QLD with a community of

3000 people,
18%females get URTI while 22% males get it as well who
are exposed to
factory smoke. 10% of females also get URTI who live away
from the factory
and are not exposed to factory smoke. The data for males
is not available.
Calculate the attributable risk for females to get URTI due
to factory smoke?
1. 28%
2. 30%
3. 6%
4. 1.8%
5. 8%
Female Male

453
 Exposed 18% 22%
Unexposed 10% —

AR= 18% - 10%

= 8%

14. A study wish to make a relation btw the fatigue in track car driver in high ways & the incidence of MVA happen.
wt is the most suitable method to carry out study?
a. Cohort
b. Case control
c. RCT
d. Cross sectional
e. Case study
The study checks the risk factor of vehicular accident (Cause and effect relationship). Risk factor is
fatigue here and effect is truck accident. It's better to retrogressive(case-control) asking truck
drivers about their history of accidents related to their tiredness and related events.
It would NOT be a wise decision to put fatigue patients on trial to see if that will lead to truck
accident (Cohort).
For RCT, there are no different groups and intervention.

15. The least important study to look for effectiveness of ccf Rx?
a. case control
b. case series
c. cohort
d. RCT
e. Systemic Review

16. You find there are more and more diabetics in your practice and you want to do a research about how many
people are diabetic. What is the best study design?
a. Cohort study
b. Case-control study
c. Randomized-control trial
d. Cross-section study

17. If you need to study whether smoking causes myocardial infarction, what kind of
study / group do you intend to conduct/study?
A) Cohort ***
B) Randomized Controlled
C) Case Control
D) Case series
E) Observational

18. A young scientist has decided to study the causes of neonatal jaundice. He selects 150 babies with
jaundice and 150 without, and examines there previous histories looking for factors that could have
determined their jaundice. This kind of study is called?
a.) cohort study
b.) case study
c.) case control study ***
d.) prospective study

19. A scientist study a case which is 30% fpv, 10% fnv. study of 1100.now the test shows 100 people are +ve for the
test. what is the actual number of people getting the disease for the people who did testing?
a, 10
b, 20

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c, 30
d, 70 ***
e,90

here we say that 100 are positive for the test (TP+FP). of these 100 30% are FPV which means that TP (70) and
FP (30). Then we have remaining 1000 of which 10% are FN, this comes out as 100. Then lastly we have T- (900).
So the 2x2 table is TP (70) FP (30) F- (100) T- (900). Now we want to know the positive predictive value
(likelihood that a positive result in test indicates disease). Formula is (TP/(TP+FP)). so (70)/(70+30)=70%

Tp=100-30=70
Formula is.. (TP/TP+FP) so 70/70+30=70%

20. A new drug is being tested for decreasing mortality in

HTN patient by 1/4, in a community of 100 you have 8
patients with the condition, what is the number
needed to treat?
a. 100
b. 50
c. 33
d. 60
e. 10

CER = 8/100
EER = (¼ of 8)/100 = 6/100
ARR = 8-6/100 = 0.02

NNT = 1/ARR = 50
In order to treat one patient, you need 4 patients
To have 4 patients you need a population of 50 persons

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Simply 8/100 ×1/4
=50

21. You want to make a study about asthmatic patients and if there have been any
exposure to smoke or
its severity to exposure to smoke. What study is the most appropriate?
a. Case control
b. Cross sectional
c. Cohort
d. Observational study

CASE-CONTROL STUDY — A case-control study starts with the outcome of interest and works backward to the
exposure. For instance, patients with a disease are identified and compared with controls for exposure to a risk
factor.
(IN MY WORDS) : case control is the opposite of cohort , so here we already know the the disease and looking back
for risk factor,,, popular recall about case-control is "3 cases of salmonella ", so here we already have affected
patients , and we need to look for the risk factor in the past ,other example if we have 10 patients with MI , and
we study who from them was smoker in the past !! ..........note , in these questions they usually give NUMBER of
ppl with a certain disease !

. CASE CONTROL STUDY (Retrospective study):

_______________________________________
. The cases and controls are assessed retrospectively to for the presence of risk factor

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. The researcher begins with a population with a certain disease

. Is very popular in exploring an exposure - disease association.

. group with the disease of interest are compared with an similar group that is disease free.

How it is measured……….Odds ratio

Can incidence be measured……..no
Can prevalence be measured……no

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22. A study is being planned to investigate the effect of environmental exposure to pesticides on
the incidence of cancer.
Which of the following study designs is most appropriate?
1.Case-control study
2.Case series
3.Cohort study ***
4.Cross-sectional survey
5.Randomised controlled trial
COHORT STUDY — A cohort study starts with an exposure and moves forward to the outcome of interest,
even if the data are collected retrospectively. As an example, a group of patients who have variable
exposure to a risk factor of interest can be followed over time for an outcome.
The Nurses' Health Study is an example of a cohort study. A large number of nurses are followed over time
for an outcome such as colon cancer, providing an estimate of the risk of colon cancer in this
population. In addition, dietary intake of various components can be assessed, and the risk of colon
cancer in those with high and low intake of fiber can be evaluated to determine if fiber is a risk factor
(or a protective factor) for colon cancer. The relative risk of colon cancer in those with high or low
fiber intakes can be calculated from such a cohort study.

(IN MY SIMPLE WORDS ABT COHORT) , its a relation between risk factor and the disease , we start from
the risk factor , and observe who will have a certain disease in the future(we don't know the number of
patients who will have this disease),, like if we have group of smokers(risk factor) and observe who will
have MI for eg , also from recalls nevus ----> melanoma

A Prospective COHORT STUDY:

__________________________________________
. Divides the study group into "exposed" and "non exposed" to the risk factors.
. Each subject is then follow prospectively till the presence of the disease.
. Is a prospective observational study in which groups are chosen based upon the presence or absence of one or more risk
factors.
. All subjects are then observed over time for the development of the disease of interest.

how it is measured ?..............relative risk.

Attritutable risk
Incidence can be measured……….yes

23. The cut-off point of screening test is increased.

A. both sensitivity and specificity will be increased
B Sensitivity increased, Specificity decreased
C. Sensitivity decreased, Specificity increased

(reference mina notes)

High cutoff --> Decrease sensitivity and Increase specificity.

. Low cutoff --> High Sensitivity --> higher negative predictive value (NPV) --> decrease false -ve results
(Ruling out probability).

. High cutoff --> Higher Specificity --> higher positive predictive value (PPV) --> decrease false +ve results
(Ruling in probability).

24. Australian government appointed you to go through a community based service and help a
local doctor there.
Hepatitis B data given in a community of total population of 200.

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 2009 2010
Antibody +ve 10 15
Antigen +ve 40 55

Need to calculate the prevalence per 1000 population in the year 2010
A- 350
B- 250
C- 70
D- 50
E- 125

2010
15+55/200x1000=350

25. Which study is most reliable for outcome of a disease in a community?

A-cohort
B-case control
C-RCT ***
D- case study
E- cross sectional study

26. A post marketing drug surveillance study of a new heart failure therapy to the market
was carried out on 10,000 subjects who had completed clinical trials. which one of the
following most accurately reflects the information generated from such a study?
1. Adverse events profile ***
2. comparative therapeutics efficacy
3. cost benefits trial
4. cost effectiveness
5. Drug potency

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 27. A new screening test is to be launched in community. Which is the most
important factor to consider?
A. High sensitivity (ans)
B. High specificity
C. High positive predictive value
D. No adverse outcomes
https://gradestack.com/Dr-Bhatia-Medical/Most-important-factor-for/168-3042-3172-16257-sf

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 28. What study would you do if you want to find out the efficacy of a vaccine
on a group of people?
a) Randomised controlled trials
b) Cohort study
c) Case control study
d) Cross sectional study

29. Ten-day care clinic patients have their

Hb measured in the clinic. The means Hb
value is
11.0. The first 9 values are 10.0, 10.2, 9.7, 13.4,
12.7, 12.1, 11.0, 12.8, 8.6.
what is the value of the 10th patient?
A. 8.5
B. 9.0
C. 9.5 110/10 = 11.0
10. 10.0
E. 10.5

30. In a trial of a new treatment for fulminant sepsis the mortality in the treatment group is
20%, whereas the mortality in the placebo group is 40%. What is the relative risk of death
with the new treatment?
A. 0.1
B. 0.2
C. 0.4
D. 0.5
E. 2.0
RR = 20/40 = 0.5
RR = risk of exposed/risk in non exposed = 20/40 = 0.5

31. A new screening test was developed for a disease. According to the survey, there is an
increase in percentage of people who are taking the screening test. However, there is no
increase in number of people diagnosed with the disease. What’s the underlying cause?

A. Because of the cultural limitation, the number of Indigenous women who take the test
are few.
B. There is not enough access to the test for the community
C. The test has low sensitivity value
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 32. A new drug is discovered, which affects the progression of the disease, but not the
mortality. Which is the most appropriate statement?
a. increase incidence
b. decrease incidence
c. Increase prevalence ***(no death all old pat and new pat inside this group)
d. decrease prevalence
KAPLAN STEP 2 CK NOTES EPIDEMIOLOGY

33. . A pharmaceutical company before the start of the trial got approval from ethical
committee to use a new anti-cancer drug for Ca Pancreas. The ethical committee gave
approval and set the target P value < or = 0.02, for the drug to be superior to other
drugs. At the end of the trial, the company claimed about the efficacy of the new drug to
be superior to all other available drugs in the market and P value at the end of the trial
was = 0.04. What does this P value show here?
1. New drug is safer as compared to other drugs.
2. New drug is as useful as other drugs with fewer side effects
3. new drug is superior to other drugs
4. New drugs is not to superior to other drugs
5. New drug is inferior to other drugs

KAPLAN STEP 2CK Epidemiology Notes

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 34. Study on Aspirin effects
on preventing MI on 100
people.
Of those who took aspirin of the
100 ppl only 1 person had a
MI.
Of those who didn't take aspirin 2
ppl had MI.
What is the decrease in relative
risk (Relative Risk Reduction)
RRR given by aspirin

1%
10%
50%
100%
200%

CER = 2/100
EER = 1/100
RR= 1/2 =0.5
RRR = 1- RR= 1-0.5= 0.5
RRR = (CER – EER)/CER = ½ = 0.5
=50%

Out of 100 volunteers each group

Coronary event No coronary
event

Aspirin 1 99
No aspirin 2 98
How much the relative risk increasein people not taking ASA to get coronary event?
1%
2%
100%
200%

Coronary event Present Absent

No Aspirin 2 98
Aspirin 1 99

!⁄(!#$%) !⁄())
Relative Risk (RR) = (⁄((#$$) (⁄()) = 2

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RR is more than 1 here,
that gives RR increase (RRI) = RR -1
= 2 -1
= 1 (100%)
RRI of 1 means 100% more likely to get coronary event in those who do not take Aspirin.

35. In pt. with pancreatitis for purpose of statistical studies, AOF are useful EXCEPT
a. Case control
b.Cohort
c.Case report/case study—(one study) ***
d. double blind study
e.systemic review

30. WOF the following least describe

primary prevention?
A. reduce incidence
B. improve lifestyle
C. giving vaccination
D. reduce prevalence(ans) secondary
prevention ref kaplan
E.identify the predisposing factor early
***

31. as a gp in rural area, you notice that recently more cases of hepatitis c has been
diagnosed and want to do a research to find out the incidence of hep c in the community
with a population of around 3000. how will you get the information you need for the
research?
a. find the number of all patients with current hepatitis c antibody +
b. all patients with current hepatitis c antigen positive
c. all patients with current hepatitis c pcr positive ***----------------incidence
d. all cases diagnosed as hepatitis c positive for the past 5 years
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for prevalence (2016Q) -----HCV antibody

32. you are a doctor in a hospital and want to do research about the outcome of babies
born to diabetic mothers and want to compare the result with the babies born to non
diabetic mothers. Which study will be the best study?
a) Cross sectional study
b) Cohort study
c) Case control study
d) Randomized control trial
e) Case study

33. You find there are more and more diabetics in your practice and you want to do a research
About how many people are diabetic. What is the best study design?
a. Cohort study
b. Case-control study
c. Randomized-control trial
d. Cross-section study***

34. Which of the following is necessary in obtaining informed consent?

a. A description of the statistical analyses that will be carried out
b. A description of the purpose of the research ***
c. A description of the reliability and validity of test instruments
d. A list of publications that the researcher has had in the last ten years
You are supposed to submit a paper or protocol of what will be done in the research
study and how it will be done to an ethical committee and on the basis of that, Ethical
committee either approves it or rejects it.
https://www.racgp.org.au/afp/2015/june/research-ethics-and-approval-process-a-guide-for-new-gp-researchers/

35. How to choose sample for a research of obesity in the community?

A. Snowballing
B. From shopping center.
C. Random in general population. ***
D. From news advertisement.
E. From website

36. You are planning on conducting a research to look at the association between hypertension
and myocardial infarction. What is the most appropriate study design for this
research?
a. Randomised controlled trial
b. Case study
c. Cohort ***
d. Cross sectional

if there is experimental study then we will choose RCT. but if there is observational
study look that is there any comparison grp..if yes it means we go for analytic study...
Cohort study (exposure to outcome) outcome to exposure (case control) and exposure and
outcome at same time then cross sectional.... there is hypertension is exposure and MI is
outcome..so we will go for cohort study

37. 15-year-old boy wants to participate in a research study. He told his parents who did
not agree. He lives with his parents. Can this boy participate in the research study?
No,
Minor living with parents. Ethics would need parents’ consent

38. What is the advantage of a randomised controlled trial?

465
A) will remove observer bias ***
b) will remove the chance of self-selection of patients to particular group
c) will be better for comparable results

The most important advantage of proper randomisation is that it minimises allocation bias, balancing both known
and unknown prognostic factors, in the assignment of treatments

****39. When evaluating a report of clinical trial, which one of the following is correct?
A. Control and treatment groups must be equivalent in size.(ans)
B. if randomization is conducted properly, chance differences are inevitable.***
C. Inadequate sample size has been shown to produce true positives and true negatives.
D. results are invalid if the trial is of not double blind construction.
E. Withdrawal of patients from a trial by the investigator does not lead to bias

In very large clinical trials, simple randomisation may lead total balance between groups
in the number of patients allocated to each of the groups, and in patient characteristics. However,
in “smaller” studies this may not be the case. Block randomisation and stratification are strategies
that may be used to help ensure balance between groups in size and patient characteristics
http://adc.bmj.com/content/90/8/840

However, after randomisation, it is almost inevitable that some participants would not
complete the study for whatever reason. When such patients are excluded from the analysis, we can
no longer be sure that important baseline prognostic factors in the two groups are similar. Thus the
main rationale for random allocation is defeated, leading to potential bias

https://www.healthknowledge.org.uk/e-learning/epidemiology/practitioners/introduction-study-design-
is-rct

Biostate question- out of 1000 patients only 700 patients at the end of the study- decrease internal reliability. A
study done on 1000 people for smoking cessation but only 700 presents at the end of the study. What will you
rely on from this? A. Confounding bias B. Decrease in reliability
C. Increase internal validity D. Recruitment bias

40. Which of the following statement about double blind pacebo control clinical trial is correct!
A: All patients receive a placebo.
B: Everybody receives both treatments
C. Some of the patients are not treated
D. Half of the patients don’t know which treatment they receive
E. The clinician assessing the effects of the treatment does not know which treatment the
patient has been given***

#biostats

a pharmaceutical company representative comes to you showing the result of a double blind randomized controlled
trial comparing two drugs for management of hyperlipidemia. which of the followings is most impartant to ask
to evaluate the how valid the study is?

1. Was there enough crossover time?

2. Did two groups received equivalent dose of the drugs?

3. were there a placebo arm?

4. was the number of participants in each arm the same?

466
41. Incidence rate of lung cancer among smokers is 10/1000 and among non-smokers is 1 per
1000.To what extent to lung cancer can be attributed to smoking
is
a. 10%
b. 90% ***
c. 1%
d. 100%

ar =rr-1/rr *100
RR=ARR/10=10-1/10=.9 meaning 90%

42. In a community pap screening was done. but there is increased incidence of Ca cervix. what is the cause?
a. failure to screen the high-risk women
b. inability of the test to identify the disease in early stage. ***

467
43. What would be the best reason to make a screening program more available to the public?
a) Possibility of early diagnosis
b) It is required for research purposes
c) It improves the treatment’s prognosis(ans)
d) Specialised treatment is available
e) It can lower the death rate from the disease

the disease should be common, treatable and easy screened with cheap
available non-invasive screening procedure

44. Average BP is 130 +/- 25. about 95% people will lie between :
a. 115-155
b. 80-180***
c. 95-100

25 is the SD
2sd=95.5%(formula)
so, 2*25=50
130+50=180
Ans d 130-50=80

45. One population, mean

systolic BP is 115 and SD
is 15 so what will be
range of 95%
population’s BP?
a) 100 to 130
b) 85 to 145***

95% SD(range) given then it means its plus and minus 2SD.so here they have
given 15 SD, SO As i said its 2SD for 95% and 2*15=30 so plus and minus 30
if they give 99% then its plus and minus 3SD
if 66% then plus and minus 1SD

46. on tv u have given a lecture. u gave education, now we need to find out that is it benefitting the people or not.
a go for randomized group in general population. ***
B case study
C case control

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 D cohart

47. A pharmaceutical company contacts you and suggests you to start prescribing the new antidepressant. What
the criteria for doing that?
A. Approval of committee ethics commission *** or fda
B. Base recent scientific research
C. Not to do so

48. 50 males taken to a research and during it he become dementia and his primary carer is his
son what will you do
a) Ask from son***
b) Guardianship
c) Ethic and comity

49. An experienced group of surgeon’s reports on a

randomised placebo controlled trial comparing a
particular surgical technique for carotid artery to a
sham procedure. Their study concludes that using this
advanced method reduces the risk of stroke from 5% to
4% ( p<0.05). what does this study proved about the
new surgical method?
1. Acceptability
2. Effectiveness
3. Efficacy***
4. Safety
5. Usefulness
5. odds ratio and attributable risk

50. You are a doctor in a remote area where a study is conducted to determine the prevalence of Hep B the study
included 200 patients and showed the following results
2008/ 2009
Patients with Hep B Ag +ve only 10 / 12 Patients with +ve Hep
B core antibody and Hep
B Ag 50 / 52 Patients with Hep B core antibody +ve only20/ 30
Calculate the incidence in
2009-2010 in 1000 patients from this population
25
50
300
325
(ANS) 50

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(here,+ve HBsAg (infectious but
not diseased)=12,+ve
HBcAb(resolving)=30, +ve
HBc Ab +
HBsAg(chronically infected)
=52.So,new cases are=(52-
12)-30=10.so,incidence rate
in
2010=(10/200)x1000=50)
(HBcAb didnt indicates all new
cases, it indicates past and
current infection...so,we have
to calculate
new cases from the given data)

51. Study on Aspirin effects on preventing MI on 100 people.

Of those who took aspirin of the 100 ppl only 1 person had a MI.
Of those who didn't take aspirin 2 ppl had MI.
What is the decrease in relative risk given by aspirin

a. 1%
b. 10%??
c. 100%??/
d. 200
ans :50%

Formula of RRR is
RRR = (EER-CER)/CER = (.01-.02)/.02= -50%

The relative risk increase is the percentage to which the treated group get more of that event than the control group
and is computed using the following:
Relative risk increase = 100x(treatment event rate -control event rate) /CER
Negative numbers, of course, mean that there is a relative risk decrease rather than increase.

ans :50%
Relative risk reduction (RRR) tells you by how much the treatment reduced the risk of bad outcomes relative to the
control group who did not have the treatment.
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Relative Risk Increase

Formula of RRR is
RRR = (EER-CER)/CER = (.01-.02)/.02= -50%
Eer=events/total number
Cer=number in control/total number
RRR=(.01-.02)/.02=.05 MULTIPLY 100 SO 50%
http://www.clintools.com/products/org/WebHelp/odds_ratio_generator_help/relative_risk_increase.htm

The relative risk increase is the percentage to which the treated group get more of that event than the control group
and is computed using the following:
Relative risk increase = 100x(treatment event rate -control event rate) /CER
Negative numbers, of course, mean that there is a relative risk decrease rather than increase.

52. Vitamin C efficacy on influenza with placebo, what to do to increase validity?

a. Random sampling
b. Cohort
c. Case-control
d. Case-report
e. Randomisation (rct)
https://study.com/academy/lesson/how-to-improve-
validity-of-a-scientific-investigation.html
There are a number of ways of improving the validity of
an experiment, including controlling more
variables, improving measurement technique,
increasing randomization to reduce sample bias,
blinding the experiment, and adding control or
placebo groups.

A 0 specificity, B 100 sensitivity and 50 specificity, c 75 sen n spec, d 100 specificity n 50 sensitivity, 0
sensitivity=====ans

A B C D E

Points Comment
A 0% Specificity
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 B 100% Sensitivity, 50% Specificity
C 75% Sensitivity, 75% Specificity
D 100% Specificity, 50% Sensitivity
E 0% Sensitivity

53. 40-year asymptomatic patient comes to you requesting stress ECG. You know the prevalence of case in
asymptomatic patient of this age is 10.
Dis Disease present Disease absent

Positive test 40 80
Negative test 60 200

What is the sensitivity of test?

E. 5%
F. 10%
G. 25%
H. 40%
I. 80%
Answer: Sensitivity = a/ a+c =40/(40+60)= 0.4 = 40%

Some imp epidemiology formulas and related imp notes...that might be helpful for exam..
TP- true positive
TN - true negatives
FP- false positive
FN - false negatives

Accordingly, formulas r as follows:

1.) SENSITIVITY = TP/ TP+ FN
2.) SPECIFICITY = TN/TN+ FP
3.) PPV - POSITIVE PREDICTIVE VALUE = TP/TP+FP
4.) NPV- NEGATIVE PREDICTIVE VALUE = TN/TN+FN
5.) FN RATE = 1 - SENSITIVITY
6.) FP RATE = 1 - SPECIFICITY
7.) Accuracy(efficiency) of test = ability to give correct result = TP+TN/ TP+TN+FP+FN
8.) FP % = FP/Total not diseased * 100
9.) FN % = FN/ Total diseased * 100
10.) Likelihood ratio of a positive Test- LR+ = TP/ Total diseased /// FP/total not diseased( /// means
whole upon)
11.) Likelihood ratio of a negative Test- LR- = FN/ Tot diseased /// TN/tot not diseased( /// means
whole upon)
12.) LR + = sensitivity/ 1-specificity
13.) LR - = 1- sensitivity/ specificity
(just a small explnation for Likelihd ratio wat it means.
e.g If LR+ =9 for a test say ELISA, then it means that likelihood of ELISA test to be
positive in HIV patients is 9 times more than not having HIV.. )
dis+ dis
Test+ a(TP) b(FP)
test - c(FN) d(TN)
.
SOME IMP formulas TO REVISE
1.) Case Fatality Rate = no. of deaths(disease)/ tot no of cases(diseases) * 100
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2.) INCIDENCE = new cases
3.) PREVALENCE = old + new cases
4.) Prevalence = Incidence * Duration (mnemonic = PID : P=I*D)
5.)ODDS RATIO = ad/bc
( see the above table , its simply the cross product, try drawing an arrow again , it vl
give u a cross...)
6.)COHORT study is = Prospective/ forward/ longitudinal study where we go from
Cause to Effect
e.g Risk factor to disease...meaning we study all smokers(RISK FACTR) and
then follow them up for Lung Cancer(DISEASE)
7.) CASE CONTROL STUDY = backward/ retrospective study
Here we study the diseased people and look for their risk factor.
e.g We stdy all Females with cervical cancer(clear cell ca) and then look for being
exposed to DES( diethyl stilbesterol..) i hope u all getting wat i m writing...;)
8.)RELATIVE RISK(RR) = INCIDENCE among Exposed/ INCIDENCE among Non-
Exposed
if RR <1 : Protective/ beneficial Risk factor
=1 : No association
>1 : association+(i.e association of disease with Risk factr)
9.)ARR-attributalbe risk = Risk in exposed Group - risk in Unexposed
but i read somewhere that : Risk in exposed Group - risk in
Unexposed///risk(exposed)
guys please confirm it...!! Drzahid khan i rem u said first formula...:)
10.)mean +/- 1SD = 68% CI
mean +/- 2SD = 95% CI
mean +/- 3SD = 99% CI
SD - standard deviation
CI - confidence interval

53. A medical condition is present in 6 out of 100 in one population. Relative risk is 50%. A
new drug is under investigation & desired to decrease the condition by 1/3. How many patients
are needed for the study?..POPULATION NEEDED = TOTAL POP /RELATIVE RISK
a. 200
b. 100
c. 33
ans...33
1st one total population is 100 CONTRO…language problem
, relative risk 50%. so, 50% of 6 is 3.
Population needed 100divided by 3 is 33.

54. Absolute risk of a disease is 6 in 100 ppl. Relative risk for the disease is 50% A new med is introduced which
will lower the risk by one third…what’s the absolute risk with new medicine? 6% 12% 3% 2% 33%

50% of 6= 3%, risk of disease= 6+3= 9%, new drug reduce risk 1/3 of 9= 3%, that means risk in treated person=3%.
Absolute risk= 9%-3%=6%. Answer 6%.....A.

55. 56. A pharmaceutical company introduced a drug which reduces the incidence of stroke in smoker
population by 25%. In a population 8 (94) out of 100 are smoker. How many people do u need to
treat to reduce the risk in a single person?NNT CALC HERE
a. 8
b.25
c.50

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ans :50
NNT CALC HERE
he NNT(number need to treat) is the average number of patients who need to be treated to prevent one additional
bad outcome (e.g. the number of patients that need to be treated for one of them to benefit compared with a
control in a clinical trial). It is defined as the inverse of the absolute risk reduction
one Absolute risk of getting disease=8 in 100=0.08
* Reduction in risk is 25% (25% of 8=2 25/100x8) (2 per 100) which leaves absolute risk to 6 per 100=0.06
* Absolute risk reduction =Absolute risk-Absolute risk after treatment=0.08-0.06=0.02
*Number need to treat to reduce risk for 1 person=1/Absolute risk reduction=1/0.02=50

56 Study for Vit D deficiency in ur community ?

A. Cross sectional (ans)
B. Cohort study
C. Case study
D. Case series
E. Rct

57 Pharma company approached you to prescribe drugs, what u want to look in that drugs

No SE \\\\1st choice FDA

RCT
case control
Cohort

58 A GP finds 3 salmonella cases in his community. What epidemiological study to do in order to find the cause?
a) Cohort
b) Case control
c) RCT
d) Case series
e) Cross sectional study

59.A doctor wants to study a few cases of TB.Which do you think is the most appropriate study for it?
474
a)Case control(ans)
b)cohort
c)RCT

60Parents have thalassemia minor.What is the probability of their child to have thalassemia minor as well?
50%(ans)
25%
100%
75%
thalassemia minor is Autosomal recessive means that both parents are career so every pregnancy 25% chances of
disease and 50%carrier and 25% may be normal.

61Couple came for counseling regarding their first child for inheritance of cystic fibrosis. One of them is carrier.
What’s the probability of disease in child?
a. 0.0(ans)
b. 0.25
c. 0.5
d. 0.5 in male offspring
e. 0.1 due to intrauterine loss

25% chance when both parents will be carrier or one parent affected and other one carrier. But when only one
parent carrier then 0 chance.

62.Grand mother suffering from Schizophrenia and the son is normal now comes to know the chances in his Son
10 fold increase
20 % chances

Second degree relative 5-6 percent . Here 10 is close option

Child has high probability of suffering from schizophrenia spectrum disease

63. A study testing drug B reveals significant benefit of drug B> drug A with probability of < 0.01. this means:
a. Drug A is better than B
b. Drug B is better than A(ans)P value <.05 is significant
c. The difference between drug A and drug B occur by chance

64. 39 week gestation pregnant lady comes with rupture of membrane. On examination, cervix is 3cm dilated, there
is no cord prolapse and normal except meconium stain liquor. CTG was done and the findings are FHR- 144bpm,
10-15 variability, no acceleration and no deceleration. What is the CTG interpretation?
A The fetus has high probability (50% chance of) Hypoxia
B The fetus has low probability (5% chance of) Hypoxia
C Abnormal CTG because the fetus is asleep
D Normal CTG:(ans)

475
65. P value of effectiveness with
drug…..
a) type 1 error
b) Type 2 error
c) Effectiveness in greater than 0.5
d) effectiveness >0.1

66There was a question regarding

p value for null hypothesis in a drug testing.
a. it will make no difference in p value if comparsion of drugs
b. if p value is less than 0.O5 then higher specific response(ans) 145 kaplan
c. if p value is <1.0 then means more difference in efficacy
d. if p value is 0 then both have equal response and efficacy
I think b but it will be <0.05??? please anyone explain with reference

67
P value <.05.what does it mean?
a-new treatment is 5% more effective then old one
b-statistical significance achieved(ans)

68#BIOSTATS
A pharmaceutical company before the start of the trial got approval from ethical committee to use a new anti-cancer
drug for ca.Pancreas. The ethical committee gave approval and set the target P value< or = 0.02, for the drug to
be superior to other drugs. At the end of the trial, the company claimed about the efficacy of the new drug to
be superior to all other available drugs in the market and P value at the end of the trial was = 0.04. What does
this P value show here.

1. New drug is safer as compared to other drugs.

2. New drug is as useful as other drugs with fewer side effects
3. new drug is superior to other drugs

476
 4. New drugs is not superior to other drugs(ans)
5. New drug is inferior to other drugs

69Parents came to you because their son has hereditary spherocytosis and they want to know what is the chance
that his siblings have the same disease?
a) 50% of his brothers and sisters(ans)
b) 25% of his brothers
c) 50% of his sisters
d) 0 % of his brothers and sisters
e) 50 % of his brothers

70newly married couple comes to u says his mom had schizophrenia what is chance of schizo in his children
A 15 %
B 10 %(ans) There is a chance of schizo of about 4-6%. kaplan
C high chance of schizo in all population
D no risk of schiz

71
. Both parents thalassemia minor chance children of thalassemia minor (50%)

72
25 yr old Dizygotic twin with schizophrenia chance of her getting schizophrenia (10%)
12%

73. What is the advantage of a randomised controlled trial?

477
A) will remove observer bias ***
b) will remove the chance of self-selection of patients to particular group
c) will be better for comparable results

72MS scenario asking about progression of disease next 10 years.

a) 20% pg 324
b) 30%
c) 70%
d) 80%
e) 50%.

73 Young lady with optic neuritis diagnosed as ms

what is the chance of neurological prob in
10years
a. 20
b. 30.
c. 70
d. 80
74B thal couple ( both), want to kw chances of hw
many children will be affected april 20
25%
74. When evaluating a report of clinical trial, which
one of the following is correct?
A. Control and treatment groups must be equivalent in
size.
B. if randomization is conducted properly, chance
differences are inevitable
C. Inadequate sample size has been shown to produce
true positives and true negatives.
D. results are invalid if the trial is of not double blind
construction.:ans)
E. Withdrawal of patients from a trial by the
investigator does not lead to bias

75. You are adoctor in a town ,where 6people out of 100 are non smoker.What are the chances of stroke.the
chances of stroke in smoker is 50%more than non smoker .Now the pharmaceutical company is introducing a
medicine which reduces the chances of stroke upto
1/3rd in smoker population .What is the percentage of
the stroke population will get stroke
a)3%
b)6%
c)9%
d)12%
e)20%

76. When evaluating a report of clinical trial, which one of the

following is correct?
A. Control and treatment groups must be equivalent in size.
B. if randomization is conducted properly, chance differences
are inevitable.
C. Inadequate sample size has been shown to produce true
positives and true negatives.
D. results are invalid if the trial is of not double blind
construction.
478
E. Withdrawal of patients from a trial by the investigator does not lead to bias

77. 1 dizygotic twin has schizophrenia…how much chance does the mother have of acquiring schizophrenia?
12%

78. When evaluating a report of clinical trial, which one of the following is correct?
A.Control and treatment groups must be equivalent in size.(ans)
B.if randomization is conducted properly, chance differences are inevitable.
C.Inadequate sample size has been shown to produce true positives and true negatives.
D.results are invalid if the trial is of not double blind construction.
E.Withdrawal of patients from a trial by the investigator does not lead to bias

79. double blind study

Vit C effect on iron tablets” which study you do ?
a) Cohort
b) Case Control
c) Case series
d) Double blind(RCT)

80. u r a doctor in the area with ppl with dementia and ppl with falling . u want to study and so u collect all the
records of ppl with dementia and their details abt falling . kind of study u r doing ?
a) case control:ans
b) cohort
C) cross sectional
D) case series

81which study to do for Vit C effect in treating Influenza ?

a) Cohort
b) Case control
c) Case Series
d) Random Studies
e) Randomization
**should be rct

82study for vit d defficiency in your community

cross sectional:ans
case study
cohort

479
case series

83Which is the best study to find out the state of Vitamin D deficiency in Australia?
a..cohort
b..case control
c..case study
d..Cross-sectional study.(ans)

88. Chalmydia prevalence

A) Cross sectional(ans) (at one point)
B) RCT
C) Cohort

89.Relation between Rota Virus & Low Birth weight?

Case Control(ans)
Cohort
Cross sectional
RCT

90. #STATS. study for vit d defficiency in your community

cross sectional(ans)
case study
cohort
case series

56. Ques with this foster plot telling about meta analysis for
comparison between antibiotic X and Y. what is your
interpretation?
a) Antibiotic X is more effective than Y
b) Antibiotic Y is more effective than X
c) data is insufficient
d) Meta analysis not adequate to make any conclusion

if the diamond is already given in graph then

simply choose that side of drug is more effective
than the other one. And if no diamond is given
then look for the lines which have not touched the
midline. Among those lines (which have not
touched midline) find the shortest line and see on
which side of graph it is(x or y) and simply choose
that side of drug as more effective than the other.
If diamond on x side ===x side is effective
If diamond on y side ====y side is effective
It cant be on 0 or if it is on 0 its not effective

480
Diabetes Hiv hep B & Endo
DIABETES RECALLS

1. If you have third nerve palsy,

which feature will tell u that it is
not due to diabetic neuropathy?
a. Ptosis
b. Intact pupil reflex
c. Impaired down and out gaze
d. Exophthalmos

https://www.aao.org/bcscsnippetdetail.aspx?id=f33e290f-49d9-4643-9bee-705907fc1647

2. What is the choice of treatment in sulphnylurea induced hypoglycaemia?

Ans. Octreotide
CONCLUSIONS:
Although relatively limited, the available data suggest that octreotide should be considered first-line therapy in both
pediatric and adult sulfonylurea poisoning with clinical and laboratory evidence of hypoglycemia. Maintenance doses
of octreotide may be required to prevent recurrent hypoglycemia.

http://www.ncbi.nlm.nih.gov/pubmed/23046209
https://www.ncbi.nlm.nih.gov/pubmed/20352540

481
Ans.A correct answer. Jm 191
High risk for developing Retinopathy
The general recommendation is that GPs need to ensure that their patients with diabetes have been appropriately
screened with a dilated fundus and a trained examiner every 2 years.6 However, many patients with diabetes will
have an extra risk factor necessitating yearly screening as per National Health and Medical Research Council
(NHMRC) recommendations (Table 1). This can be provided by suitably trained GPs, optometrists or where available,
ophthalmologists

3. 8 Yrs old, sunken eyes, thirsty,4 times U/O in 24 hrs, H/O vomitting, what initially?RBS 33mmol/l
A- ABG
B- HBA1C
C-Pulse Oximetry
Dia= diabetic ketoacidosis()metabolic acidosis

482
4. After swab and culture and beginning of antibiotics next:
a- Blood culture
b- X-ray
c- MRI
d- Ultrasound

Once diagnosed diabetic ulcer or patient came with ulcer if < 6 weeks go for
X ray if >6 weeks suspect osteomyelitis then go for MRI(this explains why C
is not the answer). I have check both JM and diagnostic imaging pathway . (B
correct).
N.B. Diabetic foot care VVI for AMC.

5. diabetic foot ulcer with

erythema on whole foot asking
for most appropriate next
A.iv ticarcillinclavaunate-
penincillin
B.oral amoxclavauante
C .MRI Foot
Ans. A correct….as whole foot is
affected

483
6. Woman with DM has a painless ulcer at dorsum of fifth toe it's 1cm for 1 week with yellow pus discharge
erythema and mild swelling noted over whole of foot dorsum . Surgical debridement was done and affected limb
immobilized next
Doppler usg
MRI
Amoxicillin clav
Tazobactam…as no proper combination is present
X ray

484
7. A diabetic 65 year old woman noticed an uler on her foot for 7 days she came to hospital and u admitted her,
surgical debridement was done and the ulcer is 1 cm and oozing a clear fluid , next best step ?
a. Oral amox. Clax + metronidazole
b. IV ticracillin + metronidazole
c. MRI
d. Dressing and checking the wound everyday
Discussion ;Diabetic ulcer heals quickly with regular and proper sterile dressing.

8. diabetic pt controlled by metformin.on multiple drugs.which drug you need to stop prior 1 wk of an elective
surgery
a)metformin
b)indomethacin
c)statin
Ans. B correct.(NSAIDs stopped 5 days ,Aspirin 7 days before surgery)
Extra info:

Extra info:
Australian diabetes society guideline specifically recommends for metformin to be continued till one
day prior to either major and minor elective surgeries. Uptodate recommend NSAIDS to be stopped one
week before surgery to minimize risk of post operative bleeding.

9. Old man with DM type 2. Has an ulcer on the medial malleolus. It started 2 mon ago after a scratch at the same
site.what is the Diagnosis?
A- Diabetic ulcer,,, peripheral sensory neuropathy, trauma, and deformity
485
 B- Ischemic ulcer
C- Venous ulcer
D- infectious ulcer
Discussion: The site of any ulcer on the lower limb is of great importance in the determination
of the underlying cause. The important causes include venous stasis, arterial
insufficiency, infection and trauma. Venous insufficiency ulcers are most often
situated around the ankle and, characteristically, over the medial malleolus. Venous
presssure tends to be highest at this site, where there are many perforating veins.
Arterial ulcers from large vessel atherosclerosis usually occur at the extremities,
typically on the toes and dorsum of the foot. Infectious ulcers may occur at any
site, as with the ulcer due to the presence of a foreign body. Ulcers associated with
neuropathic change develop secondary to prolonged trauma and/or pressure
and the plantar surfaces over the metatarsal heads represent the major weight bearing
areas of the foot and those subject to greatest pressure. Persistent pressure
on an area of ulceration combined with a precarious blood supply - such as the
microangiopathy of diabetes mellitus - make this a common hazard in these
patients. Neuropathic ulcers developing in diabetic patients in an area of insensitive
skin are characteristically deep and painless (reference AMC handbook p 391)
Similar type of another question from AMC handbook

10. A 67-year-old man with a history of Type 2 DM for 11 years presents with
a deep painless ulcer over the plantar surface of the head of the third metatarsal.
The patient is a non-smoker and has been taking oral hypoglycaemic agents for the
Past 11 years. Which one of the following is the most likely cause of the ulcer?

Ans. Neuropathic ulcer- diabetic ulcer

• Tips: Learn the sites of ulcer for answering this types of questions

11. In a diabetic pt what u'll check 2 yrly

a. BP
b. Foot care
c. eye examination
Ans. C correct

Q.A scenario with a patient under medication presenting with gynecomastia. He has Hypertension and
diabetes mellitus and has several medications. Which of the following is the cause?
a. Digoxin..painless b. ACE c. Spironolactone ..painful d. Metformin
Ans. C correct.
N.B. If young patient comes with gynaecomastia and genetic cause in option that will be the answer.

Common Side Effects of Spironolactone

• Vomiting, diarrhea, and stomach pain or cramps
• Dry mouth and thirst
• Dizziness, unsteadiness, and headache
• Gynecomastia (enlarged breast tissue) in men, and breast pain in women
• Irregular menstrual periods and post-menopausal vaginal bleeding

12. In a diabetic patient. What should be done 2yearly?

a- BP check
b- diabetic retinopathy
c-diabetic nephropathy
d-foot care
e-urine examination
Ans B correct.

486
13. Gestational diabetes screening in a woman with family hx
of DM
a. OGTT at 26 weeks with 50g of glucose
b. OGTT at 26 weeks with 75g of glucose If there is option
from first visit choose that one
c. Glucose challenge test at 26 weeks with 50g of glucose
d. Glucose challenge test at 26 weeks with 75g of glucose

14. Primigravida of irish background in 1st trimester.How

you wiII screen for GDM?
A) GCT 50 mg 26-28 wks
B) OGTT 75 mg 20 wk
C) GCT 75 mg 26-28 wk
D) OGTT 75 mg 16-20 wks
Ans. C corret answer….but best ans should be OGTT in 26-
28 wk

15. A patient has DM2 and he is taking metformin 500mg BD. And his HbA1C 6.9(normal 4.5 ---6.6) ,BP 130/80 no
other symptoms what will you do next?
A. continue same….hba1c should be less than or equal to 7
B. increased metformin
C. Commence anti HTN
D. Commence simvastatin
Ans . A Correct answer.

487
16. 55y old lady known with insulin dependent DM, has had right leg amputation 5yrs previously, now blood
pressure 175\90, normal regular pulse, BMI 32, LDL 2.8, s. triglyceride 4.5,hba1c was 8.5,fasting glucose was
9.5.Which of the following is important to keep
her other left leg from amputation?
• Meticulous foot care
• Control her blood pressure
• strict glycaemic control
• Reduce LDL
17. Gestational DM

488
 Ques . pregnant with family history of diabetes at 10weeks.what will you do?
Ogtt at 24-8wks
Ogtt at 20wks
FBS now
ANs C correct.
http://www.racgp.org.au/afp/2013/august/gestational-diabetes-mellitus/

Diabetic recalls:
18. in a patient who has an elective surgery, with medical history of taking"Metformin, ibuprofen, 2 anti
hypertensive medications" which the Bp and the glucose levels of the patient was normal.which medication you
need to stop one week before surgery?
A)Metformin
B)ibuprofen
Ans. B
NSAIDs should be stop before 7 days of surgery.

19. A 62-year-old man is reviewed in diabetes clinic. His glycaemic control is poor despite weight loss, adherence to
a diabetic diet and his current diabetes medications. He has no other past medical history of note. Which one of
the following medications would increase insulin sensitivity?
a-Repaglinide
b-Tolbutamide
c-Pioglitazone
d-Acarbose
e-Gliclazide
Ans. C
Pioglitazone is a thiazolidinedione antidiabetic agent that
depends on the presence of insulin for its mechanism of
action. Pioglitazone decreases insulin resistance in the
periphery and in the liver resulting in increased insulin-
dependent glucose disposal and decreased hepatic
glucose output. Pioglitazone
Metformin decreases hepatic glucose production,
decreases intestinal absorption of glucose, and improves
insulin sensitivity by increasing peripheral glucose uptake
and utilization

ans is D…
if proliferative change(angiogenesis) its urgent refferal

489
ans is a

ans is b
Proximal diabetic neuropathy, more commonly known as diabetic amyotrophy, is a nerve disorder that results as a
complication of diabetes mellitus. It can affect the thighs, hips, buttocks or lower legs. Proximal diabetic neuropathy
is a peripheral nerve disease (diabetic neuropathy) characterized by muscle wasting or weakness, pain, or changes in
sensation/numbness of the leg

20. Diabetic pt with 3 month ulcer, pulses not palpable, X-ray done erosion showing ,what ll do for next for
management : a. Ulcer swab b. MRI c. Leg ultrasound

21. Diabetic pt presented for routine checkup. His bp was quite high and on eye examination had artiovenous
stripping. Asking next step in management?
1. Follow up
2. Stress echo
3. Ecg
4. Holter monitoring
5. Ace inhibitor

22. Pt is htn and dm, eye prb this pt at risk of what eye prb
-htn retinopathy
-dm retinopathy
-retinal detachment
May be they are asking for the highest risk..retinal detachment can occur from both from dm and htn retinopathy

23. Regarding diabetic neuropathy, WOF is least likely?

a.Among the diabetes related complications, diabetic foot ulcer is the most common cause of prolonged hospital
stay
b.50% of the patient with diabetic neuropathy die within 3 yerars
c.If diabetes is under good control amputation can be reduced by 50%
d.If untreated 1/3 of the patients will have amputation due to diabetic neuropathy…. Should be 1/4
e.With the presence of normal pedal pulse the development of ulcer is unlikely

490
24. A 18year old patient comes to you for driving licence clearance certificate. You know that the patient is having
type 1 dm and his blood sugar level was not well controlled. What is necessary for the clearance?
A- fbs less than 12
B- hba1c less than 9
C-dietitian referral
D- attend the dm group program august 2018

25. Pregnant young women with DM type 1, comes with vomiting and ketones ++, Hba1c 16%. What to do?
A. Infusion of dextrose and insulin
B. Insulin 10 unit
C. Cek ketones in urine
D. IV saline 1L in 12 hours agust 2018

26. PVD with risk factors of smoking raised cholesterol blood pressure and diabetic. Which of the following will
decrease peripheral vascular disease after quitting smoking
BP control 1.5-3.8 fold risk
Cholesterol 1.2 -3.8
DM 2.8 -4.2
As seen in the above diagram, Smokers have a 4-5
times higher risk and Diabetics a 3-4 times higher risk
of developing PVD. When multiple risk factors exist eg
smoking, diabetes and hypertension in the same
patient, the risk is multiplied.

27. Scandinavian female 35years BMI 30 for first

antenatal check-up. What will you do? a. OGTT as
soon as possible b. OGTT @ 24-28 weeks c. RBS
@28weeks

28. Nov2018 Pt with bmi 35, family history of dm 2, obese, fbs is 11. Comes to u. Ur next step.
1. Start metformin 2. Refer to endocrinologist 3. Repeat fbs. 4. Rbs 5. Ogtt

29. 48 Patient comes to GP for a blood-pressure follow-up. HBAIC was previously high. Besides advising the patient
to lose weight and exercise, what is the most important test to perform?
A. OGTT
B. HBAIC
C. Fasting Blood Sugar
D. Random blood sugar

491
30. #drug 47. patient with type 2 diabetes on metformin 1.5g/day came to routine health checkup, lab investigation
was done showed as follows , BP 135-85 (sure) Test result Random blood sugar 5.6 (4.5-6.5) Cholesterol (within
normal) HbA1c 8% ( normal <6.5%) SURE Albumin-Creatinine ratio -530 ( normal <300) SURE Normal value are
given What is your most appropriate next step in management?
A. Ramipril
B. Glipizide
C. Insulin
D. Pioglitazone
E. Sitagliptin Exact options

A ratio of albumin (mcg/L) to creatinine (mg/L) of less than 30 is normal; a ratio of 30-300 signifies microalbuminuria
and values above 300 are considered as macroalbuminuria. On a standard urine dipstick, 10-20 mg/dL is the minimal
detection limit of protein.

31. DM1, glucose 58 (mg/dL?), urine ketone +, K 6.5, asking initial management
• NSS iv • Ca gluconate • Glucagon • Insulin

The normal blood glucose level (tested while fasting) for non-diabetics, should be between 3.9 and 7.1 mmol/L (70
to 130 mg/dL). The mean normal blood glucose level in humans is about 5.5 mmol/L (100 mg/dL); however, this level
fluctuates throughout the day.

32. Diabetic pt with 3 month ulcer ,pulses palpable ,swab done ,what ll do for next for management
: Ulcer swab
MRI
xray
Leg ultrasound for arteries
492
33. Child present with urine ketone,glycosuria,dehydration but urinate 4 times since morning. During resuscitation
what most serious complication can developed
. A.hypokalemia
B.metabolic acidosis
C.cerebral oedema

34. patient with polyuria, what will lead to tell he is

diabetic
a. more skin infections
b. obesity (DM 2 tipe)
c. family history (DM1 and2)
d. weight loss in spite of increased food intake

4 p for type 1 dm- polyuria,polydipsia,polyphagia and

wt loss in Spanish

35. old pt known diabetic. he is taking metformin and a

secreta gog. when tested for followup, his hbaic is 12
and blood sugar markedly elevated. what is the cause?
a.insulin dependant dm…in type 1 dm
b. insulin resistance has increased…metformin and secretogog increase insulin secretion and decrease insulin
resistence….pt may develop insulin resistance if he takes insulin
c. there is insulin deficiency…may be pancreas of this old pt not producing insulin anymore

36. Child with asthma,during urine test ketones and high sugar found what test for follow up?
a. HBA1c
b. FBS
c)OGTT
d)2hr OGTT
e)random blood sugaR

Ans is a

37. --72yr old male presented with moderate confusion. On examination he is afebrile and nothing abnormal
detected. He had an ulcer on lower part of her leg treated by community nurse for six months. (Pic given with
ulceration and yellow pus). What will assist diagnosis
a. Urine test
b.Blood culture
c. Wound swab
d. CT scan
e. Lumbar puncture #Sept 2018

493
38. child long term asthma controlled with SABA and inhaler, urine show ketone ++ glucose ++, blood glucose 8.5,
next inv? 1. OGTT 2.HbA1C 3. FBS

39. Which one of the following factors is most likely to invalidate the use of the Modification of Diet in Renal Disease
(MDRD) equation to calculate a patients eGFR?
A-Diuretic use
B- Pregnancy
C-Type 2 diabetes mellitus
D-Blood pressure of 180/110 mmHg
E-Female gender

40.
ans could be c

494
41. A middle-aged man with type 2 Diabetes mellitus.
Presents to you with painful and red calf. After
examination you found his leg to be tender and his
temperature is 37. What's your initial management?
A- Subcutaneous enoxaparen B- IV heparin. C- Oral
Amoxcillin. D- IV Penicillin Final PLz

42. A 55-year-old male with history of type 2 diabetes

mellitus,requested you to prescribe him aspirin for
prevention of heart disease and stroke.He does not
have history of cardiovascular disease in the past.
What will you do?
a. Refer him to cardiologist
b. Refer im to stroke specialist
c. Reassure him that he would not benefit from aspirin
d. Do an ECG and then decide
e. Prescribe aspirin

43. Elderly diabetic. What to check 3 monthly?

1. Albumin creatinine ratio 2.FBS 3.HBA1C 4. Fasting lipid
profile

44. 29 yrs old woman complains of weight loss and lethargy

and malaise, she noticed passing more frequent urine in
day about 8 times and 2 times in the midnight..
Investigations revealed HbA1c 11.9 ( N-<6.4) , FBS 9.8
mmol. What will be the best initial treatment?
A metformin
B insulin glargine
C Gliclazide

45. Diabetic patient has ulceration on the ball of 2nd toe-whats the investigation most likely to confirm reason of
ulcer
1 nerve conduction study
2 arterial doppler
3.arteriography
4.wound culture

46. An HIV positive patient comes to you. He and his wife both are your patients. You ask him how to tell her partner
about her HIV status but he refuses to do so. What will be your action?
a.Inform health authorities
b.Inform his wife (ans) she is in immediate danger
Redness his confidentiality
Tell the patient to practice safe sex from now onwards
Issue him letter
https://www.bodypositive.org.nz/Pages/HIV_and_Disclosure/

495
47. A GP with HIV recently got a job offer as surgeon…he don’t want to inform the new employer
a.Inform the employer
b.Inform the surgical cousil
c.Advice him to take universal precatuions(ans)
d.Inform board.

48. A pregnant lady sits on a needle in train came for advice?

A. Give antiviral drugs PEP might be prescribed for you if you are HIV negative or don’t know your HIV status,
and in the last 72 hours you:
Think you were exposed to HIV during your work, for example from a needlestick injury
Think you were exposed to HIV during sex
Shared needles or drug preparation equipment (“works”)
Were sexually assaulted
B. Test serum HIV now
C. Serology test of needle
D. Serial check for HIV 3. 6. 12. Month later (for follow up)
best ans is hep B prophylaxic & serology for hiv...)
https://www.nps.org.au/australian-prescriber/articles/needle-stick-injuries-in-primary-care

https://www.google.com.au/url?sa=t&source=web&rct=j&url=https://www.primaryhealthtas.com.au/s
ites/default/files/Protocol_Needlestick_Injuries.pdf&ved=0ahUKEwjVvfGQ_uXWAhVGo5QKHZaRDFcQF
gh7MAU&usg=AOvVaw0nosUTUolWEiBfG9i7JWtL
When the source is unknown
If the source of the needle-stick injury is unknown, for example exposure from a needle discarded in a
linen bag, the protocol for hepatitis B prophylaxis and serological follow-up should be followed.
Establishing the need for HIV post-exposure prophylaxis is problematic in this situation. In general,
unless it is likely that the needle was associated with a patient known to be infected with HIV, post-
exposure prophylaxis is not indicated. For example, in a general practice not specialising in HIV the risk
that the needle is contaminated is extremely low.
In the community the source is usually unknown, but the risks of transmission are extremely low
Needle-stick injuries in members of the public
A major source of distress is the needle-stick injury sustained by members of the community - usually
from syringe/needle combinations that have been discarded in a public place. The anxiety is even higher
when a child is involved. The general principles of management apply but a few points are worth
noting:
– there is no role for testing dried blood in syringes as this is unreliable
– the risk of transmission is extremely low - there have been no confirmed reports of transmission of HIV
from a needle-stick injury from a needle/syringe discarded in a public place
– post-exposure prophylaxis for HIV is not indicated.
The major issue to deal with is the potential for psychological trauma, and counselling is therefore essential.
496
49. Woman I guess pregnant one sit on needle in train and came to you after that with the needle and syringe and
afraid from HIV transmission:
A.send the needle to lab for investigation, there is no role for testing dried blood in syringes as this is unreliable
B.give HIV prophylaxis, (no)
C. tell her not to worry, (counselling)
D. check further injury risk

50. Your colleague has HIV, doesn't want to inform employer

Inform employer
Inform board of surgeons
Inform AHPRA(advise to take universal precautions)

51. patient with Hiv positive elisa ,westron blot negative : what to tell the patient:
A- NO hiv
b- should do PCR
c- repeat Western blot after 3 months. (ans) there is window period of no infection... For 3 months the test should
be after 3 wks not 3 month
Repeat ELISA at 6 weeks then after 3 months

Elisa is screening test is western blot is confirmatory

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52. Patient comes back from Thailand with hx of having sex with
multiple prostitutes. After one week presents with
lymphadenopathy, mild pharyngeal erythema, splenomegaly,
sore throat Atypical lymphocytes present. Monospot test
negative. What is the most likely diagnosis?
Answer with reason plzzz
a) HIV
b) EBV
c) CMV

53. Thailand return male, multiple sex event, and has fever with rash and jaundice and diagnosis, no pic(no much
detail know)
a. Herper
b. Syphilis
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c. Gonorrhoe
d. Chlamydia
e. EBV (ans)

54. man came with fever and other symptoms and his HIV test were ELISA positive western blot negative now after
2 weeks is fine no fever what is the cause
a)acute HIV
b)Chronic HIV
c)false positive (rare case)

http://www.medscape.com/viewarticle/410287
davidsons says (1)- duration of symptoms in primary HIV is usually not
longer than 2 wks... (2)- appearance of specific anti-HIV antibodies in
serum occurs atleast 2 weeks after the development of symptoms...
point 1 somewhat indicates acute HIV here bt given picture indicates
positive ELISA immediately at the appearance of symptoms...so may b
point 2 suits indicating a false negetive test...if no option for
repetition, i'll go for C..

C.....A positive ELISA test is always followed by a Western blot test. A

positive Western blot confirms an HIV infection. A negative Western
blot test means the ELISA test was a false positive test. The Western blot test can also be unclear, in which
case more testing is done. Ref: https://www.nlm.nih.gov/medlineplus/ency/article/003538.htm

55. Homosexual pt h/o intercourse with HIV +ve man. HIV test done Western blot and ELISA both negative now pt
came for the report now he c/o fever, sore throat with exudate, cervical lymphadenopathy
a. Repeat HIV after 2 wks
b. EBV serology(ans)
c. Observe

56. Nurse, needle pricked with HIV positive positive patient, after sending HIV, HBV, HCV
a. -start antiretroviral (ans) Post-exposure prophylaxis (PEP) involves taking antiretroviral (ARV) medicines very
soon after a possible exposure to HIV to prevent becoming infected with HIV.
PEP should be started as soon as possible to be effective and always within 72 hours (3 days) after a possible
exposure to HIV.
b. -start antiretroviral and immunoglobulin
c. -wait for serology results
57. ETHICS
couple come for infertility counseling, HIV test was done, it was positive for him, now he come for the result, what is
the most CRITICAL (exactly this word)advice?
a. Refer to visite HIV specialist
b. Tell him about his wife result
c. Ask him to tell his wife about HIV (ans)

58. Doctor pricked by needle while taking sample from patient who is suspected case of hiv.. what to do now :
a. reassure both of them
b. give antiretroviral drugs to doctor ( ?? ) first this
c. repeat hiv testing of both doctor and patient (for follow up
>PEP might be prescribed for you if you are HIV negative or don’t know your HIV status, and in the last 72
hours you:
o Think you were exposed to HIV during your work, for example from a needlestick injury
o Think you were exposed to HIV during sex
o Shared needles or drug preparation equipment (“works”)
o Were sexually assaulted
Page 1454 jm…. ? ?
499
 https://emedicine.medscape.com/article/1991375-overview#a5

59. Patient had sex with HIV positive person, comes for a test with the symptom of rash ,NO lymphadenopathy in
stem, splenomegaly. Western blot and Elisa negative, what would you do next for diagnosis?
a.EBV test (ans)
b.CMV test
c.Repeat HIV

60. A nurse with needle stick in dialysis ward with known hiv
patient
a) anti retroviral start immedietly(ans) Page 1440 jm
b) wait for hiv test
c) Reassurance
d) give immunoglobulins now
e) anti retroviral nd immunoglobulin

61. A GP with HIV recently got a job offer as surgeon…he don’t

want to inform the new employer.
Inform the employer
Inform the surgical cousil
Advice him to take universal precatuions (ans)
Inform board.

62. Nurse has incidental needle prick from ward dustbin, many
HepC +ve cases in ward, apart from HIV test what else you
check now
a. HIV antigen test
b. HepC antibody test now
c. HepC viral load test after 2 hr
d. Imiravin and Ribavirin stat
e. HepC antibody serial check for period(ans) page 1440 jm

63. .Pregnant woman who did not receive Hepatitis B vaccine before getting pregnant, gets exposed to Hep B
infection. How will you manage her?
a. Give Hep B vaccine and Immunoglobulin now(ans)
b. Give Hep B Ig now
c. Give the vaccine and Immunoglobulin after delivery
d. Exposure to HBV during pregnancy6

Ø For patient information regarding Hepatitis B

exposure – post exposure prophylaxis (PEP), follow
link to www.sahealth.sa.gov.au/hepatitisbPEP> If
previously known to be hepatitis B immune
(previously documented anti HBs titre ≥ 10 IU / mL)
no intervention is required> In the absence of
previously documented anti HBs titre ≥ 10 IU / mL,
antibody levels should be determined as quickly as
possible. If maternal anti HBs titre < 10 IU / mL with
significant exposure, and there is no evidence of
hepatitis B infection (HBsAg negative) give mother: >
**Hepatitis B immunoglobulin (HBIG) (400 IU, IM) as
soon as possible but within 72 hours of exposure AND

500
Ø HB vaccine as soon as possible but within 7 days (percutaneous, ocular or mucous membrane
exposures) or 14 days (sexual exposures) of exposure, and repeat at 1 and 6 months post initial dose>
Repeat testing of mother for HBsAG at 1 month and 3 months
https://www.sahealth.sa.gov.au/wps/wcm/connect/b8cae3804ee484c881678dd150ce4f37/hepatitis+B+in
+pregnancy_29042016.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-
b8cae3804ee484c881678dd150ce4f37-mTXhR0K

64. Hep B needle stick injury. No previous immunization

A. Give vaccine and Ig immediately.(ans)
B. Test for hep b and give vaccine if negative.
C. Test for hepatitis b and give ig if positive
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-
home~handbook10part4~handbook10-4-5
Hepatitis B vaccine
Not routinely recommended Can be given to susceptible pregnant women for whom this vaccine would
otherwise be recommended, for example, as post-exposure prophylaxis in a non-immune pregnant woman with
a significant exposure to a HBsAg-positive source

65. Needle stick injury of hep. B known pt. to a ward cleaner who is not previously immunized, which immediate
action will protect him from hep. B?
a. hep. B vaccine
b. hep. B vaccine plus ig
c. councelling
#September 2016

66. Preg lady got contact with Hep B person. What would you do
a. Check Immuninity of mother (ans) N.B: HBV Vaccine is safe in Pregnancy given only to high risk
b. Vaccinate baby
A (Check Immunity of Mother: IgG = +ve (past infection) - means good, IgM = +ve Suggest Active status. Baby
should be vaccinated soon after delievery C-Section is prefer over normal)

Note)
Pregnant with +ve HBV + and confirmed PCR ?===>
-: start treatment at week 30 with Lamuvidine and Tenovir
ONLY IF PCR > 10x7
-2nd: give baby IVIG + HBV vaccine in 12 hours after Birth
- 3rd: Continue routine Vaccination to Child at 2, 4, 6
- 4th: do HBsAg + ABsAb again at 9 months
**
What increase Fetal Transmission of HBV? ===> HBeAg
- Remember HBeAg = (E)nfective

67. 14 w gestation hep C positive mother asking what to do on next antenatal

a) Chlamidia PCR
b) Hep C PCR (ans)
c) Some other Hep C investigations

Provide counselling. This should include:- appropriate referral for support- the risk of HCV infection following
exposure (see table 2)- the risk of infecting others. The exposed person should be advised that during the follow up
period they should refrain from donating plasma, blood, organs, body tissue, breast milk or sperm.1 The exposed
person is not required to modify sexual practices or refrain from becoming pregnant or breastfeeding.1• Collect
baseline bloods for HCV Ab. Baseline testing for alanine aminotransferase (ALT) should also be undertaken.• At this
time, there is no prophylaxis proven to be effective for HCV exposure; IG (immunoglobulin) and antiviral agents are
not recommended for PEP after exposure to HCV-positive blood.1 The aim of follow-up is to detect acute hepatitis C
as soon as possible so that appropriate management can be instituted.1 • Subsequent testing for HCV Ab and ALT
501
should occur at 12 weeks and 6 months.• If the exposed
person is HCV Ab positive and/or has an elevated ALT on
subsequent testing then HCV RNA testing should be
performed. The exposed person should also be advised to
attend for evaluation if they become unwell with symptoms
consistent with acute hepatitis such as nausea, vomiting,
abdominal discomfort or jaundice.• For healthcare workers
who perform exposure prone procedures (EPP) testing may
need to occur earlier or more frequently. (Refer to the Expert
Information
Network for advice-attachment 1).

68. mother Hep C positive. What to avoid during pregnancy

to avoid transmission in infant?
a) breastfeeding
b) vaginal delivery
c) Antivirals in pregnancy
d) Fetal scalp sample
Answer - D

69. What you can do to know a new-born is suffering from

hcv virus or not
A) Hep c antibodies at 18 months (ans)
B) Hep c pcr at birrth
C) Lft at 12 months
D) Hep c antibodies of mother

70. Medical student got needle prick with a patient with HBV, Blood taken from both, and results came back with
positive HBsAg for Medical student , what to do?
A) Lamivudine and Interferon B
B) Give HBV Vaccine (if not vaccinated)
C) Give Vaccine and immunoglobulin
D) Nothing, but refer to counseling

71. 16 yr old comes with yellow sclera and says his friends noticed and asked him to see gp on exam yellow sclera
but no other significant findings diagnosis
Mild hep a(ans)
Mild hep c
Mild hep b
Mild cbd obstruction
72. Woman came to clinic saying his partner is Hep C positive, protection advice?
A)Ask him to get treatment (😊).
B)Ask him to always use condom when sex
C)Reassure her that Hep C is not sexually transmitted (? )

*don’t use same razor,blade and toothbrush

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73. A woman whose partner has hep c virus and wants to get pregnant comes for advice?
A. IVF
B. That vertical transmission is about 6%
C. That hcv is unlikely to be transmitted by sex (ans)
D. Don't breastfeed

*vertical transmission will happen if the pt is infected but the chance of getting imfected through sexual contact is
very low that’s why c is ans
#sept 2016. Final pls

74. Chronic hepatitis + cirrhosis. What is the cause of development of hepatoma?

a. HBe Ag (ans)
b. cirrhosis

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c. Hep B

75. 32 year old lady 20 weeks pregnant with underlying Hep C . Asking advice on breastfeeding
A. Contraindicated as it is vertically transmitted
B. Can breastfeed after c section
C. No evidence of as it is not vertically transmitted (ans)
D. Give pasteurised breast milk
E. Contraindicated because Hep c antigen pass through breast milk

76. surgeon operating in emergency surgery (splenic rupture) ,needle stick injury, what to do immediately
a. ask anesthetist to draw blood from pt for analysis
b. ask anesthetist to collect blood sample from surgeon
c. arrange for antiretroviral treatment
d. wash with povidone iodine solution
e. rub hand with alcohol swab, wear double glove\(ans)

77. hep b infected pregnanat woman at 26 weeks(not sure what age of gestation was). what to do next
… give hep b vaccine now
• give hep b vaccine to mother and baby as soon as baby is-born
• give immunoglobulin now and hep b vaccine after baby is born
• d.give both hep b vaccine and immunoglobulin now

if the mother is infected do nothing for mother but give baby ig and vaccine to baby but if the mother got
exposed to an infected person check serology and do accordingly

78. Pregnant woman who did not receive Hepatitis B vaccine before getting pregnant, gets exposed to Hep B
infection. How will you manage her?
a. Give Hep B vaccine and Immunoglobulin now

504
 b. Give Hep B Ig now
c. Give the vaccine and Immunoglobulin after delivery

79. 27 years old man diagnosed hiv+ few months back.. On

retrovirals..now he started having flank pain and hematuria .. Next
apropriate step
. A x ray kub
Ct abdomen
Stop indinivir
Reassure...

* indinavir induced calculi cant be detected on xray and ct. we

need usg.so here stop the offending agent.

80. A nurse got needle prick injury with a hiv positive Patient. You have ordered her blood to test her for hiv , hep b
and hep c. What is your next management
A wait for blood results
B urgent retroviral therapy
C urgent retroviral therapy and immunologlobulin
for hep b
D urgent immunoglobulin

81. 17 years old girl comes to you and says she is going
to start sexual activity. Besides contraception and
safe sex what advice you would like to give her?
A. Check chlamydia 6 monthly
B. Pap smear 12 monthly
C. HIV exam every 5yrs
D. HPV booster after 5yrs
E. Coloscopy every 5yrs

Bp screening from 18 years redbook.

82. Screening for chlamydia infection in all sexually

active people aged 15–29 years is recommended
because of increased prevalence and risk of
complications

505
83. #HIV #ethics ur collegue has HIV doesn’t want to inform employer..nw what to do?
a.inform employer
b.tell him to inform employer ans
c.inform the board of surgeons
d.inform AHPRA B?

84. Q An obsgyn doctor is recently diagnosed with HIV infection. He is receiving medications for HIV. His physical and
mental conditions are normal.What should he do?
1. Tell his patients
2. Tell his fellow physicians
3. Tell both
4. Tell nobody
5. Notify the hospital authority 4?

85. 30 years old lady,pregnant 3 months,came to to you with c/o fever severe malaise,night sweats, that she had
few weeks back,Resolved but now again she is having this problem with more severe outcome+photophobia
maculopapular rash.. Diagnosed with HIV.. Tx next best.:
A wait till baby delivery
B reassure and 1 month follow up advice
C start antiretovirals
D symptomatic treatment

**All pregnant women with HIV should receive antiretroviral therapy (ART), as early as possible in the
pregnancy, regardless of CD4 count or viral load. ART should be administered during the antepartum,
intrapartum, and postpartum periods, as well as postpartum to the neonate.

86. #march 2018 Thailand return guy was brought by a friend, after 4 wk he is forgetting stuff, irritate, talk illogical,
fever, tired pale, so may thing. What is the diagnosis?
Hiv, hep A , enteric fever …enteric encephalopathy

**In the first week, the body temperature rises slowly, and fever fluctuations are seen with relative

506
 bradycardia (Faget sign), malaise, headache, and cough. A bloody nose (epistaxis) is seen in a quarter of
cases, and abdominal pain is also possible. A decrease in the number of circulating white blood cells
(leukopenia) occurs with eosinopenia and relative lymphocytosis; blood cultures are positive for
Salmonella Typhi or S. paratyphi. The Widal test is usually negative in the first week.[16]
In the second week, the person is often too tired to get up, with high fever in plateau around 40 °C (104
°F) and bradycardia (sphygmothermic dissociation or Faget sign), classically with a dicrotic pulse wave.
Delirium is frequent, often calm, but sometimes agitated. This delirium gives to typhoid the nickname of
"nervous fever". Rose spots appear on the lower chest and abdomen in around a third of patients.
Rhonchi are heard in lung bases.

87. Recurrent candidiasis scenario but this is the third time in 6 months and when you remove the white patch it
bleeds.What to do next?
Blood sugar
HIV testing
Vaginal swab

*recurrent candiadiasis means 4 or more

88. Recurrent vAginal candidiasis blood sugar 5 what next

Vaginal swab
Culture Blood culture
OGTT
HIV

**treatment is Fluconazol (50mg) or Itraconazole(100mg) orally once daily

89. #GIT #HepatoBiliary What is most common cause of hepatoma?

a. Alcoholic liver disease
b. Hemochromatosis
c. Hepatocellular carcinoma
d. Hep A
e. Hep B
90. man has all the enzyme increased . AST(sgpt)< ALT(sgot) Bilirubin, what is the cause
. A) hep a b) hep b c) hep c d)CMVe)EBV
91. Which group is the less risk to get Hepatitis C (Sure not HIV)
A Drug abuse
B Homosexual,
C Transfusion Hep B,
D Haemodialysis,
E Haemophilia

92. Woman comes to you and says she will be travelling around Cambodia. What advice regarding her travel to is
most appropriate?
A Hep A B.Hep B C.Dengue D.Malaria E. Traveler’s diarrhea
**if ask about vaccine choose hepatitis a and typhoid
93. A man postsplenectomy 2yr back due to some injury,got all vaccination,take regular amoxicillin prophylaxis now
come for advice regarding his travel to Cambodia. which of the following infection he is at risk?
A.hepatitis A
B.hepatitis B
C.dengue
D.malaria
E.travellers diarrhoea

**sickle cell trait provides some protection against but still require antimalarial prophylaxis.

507
**splenectomy patients who have undergone splenectomy or whose splenic function is severely impaired are at
particular risk of severe malaria if possible these patients should avoid travel to malarious areas if travel is
unavoidable, rigorous use of anti-mosquito precautions and strict adherence to appropriate chemoprophylaxis
should be undertakEn

94. There are 3 children got heptatis A virus in the community. Health care contacted some authority. what will be
your next appropriate step ?
a. Check all day care kitchen staff for hep A ig M
b. Exculde all infected child
c. vaccinate all the unvaccinated staff and kids with hep A
d. Close the day care for 7 days

95. man has all the enzyme increased . AST<ASOT, Bilirubin, what is the cause. A) hep a b) hep b c) hep c d)CMV
e)EBV
96. #SEPT human bite. Tetanus vaccine given. No H/O immunisation previously. What to add?
a) Abx
b) Hep B vaccine and Ig
c)nothing
d) Suture wound

97. History of travel, headache , jaundice, RUQ pain, full blood count given HB ↓ Platelet ↓ Liver Enzyme ↑ What is
the diagnosis
a. dengue
b. Hep. A
c. Malaria
d. Other
#july

98. Clear scenario of travelling to northern Thailand and present now after few days with lethargy and neck lump
and has hx of sex with prostitutes—
HIV
EBM

99. Doctor pricked by needle while taking sample from patient who is suspected case of hiv.. what to do now :
a. reassure both of them
b. give antiretroviral drugs to doctor
c. repeat hiv testing of both doctor and patient

** first take sample from both and then start antiretroviral therapy

References:
1.http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-
home~handbook10part4~handbook10-4-6
2. http://goaskalice.columbia.edu/answered-questions/gardasil-can-i-get-it-if-i-already-have-hpv
3. http://www.cdc.gov/hpv/parents/questions-answers.html
4. http://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-vaccine-fact-sheet

All about HBV

1 ) Screen ALL Pregnant in 1st Visit for HBV, HCV, HIV, Rubella. Syphilis and mid stream urine for
asymptomatic Bacteriuria
2 ) Screen HBV with? ==> HBsAg
3 ) If -ve HBsAg?==> It means not infected nor Immunized - Only Immunize her if high Risk ((Multiple
Partners in lat 6 months, STD, Drug Abuser, Partner is HBsAg+ve)) - If not high risk then No Need to

508
 Vaccine BUT vaccinate after Delivery .. and just Education and continue all other routine
screenings))
N.B: HBV Vaccine is safe in Pregnancy given only to high risk
4 ) MCQ: If Pregnant +ve HBsAg ? ==> Infected then no place for prevention with Vaccine and next
??? ===> HBV PCR
5 ) Pregnant with +ve HBV + and confirmed PCR ?===>
- 1st : start treatment at week 30 with Lamuvidine and Tenovir
ONLY IF PCR > 10x7
-2nd: give baby IVIG + HBV vaccine in 12 hours after Birth
- 3rd: Continue routine Vaccination to Child at 2, 4, 6
- 4th: do HBsAg + ABsAb again at 9 months
6 ) What increase Fetal Transmission of HBV? ===> HBeAg
- Remember HBeAg = (E)nfective
7 ) MCQ : Any one exposed to HBV (Child, Pregnant, any ...) ===>
- 1st: do HBsAg to exposed
- 2nd: give IVIG + HBV vaccine within 72 ((ONLY if -ve HBsAg))
- 3rd: repeat Tests at 3 months.
- NB: If +ve HBsAg ( infected nothing given))
- NB: HBsAg -ve but HBsAb+ve ==> ((Vaccinated)) no need for intervention after Exposure.
8 ) If Infant born 32 weeks (premature) or < 2 Kg ==> Do routine Vaccination at 0 "Birth", 2, 4, 6 + 12
month
9 ) a Surgeon +ve HBsAg // Or HCV-Ab ??==> don't do surgeries for patients until he gets treatment
and his PCR returns -ve
NB: PCR -ve and HBsAg+ve /HCV-Ab+ve ==> treated and not infected, so can do surgeries
10 ) Most common MCQ about HBV Markers:
- Initial and 1st Marker of Acute infection?==> HBsAg
- Most Specific marker of Diagnosis of Acute Infection? ==>HBcAb-IgM
- Indicator of High (E)nfectivity? ==> HBeAg
- Indicator of Previous infecteion or Vaccination?==> HBsAb
- Most indicator of Cure? ==> Disappearance of HBsAg
- Most indicator of Chronicity? ==> HBeAg for > 3 months
- Best indicator of Need to treat? ==> PCR > 10*7

HCV

1 ) Screen ALL Pregnant in 1st Visit for HBV, HCV, HIV, Rubella. Syphilis and mid stream urine for
asymptomatic Bactiurea
2 ) Pregnant// Adult// Infant// Any + newly Diagnosed HCV Ab +ve, Next? ==> Confirm HCV PCR +
LFT
3 ) Pregnant known to be HCV +ve Next? ==>
- HIV screening, Vaccine against HBV. HAV
- At Delivery: No need C.S and fetus can delivered Vaginally
- breast feeding is Ok
- HCV-Ab for Infant at 12 months after Birth
4 ) MCQs of Prevalence:
- Prevalence of active (Chronic) HCV in Population ==> HCV PCR and ((( this is ur answer for exam)))
- Prevalence of All Population infected ( Chronic// treated// resolved)) ==> HCV AB
- Lowest Prevalence of HCV ==> Among Homosexual
====
5 ) Do We treat HCV in Pregnancy?===> NO (Contraindicated - in contrary to HBV who can be
started on treatment at Pregnancy)

509
6 ) When to treat HCV ?==> Do 1st LFTs - If elevated LFTs ===> Biopsy of liver ==> If ((Portal or
bridging Fibrosis) on Biopsy? ==> Treat with Interferon alfa + Ribavirin + Simeprevir
7 ) If hepatitis C Ab -ve and PCR +ve ?===> Acute Infection
8 ) If Hepatitis C Ab +ve and PCR +ve ? ===> Chronic Infection.
9 ) Drug Abuser wut to screen for?==> HCV, HIV, HBV
10 ) Most likely to be Chronic HCV or HBV ?==> HCV
10 ) Post HCV Exposure:
- Initial: wash blood with water and soap (do not squeeze or rub) and if in eye mucous membranes
(irrigate with Normal saline )
- 2nd: identify the source individual (if known) and test HCV Ab
- 3rd: HCV Ab + ALT for exposed NOW ((Ur Choice in EXAM more important to decide the base line
before subsequent tests))
- 4th: HCV Ab + ALT at 3 months or 6 months (( Not done if Source is -ve for HCVAb
NB: if exposed has elevated ALT or +ve HCV Ab ==> HCV RNA ((PCR))

Whom Should I Tell That I Have HIV?

All of your past sexual partners should be told so they can get counselling and be tested. It is also
important to tell your current and future partners so they can make their decision. If you have
shared needles, syringes or drug equipment with anyone, they should also be informed.

Inform your doctor and other health care providers.

You may want to tell your family and friends that you have HIV. They may be a support for you. The
decision is up to you! Before you tell someone that you have HIV, it may help to talk to your doctor
or counsellor. They can help you to decide whom you want to tell and how you want to tell them.

You do not have to tell your boss or people you work with that you have HIV. Under the Human
Rights Act you cannot be fired for being HIV positive.
https://www.qld.gov.au/health/staying-healthy/sexual-health

Post exposure prophylaxis:(mina notes)

1-hepatitis B :
History of previous vaccination….reassure
First step……..check immune status
If (+) for antibodies……..reassure
If (+) for antigens………ttt
If (-) for antibodies ,…..susceptible……vaccine and IVIG
If in the exam no option for checking the immune status…..go for vaccine and IVIG
Baby born to Hb B mother:
Vaccine and IVIG immediately to the newly born

Chronicity of hepatitis B in adult…..10-15%

Chronicity of hepatitis B in newly born….over 75 %
TTT of hepatitis B…….INTERFERON AND LAMIVUDINE
Main SE of interferon……depression and fatigue
If depression occurred…..stop interferon

Hepatitis C:
First step…….check base line immune status
510
 Second step……serial labs for 6 months
If (+) for HCV antibodies…….NEXT STEP HCV RNA
IF HCV RNA (+)……start ttt
TTT of hepatitis C…….interferon and ribavirin
Chronicity of hepatitis C ……over 75%
Counseling:
Lactation…….continue
Sex………continue but preferred to use condoms

HIV:
First step…….start immediate therapy before the labs results
If (-)…….stop ttt
If (+)……continue ttt

Prophylaxis of the newly born :

First step……start immediate ttt
Drug…….zidovudine
Duration…….6 weeks
Counseling:
Take the retroviral therapy during pregnancy…..yesss
Delivery………CS
LACTATION…….NOOOO
Sex…….with protection

Measles:
How ?........IVIG
When?....first 72th hours after exposure

Varicella:
Children:
How?……..by vaccine ( Live attenuated vaccine)
If vaccinated before…….no prophylaxis
If immune compromised…….. IVIG

If pregnant??
Vaccinated before……NOOO prophylaxis
Not vaccinated:
First step……serology
(+) IgG…..NOO prophylaxis
(-) IgG…..IVIG 5 days before delivery and 2 days after delivery

100. Endocrinology

511
Thyroid mass with hoarseness of voice and stridor ( no other
symptoms were given). what l investigation to do?
A. Thyroid function test ans
B. Ultrasound
C. radioactive iodine uptake
D. Biopsy

*initial is tft then usg then biopsy

dd is .riedels thyroiditis and anaplastic carcinoma.ALSO
retrosternal goitre maybe the cause but that commonly presents
with exertional dyspnea in a previously diagnosed
goitre(uptodate)

512
513
101. patient with pneumonia and atrial fibrillation,his inv shows TSH normal at upper level, T3 normal range,T4
slightly raised. What will you do next?
A. Thyroid scan
B. Repeat Thyroid function test after one month ans
C. Do the thyroid function test now
D. Echo
E. CT scan head

B is the answer..could be t4 toxicosis due to pneumonia but tsh should be lower..

102. Man present with tiredness fatigue and weakness for 6 months investigation for thyroid done TSH is normal
range t4 is lower than normal how will u manage
A)thyroxine 50mg
B)thyroid antibodies
C)mri brain
D)thyroid usg
Sec hypothyroidism so mri page 228 jm

103. A 67 yr old woman comes to the physician

because of fatigue, dry skin, brittle hair, ankle
swellling, and cold intolerance for 1 yr, she has
also had a 20lb wt gain during this period. Her
pulse is 55/min and BP is 150/90 mmHg. She
appears lethargic. Exam shows enlarged
nontender thyroid gland 2-3 times normal and
dry skin. There is mild ankle swelling
bilaterally. The relaxation phase of the Achilles
tendon reflex is greatly prolonged. Which of
the following is the most likely diagnosis?
A. Hashimoto
B. Defect in T4 biosynthesis
C. Graves disease
D. Multinodular goiter
E. Riedel thyroiditis
F. Thyroid cyst
G. Thyroid lymphoma
H. Thyroiditis
A is the answer
Page 229 jm

104. 33 year old lady comes with lump in the left

side of neck for 3 months which is 3 cm size
papillary carcinoma with no metastatic spread.
What is your most app management.
1. total thyroidectomy answer
2. left thyroid lobectomy(for less than 1 cm with no
mets or lymph involv)
3. radio I 131 ablation
4. radio I 131 ablation followe
5 suppresssion with thyroxine
1 is the ans
**if there is option like subtotal thyroidectomy
go for it cz 3cm doesn’t fit lobectomy (<1 cm) and

514
total thyroidectomy (>4cm)

105. Marika, aged 62 years, has noticed a swelling in the

front of her neck, which is enlarging quite rapidly. She is
otherwise well, without symptoms of hypothyroidism or
hyperthyroidism. On examination, she has a multinodular
goitre, with a dominant nodule of 4 cm diameter in the
right upper pole of her thyroid gland. Of the following
investigations, which is the MOST important in assisting
diagnosis?
1. Thyroid function tests
2. Thyroid ultrasound
3. Fine needle biopsy ans
4. Thyroid isotope scan
5. CT scan
2 next and assiting step.biopsy def step

Source. AJGP

515
Figure 2. Bethesda diagnostic categories for thyroid cytopathology with associated malignancy risk and suggested
management options in general practice1
AUS/FLUS, atypia of undetermined significance/follicular lesion of undetermined significance; FN/SFN, follicular
neoplasm/suspicious for follicular neoplasm; FNA, Fine-needle aspiration; TSH, thyroid-stimulating hormone; FNA, fine-
needle aspiration

516
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106. Pregnant woman with hypothyroidism on levothyroxine shows up for 1st trimester testing and has normal
thyroid profile. What do you do?

518
A.Increase the levothyroxine dose
by 25%
B.Decrease by 25%
C.Increase by 50%
D.Maintain current dose
E.Decrease

107. a lady presents with

lethargy low mood,
amenorrhoea and bouts of
constipation. on examination
she had an anterior neck
swelling which moves with
swallowing . lab TSH high T4
Low . you suspect hashimoto
thyroiditis apart from starting thyroxine which of the following will you go to confirm the diagnosis
A. thyroid ultrasound
B. FNAC
C. Antimicrosomal antibody test
D. trial of thyroxine therapy starting dose 75mg
E. Anti peroxidase antibody test ans

**Thyroid autoantibodies (antithyroid peroxidase and antithyroglobulin antibodies) are positive in 95% of patients
with autoimmune thyroiditis. The thyroid peroxidase (TPO) antibody assay is sufficiently sensitive and specific to
make this the only test now needed to confirm a diagnosis of autoimmune thyroiditis …,, racgp

**Anti-thyroid Antibodies Tests Anti-thyroid antibodies (ATA) tests, such as the microsomal antibody test (also
known as thyroid peroxidase antibody test) and the anti-thyroglobulin antibody test, are commonly used to detect
the presence of Hashimoto's thyroiditis. Jm231

108. A 52 year old patient who has recently been diagnosed with lung cell cancer present with weight gain
(mainly around the face and trunk), bruising easily, striae, and his skin appearing darker. On examination he has
a moon face, buffalo hump and he is hypertensive. His bloods reveal hypokalaemia. What is the most likely
diagnosis?
a. Exogenous steroids
b. Hypothyroidism
c. Addisons disease
d. Cushing disease
e. Ectopic ACTH secretion ans

JM Cushing syndrome 239

109. Pic of male with retrosternal goitre next

a. US neck
b. MRI
c. CT (uptodate)ans

519
 d. CXR
110. 55 yr old female, had radio I t/t for goitre now
presents with (features of hypothyroid) ..Tsh t3 t4
were given. Management asked:
A. Thyroxine 25
B. Thyroxine 100
C. Thyroxine 150
D. Carbimazol
Start with low dose.

111. A given image of large anterior neck swelling,

the patients complains of hoarseness (recurrent
laryngeal) of voice asking about diagnosis:
a- cancer thyroid
b- multinodular goitre
c- thyroglossal cyst

112. Young girl present with pigmentation on her

nape of the neck and axilla. She is obese. Her
menstrual cycle is regular. Her grandmother also
has Type 2 DM. One examination, there is
pigmentation on her neck and axillae. What is your
diagnosis?
(A) Cushing
(B) PCOS
(C) Metabolic syndrome
(D) Hypothyroid
(E) Addison disease
Insulin resistance…acanthosis nigrcans.
113. #endo Young girl present with pigmentation on her
nape of the neck and axilla. She is obese. Her menstrual
cycle is regular. Her grandmother also has Type 2 DM.
One examination, there is pigmentation on her neck
and axillae. What is your diagnosis?
(A) Cushing
(B) PCOS
(C) Metabolic syndrome
(D) Hypothyroid
(E) Addison disease

114. #endo 14 yr old girl with 32 BMI has striae and pigmentation on her neck and axillary region. She is very
lethargic. Grandmother was diabetic. She has amenorrhoea. Striae on abdomen. Diagnosis:
A. Cushing
B. Metabolic Syndrome
C. PCOS
D. Hypothyroidism
E. Addison disease

115. Pt with high sugar high cholesterol low hdl

Alt raised obese Dx.
1.Metabolic syndrome
2. Cushings
3. Diabetes

116. Q.A pt was on resperidone consta has amennorhea from one yr want to conceive labs were given lh was
normal fsh low tsh low normal range prolactin raised around 1465. what is the reason?
520
a) pituitary microadenoma
b) hypo pituitary dysfunction
c) primary hypothyroidism
d) risperidone

117. a 10 years old boy had seizure at home , after that he was brought to the ED via ambulance . Blood glucose 2
mmol/L , what will you give ??
A. IM glucagon
B. IV 5% glucose
C. iV glucagon
D. IV normal saline
*HYPOGLYCEMIA PG 198

**for babies it is 10% glucose and for adult 50%

118. A 50-year-old woman, who has recently been

diagnosed with hypertension,
complains of pain in her knees. She feels tired and her memory is poor. She has lost her appetite recently and feels
nauseated most of the time. Urinalysis is normal.
Which is the SINGLE MOST likely diagnosis?
A Chronic fatigue syndrome
B Chronic renal failure
C Coeliac disease
D Cushing’s syndrome
E Hyperparathyroidism (ans)

*BONES MOANS STONES ABDOMINAL GROANS

* HYPERCALCEMIA S/S :
1. weakness tired malaise
2.A/N/V abd pain
3. drowsy and dizzy
4. constipation
5 polyuria and thirst
6. personality changes
7. visual disturbance
8. muscle aches/pains
9.depression,memory loss,irritability confusion and coma

*CHRONIC FATIGUE SYNDROME PG 863

CLINICAL DIAGNOSIS WITH NORMAL BASELINE INVESTIGATION:

FATIGUE,WAKING UP TIRED ,MYALGIA, ARTHLAGIA ,COGNITIVE
DEFECTS,LYMPHADENOPATHY,HEADACHES,MILD SORETHROAT,VISUAL DISTURBANCE
IMPAIRED SHORT TERM MEMORY ,POST EXERTION MALAISE

119. diabetic patient . ulcer on foot , culture has already taken .next mx?
A-xray...
B-blood culture and swab
MRI to rule out osteomyelitis if its nt heeled in 6 weeks (PG 200 JM )

120. An old lady with long standing constipation. Her lab values were given. Calcium was high, urea and creatinine
was high. What to do to find cause?
a. CT abdomen pelvis
b. Bone scan
c. Parathyroid scan ans
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 d. not choosing bcz Serum electrophoresis **there is no bone pain
dd multiple myeloma and hyperparathyroidism.urea creatinine raised due to light chains deposition.

121. patient complaints of lethargy. some abdominal complaints. physical examination normal.
labs given
calcium was elevated( around 3)
phosphate was low(around 1,9)
what is the next investigation
a.vit d levels
b. parathormone
c.tsh
D. MRI

122. diabetic foot ulcer with arythma on whole foot asking for most appropriate next
A.iv ticarcillinclavaunate
B oral amoxclavauante
C MRI Foot

123. :Pic of large ulcer on medial side of leg around ankle looked like venous, with a history of non healing for
12months ,mx?
A.Leg elevation and rest for 2weeks
B.Topical antibiotic
C.Topical debridement with enzymatic ointment

124. A diabetic 65 year old woman noticed an ulcer on her foot for 7 days she came to hospital and u admitted
her, surgical debridment was done and the ulcer is 1 cm and oosing a clear fluid , next best step ?
a. Oral amox. Clax + metronidazole
b. IV ticracillin + metronidazole
c. MRI
d. Dressing and checking the wound everyday
e. Wound toilet with povidone iodine

125. .A man 58 yrs h/o HTN , Hyperlipidemia with DM past 5 yrs well- controlled with insulin, developed an ulcer
above the left medial malleolus ,h/o fracture to left femur 2yrs ago due to MVA, developed DVT,on warfarin,
bilateral dorsalis pedis not palpable, His right lower limb has, prominent varicose veins, what is the cause of the
ulcer
A.Diabetic Neuropathy
B.Chronic Arterial Ischaemia
C.Chronic Venous Insufficiency
D.Atherosclerosis

126. Diabetic Patient taking glimepiride,metoprolol since 20 years ,came with diabetic foot 1cm ulcer,ulcer
was debridement now how will you manage ?
A.Insulin
B.continue same medication
C. amoxycillin
D.mri
E.antibiotics

127. diabetic patient . ulcer on foot , culture has already taken .next mx?
A-xray...
B-blood culture and swab
no MRI in the options
as per oxford book we must do blood culture and xray both which one first ?

128. Woman with anemia HB 8 hypochromic microcytic ; physical exam is normal,mx?

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Packed RBC’s
Whole blood transfusion
Injectable iron
Injectable
Oral Ferrous gluconate

129. young pt e solitary thyroid nodule,normal thyroid

function tests,wats next investigation?
a.fnac
b.usg neck
c.biopsy
d.thyroid scan

130. Patient sweating, obvious thyroid, pt losing weight,

eating a lot, detected nodule, low intake, dg?
Subactute thyoiditis, …..(de quervan thyroiditis)
Acute multinodular goitre,
Acute toxis adenoma
Graves

131. 47yrs old female present at your GP with malaise. On

examination her pulse rate was 62 b.p.m.her lab values
were a.TSH-normal b.thyroxine-high asking next appropriate
investigation..?
a.Thyroid autoantibody
b.Thyroid USS
c.MRI brain
d.Radioisotope scan of thyroid

this is faulty ques. Thyroxin should be low.

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132. A 29-year-old lady was recently diagnosed with nodular thyroid disease.She is worried about getting thyroid
cancer.Which of the following does not increase the risk of thyroid cancer?
a. Family history of benign thyroid disease
b. Family history of thyroid
cancer
c. Graves disease
d. Chronic goitre.
e.Familial adenomatous
polyposis

133. A patient presents with a

hard, fixed , painless woody
goitre. She is having some
difficulty with swallowing. She
is otherwise asymptomatic. A
thyroid ultrasound is
performed and reveals a
homogeneously hypoechoic
gland. She is euthyroid. A
biopsy is organised reveals
dense infiltration. What is the
most likely diagnosis?
Riedels thyroiditis
Thyroid lymphoma
Hashimotos thyroiditis
De Quervain thyroiditis
Anaplastic carcinoma

134. 32 yr old asymptomatic woman present with 25 mm swelling in her right lower thyroid lobe which was found
incidentally in CT scan for the whiplash injury. After taking FNAB there was pssamomma bodies and what
management?
A. Review with USG next 6 months
B. Review with thyroid function tests next 6 months
C. Radio iodine scan
D. Right lower lobe lumpectomy
E. Total lumpectomy

135. 32 yr old asymptomatic woman present with 25 mm swelling in her right lower thyroid lobe which was found
incidentally in CT scan for the whiplash injury. After taking FNAB there was pssamomma bodies and what
management?
A. Review with USG next 6 months
B. Review with thyroid function tests next 6 months
C. Radio iodine scan
D. Right lower lobe thyroidectomy
E. Total lumpectomy
**in above 2 ques the ans should be subtotal thyroidectomy

**psammoma body is a round collection of calcium, seen microscopically. Psammoma bodies are commonly seen in
certain tumors such as: Papillary thyroid carcinoma

136. Which of the following is the most frequent cause of an elevated level of thyroid stimulating hormone with a
hard nodular thyroid?
a. Follicular carcinoma
b. Follicular adenoma
c. Papillary carcinoma
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 d. Ana-plastic carcinoma
e. Hashimoto thyroiditis

**as it is hypothyroid. Cz malignanacy should be euthyroid

137. A man with 3 cm papillary thyroid carcinoma in the left lobe of the thyroid. What to be done?
-Left lobectomy
-Total thyroidectomy

138. young female with mass in the neck which comes on examination as 2.5cm solid mass in the rt-lobe of the
thyroid with no lymph nodes and thyroid profile normal, how to investigate? (Don’t remember exactly U/S was
done before or not)
a.needle biopsy (investigation of choice for STN)
b. lobetomy
c. thyroid scan
d. total thyroidectomy

**if usg not done do it first and if done do fnac..we r

not doing thyroid scan bcz pt is euthyroid and its
done if the pt is hyperthyroid

A man with 3 cm papillary thyroid carcinoma in the

left lobe of the thyroid. What to be done?
-Left lobectomy
-Total thyroidectomy

139. 54 yrs man with 1.3 cm papillary ca of

thyroid in left lobe. No metastasis or nodal
involved. Tx?
A total thyroidectomy
B left lobectomy of thyroid
C ablation with radioactive iodine
D ablation with radioactive iodine followed by
thyroidectomy

140. 30yrs old F, came with malaise, fatigue, palpitation, wt loss 4kg,HR-120/min,regular.Thyroid is palpable.TSH-
0.1 low.Thyroid scan increase uptake. She was given propranolol. What is next step of management?
A.carbimazole dx graves disease
B.radio iodine
C. Subtotal thyroidectomy
D.prednisolone

141. hyperthyroid signs and symptoms With firm enlarged thyroid inv to confirm dx
Inc upatke on scan …to differentiate graves and toxic nodule
Anti Thyroid abs

142. Pregnant woman complaint of palpitation, lab result- TSH ↑, next investigation?
A. Repeat TSH
B. Thyroid antibody
C. Thyroid scan
D. Thyroid USG ….as there is no nodule
E. Give thyroxine

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143. #surgery Patient having a cystic thyroid swelling…fnac showed red blood cells and follicular cells..cyst
completely collapsed and no other symptoms…next management
a. Partial thyroidectomy
b. Repeat fnac

**If follicular cells are found on cytological testing, it is common

to carry out hemithyroidectomy to distinguish between follicular
adenoma and follicular carcinoma on histopathological
examination, proceeding to completion thyroidectomy and
postoperative radioiodine ablation where carcinoma is
confirmed. This way total thyroidectomy is not carried out
unnecessarily.

Cz benign follicular adenoma and follicular carcinoma cant be

deffernetiated by fnac

144. 66 years old patient presents for an initial visit with you.
She has not seen a physician for 10 years. Her past medical
history includes thyroidectomy and radiation treatment for
thyroid cancer 12 years ago. Thyroglobulin level came back
elevated. Which is the next step?
1. No further test needed
2. Do RAIU
3. Thyroid scan
4. Increase thyroxine dose
5. Repeat test in 6 months

145. 60 yr old patient presented with constipation. Urea high ,

creatinine high, ionized calcium level high in blood.What will
be your next step of investigation?
a)USG
b)CT abdomen
c)Parathyroid Scan NOT PTH level
d.thyroid scan

146. Hyperthyroid patient came for change in medication.had history of radioiodine therapy.wat to prescribe
newly. A.thyroxine 25
B thyroxine 100
C thyroxin 50
D.carbimazole 5
E.carbimazole 200

147. pt 4 days after parathyroid sx for parathyroid adenoma, develop finger and perioral numbness. Ca level 2
days back at time of discharge was 2.02 (it was low then the normal limits given) was low wt to give
a-ca carbonate
b- ca carbonate and vit d3-
c.calcitrol
d. calcium iv- as acute symptoms of hypocalcaemia

Transient hypoparathyroidism In transient hypoparathyroidism after thyroidectomy or partial

parathyroidectomy, supplemental oral calcium may be sufficient: 1 to 2 g of elemental calcium/day may be given
as calcium gluconate (90 mg elemental calcium/1 g) or calcium carbonate (400 mg elemental calcium/1 g).
Subtotal parathyroidectomy may cause hypocalcemia that is particularly severe and prolonged, particularly in
patients with chronic kidney disease or in patients from whom a large tumor was removed. Prolonged parenteral
administration of calcium may be necessary postoperatively; supplementation with as much as 1 g/day of
528
 elemental calcium (eg, 111 mL/day of calcium gluconate, which
contains 90 mg elemental calcium/10 mL) may be required for 5 to
10 days before oral calcium and vitamin D are sufficient. Elevated
serum alkaline phosphatase in such patients may be a sign of rapid
uptake of calcium into bone. The need for large amounts of
parenteral calcium usually does not fall until the alkaline
phosphatase concentration begins to decrease.**

148. 34-year-old woman is referred to the Endocrine Clinic with a

history of thyrotoxicosis. At her first appointment she is found to
have a smooth goitre, lid lag and bilateral exophthalmos with puffy
eyelids and conjunctival injection. She wants to discuss the
treatment of her thyroid problem as she is keen to become
pregnant. What is the most likely treatment you would advise?
A. 18 months of carbimazole alone
B. 18 months of propyl thiouracil alone
C. A combination of anti-thyroid drugs and thyroxine
D. Radioactive iodine
E. Thyroidectomy

149. woman with subtotal thyroidectomy ,in post op room , 12 hrs

may b , got difficulty breathing ,stridor, drain tube collection is
few, what to immediately?
a.remove deep muscle suture
b.remove skin staples
c.intubation
d.oxygen via mask

150. #Endocrine Female pt follow up 7days after hysterectomy. all lab was normal with normal thyroid & renal
function serum Ca-normal but c/o oral tingling & numbness.what is the cause?
a.Tetany
b.Anxiety
c.Adverse effect of anaesthesia
d.Hypocalcaemia

151. woman came e amenorrhoea of 6 mths, she previously

also had irregular cycles 4 times a year, wants to conceive
now, you ordered some investigations FSH low LH, prolactin,
thyroid all normal, what next
Serum progesterone
Serum testosterone
Pelvic ultrasound

152. 64 years old woman complaint of generalized malaise ass:

with progressing fatigue and persistent thirst for some
duration. Her blood chemical results are: Na+ (normal), K+
(normal), HCO3- (normal), Chloride (normal), Total Ca+ - 2.65
(2.1 - 2.55) Ionized Ca+ 1.38 (1.1 – 1.35) What invx?
A- 24hrs urinary calcium
B- Glucose tolerance test
C- Serum parathyroid hormone assay
D- Bone scan
E- Serum angiotensin converting enzyme

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153. #surgery. 33 years old comes with lump in the left side of neck for 3 months which is 3cm size papillary
carcinoma with No metastatic spread. What is your most appropriate Management ?
a- total thyroidectomy
b- left thyroid lobectomy
c- radio I 131 ablation
d- radio I 131 ablation followed by thyroidectomy
e- suppression with thyroxine

154. Man with abdominal pain, Calcium increased, history of

progressive dyspnoea for 3 year. What inv?
A. parathyroid hormone
B. serum ACE…sarrcoidosis
C. Anti GBM

155. pt 4 days after parathyroid sx for parathyroid adenoma,

develop finger and perioral numbness. Ca level 2 days back at
time of discharge was 2.02 (it was low then the normal limits given)
was low wt to give….iv calcium

156. A case of hypercalcemia and slightly elevated PTH. The patient

elder sister has the same but she doesn’t take any medication for it.
What is the next management ??
a.parathyroid scan
b. CT of the head or abdomen or chest (I don’t remember)
c. bone scan
d.urniary creatinine/ calcium ratio

**Familial hypocalciuric hypercalcemia D

urinary calcium:creatinine clearance ratio is the best screening test
for FHH

** Signs and symptoms[edit] Most cases of familial hypocalciuric

hypercalcemia are asymptomatic. Laboratory signs of FHH include:
High blood levels of calcium (hypercalcemia) A low amount of
calcium excreted in the urine ( Ca excretion rate < 0.02 mmol/L)
High blood levels of magnesium (hypermagnesemia) High normal to
mildly elevated parathyroid hormone

530
157. yr old male patient complaint of fatigue, tiredness, mild
confusion. He has history of hypertension, DM,
hypercholestrolaemia. He take metformin, perindopril/
indapamide, atorvastatin … other P/E is normal. Lab result Na-
125( n=135-145) Other K, bicarb, - normal TSH- 0.3 (n= 0.4-2.5)
Cause of confusion?
A. Metformin
B. Indapimide..thiazide like diuretic
C. Atorvastatin
D. Perindopril
E. Other irrelevant drug

158. A 50-year-old woman, who has recently been diagnosed

with hypertension, complains of pain in her knees. She feels
tired and her memory is poor. She has lost her appetite recently
and feels nauseated most of the time. Urinalysis is normal.
Which is the SINGLE MOST likely diagnosis?
A Chronic fatigue syndrome
B Chronic renal failure
C Coeliac disease
D Cushing’s syndrome
E Hyperparathyroidism

159. Q A 60-year-old woman is complaining of a swelling in her

neck. From the history she has rheumatoid arthritis and Sjogren
syndrome. Physical examination reveals a mildly nodular, firm,
rubbery goiter. T4 is 10 and TSH 1,2 . Thyroid peroxidase
a/b is high.
WHAT is the most likely diagnosis?
1. Graves disease
2. Hashimoto thyroiditis
3. Subclinical hypothyroidism
4. Subacute thyroiditis

160. Post op, hyponatremia, SIADH scenario asking for diagnostic

inv ?
a. serum osmolality
b. urine osmolality
c. serum electrolytes

161. Pt on polypharmacy presents with orthostatic hypotension.

Labs significant for mildly increased Na, urea and crt. Rx(
1. Stop furosemide
2. Stop digoxin
3. Iv normal saline.. #may

531
**Iv normal saline.. -- this patient has sever Dehydration and Pre
renal Azotemia .. increased Na and Cr and BUN in Elder on
diuretics

162. patient with a painless neck swelling moves with

swallowing. Now hoarseness and difficulty in breathing at
night. increased over 3 weeks. O/E smooth swelling in the
anterior triangle of neck. dullness of percussion at upper
sternal border. most likely dx? (not mention about
hyperthyroid sign and symptoms)
a. Anaplastic cancer
b. papillary carcinoma
c. MN Goiter
d. hemorrhage in nodule of MND
e. follicular

163. CA Patient who became agitated and irritable after

sustaining head injury. Na+ =123 K+=4.8. What is the reason
for his symptoms?
a) SIADH
b) physiological response to injury
c) acute renal failure

164. old pt on many medications lab ix given very long list, I

just notice s.na mildely elevated, urea and creatinine
elevated pt was irritable which drug shd stop first
a- fruesmide
b.bb
c- acei
d- aspirin

Acei cause pre renal azotemia—-> acute renal failure

** lab invs of uraemic encephalopathy: Laboratory Studies

Obtain the following laboratory studies: Renal function studies
[12] – Markedly elevated blood urea nitrogen (BUN) and
creatinine levels are seen in uremic encephalopathy Serum
electrolyte and glucose measurements – To rule out
hyponatremia, hypernatremia, hyperglycemia, and
hyperosmolar syndromes as the cause of encephalopathy
Complete blood cell count – To detect leukocytosis, which may
suggest an infectious cause, and to determine whether anemia
is present (anemia may contribute to the severity of mental
alterations) Serum calcium, phosphate, and parathyroid
hormone (PTH) levels – To assess for hypercalcemia,
hypophosphatemia, and severe hyperparathyroidism, which
cause metabolic encephalopathy Serum magnesium level –
This may be elevated in a patient with renal insufficiency, particularly if the patient is ingesting magnesium-
containing antacids; hypermagnesemia may manifest as encephalopathy Toxicology screen Medication levels

165. Old pt present with confusion Na 120 was treated by indapamide & some other drugs.recently having
diarrhoea wts the cause of hyponatremia?- a diarrhoea b SIADH c indapamide

166. 1 year old child diagnosed with bacterial meningitis was admitted to hospital.blood culture taken and iv
ceftriaxone started.after 1 day of admission child had a seizure of <1 min duration.long labs were given sodium
532
 and bicarbonate low.all others were in normal range.what is the cause of seizure?
a.SIADH
b.dehydration
c.adrenal failure please give an explanation
C is in fulminant meningococcemia. Not in simple meningitis
Commonest cause of low Na is meningitis in children is siadh

167. A patient brought to you with complaint of confusion. He was taking Indapamide and ACEI. His labs showed
serum Na 120 mmol/l. what
a. Indapamide
b. ACE inhibitors
c. Siadh

168. #sept 19. hyperkalemia ,patient on ramipril , presented with lethargy about immediate management? (ECG
doesn’t seem normal to me)
a. insulin and glucose …..no other option matches
b. haemodialysis
c. resonium A
d. Cease ramipril
e. Calcium bicarbonate

169. 2. Lady presenting with chest pain.O/E her face shows bruises and lips have cuts. Which system examination
reveals diagnosis a. CVS b. Endocrine c. Musculoskeletal d. Peripheral nerves

170. A 28-year-old lady comes to the physician to explore the cause of an endocrine disorder. Physical
examination reveals a solitary thyroid nodule. Laboratory studies showed an increased serum calcitonin level
and a gastrin-induced rise in the secretion of calcitonin. A biopsy confirmed the presence of a carcinoma. The
patient is scheduled for a total thyroidectomy. Which of the following is a potential complication of this
treatment? (A) Acromegaly (B) Cretinism (C) Hypertension (D) Hypoparathyroidism (E) Renal osteodystrophy

171. ECG of hyperkalemia with bradycardia.What to do next? Serum electrolytes Holter monitoring

172. Patient got operated for appendicectomy. There was carcinoid incidentally detected which was resected
along with appendicectomy. Persistent diarrhoea present ever since preoperative period. No other symptoms of
carcinoid. What is ur initial treatment of choice. 1. Loperamide 2. Octreotide (Diarrhoea is present from preop
period)

** Carcinoid syndrome is a paraneoplastic syndrome comprising the signs and symptoms that occur secondary
to carcinoid tumors. The syndrome includes flushing and diarrhea, and less frequently, heart failure, emesis and
bronchoconstriction.[1] It is caused by endogenous secretion of mainly serotonin and kallikrein

173. Elderly woman with H/O Ca. colon presents with lower vertebral pain.elevated PTH + ALK.PH.Dx. ? Multiple
myeloma
Malignant met
Disc prolapse
Vertebral #
Ca colon is associated with primary hyperparathyroidism... so osteoporosis because of PHP leading to vertebral
fracture
**

174. #ENDOCRINE A 45 yr old woman comes for diabetes mellitus screening. She is worried that her brother had
DM at (60 yr or something). Her parents are in good health. What will you do for her? a) OGTT 2 yearly b) no
screening till 55 yr old c) OGTT 1yearly d) fasting blood sugar every 12month by exclusion

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175. Pheochromocytoma: imp recalls 1. Patient had tachycardia, tremors, and occipital headache. BP in
165/95.Diagnosis?
Anxiety
Hyperthyroidism
Pheochromocytoma

176. What is the most common cause of false positive elevation of plasma normetanephrine and nor-epinephrine
level in a patient suspected to have pheochromocytoma?
a. Tricyclic antidepressants
b. Congestive heart failure
c. Panic disorder
d. Secondary hypertension
e. Primary hypertension

177. young male come to you with anxiety and palpitation,tell you he believe that something big will happen
soon,tachycardia ,HTN, diaphoresis ,, dx ? a.hyperthyroidism b.panic disorder c.pheochromocytoma #ENDO

*** Signs and symptoms[edit] The signs and symptoms of a pheochromocytoma are those of sympathetic nervous
system hyperactivity,[3] including: Skin sensations Flank pain Elevated heart rate Elevated blood pressure, including
paroxysmal (sporadic, episodic) high blood pressure, which sometimes can be more difficult to detect; another clue to
the presence of pheochromocytoma is orthostatic hypotension (a fall in systolic blood pressure greater than 20
mmHg or a fall in diastolic blood pressure greater than 10 mmHg upon standing) Palpitations Anxiety often
resembling that of a panic attack Diaphoresis (excessive sweating) Headaches – most common symptom Pallor
Weight loss Localized amyloid deposits found microscopically Elevated blood glucose level (due primarily to
catecholamine stimulation of lipolysis (

178. 60 yr old patient presented with constipation. Urea high , creatinine high, ionised calcium level high in
blood.What will be your next step of investigation?
a)USG
b)CT abdomen
c)Parathyroid Scan
179. an elderly lady with constipation n altered RFT and hypercalcemia with all other normal values which
investigation to reach diagnosis?
Thyroid scan
Abd CT
Bone scan
Parathyroid scan
180. An elderly lady with constipation n s/electrolytes revealed mild-moderate hypercalcemia with all other
normal values which investigation to reach diagnosis?
A-Thyroid scan
B- Abd CT
C-Bone scan
181. An old woman taking slow release subcutaneous morphine for pain due to breast cancer metastasis and high
calcium develops constipation from one week, now some liquid fecal material comes , on examination sigmoid is
full of feaces, how will you find cause
A)TSH
B)Morphine levels
C)ca level
182. normal phosphate and high calcium >4 while the normal about 2.5 may be with confusion agitation and
constipation asking diagnosis while calcium in urine was in normal range and the condition started since 4
months,dx?
a. primary hyperparathyroidism
b. malignant osteolytic dis
c. familial hypocalcuric hypercalcemia

In primary hyperparathyroidism, serum phosphate levels are often low because of the phosphaturic effects of
534
parathyroid hormone. Serum phosphate levels may also be low in the presence of a malignant growth that secretes
ectopic parathyroid hormone or parathyroid-related peptide. A normal concentration of serum phosphate does not
exclude primary hyperparathyroidism or a malignant growth….NCBI

183. Adult man has headache,palpitation,sweating high BP 160/100 and a feeling of "something bad about to
happen". What is your next step? (May, 18)
A. Investigate for pheochromocytoma
B. Thyroid function tests
C. Give beta-blockers
184. A child with profuse diarrhoea for 5 days develops convulsions. Which of the following blood test results
would most likely cause this convulsion? a) K 2.2 b) K 6.5 c) Na 132 d) Na 156 e) Cl 100

185. An old lady with long standing constipation. Her lab values were given. Calcium was high, urea was high.
What to do to find cause? a. CT abdomen pelvis b. Bone scan c. Parathyroid scan d. Serum electrophoresis

186. A lady is tiredness and confusion lab vslues ca is

elevated phophate is normal asked what next
check ca in 2 wks
Parathyroid hormone essay
Bone scane

187. A case of hyponatraemia with normal K after loose

diarrhoea . What is the cause? A.indepamide B.SIADH
C.diarrhoea
**siadh is dx cz is indepamide

188. Which of the following is the most frequent cause

of an elevated level of thyroid stimulating hormone
with a hard nodular thyroid? a. Follicular carcinoma b.
Follicular adenoma c. Papillary carcinoma d. Ana-plastic
carcinoma e. Hashimoto thyroiditis

189. A man with rheumatoid arthritis and htn is on

thiazide,enalapril,chloroquine,and diclofenac is feeling
lethargic,short of breath since a few months ago.He
looks pale and his pulse is 80 bpm.Lab values were
given.Haemoglobin was low,MCV was marginally low,
leukocytes low ,platelets low.Cause?
a)Chloroquine
b)Thiazide
c)Enalapril
d)Diclofenac Final pls........ D

535
190. What is the major cause of mortality in SLE patients? A. Lupus nephritis B. Lupus cerebritis C. Lupus hepatitis
D. Vasculitis E. Atherosclerotic disease

191. A 29-year-old lady was recently diagnosed with nodular thyroid disease.She is worried about getting thyroid
cancer. Which of the following does not increase the risk of thyroid cancer? a. Family history of benign thyroid
disease b. Family history of thyroid cancer c. Graves disease d. Chronic goiter e. Familial adenomatous polyposis

192. Pt is feeling confused and tired since one week. Has diarrhoea in the last 24 hrs. taken to the hospital. Is on
perindopril ,indapamide and some more. Has hyponatremia = 120.why? a- siadh b- diarrhoeal illness c-
indapamide d- perindopril

193. A 36 years old man presents with a thyroid swelling since one month. The swelling is dull on percussion and
has a smooth border. He is complaining of hoarseness of voice and difficulty breathing on lying down as the
swelling is heavy and compresses the trachea. What is your diagnosis. A. Multinodular Goitre B. Pappillary
carcinoma \C. Medullary carcinoma D, Thyroid cyst
194. Patient sweating, obvious thyroid, pt losing weight, eating a lot, detected nodule, low intake, dg?
a. Subacute thyoiditis (JM 232) ( Uniform high uptake – graves disease,MNG---- irregular high uptake,low
uptake---
b. de quervain thyroiditis/ subacute thyroiditis
c. thyrotoxicosisfactitia, no uptake--- cyst,Hge,carcinoma)
d. acute multinodular goitre acute toxic adenoma ????
e. Graves

195. Post op hemicolectomy pt. well.on lab there was Decreased sodium 130 S osmolarity 291(normal given toll
290) Cause asked?
a. Overinfusion of 5% dextrose
b. SIADH
c. Hyperaldosteronism
d. Hypothyroidism

196. A patient with pneumonia and atrial fibrillation,his inv shows TSH normal at upper level, T3 normal range,T4
slightly raised. What will you do next?
A. Thyroid scan
B. Repeat Thyroid function test after one month
C. Do the thyroid function test now
D. Echo E. CT scan head

197. A 56 years old woman is admitted for an elective surgery. She has been taking antithyroid medicine since 7
years and carbamazepine since 3 weeks. On admission you discover a UTI and started her on Trimethoprim. On
third day she becomes very lethargic and labs show low sodium. What is the next best step?
A. Cease Trimethoprim and and give normal saline
B. Cease Carbamazepine and fluid restriction ….carbamazeoine causing siadh so we to need to stop it and
restrict fluid
C. Cease Trimethoprim and fluid restriction
D. Cease Carbemazepine and give hypertonic saline
E. Cease both Trimethoprim and Carbemezepine

198. 23 year old young lady accountant presented with weight loss, nervousness, irritability, frequent palpitations
and excessive sweating of 2 month duration. She describes her appetite as excellent. She is planning to come off
her OCP to have a baby. On examination she has a mild diffusely enlarged thyroid gland, pulse rate was 110,
sweaty moist palms, and peripheral tremor. Her thyroid function tests show a suppressed TSH and raised T4,T3
levels. What is the best management plan you can offer to her?
1. Commence propranolol and carbimazole.
2. Offer anti-thyroid medication and reassure that the drugs are very safe in pregnancy

536
 3. Strongly recommend surgery as immediate therapy
. 4. radio iodine treatment and defer pregnancy for 6 month

199. one senerio of women taking cabermizapine for optic neuritis and trimethoprim for uti, thyroxine ,ramipril
of ht, lab given only Na reduced and urea high ask for Tx
fluid restriction
cease trimethoprim and give saline
cease cabemizapine and saline
hypertonic fluid
200. 79 Case of first degree heart block multidrugs then verapamil added
Cease verapamil
201. girl from fire with husky voice
O2
Intubation
Preoxygenation then intubation

202. mom with her sun exposed to sunburn ask about high risk for melanoma
family history
sunburn
exposed to ultraviolet ray
atypical nevus

203. ..Male for army ; during investigation found hematuria ; what the cause ??
PKD
IGA nephropathy
Thin basement membrane incidental finding
C , if not then B
**Thin basement membrane disease (TBMD, also known as benign familial hematuria and thin basement

537
 membrane nephropathy or TBMN) is, along with IgA nephropathy, the most common cause of hematuria
without other symptoms.
204. Endocrine What is the most common cause of false positive elevation of plasma normetanephrine and
norepinephrinen level in a patient suspected to have pheochromocytoma? a. Tricyclic antidepressants b. CCF c.
Panic disorder d.Senondary HTN e. Primary HTN

205. rest tremors diappear when to not focus and rigidity

Parkinsonism case
206. Anticholinergic delirium treatment ?
a.haloperidol
b.levodopa
c.diazepam
d.Phyostigmine

207. ..Pic Dupuytren and the case; normal glucose which investigation before ttt
FBS
LFT
US hand

No routine diagnostic laboratory studies apply to this disorder. However, diabetes mellitus has been associated
with Dupuytren contracture. A fasting blood glucose level should be obtained if diabetes mellitus is suggested by
the patient's clinical history and physical examination findings.
No routine radiographs are necessary, but ultrasonography can demonstrate thickening of the palmar fascia, as
well as the presence of a nodule. In addition, ultrasonography of a thickened cord may be useful prior to
intralesional injections so that the underlying tendon can be identified and avoided during the injection
Tx:
mild symptoms:
instruct to passively stretch the involved digits, to avoid a tight grip on tools and to use a glove with padding
across the palm during heavy grasping tasks.
Intralesional glucocorticoid injection with triamcinolone acetonide and lidocaine hydrochloride may be helpful if
local tenderness is bothersome
moderate to severe:
surgery (open fasciectomy), as well as percutaneous or open fasciotomy or needle aponeurotomy.
538
 Collagenase injection with or without triamcinolone injection has also shown benefit in early and less severe
disease

208. Man with severe headache for three months ; his BP is (150 / 100 or like this) ; long q ; Dx
Primary HTN

209. Very old age woman with anemia and thrombocytopenia :

A case of chronic lymphocytic Leukemia

210. ITP case?

Cytotoxic chemotherapy
IG
Steroid
211. Ver old age woman with anemia and thrombocytopenia
and axillary lymph node enlargement: management was asked
Palliative care
Steroid
radiotherapy
212. Balanitis and Phymosis
Circumcision
Mupirocin
Oral antibiotic

213. Acute angle glaucoma

a- topical pilocarpine
b- oral acetazolimide

Tx of open-angle glaucoma:
Topical drops -> Add second medication if initial monotherapy is
not effective
laser therapy
surgery
214. An alcoholics man brought in ED by police. He is easily
drowsy, smell alcohol... Ask the best Ix?
a. Blood alcohol
b. Blood urea level
c. Urine test for drugs
d. CT of the head
215. ..A mother come with her baby to do heel prick test because baby has phenylketonuria, the mother is
concerned about this test what will you tell her :
a- Inform her that phenylketonuria is not inherited à phenylketonuria is Autosomal recessive
b- This test is not harmful

539
216. A 2 month old baby with a large bump on the head. Father brought the baby in to show the doctor. They
have a 7 yr old with ADHD asked what's the cause of the bump.
A. Baby rolled off the couch. à(Baby can't roll off the couch at 2 months)
B. non accidental à May be child abuse
C. It's the ADHD boys fault
D. Bump from birth

217. ..A 4 weeks infant was brought to your office by his father. He is explaining that he found a lump on the
occipital area of head when the baby rolled and fell down from the couch to the ground. The baby has an ADHD
brother who was playing with him. What will you do?
Admit the baby
Order CT scan
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Ask to bring the brother for psychology assessment
Ask for family meeting
Talk to mother

Age of Roll over: 5-6 mo (atleast 3mo)

218. walanderstrom macroglobunemia patient now has fever 39 cough dullness left base (pleural effusion)
started on amoxclav n azithromycine now developed rash on chest. N rash was 100% papular hard and few
vesicle. NO macule
a- Ganciclovir
b- Ceftriaxone
c- Prednisolone
219. 2- waldenstorm macroglobenemia patient came with rigors and fever and right lower lobar pneumonia or
some infection like this admitted and started ampicillin and after minimal time generalised vesicular rash
appeared asking management A.prednisolone - B.immunoglobulin - C.cease ampicillin – D.antiviral
220. -A57yr male with waldenstorm macroglobulinemia and myelodysplastic syndrome developed pneumonia.
Penicillin given. After 2 days he developed maculopapular rash with some pustular lesion (no pic was
there).What would lead to definitive diagnosis: A. Skin biopsy B. Immunoflourescense of lesion C. Blood culture
D. Marrow biopsy
**drug reaction cuases maculo popular rash
221. walderstorm recall with appearance of vesicular not in corps but scattered some healed some in evolution
after starting ampicillin /azithromycin in patient with fever chill n rigor n on X-ray lower lobe consolidation
confirmed as pneumonia.options were
A)prednisolone
B)stop amoxi n start ceftriaxone
C)amphotericin
D)acyclovir

222. Most common cause of macroscopic hematuria?

Despite extensive investigation, studies have shown that up to 50% of patients with macroscopic haematuria and
70% with microscopic haematuria have no identifiable cause found.This could also be attributed to transient benign
physiological conditions, including vigorous physical exercise, sexual intercourse or menstrual contamination
223. Woman with Hepatitis C, she is concerned about her partner, what is your advice ?
a- Avoid oral sex
b- Avoid contact with any split blood

You can catch the hepatitis C virus if you have contact with the blood of someone who is infected. This can happen if
you:
Share drug needles or cocaine straws
Have sex with someone who is infected
Use infected needles for tattooing, acupuncture, or piercings
Share toothbrushes, razors, or other things that could have blood on them
Got a blood transfusion before 1990 (when the way blood was handled changed)

If you have hepatitis C, it is still safe to:

Hug, kiss, and touch other people (but you can spread the infection through sex)
Share forks, spoons, cups, and food
Sneeze or cough
Breastfeed
224. ..patient on warfarin with INR 3.5 with cerebral hemorrhage on ct whats the best initial
a) stop warfarin
b) vit k
c) FFP

541
225. A 55y old man after return from Bali after short holiday of 5 days with his wife presents with Fever, chill,
abdominal pain, malaise and jaundice. All of liver function tests show impairment (↑AST, ↑ALT, ↑ALK). Dx:
a. Hepatitis A (15 to 45 days)
b. Hepatitis B
c. Hepatitis C
d. Cholangitis
e. Malaria (incubation period 12 to 40 days for all malaria and for falciparum its 7 to 14 days)

542
226. A 14 years boy with ADHD , he does not want to take his medication with lunch at school , what will you do :
a- Talk to the child
b- Give him a long acting stimulant
C.appoint a nurse to give him regularly
D.normal late adolescent develpoement

Short-acting forms of medication ( methylphenidate ,

dexmethylphenidate , and amphetamines ) are often used as the
initial treatment in children <6 years, However, in children older than six years, a longer-acting preparation may be
used initially, starting at the lowest dose and titrating up
Intermediate or long-acting preparations generally are indicated for children who require a duration of action longer
than four hours or in whom the administration of medication every four hours is inconvenient, stigmatizing, or
impossible
A combination of a long-acting and late-afternoon short-acting medication may be necessary to provide adequate
coverage in the evening hours for homework completion or driving

227. 100..a boy presents with auditory hallucinations since one day when at rave party he was given white tablets
what additional finding will confirm diagnosis?
A visual hallucinations
B memory loss
C aggressiveness

Jm 200
The stimulants include amphetamines and their analogues, ephedrine, cocaine and certain appetite suppressants.
Stimulant-induced syndromes:
• Aggressive behaviour
• Paranoid behaviour
• Irritability
• Transient toxic psychosis
• Delirium
• Schizophrenic-like syndrome

Ecstasy (MDMA or 3,4-methylenedioxymethamphetamine) continues to gain popularity as a drug of abuse,

particularly among adolescent and young adults who attend all-night dance parties, sometimes referred to as
"raves" or "circuit parties"

Ecstasy increases alertness, reduces fatigue, and leads to feelings of increased physical and mental powers, and
euphoria after approximately one hour. It has high abuse potential, some hallucinogenic properties and a tendency
to neurotoxicity

543
Minor adverse reactions: agitation, nausea, bruxism (grinding teeth), ataxia, diaphoresis, blurry vision, tachycardia,
and hypertension à These effects are usually self-limited and resolve within hours
serious effects: severe hypertension, hyperthermia, delirium, psychomotor agitation, and profound hyponatremia.
Potential life-threatening complications of these effects include intracranial hemorrhage, myocardial infarction,
aortic dissection, disseminated intravascular coagulation, rhabdomyolysis, seizure, and serotonin syndrome.
228. what is the normal development task of a late adolescent
object of permanence
identity of sexuality (attain a stable sex identity) …transvestism
having peers of same sex
leave home
Page 920 jm Late adolescence (maturity: 17-19 years) is the stage of reaching maturity and leads to more
self -confidence with relationships and successful rapport with parents.
But in adolescence There are usually special concerns about boy-girl and same sex relationships and maybe guilt or
frustration about sexual matters. Many adolescents therefore feel a lack of self-worth or have a poor body image.
While there are concerns about their identity, parental conflict, school, their peers and the world around them,
there is also an innate separation anxiety.

229. A mum come with son he has measles rash for 6 days , she is asking about exclusion from school, the teacher
says that all the children at school are immunised. what is your advice ?
a- no need to exclusion measles exclusion is 4 days
b- exclusion for 4 days
Don't remember
Jm 881 Children should be kept away from school until they have recovered or for at leas t 5 days from the onset of
the rash.
There is no specific treatment although some symptoms can be relieved (e.g. a linctus for the cough, paracetamol
for fever) . The patient should rest quietly, avoid bright lights and stay in bed until the fever subsides.

230. A young girl with hepatomegaly lymphadenopathy microcephaly pigmented retina but no cataract
a- zellweger synd
b- congenital cmv
c- Rubella

231. 55y old lady known with insulin dependent DM, has had right leg amputation 5yrs previously, now bp
175\90, normal regular pulse, BMI 32, LDL 2.8, s. triglyceride 4.5,hba1c was 8.5,fasting glucose was 9.5, which of
the following is important to keep her other left leg from amputation,(no smoking no hx of smoking mention)
a- meticulious foot care
b- control her bp
c- tight glycemic control
d- reduce LDL
e- reduce her body weight

If the scenario is 5 years, we go with A (since already very advanced disease), but if the scenario is 2 years, we go
with C, since there would still be time to correct the blood sugar levels and prevent future amputation.

232. Melanoma skin care screening. 40 years old IT guys come for screening. What would be the risk for him?
a. recent diagnosis of melanoma in cousin
b. outdoor working in early twenties
c. history of sunburn in childhood
d. family history of BCC

233. farmer have cut on thigh and now having c/o of erythema on thigh. Asking for most common organism
causing it. ITS SRETP WITH FARMER
a) strep. Viridans
b) staph aureus. ………if there wasn’t strep pyogens
234. .Sheep farmer with RUQ pain with H/O cholecystectomy and hemicolectomy for carcinoma colon 2 yers
ago.usg pic given.but I cant recognize the pic.
544
Next inv
1.Hydatid serology
2.Triphasic CT à r/o new carcinoma

Same recall with given CT - on the CT two shadows marked with arrows - was not hydatid for sure

235. Greek lady, presented with right upper quadrant pain, fever at 38c. U/S given which showed multiple cysts
with septae. Next appropriate management aasked?
a. Hydatid serology
b. Percutaneous drainage
c. Surgery
Treatment Surgical removal of the cysts is the most common treatment, often in combination with specific anti-
parasitic drug therapy.

The “floating membrane” represents the complete detachment of the endocyst Laminated membrane from the
pericyst and is referred as “Water-Lily” sign (pathognomonic for Echinococcosis Hydatid Cyst)

The diagnosis of echinococcosis is typically established by ultrasound in combination with serologic testing (usually
ELISA).
ultrasound demonstrates infoldings of the inner cyst wall, separation of the hydatid membrane from the wall of the
cyst, or hydatid sand. E. multilocularis lesions may have an irregular contour and may be difficult to differentiate
from tumor.
Percutaneous aspiration or biopsy should be reserved for situations when other diagnostic methods are inconclusive
because of the potential for anaphylaxis and secondary spread of the infection. If aspiration is required, it should be
performed under ultrasound or CT guidance. Complications can be minimized by concurrent administration of
albendazole and praziquantel.

236. Paracetamol toxicity after 4 hours

545
A-activated charcoal
B-paracetamol levels
C-N acetyl cysteine

<1hr... activated charcoal 1g/kg

4 to 8 hours PCM levels
>8hrs immediate NAC and then levels

237. WOF is least likely effective in treatment of paracetamol poisoning within 8 hours ingestion?
a. Charcoal
b. Oral NAC….we don’t give oral nac
c. Iv NAC
d. Oral methinoine
e. Peritoneal dialysis

<1hr...charcoal,
>1hr,nac, if allergic reaction of nac…. methionine
after 8 hrs peritoneal dialysis
NAC is the treatment of choice and should be readily available in developed countries such as the US. In situations
where it is not available, oral methionine may be an alternative option. If no other options are available,
hemodialysis may be considered as a means of rapidly decreasing the serum acetaminophen concentration in
patients presenting soon after an acute acetaminophen overdose, provided hemodialysis can be expeditiously
initiated and its benefits outweigh its risks.
For me it is EEEEEEEEEEEE

238. scenaro of hyperkalemia pt present with confusion,K was 6.5,urea and CR also very high.next
1.urgent hemodialysis

546
2.rectal calcium resonium
3.5%dextrose with insulin 10 unit

239. 62 yr old man with productive cough , fever 38 , difficulty in

breath , chest pain , pleurisy . Rx ?
A) IV penicillin
B) NsaidS
C) doxycycline
D) amoxillin clav. Jm472 mild pneumonia

240. middle aged male with h/o recurrent productives presented

with fever, greenish copious amount of sputum n cough. On xray
chest : widend bronchioles present at both lung bases. Next best
step in Mx?
a. Amoxicillin n calvulante dx bronchiactesis
b. Ampicilline
c. i/v penicillins
d. erythromycin

241. Old age female had a will not to admit her when she is
terminally ill , today she fall & had # femur , she became very
drowsy after morhine inj. , what to do now ?
A)Analgesia only
B)arrange family meeting
C) admit her
D) wait for court decision
E) wait her awake and ask her wish

242. An old lady who is taking warfarin for (i think dvt) comes with an acute severe pain in her RIF and back pain.
Vital stable. Her bowel habit, constipation and vomiting not mentioned. On examination, a tender mass in RIF
with pain on palpation. (Tried to find an image that looked closest to what they showed, here it is) What's your
dx?
A appendix abscess
B Rectus sheath haematoma
C Cecal volvulus
D leaking AAA
E sigmoid volvulus

rectus shesth haematoma causing large bowel obstruction

547
**A rectus sheath haematoma caused by rupture of epigastric vessels is an uncommon condition that
can occur spontaneously especially in patients who are being anticoagulated. It may present in a number
of ways, most commonly with abdominal pain and a palpable abdominal mass. Depending on site, it can
mimic acute abdominal conditions, for example, appendicitis1 and splenic rupture.2 This unusual
presentation of large bowel obstruction occurred in a 75 year old women taking long term anticoagulation
treatment for atrial fibrillation. She presented with a 24 hour history of abdominal pain, distension, and
absolute constipation. On examination she had generalised tenderness and a palpable 10×10 cm mass in
the left iliac fossa. On admission INR was 3.4 and Hb 8 g/dl. An abdominal radiograph showed grossly
dilated loops of large bowel (fig 1). An ultrasound scan and gastrograffin enema were inconclusive.
Computed tomography was performed and a diagnosis of obstruction secondary to external compression
by an abdominal wall haematoma was made (fig 2).

Conservative treatment
proved successful in permitting resolution of obstructive symptoms within 48 hours. Diagnosis of
rectus sheath haematoma should be suspected in patients taking anticoagulation treatment
presenting with a palpable mass, abdominal pain, and anaemia.3 A review of the literature shows
computed tomography to be the most accurate imaging technique in the diagnosis of rectus sheath
haematomas

Carnett's sign: patient is asked to lye on the the examination table and lift head and shoulders from
to tense the abdominal muscles. or raise both legs with straight knees.
positive Carnett's sign (abdominal pain remains unchanged or increases when pt lift his head)
increases the likelihood that the abdominal wall is the source of the pain (rectus sheath hematoma)
(negative Carnett's sign (abdominal pain decreases when pt lift the head) points to an intra-
abdominal cause of the pain (appendicitis)

Fothergill's sign: If a mass in the abdominal wall does not cross midline and does not change with
flexion of the rectus muscles, this is a positive sign for a rectus sheath hematoma.

243. A 69-year-old woman has been in the intensive care unit for 7 days following complicated hip replacement
surgery. The patient is currently receiving heparin subcutaneously and wears intermittent pneumatic
compression devices on her lower extremities bilaterally. The patient has developed new-onset right calf pain,
oedema, tenderness, and a positive Homans’ sign. A Doppler ultrasound revealed a deep vein thrombosis. Her
platelet count is 78,000/mm³, and there has been no evidence of spontaneous bleeding. Which of the following
is the next step in management?
Begin warfarin therapy
Discontinue bilateral pneumatic compression devices
Discontinue heparin
Perform venography
Transfuse platelets

this is a typical case of heparin-induced thrombocytopenia... thrombosis (e.g. PE, DVT or even
arterial embolism) occurs despite the fact that the platelet count falls below half of the baseline. it
occurs 4-10 days after hepariin. sometimes just with development of VTE despite being on
therapeutic dose of heparin you should suspect the condition. presently, it is called heparin-
induced thrombocytopenia / thrombosis (HITT). the next best step in management is cessation of
heparin n replace with lipirudin and danaparoid

244. A 55 year old woman with history of right mastectomy 5 years ago for breast cancer is brought to
the ER by her husband as she has been increasingly drowsy over the past 48 hours. He mentions that

548
 she has been complaining of increased thirst for past week. She suffers with depression and has started
fluoxetine 4 months ago. What is the SINGLE most likely cause of her symptoms.
A. Cerebral Oedema
B. Cerebral atrophy
C. Cerebral deposits of amyloid plaques
D.Hyponatremia
E. Hypercalcaemia

Increased thirst points towards hypercalcemia

GIT
1. CA colon post-surgery. Histopathology showing node positives, treatment asked….

A: CHEMO(ans)
B RADIO
C CHEMORADIO

IF T1 AND T2 AND ALL REMOVED NODES

NEGATIVE...NO CHEMOTHERAPY

CHEMO FOR ALL OTHERS.T3 T4 AND NODE

POSTIVES

2. Colorectal ca. Right hemicolectomy done .2/27 lymph

nodes positive for invasion . What next ...
Total colectomy,
chemo,
radio,
chemo plus radio
radiotherapy carries a potential to abdominal viscera
injury ; it has no role in cancer colon .... answer here is
CHEMO

3. …New blood test for Ca colon comparing the results

with the results from colonoscopy.Graph given.Asking the point of 100% specificity.
It looks like this.Asking A , B , C , D , E #September ans d (chemo)

4. GIT 50 guy his father died of colon ca at 57 and his maternal aunt had colon cancer too . how will u screen for
him

549
 a. colonoscopy now
b.colonoscopy every 5 years
fobt 2 yearly

5. A 45-yr. old male came to you for screening of colon cancer. His father was diagnosed at 57 yr age for colon CA.
and maternal aunt at age of 62 yr. What is your most appropriate step regarding to his situation?
A) Fecal Occult Blood Test 2 yearly
B) sigmoidoscopy 2 yearly
C) colonoscopy yearly
D) reassurance
Red book 106

6. CA colon diagnosed what next?

a-chemo(ans)
b-radiotherapy
7. after ca colon treatment? After CEA, what next?
a)colonoscopy (ans)
b)ct scan
c) usg abd

8. 3yr old child complaining of colicky abdominal pain and anorexia for 7days.then 2 days of diarrhoea nw
presented to u.tenderness all over the abdomen with guarding .temp 39most likely dx?
A.perforated appendicitis(ans) so inc temp
Mesenteric adenitis
Jm 349

9. 3-year child was complaining of colicky abdominal pain and anorexia for 7 days, then 2 days of diarrhea and
other feature now presented to you his there was tenderness all over the abdomen with guarding , temperature
39. What is the most likely diagnosis?
A-perforated appendicitis
B-mesenteric adenitis
C-norovirus gastroenteritis
D-giardiasis
E-campylobacter gastroenteritis
.tenderness should be typically in RIF in MA. Generally, in MA
fever should be high>38.5...here saying mild fever. And in MA
guarding and tenderness is not as definite like appendicitis

Ø A 3yr old with complain of anorexia and diarrhoea for the

past 2days and fever. On examination Temp 39, tenderness
and guarding in Left iliac fossa. What is diagnosis
a. Mesenteric adenitis
b. Appendicitis
c. Giardiasis
d. Amoebic dysentery
Ø girl with abdominal pain for one week not peritoneal signs,
also with mild diarrhoea for 2 days, on physical
examination with fever and abdominal pain. Diagnosis?
a. diarrea for norovirus
b. mesenteric adenitis
c. Appendicitis rupture
Ø 2-year-old child with diarrhoea ,mild fever and abdominal
guarding and tenderness. Most probable cause?
Perforated viscera
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 Acute appendicitis
Mesenteric adenitis

10. 58 old woman with low calcium.other blood report are normal.wats her cause of having low calcium.chest X-ray
given-
a.dietary deficiency(if nothing in x-ray)
paraoesophageal hernia
c. ca colon.
d.chronic duodenal ulcer
if x-ray given than think for that one…

Plain radiograph

• retrocardiac opacity with air-fluid level

Hypocalcaemia is found among people with Hiatal hernia,

especially for people who are male, 60+ old, take medication
Omeprazole and have High blood pressure

11. GIT presented with mild pain and Distention ; physical exam is
normal…... diagnosis ?
a.fecal impaction……!!
b.ca colon
c.diveticlosis
d. sig. volvulus
e. pseudo obs (Ans)

Fecal impaction vs pseudo obstruction

faecal impaction-there is history of prolonged constipation, use of laxative and there is soiling , faecal
incontinence ,vomiting unlikely....in pseudo obstruction-most commonly in debilitated, hospitalised patients
with multiple medical problems and is associated with various medical and surgical conditions. Surgical
patients begin developing symptoms, which are often insidious in onset, an average of 3-5 days
postoperatively, constipation is recent and its usually absolute. Vomiting present

12. 8o old patient having fresh rectal bleeding & blood not mixed with stool. He was treated for prostrate cancer
given chemotherapy. Cause of bleeding
A- Diverticular disease of colon???

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 B- Ulcerative colitis JM 511
C- Ca rectum(blood at wall of stool and ca colon mixed with
stool)
D- radiation proctitis(acute: 3 to 6 mon and chr 12 mon)
E: HAEMORRHOID(ANS if IN OPTIOPN)

13. Elderly woman with H/O Ca. colon presents with lower vertebral pain.elevated PTH + ALK.PH.Dx. ?

Multiple myeloma
Malignant met
Disc prolapse
Vertebral fracture(low ca causing vert fracture)

Here one point is very clear raised PTH...means low Ca...in mets it causes high Ca and low PTH...so only elderly
female vertebral fracture with low Ca+ and high PTH...CA colon is a distract I think

Because many organs can be affected by myeloma, the symptoms and signs vary greatly. A mnemonic
sometimes used to remember some of the common symptoms of multiple myeloma is CRAB: C = calcium
(elevated), R = renal failure, A = anaemia, B = bone lesion

14. Patient with ca colon, on warfarin after cardiac stent for 6 months. Came to you in the ER. What will you do?
A. Change warfarin to clopidogrel and proceed to surgery after 10days
B. Stop warfarin. Give vit K and proceed now
C. Stop warfarin, give FFP and proceed now
D. Stop warfarin for 10 days and proceed to operation

C. we have to keep in mind one thing, pt. came into ER with colon CA, that means he is in emegency,He
needs urgent surgery, if he came into opd we can differ him for couple of week by changing warfarin to
clopid or aspirin than go to surgery with platelet and ffp in hand, many guideline suggest that it is safe to do
operation with aspirin in case of patient with cardiac stent, however in this case it is emergency, pt. mayy be
in intestinal obstruction, we cannot delay save his life first think about stent blockage later, stop warfarin
keep ready ffp if bleeds give it and go for operation as early as possible. I have to add one last think.
According to guideline. After operation start the aspiring as soon as possible...we use to give aspiring by NG
tube just after the operation.

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 The current guidelines recommend that elective non-cardiac surgeries be postponed for at least 6 weeks
(ideally 3 months) following angioplasty with BMS and for 12 months after DES,15 as the risk of thrombosis
is highest within 6 weeks after the placement of a bare-metal stent and within 3–6 months after the
placement of a DES.16
Perioperative continuation of aspirin increases bleeding risk slightly but does not increase the risk for
bleeding that requires medical or other interventions and therefore can usually be continued.17,18 On the
other hand, perioperative interruption of aspirin confers a 3-fold increased risk for adverse cardiovascular
events.19 If a patient is to undergo surgery with a high risk of bleeding and an antiplatelet effect is not
desired, clopidogrel, prasugrel and ticagrelor should be discontinued 5–7 days prior to the procedure.13,20
Good communication with the treating cardiologist and, in some cases, individualised treatment plans may
be necessary in managing such patients in the perioperative periods.

15. Farmer with left inguinal swelling biopsy noted squamous cell ca
asking which region is primary
A)colon
B)rectum
C)left leg(ans)
D)anus

16. History of appendicectomy & cholecystectomy presented with 3

wk history of abd pain, distension. X-ray shows dilated ascending
colon, transverse colon & descending colon, no air. Rectum is
empty.
A- Sigmoid volvulus
B- Adhesive IO
C- CA Sigmoid

There is distension of the large bowel proximal to the sigmoid,

with prominent fluid levels. An obstructing mass in the upper
sigmoid / distal descending colon with contrast enhancement is
noted, the large bowel beyond it being collapsed.

CAECAL CARCINOMA+ small bowel obstruction

17. History of appendicectomy & cholecystectomy presented with

3 wk history of abd pain, distension, BS EXAGERRATED , CT Abd
image given
A- Sigmoid volvulus
B- Adhesive IO
C- CA Sigmoid
D- Pseudo obstruction

18. 70 yrs. old pt. came wd profuse bleeding per rectum, cAuse?
Ca colon
Polyp
Diverticulitis(ans)

19. Old man after colectomy for CA colon, 4th POD, sudden collapse, u hv started O2 by mask, CPR, what most
appropriate next management?
-ecg
-defib(Ans)

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-iv adrenaline

20. farmer with hx of ca colon with ct of liver metastasis what to do

A-triph CT (Ans)
B-colonoscopy
C-ultrasound

21. 34 yrs old female with normal fobt and no history of ca colon in family what to do next.

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1. colonoscopy
2. referral
3. reassure as no further needed.(ans)

22. a very weird CT I can’t interpret it although i studied

CT in a satisfactory way , and they give scenario
which is really a mix between volvulus and ca colon
" old age , progressing constipation for 3 wks , then
absolute constipation pain and tenderness " what is
ur Dx ?
1- sigmoid volvulus
2- caecal volvulus
3- ca sigmoid(ans)

23. .45yr male,FOBT negative 2weeks ago.father was

diagnosed of ca colon at 57yr.maternal aunt was
diagnosed at 61.next what to do
a. FOBT 2yearly
b. Colonoscopy yearly
c. Sigmoidoscopy yearly
d. Nothing

24. old pt. with long history of constipation, taking

laxatives now presented with mild pain for 48
hr.mild destination vomiting , physical exam is
normal. diagnosis ?
a.fecal impaction
b.ca colon
c.diveticlosis
d. sig. volvulus
e. pseudo obs
in western countries SV is essentially a condition of the elderly and frail, often with a long history of constipation and
laxative.( tjandra 165).

25. .a pt. has Alzheimer’s dementia and ca colon. U have planned colostomy. One of her daughter asked as her
mother is not capable of caring and she don’t want her mother to be operate.her MMSE is 20/30. You talk to pt
and pt has given consent for operation. What is your most appropriate advice?
a) you will proceed for operate as pt has given consent
b)you will not operate as pt is not capable of giving consent
c)discuss with family physician and surgeon regarding management of pt.
d) as her daughter has power of attorney, she can give consent for not operating her mother

26. 58 yr. old Algerian vegetarian complain fatigue .lab finding micro cystic hypo chronic anaemia.
-diet
-ca colon
–hookworm

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27. A 52 yr old male asks for advice on screening for ca large bowel. He has no GI symptoms. His younger brother
has just developed ca colon at the age of 50. There is no other family history. Most appropriate advice to give
him.
A, no screening is required at this time
B, faecal occult blood test now
C, colonoscopy now, but if clear no further screening required
D, colonoscopy now and at five yearly intervals thereafter
E, colonoscopy now and yearly thereafter
Red book 106

28. Nursing home old woman with h/o fecal impaction. Now comes
with abd distention,pain ,no flatus o/e soft abd,DRE empty
rectum
a. Ca colon
b. Small int. obst.
c. Fecal impaction

29. Nursing home old woman with h/o fecal impaction. Now comes
with abdominal distention,pain & no flatus.By examination, soft
abdomen,DRE revealed empty rectum. Dx ?
A) Cancer colon
B) Small intestinal obstruction
C) Fecal impaction
D) Sigmoid volvulus

Risk factors of volvulus include:

• a birth defect known as intestinal malrotation,

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 • an enlarged colon
• , Hirschsprung disease,
• pregnancy, and
• abdominal adhesions.[1]
• Long term constipation and a high fibre diet may also
increase the risk.[3]
Ø The most commonly affected part of the intestines in
adults is the sigmoid colon with the cecum being second
most affected.[1] In children the small intestine is more
often involved.[5] The stomach can also be affected.[6]
Diagnosis is typically with medical imaging such as plain
X-rays, a GI series, or CT scan.[1]

Hb.3.111…if no sigmoid volvulus in option than choose ca colon

30. Patient with history of chronic progressive constipation since 3 months and recently took diclofenac for back
pain . diagnosis ask
Volvulus
Ca colon(ans)

32. A pregnant lady with multiple gallstones came to a GP. He advised her cholecystectomy after delivery. Why?
a. risk of Ca gallbladder
b. increased risk of CHOLESTATIC jaundice in next pregnancy
c. increased risk of Ca pancreas
d. increased risk for primary biliary cirrhosis
.by exclusion gall stones don’t lead to ca gall bladder nor ca pancreas .so exclude A and C ...in the same time primary
biliary cirrhosis is autoimmune disease no relation between it and gall stones

Primary biliary cholangitis (PBC),

previously known as primary biliary cirrhosis, is an autoimmune disease of the liver.[1][2][3] It results from a slow,
progressive destruction of the small bile ducts of the liver, causing bile and other toxins to build up in the liver, a
condition called cholestasis. Further slow damage to the liver tissue can lead to scarring, fibrosis, and eventually
cirrhosis.

31. A young woman complain of 1 week of fatigue , change in colour and dark brown urine . She has RUQ tenderness
and ALT 1055u/l .
A- Ac viral hep(ans)
B- cholecystitis
C- pancreatic CA

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D- gallbladder CA

32. Woman come to clinic for recurrent colicky pain & found to have multiple stones in gall bladder. She told you to
refer to surgeon whom she found out on internet mentioning small scar and little complication in his (surgeon)
web. You known that surgeon has unusually high complication.
A) Refer her to surgeon she mentioned
B. Told her to do cholecystectomy
C) Told her to do laser lithotripsy
D) Tell her to refer other surgeon

33. another patient with RUQ pain had gall stone and CBD 0.7 mm asking for the reason to do ERCP( recall)
A cbd .7mm
B jaundice
C. Gallstone etc

Indication of ERCP------------------obstructed jaundice

ERCP helps in diagnosing and often treating these conditions:

o . Gallstones, which are trapped in the main

bile ducts

o . Blockage of the bile duct

o . Jaundice, which turns the skin yellow and the

urine dark (due to an obstruction)

o . Undiagnosed upper abdominal pain

o . Cancer of the bile ducts or pancreas

o . Pancreatitis (inflammation of the pancreas)

34. A woman admitted with obstructive jaundice. After 2 days of treatment, jaundice resolving. On usg, multiple
stones in GB, CBD 10 mm dilated. What will bee next
A.Cholecystectomy in this admission
B.Cholecystectomy after 2months
C.Mrcp
D.Ercp
E.Do nothing

35. patient had abdominal pain liver enzymes elevated. Pancreatitis dx treated. Now she is normal. On USS she had
multiple gall stones and cbd 10mm next mx
A ercp
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B Mrcp
C Elective cholecystectomy in current admission
D elective cholecystectomy after 3 months

36. GP REFRRED A PREGNANT LADY IN FIRST TRIMESTER FOR CHOLECYSTECTOMY FOR GALL STONES.RATIONALE
FOR HIS DECISION
A: SHE WILL BE ABLE TO EAT NORMAL DURING PREGNANCY
B: INCREASE CHANCE OF STONE COMPLICATIONS DUEING PREGNANCY
C INCREASE CHANCE OF CHOLESTATIC JAUNDICE
D INCREASE CHANCE OF FATTY LIVER OF PREGNANCY
E MORE PREGNANCY COMPLICATIONS WITH GALL STONES

Usually surgery recommended after 20 wks, to avoid chance of abortion. Surgery advised to prevent chance of
cholestatic jaundice

Acute fatty liver of pregnancy (or hepatic lipidosis of pregnancy)

usually manifests in the third trimester of pregnancy, but may occur any time in the second half of
pregnancy, or in the puerperium, the period immediately after delivery.[1] On average, the disease
presents during the 35th or 36th week of pregnancy.[5] The usual symptoms in the mother are non-
specific including nausea, vomiting, anorexia (or lack of desire to eat) and abdominal pain; excessive thirst
may be the earliest symptom without overlap with otherwise considered normal pregnancy symptoms; [5]
however, jaundice and fever may occur in as many as 70% of patients.[1][6]

In patients with more severe disease, pre-eclampsia may occur, which involves elevation of blood pressure
and accumulation of fluid (termed oedema).[5] This may progress to involvement of additional systems,
including acute kidney failure,[7] hepatic encephalopathy,[8] and pancreatitis.[9] There have also been
reports of diabetes insipidus complicating this condition.[10]

37. A patient presented with upper abdominal pain, fever, and

vomiting. Ultrasound revealed thickened wall of the gall
bladder and gallbladder stones. You commenced
antibiotics but condition got worse with sign of peritonitis.
What to do?
a.Cholecstostomy
b. ERCP
c. Cholecystectomy
d. Whipples

38. patient had abdominal pain liver enzymes elevated. Pancreatitis dx treated. Now she is normal. On USS she had
multiple gall stones and cbd 10mm next mx
A ercp
B Mrcp
C Elective cholecystectomy in current admission
D elective cholecystectomy after 3 months

39. RUQ pain , fever, palpable mass, US shows thick walled gall bladder full of stone, bile duct 8 mm with no filling
defect, dx
1.biliary colic
2.acute cholecystitis(ans)
3.choledocholycystitis
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4.cholangitis

Cbd normally is less than 6mm in diameter . However, range is 4 to 8 at porta hepatis. Also, it's size increases by 1mm over
each decade after 60 . After cholecystectomy it could be of 10mm diameter

40. Scenario of gall stone ileus. Already say x-ray features like air in biliary tree and dilated small bowel, didn’t give x-
ray, they already said, feature is abdominal pain only, asking underlying cause
a. Cholangitis
b. Cholelithiasis
c. Sepsis
d. Ca pancreas

1) A man presented with epigastric pain and vomiting and. Abdominal distension and lower abdominal
tenderness also there. Xray abdomen showed- gas in the biliary tree with multiple fluid level and distended
bowel, what is reason for developing his condition-
a. Cholelithiasis
b. Portal empyema
c. Cholangitis
d. Pancreatitis
If in option gallstone ileus. Then chose it…
Explanation
Cholelithiasis causes phlegmon around the stone creating a fistula between biliary tree and small intestine
and the pathognomic pattern of air in biliary tree. Also passage of stone to the small intestine causes
pseudo-obstruction( ileus) creating the pattern of small bowel obstruction(multiple fluid level).

Spontaneous biliary enteric fistula (e.g. gallstone ileus)

Infection by gas-forming organisms, (e.g. emphysematous cholangitis)
Congenital abnormalities,
2) #old male on observation for conservative treatment for Intestinal obstruction, what happen will indicate
urgent intervention ?
a.constant pain
b.high grade fever
backpain

Changed to A....normally intestinal obstruction pain is cramps it comes and goes when it becomes constant that
shows….first stabile fever ...don't operate in fever
Continuous pain indicate ischemia of the bowel

3) Patient is presenting with severe central abdominal pain.,with mild nausea.,no vomiting, no abdominal
distension. Mild tenderness is present on exam. No rebound tenderness on release. You admitted him and
gave fluids. USG was unremarkable. X ray Erect view showed mildly dilated small bowel loops. Now he
suddenly developed sharp severe abdominal pain which is localized with focal tenderness... And pain is being
localized to one point. He recently developed back pain. What is your diagnosis?
a.Simple intestinal obstruction
intestinal obstruction with perforated viscus
localized bowel loop obstruction with secondary ischemia
d.Other irrelevant options

The patient with a perforated viscus classically presents with sudden and severe abdominal pain. The pain may
initially have a focal location – especially in perforated peptic ulcers ? but a generalized peritonitis shortly ensues as
the leakage of air, chemical and bacterial products contaminates the peritoneum

41. Cholecystectomy for gall stones

Give antibiotics a. before sx b. at sx something
Antibiotics given at induction of anaesthesia, so at surgery, B
42. .Multiple Gall stone in pregnancy advised for cholecystectomy ; your advice (contro)
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 a. Increase chance of cholecystitis
b. Increase chance of cholestatic jaundice of pregnancy (in second trimester, go for surgery)
c. increased complications during pregnancy (1st and 3rd trimester, don’t go for surgery)
if c in option than choose c…if not in option than choose b
43. - Gallbladder usg with gall stones and hx of CBD dilated to 9cm. Asked management ? " NO CHOLECYSTECTOMY
IN OPTION "
A- ERCP (ans)
B- MRCP
C- Percutaneous drainage
44. Pregnant lady comes to you with pain in the right upper quadrant. USG shows gallstones. Which of the following
is the most important reason because of which you would suggest her cholecystectomy?
A) At risk of carcinoma of gallbladder
B) At risk of developing gall stone ileus in subsequent pregnancy
C) Can have recurrent cholangitis
D) Can have recurrent gallstones

Common reason: cholecystitis

Most imp reason: cholangitis

45. What is the US finding of gall bladder containing stones?

a. A thick gall bladder wall with pericolic fluid
b. Acoustic shadow beneath the gall bladder

Thick wall = cholecystitis

Shadow = stone

46. Gall stones in obese persons – what to do :

a. percutaneous cholecystectomy
b. laparoscopic (Ans)
c. laparotomy

47. risk of 5 years of HRT treatment. Jm 1163

A. increase breast cancer by 25%(ans)
B. increase stroke by 10%
C. decrease gall stone by 1%

4) HRT risk per year; which is correct?

a) Breast CA 10% increase per year
b) Gall stones 2% decrease per year
c) Heart disease 1% increase per year

https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/wh35_hrt_summary_evidence.pdf

48. enlarged gall bladder with multiple stones, found dilated bile duct and stone obstruction in common bile duct,
patient developed toxic shock, what to do after fluid resuscitation?
a. laparotomy cholecystectomy
b. laparoscopic bile duct explore
C. percutaneous bile drainage
D.endoscopic duct drainage
D....Endoscopic GB drainage ...patient is in shock and is categorised as ASA III-V so
laparoscopy and laparotomy are contraindicated...ERCP is the best choice

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49. One x-ray was given with small black spots in small bowel – and had pain in left iliac and hypochondrium and dx
was asked :
a. appendectomy
b. gall stone metastasis in ileum (stone ileus) (Ans)
c. perforated duodenal ulcer
d. renal stone disease

Xray pneumobilia

50. x-ray with circular dense lesion on the epigastric region. h/o of farmer
with epigastric pain?
aortic aneurysm
hydatid cyst
gallstone
peptic ulcer

Hepatic hydatid cyst projects as a calcification inferior to the right

hemidiaphragm.

51. Epigastric pain, fever. Started central and now is general. Rebound tenderness.
a) Cholecystic
b) Cholelithiasis
c) Pancreatitis (ans)
d) Duodenal ulcer

initial presentation of pain and fever means pancreatitis or cholecystitis, but cholecystitis pain never
generalised. If late presentation of fever, then it is perforated duodenal ulcer.

pancreatitis:
The most common symptoms of pancreatitis are severe upper
abdominal or left upper quadrant burning pain radiating to the
back, nausea, and vomiting that is worse with eating. The
physical examination will vary depending on severity and
presence of internal bleeding. Blood pressure may be elevated
by pain or decreased by dehydration or bleeding. Heart and
respiratory rates are often elevated. The abdomen is usually
tender but to a lesser degree than the pain itself. As is common
in abdominal disease, bowel sounds may be reduced from
reflex bowel paralysis. Fever or jaundice may be present.
Chronic pancreatitis can lead to diabetes or pancreatic cancer.
Unexplained weight loss may occur from a lack of pancreatic
enzymes hindering digestion.

Signs and symptoms may include a sudden pain in the epigastrium to the right of the midline indicating the
perforation of a duodenal ulcer. In a gastric ulcer perforation creates a history of burning pain in
epigastrium, with flatulence and dyspepsia.

GI perforation

In intestinal perforation, pain starts from the site of perforation and spreads across the abdomen.

Gastrointestinal perforation results in severe abdominal pain intensified by movement, nausea, vomiting and
hematemesis. Later symptoms include fever and or chills.[7] In any case, the abdomen becomes rigid with
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 tenderness and rebound tenderness. After some time, the abdomen becomes silent and heart sounds can be
heard all over. Patient stops passing flatus and motion, abdomen is distended.

52. . A 35 yrs old woman having severe sudden abdominal pain throughout the night wakes up and passes dark urine
in the bathroom. She immediately goes to see the doctor. Investigation showed:
Bilirubin: 5x the normal
Alkaline phosphatase: 4x the normal
AST and ALT: 4x the normal
S. amylase: 2x the normal
What is most likely diagnosis?
a. acute cholelithiasis
b. acute cholecystitis
c. Ca gall bladder
d. Acute choledocholelithiasis(ans)
#gastro
53. there was another question which says that obese lady had pain in hypochondrium which was very severe, and
after one hour its completely relieved so what do u expect to find ??
A stone within gall bladder,
B stone in cystic duct,
C stone in bile
duct
actually, the stone rolls back to gb and now at resolution u will find stone in gb.

54. A man presented with epigastric pain and vomiting and. Abdominal distension and lower abdominal tenderness
also there. Xray abdomen showed- gas in the biliary tree with multiple fluid level and distended bowel, what is
reason for developing his condition-
Cholelithiasis
Portal empyema
Cholangitis
Pancreatitis

55. Hx of cholecystectomy due to gall stone with pancreatitis resolved, after that patient complaint of epigastric
fullness.what to do for dx?
A.colonoscopy
B.ct abdomen (ans)
C.xray

A pancreatic pseudocyst is a circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic
tissue, typically located in the lesser sac of the abdomen. Pancreatic pseudocysts are usually complications of
pancreatitis,[4] although in children they frequently occur following abdominal trauma. Pancreatic pseudocysts
account for approximately 75% of all pancreatic masses.[5]
Signs and symptoms of pancreatic pseudocyst include abdominal discomfort and indigestion

56. 45 years old female got Upper abdominal pain for about 45 minutes on the morning and now comes to clinic.
She got similar pain last month which is less severe than recent attack. On examination, No pain, no tenderness,
no mass. CT scan done and shown. What is the diagnosis?

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 A. Right adrenal haemorrhage
B. Hydatid cyst
C. Gall stones(ans)
D. CA HOP (head of pancreas)

Pancreatic pseudocyst ct

Ca pancreas

Ct gall stone

57. 28 weeks gestation with RUQ pain and headache.BP normal.Diagnosis?dx: biliary colic(cause)
a. Cholelithiasis(ans)
b. Pre eclampsia
c. Acute cholecystitis: pain+nausea + vomiting+fever+Murphy’s sign positive

58. Pancreatic pseudocyst 10cm after some episode of pancreatits,what is your management?
A)endoscopic cyst gastrostomy
B)laparotomy with drainage
C)ERCP with pancreatic duct drainage

Endoscopic cystgastrostomy (ECG) or duodenostomy (ECD) are methods of choice if the pseudocyst is not communicating
with the pancreatic duct. (Amedex)

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59. A 34-year-old alcoholic man presented with acute
pancreatitis and developed mild discomfort in the
epigastrium 3-4 weeks later. CT abdomen showed 4cm
pseudocyst. What will you do next?
a. Endoscopic decompression
b. Open surface decompression
c. Observe :(ans)
d. Percutaneous catheter drainage
e. Urgently take him to surgical theatre

ans:C.for cyst less than 6cm n present fot less than 6 weeks
you observe for spontaneous resolution.

60. 65 years old Asian Australian man comes to the clinic

for a follow up Appointment for symptoms of
dysphagia . He has difficulty of swallowing solid food
off and on for the past year. He has no difficulty swallowing liquids or pills . He has no significant medical
problems and his only medication is an occasional Aspirin for arthritis pain in his knees. He has no history of
smoking but drinks wine in every week.xray has done and showing one of the following risk for developing of
1.Barrett's oesophagus (diagnosed by endoscopy guided biopsy)
2.Esophageal cancer (x-ray barium swallow)
3.Gastric ulcers
4.Gastroesophageal reflux
5.Zencker's diverticulum

dysphagia only for solids that's go with ca oesophagus

for Zenker diverticulum need to present dysphagia for both solid & liquid
In carcinoma its progressive dysphagia so it would have any history of first dysphagia to solid then liquid

61. Scenario of pancreatitis….long stem…asking for common complication?

a. Ch. Pancreatitis
b. pseudocyst(ans)
c. P. abscess
d. P. carcinoma.
62. scenario of pancreatic pseudocyst , it protrudes through stomach. What is the management?
- drainage by ERCP
- endoscopic gastrostomy
- percutaneous aspiration

63. Pancreatic pseudocyst Mx

a) Laparotomy + drainage (Gastrostomy)
b) Endoscopy + Gastrostomy(ans)
c) ERCP + Pancreatic duct drainage

Endoscopic cystgastrostomy (ECG) or duodenostomy (ECD) are methods of choice if the pseudocyst is not
communicating with the pancreatic duct. (Amedex) if communicating = transpapillary ERCP

#git
64. CT of abdomen after acute abdominal pain for a week. Patient consumes a lot of alcohol. large mass on mid- left
abdomen, next to liver.
a) pancreatic pseudocyst?(ans)
b) hepatoma
c) cancer: upper abd pain+ jaundice+ wt loss

65. :acute pancreatitis scenario,lipase3200,when to do CT scan

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 A. Immediately
B. ,after 2days,
C. More clinical deterioration

Indications for “pancreatic protocol CT scan” (rarely in

1st week)
• For significant clinical deterioration and elevated CRP
• For suspicion of local pancreatic complications
• For suspected bowel ischemia
• For acute bleeding (CTa) (if stable enough & consider
embolization)
• For abdominal compartment syndrome

66. ct of acute pancreatitis with abd pain radiating to back what is most app next inv
a. ct abd
b. usg abd

CT is not necessary for all patients, particularly those deemed to have a mild attack on prognostic criteria.
However, a contrast- enhanced CT is indicated in the following situations:
• if there is diagnostic uncertainty;
• in patients with severe acute pancreatitis, to distinguish interstitial from necrotising pancreatitis (Figure 68.22).
In the first 72 hours, CT may underestimate the extent of necrosis.
The severity of pancreatitis detected on CT may be staged according to the Balthazar criteria;
• in patients with organ failure, signs of sepsis or progressive clinical deterioration;
• when a localised complication is suspected, such as fluid collection, pseudocyst or a pseudo-aneurysm.

67. pt presented with features of acute pancreatitis.what's the best time to use CT
a.now
b.within 24 hrs
c.within 2days
d.within one week
according to Medscape CT is indicated if no rapid improvement after 72 hours of conservative treatment.

5) Acute pancreatitis scenario .lipase >2500. Asking when should a ct scan be performed.
A) Now
B)Within 24 hours.
C After 2 days
D) After 1 week
E) When clinical condition deteriorates

according to Medscape CT is indicated if no rapid improvement after 72 hours of conservative treatment.

after 72 hours exactly or deterioration of pts condition

68. Which of the following parameters effectively rules out severe disease in acute pancreatitis?
A. Haematocrit
B.Leukocyte count
C.Amylase levels

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 D.Lipase levels

69. restraining a person with severe abdominal pain due to acute pancreatitis, after security has arrived
a)oral benzodiazepine
b) im haloperidol
c)iv diazepam

567
568
70. child with nephrotic syndrome treated with steroid developed hypertension , diffuse abd pain and vomiting for 1
week ,afebrile
An acute pancreatitis
B acute pyelonephritis
C renal artery stenosis (ans)

C- renal artery stenosis can present as NS, HTN, failure to thrive, hyponatraemia. After treatment with steroid NS
related proteinuria resolved but hypertension will persist like this case.
https://www.researchgate.net/.../10849000_Renal_artery..

71. Acute pancreatitis scenario .lipase >2500

Asking when should a ct scan be performed.
a, now
B. Within 24 hours.
C after 2 days (ans)

72. Acute gallstone pancreatitis with no features of obstructive jaundice asked most appropriate plan of mx
a. Ct abdomen
b. Elective cholecystectomy now(ana)
c. Elective cholecystectomy after 2months
569
** Laparoscopic cholecystectomy with preoperative endoscopic CBD clearance is recommended as a treatment of
choice for biliary acute pancreatitis. In mild disease, this is performed safely within seven days, whereas in severe
disease, especially in extended pancreatic necrosis, at least three weeks should elapse because of an increased
infection risk.
UK guidelines for gallstone pancreatitis advocate definitive treatment during the index admission, or within two
weeks of discharge

73. A 50-year old man presents with sudden onset of severe abdominal pain. Which of the following is least likely to
be the cause?
a) Acute appendicitis (due to age)
b) Perforated peptic ulcer
c) Acute pancreatitis
d) Ruptured abdominal aortic aortic aneurysm
e) Renal colic (ans)

The hallmark of a stone that obstructs the ureter or renal pelvis is excruciating,
intermittent pain that radiates from the flank to the groin or to the inner thigh.[11]
This pain, known as renal colic, is often described as one of the strongest pain
sensations known.

74. In emergency department man presents with severe upper abdominal pain and
shock.abd rigid.what is the cause.
a. Acute pancreatitis
b. Perforated duodenal ulcer
c. Perforated peptic ulcer
it's more common n due to its arterial supply
Symptoms and signs of acute pancreatitis
The most common symptoms and signs include:
570
 • severe epigastric pain (upper abdominal pain) radiating to the back in 50% of cases
• nausea
• vomiting
• loss of appetite
• fever
• chills (shivering)
• hemodynamic instability, including shock
• tachycardia (rapid heartbeat)
• respiratory distress
• peritonitis
• hiccup

75. 45-year-old female is diagnosed with acute pancreatitis and deranged function test. past medical history include
hypertension, type II diabetes mellitus and gallstones. abdominal ultrasound was done which showed stone in
the common bile duct with mild dilation? what is the appropriate next step?
a. magnetic resonance cholangiopancreatography
b. ERCP(ans)
c. CT abdomen
d. monitor liver function test
e. repeat ultrasound by a senior radiologist

76. child with nephrotic syndrome treated with steroid developed hypertension , diffuse abd pain and vomiting for 1
week ,afebrile
A acute pancreatitis
B acute pyelonephritis
C renal artery stenosis

77. Which one of the fallowing is not a complication of acute pancreatitis ?

a. Hyperglycaemia
b. Hypocalcemia
c. Hypercalcemia(ans)
d. Prerenal azotaemia

Systemic complications of acute pancreatitis

include ARDS, multiple organ dysfunction
syndrome, DIC, hypocalcemia (from fat
saponification), hyperglycaemia and insulin
dependent diabetes mellitus (from pancreatic
insulin-producing beta cell damage),
malabsorption due to exocrine failure
• Metabolic
• Hypocalcaemia, hyperglycaemia,
hypertriglyceridemia

78. acute pancreatic scenario .lipase 3200 .what u do ct?

1.immediately
2.afterv24:hour
3.after 2 days (72 hrs) ans
4.after 3 days
5.more clinical deteriorate
79. Epigastric pain and tenderness followed by episodes of repeated vomiting and nausea along with muscle
guarding and shock.Diagnosis?
a. Acute pancreatitis
b. Perforated peptic ulcer (ans)

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80. WOF is most likely occur in the 24 hours of acute pancreatitis?
a. Heart failure
b. Renal failure
c. Lung failure(Ans) ards Here is C answer...
d. Pseudocyst
e. Pancreatic disease

(1)lung failure 45%

2)hepatic 18%
3)cardiac 17%
4)renal 16%)

81. man had a fun night , drank heavily with friends, after drinks, had pizza and
then vomited . he felt pain in epigastrium after vomit. abdomen is mild
tender and pain around stern notch. whats dx.
A. oesophagus rupture
b. Mallory Weiss
c. acute pancreatitis

82. Another obst quiz about obese pregnant lady in 3 trimester presents with severe headache, feverish,BP 150/100,
tachycardia, severe RUQ pain, no vaginal bleeding, foetus is intact, heart tone is normal. Liver isn't palpable.
Don't remember blood film
1- acute cholecystitis
2- pancreatitis
3- HELLP( I pick this one )

572
 HELLP usually begins during the third trimester; rare cases have been reported as early as 21 weeks gestation.
Often, a woman who develops HELLP syndrome has already been followed up for pregnancy-induced
hypertension (gestational hypertension) or is suspected to develop pre-eclampsia (high blood pressure and
proteinuria). Up to 8% of all cases occur after delivery.

Women with HELLP syndrome often "do not look very sick." Early symptoms can include:

In 90% of cases, either epigastric pain described as "heartburn" or right upper quadrant pain
In 90% of cases, malaise
In 50% of cases, nausea or vomiting.
There can be gradual but marked onset of headaches (30%), blurred vision, and paraesthesia (tingling in the
extremities). Oedema may occur but its absence does not exclude HELLP syndrome. Arterial hypertension is a
diagnostic requirement but may be mild. Rupture of the liver capsule and a resultant hematoma may occur. If a
woman has a seizure or coma, the condition has progressed into full-blown eclampsia.

83. A middle-aged man presented with central abdominal pain radiating to the back. During the attack he becomes
hypotensive , after 6 hours he returns to normotensive. This is happening for last 6 months, what can be the
cause?
a) Acute pancreatitis
b) Leaking(rupture/dissection) aneurysm
c) Ureteric calculus
d) Mesenteric ischemia
e) Mesenteric adenitis

84. 58yr old man returned from Thailand after 2 weeks holiday with his wife. Now presents with fever, malaise, pain
in the right upper quadrant. His lab findings were given with a big list of all the FBE, LFTs, etc. Almost all his LFTs
raised. GGT was very high. Whats the diagnosis?
a. Hepatitis A( if liver funct less altered)
b. Cholangitis (Ans) (if liver func more altered)
c. Liver abscess
d. Acute pancreatitis
e. Cholecystitis

85. CT of abdomen after acute abdominal pain for a week. Patient consumes a lot of alcohol. large mass on mid- left
abdomen, next to liver.
a) pancreatic pseudocyst? (ans)
b) hepatoma
c) cancer
86. Chest pain radiating to epigastrium with sign of shock and sever vomiting ,, cause
a. Perforating gastric ulcer
b. Penetrating duodenal ulcer
c. Acute pancreatitis

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 d. Cholestasis
87. Mesenteric ischemia best seen in (contro)
A. Erect abdominal x ray.
B. Supine abdominal x ray
C. Ultrasound

Ans. Ct

Mesenteric artery occlusion x-ray

Thumb-printing may be seen in:

I. inflammatory bowel disease

II. Crohn disease
III. ulcerative colitis
IV. infection (i.e. pseudomembranous
colitis)
V. ischaemic bowel
VI. diverticulitis
VII. mucosal/submucosal haemorrhage 2
VIII. lymphoma
IX. amyloid
X. typhlitis

88. man comes with pain in epigastric and small pulsation is seen too. He has vomited and has developed pain after
last night heavy drinking and eating. Suddenly he developed this and now presenting to u in early morning ,
chest is clear, something felt at suprasternal notch ,what is likely diagnosis:
a. oesophageal rupture...(Ans)
b. Mallory Weiss tear.
c. acute pancreatitis
d. duodenal ulcer rupture

The Mackle triad defines the classic presentation of Boerhaave syndrome. It consists of vomiting, lower
thoracic pain, and subcutaneous emphysema.
Presentation may vary depending on the following: The location of the tear the cause of the injury the
amount of time that has passed from the perforation to the intervention Patients with cervical oesophagus
perforation may present with neck or upper chest pain. Patients with middle or lower oesophagus
perforation may present with interscapular or epigastric discomfort.
Findings of pleural effusion are common. If present, subcutaneous emphysema is particularly helpful in
confirming the diagnosis. Subcutaneous emphysema is seen in 28-66% of patients at initial presentation.
More typically, subcutaneous emphysema is found later. Other classic findings include tachypnea and
abdominal rigidity. Tachycardia, diaphoresis, fever, and hypotension are common, particularly as the illness
progresses. However, these findings are nonspecific.

http://emedicine.medscape.com/article/931141-
clinical?pa=nT83hSJEf6bHYKLzbrTaf3WePwywSW69rxqPfyex1ZWrt6EjrSovFbr9RNKg%2FWc6AFM0ZITeA0MTO4MEQ
MsLUgf1%2FT5AOtgCo%2FGiWn3Mk%2BU%3D#b4

89. A 55 yr male pt. presented with recurrent epic. Pain that is radiating to the back , lasting 3 - 4 hours each time
and has no relations with specific trigger ,, his ECG , S. Amylase , S. Lipase , troponins and Abd U/S are normal ,,
what is the most likely diagnosis ?(contro)

574
a ) Oesophagitis
b) acute coronary syndrome
c) duodenal ulcer
d ) cholecystitis
e ) pancreatitis
It is chronic pancreatitis... epigastric pain radiating to back in a
bandlike fashion. intermittent pain that gradually becomes worse,
normal amylase lipase (or just slightly elevated) ... sono shows
calcifications in only 60-70%. pain may or may not be brought on by
eating. ACS is ACUTE. Troponin is normal. DU ulcer is worse with
hunger and better after eating. Cholecystitis is unlikely to be missed
on US and esophagitis presents with dysphagia/odynophagia. Phagia
(eating) is a trigger isn't it?

90. What is the most common cause of intestinal obstruction in an

abdomen without any previous abdominal surgery in Australia?
A- Internal hernia
B- Groin hernia
C- Malignancy
D- Volvulus
E- Intussusception

91. Chest x scenario of intestinal obstruction but there is calcification in chest and near hilum asking about the cause
of symptoms,
A-tb (Ana)
B-fecalith

tb cause calcification of lung,pt may have intestinal tb as well. Intestinal tb pt. most commonly present with
intestinal obstruction feature. Ileum is more commonly involved.

575
92. An X ray abdomen was given with very obvious small intestinal
obstruction. They had given a history of vomiting etc as well, but
they had asked for the next best investigation.
1.Barium swallow (oesophagus)
2.Barium follow-through (ans)
3. Barium enema

93. old male on observation for conservative treatment for Intestinal

obstruction, what happen will indicate urgent intervention ?
a.constant pain
b.high grade fever
c. back pain
94. The cardinal feature of intestinal obstruction includes all except
A. Abdominal pain and cramping
B nausea vomiting
Curable to pass stool and flatus
D abdominal guarding(ans)
E abdominal fullness gaseous distension
95. A 54-year-old Pt with DM, AF operated for intestinal obstruction
developed abdominal distension in 4th POD. His Serum Na 135, K
3.1, Cl 80 urine output 40cc/hr. X ray given. What will you do next
other than NPO & nasogastric suction.?
A. K Supplement
B. Heparin
C. Reopen
D. Observe
E. Endoscopic decompression

Paralytic ileus after surgery develop---metabolic alkalosis.

mx---1…NG suction
2…K correction

operative fever= post operative agitation:

Causes:
1st day -2nd day………atelectasis
2-3 days………endometritis or UTI or pneumonia
5-7 days…….PE, DVT
5-7 days……wound infection
After 10 days……abscess
After 2 weeks……mastitis

96. scenario came with abdomen obstruction small intestine obstruction (x ray clear) asking best next step
- nasogastric decompression
- barium enema
- US abdomen
- x ray erect and supine
#May
97. Patient is presenting with severe central abdominal pain.,with mild nausea.,no vomiting, no abdominal
distension. Mild tenderness is present on exam. No rebound tenderness on release.
You admitted him and gave fluids. USG was unremarkable. X ray Erect view showed mildly dilated small bowel loops.
Now he suddenly developed sharp severe abdominal pain which is localized with focal tenderness... And pain is
being localized to one point. He recently developed back pain. What is your diagnosis?
a. Simple intestinal obstruction
b. Intestinal obstruction with perforated viscus
c. Localized bowel loop obstruction with secondary ischemia

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 d. Other irrelevant options
98. #GYNOBS
pregnant woman 20 weeks starts to have pain in the right iliac fossa specially when she stands up or cough, she had
appendectomy when she was 12-year-old , what’s most likely the diagnosis ?
a. Round ligament pain
b. Complex ovarian cyst
c. Ectopic pregnancy
d. Intestinal obstruction

99. A patient comes with history of stricturoplasty for Crohns disease. Six months ago he was started on warfarin
after an episode of pulmonary embolism. Now presents with right iliac fossa tenderness. Rest of the examination
is normal. What is your diagnosis?
a. Mesenteric adenitis
b. Rectus sheath haematoma(Ans)
c. Intestinal obstruction
d. Peritonitis
A rectus sheath hematoma is an accumulation of blood in the sheath of the rectus abdominis muscle. It causes
abdominal pain with or without a mass. Causes of this include anticoagulation, coughing, pregnancy, abdominal
surgery and trauma.

100. A mom brings her 6 weeks child to your clinic as he recently starts to vomit out the milk he’s drinking with no
bilious. He’s been developing well until last week when he stopped gaining weight. On examination there is no
abdominal pain and no palpable masses. What do you think is the diagnosis?
A- Gastroesophageal reflux (Ans)
B- Pyloric stenosis (mass)
C- Urinary tract infection
D- Intestinal obstruction
E- Duodenal atresia

101. Old patient with abdominal distention and nausea, no

vomiting, he’s unable to pass stool or flatus, he has history
of appendectomy. Abdominal X-ray given showing large
bowel obstruction. what’s the cause?
a. small intestinal adhesions
b. fecal impaction
c. cancer colon (ans)

102. Scenario of old lady with abdominal distention, vomiting & on medications for hypertension & diabetes , had
AF , asking what`s mostly the cause of abdominal manifestations?
a) intestinal tumour
b) ischemic bowel(Ans)
c) other causes of intestinal obstruction

577
103. whats the final answer fo these three question plzz. Old patient with iloischial abscess, has this problem
recurrent many times, what s the cause?(contro)
A. Anal fistula jm-388
B. Diverticular disease — perianal abscess
C. Crohns ……bcz of recurrence
D. Diabetic
E. Immunodeficiency disorder
anal fistula is most recurrent in old age,
if young and ischiorectal then Crohns disease
cause if fistula is abscess

104. pregnant woman 10 weeks starts to have pain in the right iliac fossa specially when she stands up or cough,
she had appendectomy when she was 12-year-old , no rebound tenderness and guarding. wts most likely the
diagnosis
a. Round ligament pain …….get better with walking (ans) in 1st trimester
b. Complex ovarian cyst
c. Unruptured Ectopic pregnancy
d. Intestinal obstruction

105. similar but confusing qs: Child with intermittent abdominal pain between attacks he is ok, attacks usually
last couple of hours and subside, this time he came with the same pain on RUQ and also a mass ,pain lasted 12 h
this time, no fever .dx (contro)
Hepatoblastoma— Old ans
Neuroblastoma
Wilms(can’t cross midline)
Pyelonephritis
Ans—should be PUJ obstruction. — No age mass description Cant figure out

578
579
580
106. 4year old boy with a 2-year history of vomiting and abdominal pain, now presents with abdominal pain and a
right upper quadrant mass, what's the most
likely diagnosis?
A. Wilm's tumour.
B. Neuroblastoma.
C. Hepatoblastoma.
D. PUJ obstruction. (ans)

Symptoms of UPJ obstructions include:

• The renal pelvis and/or kidneys are

dilated (hydronephrosis)
• Urinary tract infection.
• Abdominal mass.
• Vomiting.
• Poor growth in infants (failure to
thrive)
• Back pain.
• Flank pain.

107. pt with abdominal pain he is 4 years old

, pain recurrent for last 2 years , last attack (contro)
was in left flank inv:
A.us during attack (ans)
B. micturating cystogram
C.erect and supine X-ray
D. small intestine meal and follow
E. electrolytes and urea , creatinine
Ans. USG. DD: PUJ obstruction or VUR

108. Renal transplant patient. No urine output so has to do haemodialysis for 7 days. What's the cause? No fever,
no pain and tenderness.
A. Acute graft reaction.
B. Acute tubular necrosis (ana)
C. UTI D. Catheter Obstruction

581
109. A male maybe 50 years with H/O renal transplant for 10 years. has fever, headache, neck stiffness n rigidity.
CXR explained in q as round opacity on middle lobe. Dx? (contro)
a. TB
b. aspergillosis
c. lymphoma…as 10 years
d. pneumocystis pneumonia

The most common organ affected by aspergilloma is the lung. Aspergilloma mainly affects people with underlying
cavitary lung disease such as tuberculosis, sarcoidosis, bronchiectasis, cystic fibrosis and systemic immunodeficiency.
Aspergillus fumigatus, the most common causative species, is typically inhaled as small (2 to 3 micron) spores. The
fungus settles in a cavity and is able to grow free from interference because critical elements of the immune system
are unable to penetrate into the cavity. As the fungus multiplies, it forms a ball, which incorporates dead tissue from
the surrounding lung, mucus, and other debris.[3]
Xrayx

x-ray aspergilloma

Xray tb

582
110. A 43-year-old man comes to you with decision of donating his kidney after watching a TV program about
kidney transplantation last week, after assessing that it's not a delusional idea, what in the history will lead you
to provide him with the appropriate advice?
A. His wife hasn't approved this idea.
B. His financial situation.
C. His family history of diseases.
D. Other altruistic behaviours. (ana)
E. "Irrelevant thing"

111. A living donor kidney transplant is assessed after OT. Doctor said, he will recover well, which ego
mechanism?
a. Repression(unintentionally forgetful)
b. Reaction formation(hypocrisy)
c. Altruism(ans)
d. Sublimation(fulfil gratification in socially acceptable way)
e. Introjection(follow someone subconsciously)

112. Child coming for vaccine, her sister done renal

transplant. Which vaccine should be avoided in that
child?
A. Opv(Ans)-herd immunity
B. Measles

113. Patient had kidney transplant from cadaver.No

urine output till the 7th post operative day ,requiring
dialysis.What is the cause? (contro)
a. Acute rejection
b. Blocked catheter
c. Ureteric obstruction
d. Donor venous thrombosis
Ans: acute tubular necrosis

114. 25-year-old woman has a blood pressure of 160/90 mmHg at week 10 of her first pregnancy. She had
recurrent urinary infections in childhood. Her urinalysis shows protein but no blood. Her blood tests show:
Haemoglobin 109 g/L
Serum urea 7.5 mmol/L
Serum creatinine 125 μmol/L
What is the most likely cause of her hypertension?

A Chronic glomerulonephritis
B Chronic pyelonephritis(ans) (recurrent UTI +HTN +poor kidney function)

583
C Essential hypertension
D Pre-eclampsia
E Renal artery stenosis

Chronic pyelonephritis finding:

Urinalysis results may reveal pyuria. Obtain a urine culture, which often isolates
gram-negative bacteria, such as Escherichia coli or Proteus species. A negative
result from urine culture does not exclude a diagnosis of chronic pyelonephritis.
Proteinuria may be present and is a negative prognostic factor for this chronic
pyelonephritis. Serum creatinine and blood urine nitrogen levels are elevated
(azotemia).

#Nephro #Renal #Kidney

115. Unilateral Renal Artery Stenosis with Htn
Ace Inhibitor (ans)
Beta Blockers
Stent

116. Young lady with unilateral renal artery stenosis with hypertension. She said she doesn't want to get
operated. mx?
a. calcium channel blocker
b. beta blocker
c. acei
d. frusemide
e. diuretics.
Can given in bilateral renal artery stenosis
1.diuretics
2.ca channel blocker
3.Beta blocker with caution

117. patient with ckd creatinine 0,2 (normal less then o.1)admitted (reason I forgot)…creatinine raised to 0.35
after 2 days, cause no other history that was stem
1: renal artery stenosis
2: urine retention
3 urine infection
4: dehydration(ans) (if patient presented with diarrhoea and vomiting)
5. acute interstitial nephritis( with fever and hematuria)

Acute interstitial nephritis could be answer with haematuria, fever,oliguria

584
 Acute tubular necrosis (ATN) is a medical condition involving the death of tubular epithelial cells
that form the renal tubules of the kidneys. ATN presents with acute kidney injury (AKI) and is one of
the most common causes of AKI.[1] Common causes of ATN include low blood pressure and use of
nephrotoxic drugs.[1] The presence of "muddy brown casts" of epithelial cells found in the urine
during urinalysis is pathognomonic for ATN.[2] Management relies on aggressive treatment of the
factors that precipitated ATN (e.g. hydration and cessation of the offending drug). Because the
tubular cells continually replace themselves, the overall prognosis for ATN is quite good if the cause
is corrected, and recovery is likely within 7 to 21 days.[1]

118. A 52-year-old alcoholic man, presents with ankle oedema, distended abdomen, urine protein ++, blood + bp
high, with past history of MI? What’s the diagnosis(contro)
A CHF
B Ac nephritis
C Renal Artery stenosis
D Nephrotic Syndrome
E Liver cirrhosis

**hint nothing like azotemia or oligourea or even the haematurea is so low plus no causative agent
findings ... it’s not nephrotic either bcz proteinuria is not in that range plus it’s not chef as it could
not cause haematurea or proteinuria... neither CLD present this way ... we can go for stenosis bcz
mi shown their is atherosclerotic disease plus low grade proteinuria is possible plus no classic
findings have been given like resistant hypertension or flush pulmonary edemaa
Ans: chronic glomeruli nephritis

585
119. #Nephro final answer please
1. soldier with routine health check high bp.creatinine and urea increases .with a family renal disease.dx?
a.Alport syndrome
b.CKD(discovered on routine health screening)
c.renal artery stenosis

Alport syndrome is a genetic disorder[1] affecting around 1 in 50,000 children, characterized by

glomerulonephritis, end-stage kidney disease, and hearing loss, hematuria

Alport syndrome is a genetic condition characterized by kidney disease, hearing loss, and eye
abnormalities. People with Alport syndrome experience progressive loss of kidney function. Almost all
affected individuals have blood in their urine (hematuria), which indicates abnormal functioning of the
kidneys

586
Other causes of kidney disease
Other causes of kidney disease include
• a genetic disorder that causes many cysts to grow in the
kidneys, polycystic kidney disease (PKD)

120. 2 yr old with haematuria and hypertension.history of recurrent

nephrotic syndrome ( thrice in the last 18 months). Symptoms
unresponsive to steroids.Diagnosis?
A) Iga nephropathy
😎 PSGN
C)vesicoureteral reflux
D) Family history of kidney disease
E) flank non tender mass
Ans: focal segmental glomerulosclerosis

I checked again it's in adolescent group ... Looking at question

again I found family hx which makes me think about thin GbM
disease with hypertension haematuria and nephrotic range
proteinuria so I think I will change to D...recurrent UTII made me
think of C

Polycystic kidney disease (PKD or PCKD, also known as

polycystic kidney syndrome) is a genetic disorder in which
the renal tubules become structurally abnormal, resulting
in the development and growth of multiple cysts within
the kidney.[5]
Signs and symptoms include high blood pressure,
headaches, abdominal pain, blood in the urine, and
excessive urination.[3] Other symptoms include pain in the
back, and cyst formation (renal and other organs).[7]

Presentation of iga nephropathy

587
121. 4 years old boy with hematuria, proteinuria and hypertension now, who initially
responded to steroids. Diagnosis?
A- PSGN
B- Minimal change disease( if responding to steroid)
C- FSGN
D- Anti GBM disease

If responding to steroid now choose minimal change disease

And not responding to steroid anymore then fsgn

122. renal artery stenosis with pregnancy hypertension.

Methyldopa(Ans)
beta blocker
perindopril
#april2016
123. CARDO #PHARMA All of the following are contraindications to ACEI use except
A. Bilateral renal artery stenosis
B.pregnancy
Angioedema
Cough(Ans)

124. young female with unilateral renal artery stenosis with hypertension. mx?
a. calcium channel blocker
b. beta blocker
c. acei(Ans)
d. frusemide
d. diuretics.
C....Acei DOC in unilateral CI in bilateral Renal artery stenosis

125. soldier with routine health check high bp.creatinine and urea increas.with a family renal disease.dr?
a.Alport syndrome:
b.pKD
c.renal artery stenosis
Renal stones
#renal
Ureteric stone disease management
In JM for more than 6mm ESWL is only mentioned
Racgp guidelines
1----- <5mm passes spontaneously
Conservative with analgesia
Repeat imaging after 6 weeks
2----->5mm
Definitive treatment is
Ureteroscopy laser lithotripsy which is now superior to ESWL
588
126. Which of the following tests is most sensitive & specific for the detection of renal stones ?
A Kub plain film
b ultrasound
c ivp
d non-contrast helical ct ?
589
 Renal stone --------non contrast helical ct
Borhave--------contrast ct

The diagnosis of Boerhaave's syndrome is suggested on the plain chest radiography and confirmed by chest
CT scan.
@easy rule first time renal calculi d ....
renal calculi on indinavir HIV pt. C.......
recurrent renal coli for position x-ray Kub n u/s
in preg fr recurrent u/s

127. kidney stones scenario Hematuria loin pain casts appropriate inv?
a. Xray (initial)
b. CT (app)
c. IVP
d. USG

128. Renal pelvis stone 2.5cm with dilated renal pelvis. Mx

asked: percutaneous nephrolithotrypsy
another ques:one stone with patient having severe pain,fever,1cm
stone at renal pelvis.mx asked: laser lithotripsy

129. Renal pelvis stone 0.5 cm. Next?

a. ESWL(ans)
b. PCNL
c. IVU
130. Renal stone .5mm in calyx, incidental finding in CT
Follow up
Lithotripsy
Stone less than 5 mm :95% will pass
Stone 5-7mm: 60%pass
Stone>7mm: minority will pass

131. Choice of Ix just before surgical approach of renal stone ??? X ray Kub

590
132. Indication of surgery in renal stone
1 severe pain persistent for more than 48 hr(ans)
2 stone near bladder
3 more than 5 mm
4 intermittent low-grade fever

133. Renal stone at distal site with urinary problems size was 4mm,what to do ?
A- ESWL
B- ureteroscopy with basket removal
Dx-ureteric stone
Our ans:conservative mx

134. 2 cm renal stone in pelvic brim. (means distal ureter).so Laser lithotripsy would be the best option. Eswl can
also be done but never pcnl.
Mx
a. ESWL(ana)
b. PCNL
135. A man c/o of loin pain . cxr showed 2.5cm stone in the renal pelvis. USS was done and nil hydronephrosis.
Next appropriate mgt?
A. Increase water intake and review in 4 wks

591
B. Percutaneous nephrolitothomy(Ans)
C. Dietary advice
D. Extracorporeal shockwave litosthoscopy
E. Review after one week?

136. 44 yr old man comes vid painless macroscopic

haematuria . Cause ? A. Ca bladder (ans) B. Rcc C.
Renal stone D. Pyelonephritis

RCC: Historically, medical practitioners expected a

person to present with three findings. This classic
triad[8] is 1: haematuria, which is when there is blood
present in the urine, 2: flank pain, which is pain on the
side of the body between the hip and ribs, and 3: an
abdominal mass, similar to bloating but larger.

592
137. A man previously presented with loin pain radiating to his groin. A non- contrast CT revealed 9mm renal
stone. He now presents with worsening pain. What is the investigation you must do on the way to the OT?
a) Contrast CT
593
 b) Plain x-ray (ans)
c) Ultrasound
d) MRI
138. Scenario Pt with HTN and IDDM.S/S of kidney stone. most appropriate inv for Dx?
A) KUB
B) USG
C) U/A
Ans : ct abdomen
139. Pt w ho renal stone surgery, I think. Some genitourinary minor procedure. Took amoxycillin. Now presents w
fever, chills (incomplete question)
1. Ceftriaxone
2. Amoxiclav

594
140. A 43-year-old man attends for review. His past medical history includes renal stones treated by lithotripsy,
and he also has type II diabetes. He is taking treatment for high cholesterol. He has been attending the clinic for
a number of months with long-standing pain and swelling in his fingers. This is the clinical appearance of his
hands:
What is the most likely diagnosis? (incomplete without pic)
a. Calcinosis
b. Gout
c. Pseudogout
d. Psoriatic arthropathy
e. Rheumatoid arthritis (ans)

Pseudo-gout
Swollen joint that's warm to the touch
Red or purple skin around the joint
Severe tenderness around the joint (even the
slightest touch or pressure may bring extreme pain)
Pseudogout affects both men and women. Like gout,
pseudogout occurs more frequently in people over age 60. People who have a thyroid condition, kidney
failure, or disorders that affect calcium, phosphate, or iron metabolism are at increased risk for pseudogout.

595
596
141. One x-ray was given with small black spots in small bowel –
and had pain in left iliac and hypochondrium(rt) and dx was asked :
a. appendectomy
b. gall stone metastasis in ileum (stone ileus) (Ans)
c. perforated duodenal ulcer
d. renal stone disease
142. 45 years old pt with painless hemauria and history of difficult
micturition with some weight loss
a. UB cancer(ans)
b. RCC
c. Prostatic cancer
d. BPH
e. Renal stone

#SURGERY
143. Here another stem A man 42 yrs,with a calculus 4mm at the right uretero-vesicular junction, his right ureter
,pelvicalyceal system are dilated due to mild hydronephrosis. what will be your next step in the management ?
a. ESWL
b. PCNL
c. Ureteroscopy with basket removal of stone
d. Ureteroscopy with removal of stone and placement of a stent
e. Cystoscopic removal of stone

#renal
144. patient with pancreatic carcinoma and jaundice asks for investing ???
a. CT abd
b. MRCP
c. ERCP

597
145. 87y old patient with advanced pancreatic carcinoma not fit for surgery. Son is the only relative without any
power of attorney asking for surgery. What to do,
A. Do surgery
B. Guardianship court (ans)

598
146. 4 yrs old with pain RUQ for 2 years weight loss and loss of appetite mass in RUQ .mother with FAP dx?
599
 A. Hepatoblastoma(Ans)
B. Wilms tumour
C. Hepatocellular carcinoma
D. Pancreatic tumour
E. Neuroblastoma

147. Which carcinoma has the worst prognosis ?

a. Breast CA
b. Adenocarcinoma colon
c. Gastric CA
d. Adenocarcinoma pancreas (ans)

148. Patient with the history of biliary stent with carcinoma

of head of pancreas. Now presented with fainting shock.
Urine is totally dark colour. What is the cause?
Rupture of bile duct (rare)(contro)
Worsening of obstruction due to increased size of
pancreas(amedex)

149. 50 years old male with family history of cancer

pancreas. He’s normal and healthy but coming for regular
screening. What screening test will you recommend?
A. CEA
B. CA 19-9
C. FOBT
#SCREENING
150. Epigastric pain, fever. Started central and now is
general. Rebound tenderness.
a) Cholecystitis
b) Cholelithiasis
c) Pancreatitis (ans) . rebound tenderness
d) Duodenal ulcer

151. Cholelithiasis USG finding:

a. Thick wall with pericholecystic fluid
b. Collapsed gall bladder

152. 28 weeks gestation RUQ pain and Headache : BP normal asking

Dx:
a. Cholelithiasis
b. Preeclampsia(as bp normal)
c. Acute cholecystitis (no fever)

153. Most common cause of biliary tract obstruction in tertiary care

1. Ercp —— in hospital setting
2.cholelithiasis
3.strictures

Gallstones are a common cause of bile duct obstruction. They can form when there is a chemical imbalance
in the gallbladder. If they are large enough, they may block a bile duct as they pass through the biliary
system

154. A 35 yrs old woman having severe sudden abdominal pain throughout the night wakes up and passes dark
urine in the bathroom. She immediately goes to see the doctor. Investigation showed:
Bilirubin: 5x the normal
600
Alkaline phosphatase: 4x the normal
AST and ALT: 4x the normal
S. amylase: 2x the normal
What is most likely diagnosis?
a. acute cholelithiasis
b. acute cholecystitis
c. Ca gall bladder
d. Acute choledocholelithiasis(ans)
in obstruction –increase ALP
#gastro
155. According to hierarchy of study, what will be least significant in study of cholelithiasis treatment?
a) Cohort
b) Case control
c) Cross sectional
d) System review
e) Case report(ans)

156. Testicular tumour. AFP raised , what another marker will u check ?? (HCG or LDH)
LDH has low specificity for seminomatous gct

601
157. 32wks pregnant with headache for 24hrs and rt upper
quadrant pain.bp 140/90.PR normal. Nothing about urine analysis.
Asking dx.no hx of jaundice. Soft uterus. Fundal height 34wks??
A) cholestasis.
B) concealed placental abruption.
C)cholelithiasis.
D)pre eclampsia
After 20weeks of pregnancy,Systolic Bp>140 plus Rt Upper quadrant
pain or severe headache suggest the criteria of pre-eclampsia here

158. SBO diagnosis says in ques, no x-ray, central abdominal pain.

What can be the cause? no surgery history...
a) pancreatitis b)cholelithiasis (Ans) c)adhesion d)cholecystitis

159. Epigastric pain, fever. Started central and now is general.

Rebound tenderness.
a) Cholecystitis
b) Cholelithiasis
c) chronic Pancreatitis
d) Duodenal ulcer

160. Pt presents with 24 hrs hx of vomiting and abdominal pain

tenderness in lower abdomen. x-ray shows dilated small intestinal
loops with air fluid levels. Dx
(incomplete question)
a. Pancreatitis
b. Cholangitis
c. Cholelithiasis…no stone or pneumobilia in x-ray
plus only one site pain
d. Crohns ileitis(Ans)…should be with more s/s

161. Case of pseudocyst of pancreas:

a. ERCP with biliary drain
b. Endoscopic-cyst-gastrostomy
c. open cyst-gastrostomy

162. A guy after coming back from a trip suffering from

chronic diarrhea, no blood and mucus for 7 months,
weight loss for 6 kg but appetite is good, stool is
greasy and fat globules are seen, He has undergone
repeated tests for enteropathic organisms and all negative, also antigliadin and antiendomysial tests negative,
his B12 and iron level are also normal. What is most appropriate next management?
1) Colonoscopy and biopsy
2) Serum immunoglobulins
3) ERCP
4) Small bowel biopsy (ans) -dx tropical sprue
Jm-504

Tropical sprue
is a malabsorption disease commonly found in tropical regions, marked with abnormal flattening of the villi and
inflammation of the lining of the small intestine.[1] It differs significantly from coeliac sprue. It appears to be a more
severe form of environmental enteropathy.[2][3][4]

602
 Signs and symptoms
The illness usually starts with an attack of acute diarrhoea, fever and malaise following which, after a variable period,
the patient settles into the chronic phase of diarrhoea, steatorrhoea, weight loss, anorexia, malaise, and nutritional
deficiencies.[1][3] The symptoms of tropical sprue are:
• Diarrhoea
• Steatorrhoea or fatty stool (often foul-smelling and whitish in colour)
• Indigestion
• Cramps
• Weight loss and malnutrition
• Fatigue
Left untreated, nutrient and vitamin deficiencies may develop in patients with tropical sprue.[1] These deficiencies
may have these symptoms:
• Vitamin A deficiency: hyperkeratosis or skin scales
• Vitamin B12 and folic acid deficiencies: anaemia
• Vitamin D and calcium deficiencies: spasm, bone pain, numbness, and tingling sensation
• Vitamin K deficiency: bruises
Diagnosis of tropical sprue can be complicated because many diseases have similar symptoms. The following
investigation results are suggestive:
• Abnormal flattening of villi and inflammation of the lining of the small intestine, observed during an
endoscopic procedure.
• Presence of inflammatory cells (most often lymphocytes) in the biopsy of small intestine tissue.
• Low levels of vitamins A, B12, E, D, and K, as well as serum albumin, calcium, and folate, revealed by a blood
test.
• Excess fat in the faeces (steatorrhea).
• Thickened small bowel folds seen on imaging.
Once diagnosed, tropical sprue can be treated by a course of the antibiotic tetracycline or
sulphamethoxazole/trimethoprim (co-trimoxazole) for 3 to 6 months.[1][8] Supplementation of vitamins B12 and
folic acid improves appetite and leads to a gain in weight.[

163. A female middle aged had 3 episodes of biliary colic pain. History of jaundice and fever. USG revealed
multiple stones in the gall bladder. What is the most appropriate indication to do ERCP before cholecystectomy
in this patient?
a. Thickened gall bladder wall
b. Multiple small stones
c. Jaundice (don’t remember what exactly) (ans)
d. Thickness of bile duct 0.7 cm

164. 70 yr old woman with ca pancreas scenario with obstructive jaundice EF 20% what to do
a. Cholecystectomy
b. Choledocojeujenostomy
c. Whipple
d. Mrcp
e. Ercp(ans)
Ans : percutaneous transhepatic cholangiopancreatography

165. abdominal pain , jaundice, fever >> 2 Q one about next step management
a. us
b. ERCP (if cbd dilated)
c. MRCP

603
 Ø 2nd initial investigation
a. Us (ans)
b. Ct
c. ERCP
#GIT

1st us to detect intrabiliary radicle dilatation 2nd ercp for proper diagnosis and treatment if applicable

166. 78yo women pancreatic cancer with recurrent bile duct obstruction from Pancreatic tumour. Previously
inserted a stent in the common bile duct but obstructive symptoms occurred again; jaundice, conj bilirubin etc.
wat to do?
a)Palliative biliary bypass,
b)percutaneous hepatic drainage?
c)ERCP with stent change
Ans- should be percutaneous biliary drainage.

167. patient with pancreatic carcinoma and jaundice asks for investing ???
CT abd(ans)
MRCP
ERCP….if known pancreatic cancer

168. cholangitis scenario dx

a. ERCP
b. MRCP
c. USG
Initial USG
Best ERCP

169. A lady came from travel had right upper quadrant pain, temp 38.4 , dark urine sclera icteric best next step
a- us (initial)
b- ERCP and decompression as best
c- X-ray
d- surgery next is us ? best is ERCP ?
n patients with Charcot's triad and abnormal liver tests, we proceed directly to ERCP to confirm the diagnosis
and provide biliary drainage since immediate drainage is a life saving procedure. In patients with signs and
symptoms suggestive of acute cholangitis, but without Charcot's triad, we recommend transabdominal
ultrasonography to look for common bile duct dilatation or stones. If the ultrasound shows ductal dilation or
stones, it should be followed promptly (within 24 hours) by ERCP to provide biliary drainage (image 1 and
picture 1). If the aetiology of the obstruction remains unclear after ERCP, then cross sectional imaging
(computed tomography or magnetic resonance cholangiopancreatography [MRCP]) should be performed. ,
source

170. An obstructive jaundice scenario with C/F of jaundice fatigue loss of weight .O/E mass felt in right
hypochondrium. On US CBD is clear, normal Gallbladder. Next inv
A) ERCP
B)MRCP
C) CT(ans)

171. A man comes with pale stool and dark urine, jaundice, lost 3kg. Usg showed no stone in bile duct. But
common bile duct was dilated. Next investigation of choice?
A. CT. (ans)
B. ERCP.
Ct—best---------------pancreatic ca,pancreatitis,obstructed jaundice
Cholangitis with obstructive jaundice-----ercp(best)
Initially---usg
604
172. 75-year-old man come with complain of right upper quadrant pain. He has mild jaundice. USG was done
which showed no stone in the bile duct. However, the duct is dilated. Which of the following is the most
appropriate management?
A) MRCP (cause unclear and clinical suspicion of cbd stone)
B) Cholecystectomy
c)ERCP
D)X-ray
173. recent episode jaundice, rise in transaminase (hepatitis and liver cirrhosis)ultrasound: dilatation of CBD,
cholelithiasis have not dected. ( I think pt didn’t have abdominal
pain)
ERCP
CT scan (ans) (ca head of pancreas)
MRCp( suspected cbd stone)

174. A farmer came with pruritus’, dark urine, jaundice, Abdo

pain, what is the next investigations?
a. USG(ans)
b. ERCP
c. CT Abdo
next----usg
best----CT
175. GERD patient well control with PPI.what is the feature will
further Investi need ?
A. nocturnal cough
B. Regurgitation
C .present of dysphagia(ans) (stricture)
D. weight loss

176. peptic Ulcer bleeding episode. Two attempts done for haemostasis endoscopically but no success. Next?
a-Operate n Suture (ans)
b-Again try endoscope
c-Gastrectomy
d-heater probe
ERCP done------1…obstruction,2….jaundice…3….cholangitis……

**The indications for urgent surgery

include failure to achieve haemostasis endoscopically, recurrent bleeding despite endoscopic attempts at achieving
haemostasis (many advocate surgery after 2 failed endoscopic attempts), and perforation. Many authorities
recommend simple oversewing of the ulcer with treatment of the underlying H pylori infection or cessation of
NSAIDs for bleeding PUD. Additional surgical options for refractory or complicated PUD include vagotomy and
pyloroplasty, vagotomy and antrectomy with gastroduodenal reconstruction (Billroth I) or gastrojejunal
reconstruction (Billroth II), or a highly selective vagotomy.

Bleeding
For those with bleeding peptic ulcers, fluid replacement with crystalloids should be given to maintain volume in the
blood vessels. Haemoglobin should be maintained at greater than 70 g/dL through restrictive blood transfusion
because it has been associated with reduced rate of death. Glasgow-Blatchford score is useful in determining
whether a patient should be treated inside hospital or as outpatient. Intravenous PPI can give faster stomach
bleeding suppression compared to oral ones. A neutral stomach pH is required to keep platelet in place and to
prevent clot lysis. Tranexamic acid and antifibrinolytic agents are not useful in peptic ulcer disease.[14]
Early endoscopic therapy can help to stop bleeding by using cautery, endoclip or epinephrine injection. Treatment is
indicated if there is active bleeding in the stomach, visible vessel, or an adherent clot. Endoscopy is also helpful in

605
identifying patients suitable for hospital discharge. Prokinetic agents such as erythromycin and metoclopramide can
be given before endoscopy to improve endoscopic view. Either high or low dose PPI are equally effective in reducing
bleeding after endoscopy. High dose intravenous PPI is defined as bolus dose of 80 mg followed by infusion of 8 mg
per hour for 72 hours. In other words, it is the continuous infusion of PPI of greater than 192 mg per day.
Intravenous PPI can be changed to oral once there is no high risk of rebleeding from peptic ulcer.[14]
For those with hypovolemic shock and ulcer size of greater than 2 cm, there is a high chance that the endoscopic
treatment would fail. Therefore, surgery and angiographic embolism are reserved for these complicated cases.
However, there is a higher rate of complication for those who underwent surgery to patch the stomach bleeding site
when compared to repeated endoscopy. Angiographic embolization has higher rebleeding rate but has similar rate
of death when compared to surgery.[1

177. A man history of peptic ulcer presented with abdominal pain, tenderness, collapse, shock. Cause?
a. Gastric ulcer
b. perforated Duodenal ulcer(ans)
178. A patient presented with dyspepsia after several months of gastrectomy operation. This problem occurs
mostly after 30 min of taking food and also in breakfast after eating toast, cereal. What to do?
a. Use pillow during sleep
b. Revision (exact this word ) of gastrectomy
c. Ranitidine
d. Esomeprazole
e. Advice dietary change (ans)
Dx---dumping syndrome---dietary change

179. Pt has symptoms abdominal pain. Dx peptic ulcer

disease, urea breath test (-). After giving medication
what should be done next?
a. Esophagogastroduodenoscopy in 6 wk
b. Urea breath test in 6 wk
c. Reassure
d. Omeprazole

180. Peptic ulcer case with Hpylori positive , took triple

therapy (amoxicillin+metro+PPI) for a week or 10 days
(not sure) urea breath test still positive after completion
of course .asking the reason-
a. resistant to metronidazole
b. Resistant to amoxicillin

first line:ppi+clarithro+amoxycilin
or ppi+clarytho+metro JM 552

181. man who is a smoker, 15 cigarettes per day for last 10 years, complaining of epigastric pain which is colicky
in nature, now presenting with an acute abdominal pain. On examination succession splash is positive(goo).
Most likely diagnosis???
a) Gastric CA (ans)
b) peptic ulcer
c) oesophageal perforation
d) duodenal perforations

606
182. A patient comes to you with post prandial pain. a barium study (and
amylase levels and all were also there i guess) show no abnormality. he has
lost 14 kg weight as well. whats the diagnosis?
A peptic ulcer disease (ans)
B Cholelithiasis
C Cholecystitis

183. Pt with 6kg Wt. Loss and Dysphagia and Succussion Splash. Diag?
Colon Cancer
Stomach Cancer
Chronic Duodenal Ulcer

Signs and symptoms

Endoscopic image of linitis plastica, a type of stomach cancer where the entire
stomach is invaded, leading to a leather bottle-like appearance with blood coming
out of it.

Endoscopic images of the stomach cancer in early stage. Its histology was poorly
differentiated adenocarcinoma with signet ring cells. Left above: normal, right
above: FICE, left low: acetate stained, right low: AIM stained
Stomach cancer is often either asymptomatic (producing no noticeable symptoms)
or it may cause only nonspecific symptoms (symptoms that may also be present in
other related or unrelated disorders) in its early stages. By the time symptoms
occur, the cancer has often reached an advanced stage (see below) and may have
metastasized (spread to other, perhaps distant, parts of the body), which is one of
the main reasons for its relatively poor prognosis.[19] Stomach cancer can cause
the following signs and symptoms:
Early cancers may be associated with indigestion or a burning sensation (heartburn). However, less than 1 in every
50 people referred for endoscopy due to indigestion has cancer.[20] Abdominal discomfort and loss of appetite,
especially for meat, can occur.
Gastric cancers that have enlarged and invaded normal tissue can cause weakness, fatigue, bloating of the stomach
after meals, abdominal pain in the upper abdomen, nausea and occasional vomiting, diarrhoea or constipation.
Further enlargement may cause weight loss or bleeding with vomiting blood or having blood in the stool, the latter
apparent as black discolouration (melena) and sometimes leading to anaemia. Dysphagia suggests a tumour in the
cardia or extension of the gastric tumour into the oesophagus.
These can be symptoms of other problems such as a stomach virus, gastric ulcer, or tropical sprue.

184. 7 days old child comes with poor feeding and bile stained vomits. Delayed passage of meconium at day
4.birth at 36 wks and weight 2.5 kg.breast feeding and mild jaundice.abd distension present.cause?
a. Oesophageal atresia
b. Duodenal atresia
c. Hirschsprung disease (Ans)
d. Necrotising enterocolitis

185. 1-week old infant is brought to you with bile stained vomiting. The child has a history of passing meconium
on day 4 of birth. What is the appropriate diagnosis?
a. Meconium ileus
b. Duodenal atresia
c. Hirschsprung disease
d. Mid gut volvulus

186. Old patient with iloischial abscess, has this problem recurrent many times. On examination there is no
abnormal feature. what s the cause?
A. Anal fistula
607
B. Diverticular disease
C. Crohns disease (ischiorectal abscess)
D. Diabetic
E. Immunodeficiency disorder

infection is the main cause only 10% of anorectal abscesses may be caused by reasons other than anal gland
infection, including Crohn disease, trauma, immunodeficiency resulting from HIV infection or malignancy (both
hematologic and anorectal cancer), tuberculosis, hidradenitis suppurativa, sexually transmitted diseases, radiation
therapy, foreign bodies, perforated diverticular disease, inflammatory bowel disease, or appendicitis..so A would be
the answer.

187. A neonate aged 6 weeks presents with vomiting at night since 2 days, he has been gaining weight well
except for the last week, no dehydration, totally normal. Asking about diagnosis:
a- pyloric stenosis
b- hypothyroidism
c- GERD(ans)

188. mother complaints that her infant vomits after each feed, it started at 6 weeks of age, before that his growth
was normal, but he stopped gaining weight at 6 weeks of age, what’s the most probable cause:
a. GERD
b. pyloric stenosis(ans)
c. duodenal atresia
Pyloric stenosis is a narrowing of the opening from the stomach to the first part of the small intestine (the
pylorus).[1] Symptoms include projectile vomiting without the presence of bile.[1] This most often occurs
after the baby is fed.[1] The typical age that symptoms become obvious is two to twelve weeks old

189. A 4 yr boy with abd pain and vomiting on and off for 2 yrs. The episode resolves spontaneously usually
within 12 hours. He has been developing normally. Dx?
A. Meckel’s diverticulum
B. Malrotation with volvulus(Ans)----bilious vomiting, tender Abd, distended abd.inv---upper GIT contrast
study…(barium)
C. Pyloric stenosis
D. Duodenal atresia

B is the answer

A : Most common presentation if symptomatic is bleeding per rectum

C : Presentation 2-3 weeks after birth
D : Presentation since birth

Boerhaave----inv-gastrogarffin…if not in option than contrast CT

After operation(slippage)----upper GI contrast CT

608
190. mother complaints that her infant vomits after each feed, it started at 6 weeks of age, before that his growth
was normal, but he stopped gaining weight at 6 weeks of age, what’s the
most probable cause:
a. GERD
b. pyloric stenosis
c. duodenal atresia
Note this:
#paeds
-biliary vomitus day 1 of life.... Duodenal atresia
-cyanosis day 4 of life with NO murmur.... Hypo-plastic left
heart failure
- cyanosis day 1 of life, no murmur.... TGA.
- cyanosis after 3rd month, pan-systolic murmur.... Fallot’s
tetralogy
-croup....... Para-influenzas type I
-bronchiolitis.... RSV
-epiglottitis.... Hemophilus influenza type B..... Ttt.
Cephalosporins

191. 7 years old boy passes a large bloody stool. The most likely cause is:
A) Meckel's Diverticulum —— adults
B) Duodenal Ulcer
C) Polyps of the Colon
D) Diverticulitis of Colon —— elderly
E) Intussusception—- red current jelly

609
192. Which of the following is not a cause of PR bleeding?
A. Constipation with an anal fissure
B. Intussusception
C. Meckel’s diverticulum
D. Bacterial gastroenteritis
E. Abdominal migraine(ans)

Abdominal migraines are diagnosed in children who meet these

criteria:
at least five attacks of abdominal pain that each last 1 to 72 hours.
dull pain around the belly button that may be of moderate to severe
intensity.
at least two of these symptoms: appetite loss, nausea, vomiting, pale
skin.
193. The most common cause of diarrhea in bedridden elderly
patient are:
a. Ca colon
b. Crohn’s disease
c. Ulcerative colitis
d. Diverticulosis
e. Faecal impaction(ans)

194. Man from Somalia comes to you with soiling. On examination you notice a fistulous tract. Which of the
following is the most likely cause?
A) Crohn’s disease
B) Ulcerative Colitis
C) Schistosomiasis
D) Perianal Abscess

195. What is the most common cause for recurrent ano

rectal abscesses in elderly
a. Diverticulosis
b. Ano rectal fistula
c. Crohn’s disease
d. Ulcerative colitis

Certain people are more likely to develop perirectal and

perianal abscesses, including those with the following medical
conditions:
• Diabetes
• AIDS or HIV infection with low white blood cell counts
• Crohn's disease

610
Persons on medications that suppress the body's immune system, such as steroids (prednisone,
methylprednisolone), or those undergoing chemotherapy for cancer
• Pregnancy
• Placement of foreign bodies into the anus
• Sexually transmitted diseases
• anal fissures
•
196. A 63-year-old male is diagnosed with e
emphysematous cholecystitis. She is discharged on oral antibiotics. Now she has an
abdominal pain and bloody diarrhoea. What is dx ?
a.ischemic colitis
b.campylobacter colitis
c.pseudomembranous colitis(ans)
d. ulcerative colitis

197. A 38 yr old woman comes to the office with several months of progressively worsening dysphagia. The
difficulty swallowing feels like food stuck in my chest and she tries to adopt different physical positions to push
the food. Although the difficulty was first with meat within days it occurred with water and alcohol. She has lost
7 kgs over last few months and is very anxious. At times she also has chest pain, regurgitation without nausea.
She has used antacids with no benefit. She used to smoke half a pack but stopped 5 yrs ago. Which is the most
likely diagnosis?
A.Progressive systemic sclerosis
B.Lung cancer compressing oesophagus
C.Esophageal cancer(Ans)
D.Achalasia
E.Progressive systemic sclerosis
Esophagitis

Initial complication after TURP

urinary incontinence-initial
Retrograde ejaculation-most common
Erectile dysfunction
Infection

611
198. 6 years old child with edema , proteinuria ++. Hematuria +++. Bp 130/ 90. What to do? a. Admit for salt n
fluid restriction b. Oral nifedipine and review in 5 days c. Do nothing n observe
199. )Pic of large hydrocele . Investigation??—(USG )

200. Male with features of CLD has moderate ascites and edema b/l upto knees. What is appropriate rx? a. Salt n
fluid restriction b. Spironolactone n furosemide c. Lactulose
first salt and fluid restriction
then spirano lactone
if that fails then spiron plus frusemide

201. Rhabdomyolysis scenario-most app tx asked Normal saline till CPK falls down and then give NaHCO3 for correction
of Acidosis.

202. Q. ca stomach surgery…had developed fever rigidity … but ck high

a. rhabdomyolysis

b. malignant hyperthermia****( ts malignant hyperthermia,

complication of inhaled anaesthetic most probably halothane)

203. ca stomach surgery…had developed fever rigidity …but ck high

a. rhabdomyolysis
b. malignant hyperthermia
its malignant hyperthermia, complication of inhaled anaesthetic most probably halothane

204. 2. 19 yo female, h/o recurrent throat infection , recently muscle tenderness and easily gets tired - fibromyalgia

Fibromyalgia (FM) is a medical condition characterised by chronic widespread pain and a heightened pain response
to pressure.[3] Other symptoms include tiredness to a degree that normal activities are affected, sleep problems and
troubles with memory.[4] Some people also report restless legs syndrome, bowel or bladder problems, numbness
and tingling and sensitivity to noise, lights or temperature.[5] Fibromyalgia is frequently associated with depression,
anxiety and post traumatic stress disorder.[4] Other types of chronic pain are also frequently present.[4]
The cause of fibromyalgia is unknown; however, it is believed to involve a combination of genetic and environmental
factors, with each playing a substantial role.[4][5] The condition runs in families, and many genes are believed to be
involved.[8] Environmental factors may include psychological stress, trauma and certain infections

he treatment of fibromyalgia can be difficult.[5] Recommendations often include getting enough sleep, exercising
regularly and eating a healthy diet.[5] Cognitive behavioral therapy (CBT) may also be helpful.[4] The medications
duloxetine, milnacipran or pregabalin may be used

612
205. 18 years old came from China, presented with history of recurrent URTI in China, now presented with fatigue
and mild cervical lymphadenopathy and muscle tenderness.
asking cause:
1. Depression
2. post viral fatigue syndrome jm 852
3. Fibromyalgia

206. Patient came 6 days after roux en y surgery, nauseated without vomiting or fever,mild abdominal
tenderness around epigastric, no garding.HR:124, Bp: 95/80.With this CT, what’s the Dx?
A-Pancreatitis
B-Afferent loop obstruction
C-gastric perforation
D-oesophageal perforation
E-large bowel obstruction

207. 40-year-old man dx with colon ca..noted many polyps on colonoscope initially then dx with colon ca..mom and
two sisters have uterine ca..what hereditary illness does he have?
a. Lynch ***
b. Fap
c. adenomatous
d. Gardner’s

208. Child with respiratory disease and rectal prolapse

1celiac
2cycstic fibrosis*** JM 160

209. Pt.travel a lot of to asia live alone presented with alopecia and palmar rash?
1 secondary syphilis*** 2 eczema
3 zinc deficiency
(moth eaten type Alopecia is pathognomonic of 2’ syphilis

Secondary syphilis occurs approximately four to ten weeks after the primary infection.[2] While secondary disease is
known for the many different ways it can manifest, symptoms most commonly involve the skin, mucous
membranes, and lymph nodes.[19] There may be a symmetrical, reddish-pink, non-itchy rash on the trunk and
extremities, including the palms and soles.[2][20] The rash may become maculopapular or pustular. It may form flat,
broad, whitish, wart-like lesions on mucous membranes, known as condyloma latum. All of these lesions harbor
bacteria and are infectious. Other symptoms may include fever, sore throat, malaise, weight loss, hair loss, and
headache

210. patient is presenting with severe central abdominal pain.,with mild nausea.,no vomiting, no abdominal distension.
Mild tenderness is present on exam. No rebound tenderness on release.
You admitted him and gave fluids. USG was unremarkable. X ray Erect view showed mildly dilated small bowel loops. Now
he suddenly developed sharp severe abdominal pain which is localized with focal tenderness... And pain is being localized
to one point. He recently developed back pain. What is your diagnosis?
a. Simple intestinal obstruction
b. Intestinal obstruction with perforated viscus
c. Localized bowel loop obstruction with secondary ischemia***

211. Child with ankle and knee oedema RF_ve .ana+ve diagnosis
1R.A. =(age 25- 50 & 65_75 Bimodal)
2 juvenile idiopathic =( coppery red rash, lymphadenopathy, splenomegaly. First symp is arthritis affecting small joints of
hand wrist and knees.
3 sle= ( 15 - 40 yrs age)***
613
JIA, also known as juvenile chronic arthritis and juvenile rheumatoid arthritis (US), is defined as a chronic arthritis
persisting for a minimum of 6 weeks (some criteria suggest 3 months) in one or more joints in a child younger than
16 years of age.5 It is rare, affecting only about 1 in 1000 children, but produces profound medical and psychosocial
problems.

The commonest types of JIA are oligoarticular (periarticular) arthritis, affecting four or fewer joints (about 50%), and
polyarticular arthritis, affecting five or more joints (about 40%). Systemic onset arthritis, previously known as Still
syndrome, accounts for about 10% of cases. It is usually seen in children under the age of 5 but can occur throughout
childhood. The children can present with a high remittent fever and coppery red rash, plus other features, including
lymphadenopathy, splenomegaly and pericarditis. Arthritis is not an initial feature but develops ultimately, usually
involving the small joints of the hands, wrists, knees, ankles and metatarsophalangeal joints.

These children should be referred once the problem is suspected or recognised. JIA is not a benign disease—50%
have persistent active disease as
adults.
Rheumatic fever typically occurs in children and young adults, the first attack usually occurring between 5 and 15
years of age.

212. man back from Thailand, neighbours say his is clumsy, unkempt, clothes look loose, which lead to diagnosis
a. HIV serology*** b. ct brain —— to dx EBV
c. thick and thin smear

Ø Man coming from Thailand complains sore throat rash lymphadenopathy he had sexual history there Ebm
Cmv HIV

Ø Man came from Thailand w headache myalgia fever arthralgia long labs given lft all enzymes raised. also
complain of anuria science 2 days he took cephalosporin for
fever y 3 days but still not improves .DX???
A-Dengue fever
B – malaria JM 130
C- hepatitis A
D- toxic shock synd
1 ans:a. 2:a

614
213. A woman had Tb I guess but the child got TB and was strongly positive for QuantiFERON test(igra) . What to do
next most app and investigation was found isoniazid sensitive . No option of admit and observe ,
a. does Mountox test ,
b.start isoniazid course ***. . .

214. business man got bankrupt, many financial problems,

complaining of late insomnia, lack of pleasure, loss 15 kg from his weight through 3 months, and many other
symptoms of depression, his family concern about him and the patient refused to take any medication as he doesn’t
believe he is sick, he admit he is tired and exhausted but not depressed, what’s this called?
A Denial
B Reaction formation
C Depersonalisation
D Rationalisation

215. A 35-year-old woman gives birth to her second child. The baby becomes jaundiced on the tenth day and the
mother tells the doctor that her previous child had jaundice after birth and then later developed bilateral cataracts.
What is the most likely diagnosis:
Neonatal hepatis?
Galactosemia
Diabetes mellitus
Syphilis
Congenital rubella

216. Scenario of a man who got epigastric pain after eating food with his friend in a restaurant. He has past
history of anaphylactic shock after eating carrot cake. What is the cause of presenting symptom? (contro)
A. Egg
B. Milk (something like that)
C. Gluten
D. Carrot

217. Scenario a man who is suffering from epigastric pain after eating food with his friend in a restaurant . Who
had the same problem and allergy when he ate a carrot cake? What's the cause of his problem now?
(contro)
a) carrot b ) peanut c) dietary produces) gluten e) glutaminase

carrot cake allergy scenario -

615
 Check for other allergies
Food allergies
Atopy

218. A man developed abdominal pain and gastroenteritis following eating a carrot cake. What is the cause?
A) Gluten Peanut C) Carrot

219. old woman ca oxalate stone repeatedly. What to

do
a.low calcium
B. hydrochlorothiazide
c.phosphate diet

220. a case of chronic liver disease presented with

ascites and low albumin level. What is the next
appropriate management/?
a. lactulose
b. albumin infusion
c. salt and fluid restriction
d. spironolactone and frusemide

**first salt and fluid restriction then spirano lactone if that fails then spiron plus frusemide

616
617
618
619
 For ascites
Salt restriction
Spironolactone
Paracentesis

Albumin given in large volume paracentesis

Lactulose to make 3 bowel motion daily

221. A 72-y old male presents with progressive dysphagia for

solids and liquids over 2 years. There have been no episodes of
bolus impaction. There has been a 2 kg weight loss over 6
months. Oesophageal manometer demonstrated tertiary wave
activity and decreased amplitude of contractions. What is the
most likely dx?
A. Ulcerative reflux oesophagitis
B. Achalasia
C. Scleroderma
D. Diffuse oesophageal spasm
E. Presybyoesphagus

Presybyoesphagus: tertiary contractions easily visualized as multiple transverse or ring-like contractions

Characteristic manometric findings of achalasia are:[citation

needed]
Lower oesophageal sphincter (LES) fails to relax upon wet
swallow (<75% relaxation)
Pressure of LES <26 mm Hg is normal,>100 is considered
achalasia, > 200 is nutcracker achalasia.

Aperistalsis in oesophageal body

Relative increase in intra-oesophageal pressure as compared
with intra-gastric pressure

620
222. a man had surgery of colorectal ca he was given 60ml/hr of saline and 30g of potassium his ecg was of
hypercalcemia options were, insulin, iv hydration

Mild hypercalcemia — Patients with asymptomatic or mildly symptomatic hypercalcemia (calcium <12 mg/dL [3
mmol/L]) do not require immediate treatment. However, they should be advised to avoid factors that can
aggravate hypercalcemia, including thiazide diuretics and lithium carbonate therapy, volume depletion,
prolonged bed rest or inactivity, and a high calcium diet (>1000 mg/day). Adequate hydration (at least six to
eight glasses of water per day) is recommended to minimise the risk of nephrolithiasis. Additional therapy
depends mostly upon the cause of the hypercalcemia. (See 'Disease-specific approach' below.)
Moderate hypercalcemia — Asymptomatic or mildly symptomatic individuals with chronic moderate
hypercalcemia (calcium between 12 and 14 mg/dL [3 to 3.5 mmol/L]) may not require immediate therapy.
However, they should follow the same precautions described above for mild hypercalcemia.
It is important to note that an acute rise to these concentrations may cause marked changes in sensorium, which
requires more aggressive therapy. In these patients, we typically treat with saline hydration and
bisphosphonates, as described for severe hypercalcemia (below).
Severe hypercalcemia — Patients with calcium >14 mg/dL (3.5 mmol/L) require more aggressive therapy.
Immediate therapy — The acute therapy of patients with severe hypercalcemia consists of a three-pronged
approach [1,2,4]:
●Volume expansion with isotonic saline at an initial rate of 200 to 300 mL/hour that is then adjusted to maintain
the urine output at 100 to 150 mL/hour. (See 'Saline hydration' below.)
In the absence of renal failure or heart failure, loop diuretic therapy to directly increase calcium excretion is not
recommended, because of potential complications and the availability of drugs that inhibit bone resorption,
which is primarily responsible for the hypercalcemia.
●Administration of salmon calcitonin (4 international units/kg) and repeat measurement of serum calcium in
several hours. If a hypocalcemic response is noted, then the patient is calcitonin sensitive and the calcitonin can
be repeated every 6 to 12 hours (4 to 8 international units/kg). We typically administer calcitonin (along with a
bisphosphonate) in patients with calcium >14 mg/dL who are also symptomatic. (See 'Calcitonin' below.

IgA -anti Htn +steroid. , PSGN -anti Htn+ antibiotics

223. case of chronic liver disease presented with ascites and low albumin level. What is the next appropriate
management/?
a. lactulose
b. albumin infusion
c. salt and fluid restriction
d. spironolactone and frusemide
1st C,then D,then B

224. A 56-y old farmer from queensland presented with a lacerated wound from a farming equipment.he had
similar wound 5 weeks ago and received tetanus toxoid. He has the history of completed tetanus vaccination in
the past. What is the most appropriate next step in his management?
A. Start penicillin
B. Give tetanus ig
C. Give tetanus toxoid
D. Give tetanus toxoid and ig
E. Discharge to home with follow up to consider ab

225. A 40-year-old woman presents to the clinic complaining of mild abdominal pain and fullness. She says that
this has persisted for the last three weeks and has gradually worsened. She is otherwise in good health besides a
diagnosis of crohn’s disease which was effectively treated with Pentasa. She drinks 2 glasses of wine per night.
On physical examination, you noted a distended abdomen with a positive fluid wave and visible superficial veins.
There is also mild peripheral oedema. Which of the following is the most likely diagnosis in this patient?
A. Hepatitis A
621
B. Alcoholic cirrhosis
C. Primary Biliary Cirrhosis
D. Non-alcoholic fatty liver disease
E. Primary sclerosing cholangitis (liver cirrhosis+obstructive jaundice+IBD)

Primary sclerosing cholangitis (PSC) is a chronic liver disease characterized

by a progressive course of cholestasis with inflammation and fibrosis of the
intrahepatic and extrahepatic bile ducts. [1, 2, 3, 4] The underlying cause of
the inflammation is believed to be autoimmunity. The condition may lead
to cirrhosis of the liver with portal hypertension and end-stage liver disease
(ESLD). [1, 5] (See Presentation.)
PSC is strongly associated with inflammatory
bowel disease (IBD), [5, 6, 7] mainly ulcerative
colitis, and is often complicated by the
development of cholangiocarcinoma.

226. several ppl in a city has abdominal pain,

nausea, vomiting. There is a recent work
with open coal steam. What to do next?
1. Inform health authority
2. Inform environmental protection authority
3.check CBC,blood biochemistry

622
227. Small bowel obstruction in a child 3 years, what
investigation should be done next:
a. barium meal and follow thru
b. usg abdomen
c. ct abdomen
d. urgent surgery
DX: intussusception

228. 78yo women pancreatic cancer with recurrent

bile duct obstruction from Pancreatic tumour.
Previously inserted a stent in the common bile duct
but obstructive symptoms occurred again; jaundice,
conj bilirubin etc. wat to do?
a)Palliative biliary bypass,
b)percutaneous hepatic drainage?
c)ERCP with stent change

GIT LATEST QUES

Git... Recalls

229. adult with long history of dysphagia , more after

certain types of food lasting for few days , also history
of asthma, endoscopy done: multiple constrictions ,
diagnosis:
a- eosinophilic esophagitis (Ans)
b- achalasia
c- ca oesophagus

230. middle aged man who had a history of surgery for

achalasia a few years back presents to you with a
complaint of hoarseness for 1 month and dysphagia
for 2 weeks. On examination , vocal cord paralysis
was noted and a mass in the thoracic inlet was seen in imaging.
What is the probable diagnosis?
A. cancer of the larynx —— horseness longer
B. cancer of the oesophagus
C. cancer of the lung
D. cancer of thyroid

231. Berium swallow x-ray of achalasia cardia, specific treatment

asked.
a. Nifedipine
b. botulinum toxin
c. Cardio myotomy(Ans) long term treatment JM 547

232. Out of the following, the MOST LIKELY risk factor for the
development of a squamous cell cancer of the
oesophagus is:
a smoking(ans) Smoking & Alcohol is best ans.
b alcohol intake
c obesity
623
 d history of cancer of the larynx
e achalasia

233. 55-year-old male comes with progressive difficulty in swallowing meat and some liquid. It takes a lot of time
for him to finish meal and after lying down it feels like the food is coming back to his mouth.He is obese and
otherwise healthy. What could be Diagnosis
A) Achalasia
B) Oesophageal cancer
C) Peptic stricture
D) Pharyngeal pouch JM 544
E) PUD

234. Adult with long history of dysphagia, more after certain

types of food lasting for few days, also history of asthma,
endoscopy done revealing multiple constrictions, what’s the
most likely diagnosis?
* Eosinophilic esophagitis (Ans)
* Achalasia
* Ca oesophagus

235. All of the following cause dysphagia except?

A. Oesophageal cancer
B. Achalasia
C. Barret’s oesophagus
D. Oesophageal varices (Ans)
E. Hiatus hernia

236. old man PHx of cardio myotomy of achalasia and came to

you with a mass in the posterior clavicalsternal angle, where
is the site of the lesion? (contro)
1. LUNG
2. Esophagis
3. tongue,
4. pharynx

What is posterior sternoclavicular angle anyway? If post triangle then nasopharynx. If above clavicle then lungs can
be too

624
237. 35-year-old man presents with a 5-year history of dysphagia. Initially his problem was related to slow eating
but more recently he has found that food tends to stick, and he gets nocturnal regurgitation. He has not
experienced any changes in weight. Which one of the following is the MOST LIKELY diagnosis?
a. Peptic oesophageal stricture
b. Carcinoma of the oesophagus
c. Achalasia of the oesophagus:(ans)
d. Pharyngeal pouch (Zenker diverticulum)

238. all of the following features favour the diagnosis of achalasia expect?
a. dysphagia of liquids
b. regurgitation of food
c. painful swallowing (b or c)
d. nocturnal regurgitation
e. dysphagia of solids

239. Which one of the following is not a complication of GORD?

a. Achalasia of the oesophagus.(ans) A. Because achalasia is neuromuscular disorder.
b. Ulcerative oesophagitis.
c. Barrett’s oesophagus.
d. Adenocarcinoma of the oesophagus.
e. Oesophageal stricture.

240. Most appropriate treatment for achalasia. laparoscopic cardio myotomy or nifedipine?
Ist line nifedipine...definite tx botulinum toxin inj ... and long term tx cardio myotomy

241. Old Pt begun dysphagia for solid food and regurgitation after meals?
1- achalasia
2- ca oesophagus
3- oesophageal pouch

242. A 40-year-old man presents with a 18-month history of heartburn and atypical chest pain, both unrelated to
food. He noted that elevating his arms makes it easier to swallow. A month before presentation he developed
intermittent dysphagia to both solids and liquids, regurgitation, and weight loss of 3 kg. Which one of the
following is the MOST LIKELY diagnosis?
a. Oesophageal stricture
b. Oesophagitis
c. Scleroderma
d. Achalasia
e. Gastro-oesophageal reflux

. Features which present in the early stages of the disease may be similar to that of gastro-oesophageal reflux
(GERD), including retrosternal chest pain typically after eating and heartburn

625
In the early stages of achalasia, chest pain or heartburn, and regurgitation commonly occurs. The sensitivity and the
specificity of symptoms are poor indicators of the status of oesophageal motility disorder. Heartburn and
regurgitation is the main symptom of GERD, caused by reflux of gastric acid.

243. 16Achalasia diagnostic

investigation?
A: manometry. (ans)
B: barium swallow

244. In patients with GERD with osteoporosis ,which is better

Zoledronic acid (Ans)
Strontium ranelate

245. Pic of barret oesophagus. A man with long history of Gerd

recently had retrosternal heart burning not associated with exertion.
He was given PPI 20 mg with prompt relief. On follow up endoscopy 6
weeks later he was found to have intestinal metaplasia, n no dysplasia.
Next
A. Double the dose of PPI
B. Anti-acid surgery
C. Oesophageal
manometry
D. Repeat endoscopy in 18
months(ans) JM 553

246. 8 wks old baby

with frequent crying and
vomiting in night. mother
feeds d baby every hourly.
wat investigation you do next
a. -GERD
b. -24 hours ph monitoring(ans) JM 553

247. PT young suffering progressive dysphagia and treated PPI 20 mg still symptom don't relieve and on check red
throat and narrow in oesophagus severe case of GERD may be

a. increase dose (ans) for alarm symptom next shud b endoscopy (red flag) and in absence of alarm features we can
Inc. the dose
b. gastrogarffin.
c. change to another PPI
626
248. 25 y pt used to has asthma since he was a child has Gerd on esomeprazole 20 mg, he feels he has troubles
with swallowing certain types of food. Not respond
a- give gaszoin b- double dose of ppi c- give mythlepridnisolone oral
d.budesonide(Ans)(aerosol)

249. 6 weeks baby brought by her mother C/o increasing vomiting since 3 days and have not gained weight since
last week. On examination all normal, child is alert and well hydrated. Dx?
a. PS
b. GERD-
c. Irrelevant

250. Old woman with GERD history and taking PPI, Tscore given and asking treatment.
-alendronate Zoledronic acid
-HRT
-Strontium ranelate (Ans)

251. . obese man Gerd on ranitidine symp increase with spicy food smoker stops to eat meat as he has difficulty
for its swallowing wt. to do
ppi
endoscopy to explore oesophagus red flag
reduce weight

252. . scenario of GERD WITH epigastric pain alcoholic,smoker,eating spicy food,obse what is the best mangemt:
stop alcohol
,stop spicy food
,stop smoking,
sleep semi sitting position.(Ans) then weight reduction

627
253. 2 months old baby while
breastfeeding crying flexing leg and
scratching mother breast cause
Infantile colic (ans) JM 339
GERD

254. . 6 wk boy was ok and increase

weight, 1 wk H/O vomiting but he is
well hydrated but not increase weight
since vomit started ?
A-GERD
B-PS
255. GERD patient well control with
PPI. what is the feature will further
Investi need ?
A. nocturnal cough
B. Regurgitation
C .present of dysphagia(ans) red flag
D. weight loss

256. Patient with stroke and has

previous surgery for perforated
peptic ulcer what to prescribe ?
(contro)
a.warfarin
b.heparin
c.clopidogrel JM 1433

628
d.dypyridamol
e.aspirin

257. a old man with right upper abdomen

pain only for 3 hours. physical
examination is unremarkable .and a CT
given (two suspected points- a
hypodense area occupying liver and a
very large mass in left side (yes left side )
A haemorrhage into adrenal
B liver CA
C gallstone
D CA head of pancreas
E left RCC (ans)
The most common sites for renal ca
metastasis are the lymph nodes, lung, bones,
liver and brain

258. Ca head of pancreas initial

investigation?
CT JM 658
USG abd (if confusing scenario)
X-ray

So..a helpful tip

A) acute pancreatitis gold
stand investigation = contrast enhanced CT
on day 3-4
B) chronic pancreatitis gold standard investigation = ERCP
C) ca pancreas = CT, ERCP if the patient is Jaundiced...

259. . Patient had RUQ pain . Palpable mass under right intercostal mid clavicular area. Wt losss
Ca head of pancreas (ans) JM 670
Gall stones
#feb
cancer head of Pancreas ?

260. . Patient with the history of biliary stent with CA head of pancreas. Now presented with fainting,shock.Urine
is totally dark colour.What is the cause?
A.rupture bile duct
B.Worsening of obstruction due to increased size of CA pancreas(ans)

261. patient now with RUQ pain fever 38.9 and jaundice. 2 days before episodes of dark urine. bilirubin high GGT
525 ALP 421 AST& ALT 50,80. whats the most likely cause?
a. acute cholecystitis
b. cholangitis::(Ans) JM 670
c. acute hepatitis
d. pancreatitis
e. ca of head of pancreas

262. Female presents with jaundice, went to bali. Hx of wt loss. Took doxy for malaria prophylaxis. Long labs with
obstructive jaundice. Diagnosis
629
 A. CA head of pancreas:(ans)
B. Viral hepatitis
C. Drug reaction
D. Malaria

263. 55yr old man visited Bali & taking Doxycycline for malaria
prophylaxis & during his trip, he developed fever with chills, malaise, deep
jaundice, pain in RHC with pale stool & dark urine. Investigation given:
Serum bilirubin increased, alkaline phos: markedly increase, AST/ALT
– increased. What will be ur diagnosis?
a) Ca head of pancreas
b) Drug reaction
c) Malaria
d) Cholangitis:(Ans)
e) Hep A

264. 50yr old man visits to Bali & after he got back, developed fever with chills, mild jaundice, diarrhea. On
examination, hepatosplenomegaly present. What will be the fact least indicate malaria?
Diarrhoea
Daily fever
Absence of splenomegaly

265. Jaundice man going to bali .what will be ur advice to reduce MORTALITY ?
a- Save urself from mosquito bite
b- Eat cooked food
c- Have all travel vaccination before leaving

266. A man went to bali two weeks ago . had Abdo pain , no fever , diarrhea couple of episodes, bilateral
conjunctivitis, rash ,fatigue, haematuria. Diagnosis - malaria - dengue - meningococcemia - some renal cause

267. 48 yrs Man comes with complaint of being unable to remember

details of Bali trip taken last year and details of last Christmas. 3
months ago, was hospitalized for major depression, was given a course
of ECT , and released 2 months ago. Cause?
a) early onset dementia
b) depression
c) effect of ECT
d)benign senescent forgetfulness

630
268. 40 y old male came from Bali after that he start developing RUQ pain, which is now moved to the left, his
liver is palpable mild Abd pain no vomiting 38 pr 112, bp 130/95 what is Diag? a-ameboma (amoebic liver
abscess) b-hydatid cyst c-simple cyst

269. Patient will Long labs with recent trip to bali afebrile now , GGt high ALK ALP ALT all normal and Bili high
Patient jaundiced asking cause :
Hep A
Hep B
Malaria
Cholangitis

normal transaminases rules out hep a and b . alk phosphatase normal rules out cholangitis . left is malaria. But this is
incomp stem if this would have low platelet then malaria wil be the answer... . Dengue and salmonella enterigastritis
are most prevalent in bali Indonesia.

Not obstructive pattern. Malaria cause inflammation of liver resulting in raised levels of GGT possibly . fever is
invariable. So, ac to this malaria is the answer.

631
in vivax malaria, this typical pattern of fever recurs once every 48 hours and this is called as Benign Tertian malaria

270. 45 years old female got Upper abdominal pain for about 45 minutes on the morning and now comes to
clinic. She got similar pain last month which is less severe than recent attack. On examination, No pain, no
tenderness, no mass. CT scan done and shown. What is the diagnosis?
A. Right adrenal haemorrhage
B. Hydatid cyst
C. Gall stones:(ans)
D. CA HOP (head of pancreas)
271. pt. with adenomatous polyposis had sx proctocolectomy
and ileostomy. cause of death
1 ca oesophagus
2 ca stomach
3 ca duodenum (Ans)
4 ca ilium
5 ca lung

632
272. Old man smoker, retrosternal chest pain, hoarseness of
voice for 1 month. No dysphagia. Cause?
a. Ca lung (ans)
b. Ca oesophagus
c. TB (NO LARYNGEAL CARCINOMA)

273. after being diagnosed with ca of oesophagus

esophagectomy has been done . on 4th post op day pt
developed pain in the epigastrium and shortness of breath .
on examination left breath sounds diminished , percussion
note dull . x -ray of chest been done. what would be the
findings on x-ray?
a hemothorax (from leaking)
b pleural effusion (from pneumonia)
c mediastinal lymph node enlargement
d pneumothorax

274. One question was twisted with such a long hx but all labs were normal which were given electrolytes,
thyroid and liver functions test, but he has asthma history in childhood- treatment was not given which he took
but he is now 26 years old and from last night he developed dysphagia , it is progressing even cxr was not given
there. What could be the likely cause?
a. drug induced esophagitis
b. eosinophilic esophagitis
c. stricture of esophagia
d. ca oesophagus

275. ca Almost similar picture but left sided.

A lady presented with this swelling, hoarseness of
voice, dysphagia. Where is the primary site?
a. lung
b. thyroid(same ques , midline swelling, thyroid)
c. oesophagus
d. Nasopharynx
e. larynx

276. 1-old woman with low calcium. other blood

report are normal. wats her cause of having low
calcium.cxray given
a.dietary deficiency
paraoesophageal hernia
633
c. ca colon
d.chronic duodenal ulcer

277. -cxr given showing air fluid level in retro cardiac area and fundal gas also present. pt came with tiredness.Lab
values given.HB ,MCV,MCHC reduced.your dx?
a.para oesophageal hernia
b. dietary deficiency

Complications of hiatal hernia may include iron deficiency anaemia, volvulus, or bowel obstruction

278. . 39 The most common cause of diarrhea in bedridden elderly patient are:
a. Ca colon
b. Crohn’s disease
c. Ulcerative colitis
d. Diverticulosis
e. Faecal impaction

279. . 82-year-old lady had a hx of smoking 24 pack a

year, now 10 kg wt. loss hx, on physical ex only
anorexia present and left sided supraclavicular LN
found. On chest and abd CT done, nothing specific.
what is the cause?
a)ca lung
b)ca stomach (Ans)( left supraclavicular)
c)ca colon
d)ca breast(rt supraclavicular)

280. 23 young age man with father died from ca colon

at 35 and his aunt died at 43 what to do A-fobt B-
colonoscopy now …maybe fap associated lynch
:(Ans)C-colonoscopy 40year

Category 3 – High risk (relative risk of ~4–20%; <1% of the population)†

Asymptomatic people with 25,26: Refer to familial cancer clinic iFOBT every two years from 35
at least three first-degree or for genetic risk assessment to 44 years of age
second-degree relatives with CRC, with at
least one relative diagnosed aged <55 Colonoscopy every five years
years High-risk familial syndromes from 45 to 74 years of age
at least three first-degree relatives with
CRC diagnosed at any age Refer to familial cancer clinic
People with high-risk familial syndromes, for genetic risk assessment Frequency and starting age of
Lynch syndrome: and genetic screening of colonoscopic surveillance will
three or more first-degree or second- affected relatives be determined by specialist
degree relatives on the same side of the team
family diagnosed with CRC or other Lynch
syndrome–related cancers§ (suspected
Lynch syndrome) Refer to bowel cancer Starting age and dose of aspirin
OR specialist to plan appropriate will be determined by specialist

634
 two or more first-degree or second-degree surveillance (III, B) and dose team||
relatives on the same side of the family of aspirin
diagnosed with CRC, including any of the
following high-risk features Frequency and starting age of
multiple CRC in the one person colonic surveillance and
CRC aged <50 years="" li=""> chemoprevention will be
A family member who has or had Lynch determined by specialist team
syndrome-related cancer

People with familial polyposis syndromes:

at least one first-degree or second-degree
relative with CRC, with a large number of
adenomas throughout the large bowel# Familial polyposis syndromes

Refer to familial cancer clinic

for genetic risk assessment
and genetic screening of
affected relatives

Refer to bowel cancer

specialist to plan appropriate
surveillance (III, B) and
chemoprevention

281. a man 25 yr old with colon ca. Familial h/0 colon carcinoma. his 2 siblings has h/0 uterine carcinoma .wats
his syndrome-
a.familial adenomatous polyposis
b.hereditary non polyposis colorectal carcinoma
c. puetz zeghers
d.lynch syndrome:ans

282. . 35 typical x ray of small bowel obstruction with hx of appendicectomy when she was 15 years, He is 62
years old now . asking for cause?-
A. adhesion obstruction: ans
B. ca colon
C. Sigmoid volvulus.
D. Pseudo obstruction

283. The woman has jaundice, itchy, puritus. Her AST, ALT very high, Ultrasound Pic given. All the labs LFTs are
given. What is your next appropriate management?
A) Acute pancreatitis
B) Laprotomy
C) Cholecystomy- if young
Others don’t remember

284. Non pregnant lady, all the enzmes raised, GGT HIGH, AST , ALT BOTH 300, ALP 300, bilirubin raised direct and
indirect both high, took antibiotics amoxicillin, RUQ pain, what is cause
A-Acute cholecysttis
B-Acute hepatitis
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 C-Amoxicillin hepatitis
D-Choledocholithiasis

BLOOD
1. child 13 month just start walking and fall in gruond had laceration bleeding and sever hematoma not resolve and
no family history of blood disease mother scared ask about diagnosis ?
1 VWD
2 haemophilia A 1 in 5000
3 immune thrombocytopenia
4 prothrombin def very rare 1 in 2 million autosomzal
recessive
5 haemophilia B 1 in 30000 x linked recessive

** Spontaneous Mutations Approximately 30% of cases of

hemophilia are caused by a spontaneous mutation of the
gene. In some cases, the mother is not a carrier of hemophilia,
and the child is affected. This child may be the first in the
family to have hemophilia and to carry the defective factor
gene. In some cases, the genetic mutation occurs in the
mother, and she finds out she is a carrier (through DNA
testing) after she has a child with hemophilia A.

Rx infusion of recombinant factor 8 concentrate ,avoid aspirin

2. man back from Thailand, neighbors say his is clumsy, unkempt,

clothes look loose, which lead to diagnosis
a. hiv serology***

b. ct brain

c. thick and thin smear

3. Young parents come to your clinic asking about the possibilities of their children to get Hemophilia as the
mother is known to be haemophiliacarrier, what will you tell them:
A- Reassure as it will not affect their children
B- Half of the boys will have hemophilia and half of their daughters will be carriers
C- All the boys will have haemophilia
D- ¼ the children will have haemophilia
E- Only the girls will have haemophilia as carriers

4. A mother comes with hemochromatosis in brother. she has 2 kids aged 2 and 5 yrs respectively. Wants advice regarding
screening
A. screen only mother ****
B. mother n kids
C. ask her to come witsssssssssssssssssssssssssssssssssh husband
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 D. Screen only children

5. a mother of two children healthy presented to you asking you to have test for hemochromatosis for
her and children as her brother diagnosed with this disease. What is your most appropriate advice?
A-iron blood test for children
B-do test for mother alone

C-refer her and children for DNA test

D-ask for an appointment with the husband and the mother

6. A 12 years old girl presents with a sudden history of loss of sensation on the lower limbs associated with decreased
reflexes and progressive ataxia . Which of the following is most likely the cause of her condition
A. B12 deficiency

B. Friedreich´s ataxia ****

C. Charcot marie tooth disease

D. Dermatomyositis

7. 14 yr old girl bought by parents ,

abnormal menstrual cycle heavy bleeding
when it occurs. on some bruises on legs
history of easy bruising
a. platelet count
b. protein s def

c. haemophilia

d. vwD

8. 7 months old child with mother came that he is continually bleeding from mouth since yesterday after he struck
his head in table.you notice old bruises on forehead & legs cause
Hemophilia
ITP
Vwd
Non accidental
**bleeding from mouth means phrenulum injury and may be mother lying about duration plus previous bruises,

9. baby present with hematoma in scalp not resolved by pressure or ice has no family history of blood disorder
asking diagnosis
a.hemophilia
b. von willbrand
c. platelet dysfunction

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10. Boy hit to coffee table while playing, presents with epistaxis, lip and mucosal bleeds, thigh
With bruises, petachie, no hepatomegaly.
ITP
Vwd
Factor 8
11. Boy hit to coffee table while playing, presents with epistaxis, lip and mucosal bleeds, thigh With bruises, no
petachie, no hepatomegaly.
ITP
Vwd
Factor 8

12. A 2 month old baby had severe bleeding from frenulum after hitting coffee table. Which is the investigation you
will do next ?
APTT
Factor 9
Platelet count and morphology

13. 14 yr old girl bought by parents , abnormal menstrual cycle heavy bleeding when it occurs. on some bruises on
legs history of easy bruising
a. platelet count b. protein s def c. haemophilia d. vwD

14. . A mother brought a child of 8 months who is

bleeding from the frenulum from one day,some
other old marks of bruises there,what could be the
cause?
A)..Non accidental
B)factor 8 defeciencc
c).VWD,
D).platlets def

15. Elective cholecystectomy, has vWD, what does he

need before surgery?
FFP,
Platelets,
Factors 8
blood transfusion

16. Non diabetic patient complaining of weakness and clumsiness of lft hand numbness on both feet, foot drop on
left side. What inv to find out the lesssion
A.Nerve conduction study
B.Muscle biopsy ( PAN
C.Vit B12
D.MRI of spine

17. A guy after coming back from a trip suffering from chronic diarrhea, no blood and mucus for 7 months, weight
loss for 6 kg but appetite is good, stool is greasy and fat globules are seen, He has undergone repeated tests for
enteropathic organisms and all negative, also antigliadin and antiendomysial tests negative, his B12 and iron
level are also normal. What is most appropritate next management?

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 1) Colonoscopy and biopsy
2) Serum immunoglobulins
3) ERCP
4) Small bowel biopsy. dx-tropical spreu..tx-tetracycline

18. 55 female , micr. Hypo anemia . ferritin decrease with angular stomatitis and thin skin with pigmentation..
normal bowel habit and normal stool consistency..she also have clubbing ..next
a.small bowl biopsy (Celiac)
b.colonoscopy
c.b12 level

19. A lady lethargic anaemia .. mild icterus ... not a vegetarian no menorrhagia .... macrocytosis n megaloblasts ..
what is next i think
A red cell folate level
B iron studies
C intrinsic factor antibodies
D vit b12 levels

**Testing algorithm (serial) for pernicious anemia Testing Algorithm If vitamin B12 is <150 ng/L,
then intrinsic factor blocking antibody (IFBA) is performed.
If IFBA is negative or indeterminate, then gastrin is performed.
If vitamin B12 is 150 to 400 ng/L, then methylmalonic acid (MMA) is performed.
If MMA is >0.40 nmol/mL, then IFBA is performed. So first D

(If vegetarian then b12 possible here

20. A guy after coming back from a trip suffering from chronic diarrhea, no blood and mucus for 7 months, weight
loss for 6 kg but appetite is good, stool is greasy and fat globules are seen, He has undergone repeated tests for
enteropathic organisms and all negative, also antigliadin and antiendomysial tests negative, his B12 and iron
level are also normal. What is most appropritate next management?
1) Colonoscopy and biopsy
2) Serum immunoglobulins
3) ERCP
4) Small bowel biopsy

21. confusing scenerio of wasting of hand muscle, weakness of tibialis anterior, weak hip flexors, fasiculations in
hand n leg. All lower motor signs with few weeks history. No sensory or cranial nerve issue
Options emg, ck levels, anti ach antibodies, b12 levels

**Scenario incomplete CK level done in myositis here LMN leison with distal weakness rule out
polymyositis B12 not present in this way AntiACH is seen in myasthenia gravis also not possible…EMG
could b done to rule out any motor neuron disease but at least it has some acceptability with this scen

22. pallor patient with picture of microcytic anemia MCV low Serum ferritin normal Almost same scenario above but
increase reticulocytes. Cause?
A) Iron def

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 B) Vit B12 Def
C) Hemolytic Anemia

23. pallor patient with picture of microcytic anemia MCV low Serum ferritin normal
A) HB electrophoresis
B) Vit B12 levels
C) folate levels

24. 2 years old male complains of inability to climb stairs on

examination his muscle bulk is normal has loss of ankle reflex
his mother also has loss of ankle reflex most appropriate next
investigation??
a. CK level
b. Vit B 12
c. Muscle biopsy
( DMD )

25. case of a baby with Macrocytic anemia and malapsorption

(watery diarrhoea, flatus) , how u manage?
Decrease Lactose dx lactose intolerance jm499
Cow milk
Soy based Milk

26. 70years Algerian lady with weakness and anaemia and is

vegetarian lab inv given typical of microcytic anaemia.cause
1.hook warm infestation
2.ca cecum
3.vit B12 deficiency
4.thalassaemia minor
5.diet
in July recalls people answering DIET and in june answered
CA.Cecum any difference both recalls Anemia
if macrocytic anaemia answer will b same or change
Macrocytic is IDA or vit B 12 deficiency???

27. ESR is elevated in all of the following except:

a. Multiple Myloma
b. Sickle cell anaemia
c. Macrocytic anaemia
d. Pregnancy
e. chronic hepatitis
**The ESR is decreased in polycythemia, hyper viscosity, sickle cell anemia, leukemia, low plasma
protein (due to liver or kidney disease) and congestive heart failure.

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28. Lead poisoning anemia?
A- Hypochromic microcytic
B- normochromic normocytic
C- hypochromic normocytic
D- macrocytic
29. 55 yrs old patient with low folic acid, howel jolly body , stomatitis , normal bowel, weight loss...Inv??
a. small bowel biopsy……. appropriate ( celiac )
b. colonoscopy
c. Vit B 12…. Next

30. Patient on methotrexate and prednisolone complaining of mouth & tongue ulcer. Treatment asked?
a) Folic acid
b) Folinic acid
c) Stop methotrexate
d) Increase prednisolone

31. Patient is taking methotrexate, prednisolone and celecoxib for RA. Lab results show pancytopenia
with high ESR (67). Management?

a. Increased prednisolone
b. HCQ
c. Folic acid
d. Folinic acid
e. Cease celecoxib

** Dehydration (low fluid levels in your body) can worsen the side effects of this drug. Be sure to drink
enough fluids before taking this drug. Methotrexate can cause mouth sores. Taking a folic acid
supplement may decrease this side effect. It may also help decrease certain kidney or liver side effects
from methotrexate. Your doctor can tell you more

Methotrexate side effects Methotrexate injectable solution can cause drowsiness. Don’t drive or use heavy machinery
until you know you can function normally. Methotrexate can also cause other side effects. More common side effects
The more common side effects of methotrexate can include: nausea or vomiting stomach pain or upset diarrhea hair
loss tiredness dizziness chills headache sores in your lungs mouth sores painful skin sores bronchitis fever bruising
more easily increased risk of infection sun sensitivity rash stuffy or runny nose and sore throat abnormal results on
liver function tests (may indicate liver damage) low blood cell levels If these effects are mild, they may go away
within a few days or a couple of weeks. If they’re more severe or don’t go away, talk to your doctor or pharmacist.

Serious side effects Call your doctor right away if you have serious side effects. Call 911 if your symptoms feel life-
threatening or if you think you’re having a medical emergency. Serious side effects and their symptoms can include
the following: Unusual bleeding. Symptoms can include: vomit that contains blood or looks like coffee grounds
coughing up blood blood in your stool, or black, tarry stool bleeding from your gums unusual vaginal bleeding
increased bruising Liver problems. Symptoms can include: dark-colored urine vomiting pain in your abdomen
yellowing of your skin or the whites of your eyes tiredness lack of appetite light-colored stools Kidney problems.
Symptoms can include: not being able to pass urine decreased urination blood in your urine significant or sudden
weight gain Pancreas problems. Symptoms can include: severe pain in your abdomen severe back pain upset stomach
vomiting Lung lesions (sores). Symptoms can include: a dry cough that doesn’t produce phlegm fever shortness of
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breath Lymphoma (cancer). Symptoms can include: tiredness fever chills weight loss loss of appetite Skin reactions.
Symptoms can include: rash redness swelling blisters peeling skin Infections. Symptoms can include: fever chills sore
throat cough ear or sinus pain saliva or mucus that increases in amount or is a different color than normal pain while
urinating mouth sores wounds that won’t heal anal itching Bone damage and pain Bone marrow damage. Symptoms
can include: low white blood cell levels, which can cause infection low red blood cell levels, which can cause anemia
(with symptoms of tiredness, pale skin, shortness of breath, or a fast heart rate) low platelet levels, which can lead to
bleeding

32. 31-year-old woman G2P1 presents at 10 weeks’ gestation for antenatal visit. She is found to have a twin
pregnancy. Her previous pregnancy was complicated with placental abruption at 34 weeks. Which one of the
following is the next best step in management in addition to standard antenatal care? The options I have seen
for this question are: •
a.Admit to the hospital for rest after 34 weeks. •
b. Cervical suture. •
c. Vitamin supplementation. •
d. iron and folic acid supplementation. ... •
e. serial CTGs from 34 wks

33. Pregnant woman 10 weeks of gestation comes with anemia and MCV 60 most likely cause
Folic acid
Iron
Pernicious
Thalassaemia trait ( as 1st trimester )

34. A vegan pregnant woman (in early first trimester) came to you for antenatal care.She takes folic acid pill
regularly.What is your advice?
Zinc and Iron

Iron and Vitamin K

Iron and vit C**

A meatless diet can be healthy, but vegetarians -- especially

vegans -- need to make sure they're getting enough vitamin
B12, calcium, iron, and zinc

35. Young girl came with parents for check up,labs-HB:9 or 10,rest all
normal except APTT raised,HBA2 positive,what to do next?
A.Iron
B.Blood transfusion
C.Folate jm 161 dx thalassemia

36. A mother brings her child to ur clinic who has history of spherocyrosis and neonatal jaundice. He recently
became progressively pale for last 2 months after an upper rti episode. On inv anemia hb 5 and increased
reticulocytes with normal WBC and plat. Bilirubin normal. What is the cause

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Folate deficiency
Spherocytosis
Aplastic crisis
Hemolysis
Leukaemia
**what is mentioned here then this patient is having recovery phase of aplastic crisis done by
spherocytosis superimposed parvovirus. Usually we do have retic count decrease with aplastic crisis
but in recovery phase it starts getting raised. If bilurubin is raised here then its spherocytosis(it also
causes hemolysis with RTI butbif its specifically parvo then it will cause aplastic crisis).

643
644
37. Hereditary Spherocytosis scenario. Child had URTI. Pallor, no jaundice. Retics count 6% (increase), low HB, low
platelets. On exam child had pan-systolic murmur at left sterna border. Cause asked?
A. Parvovirus
B.Hep A
C.ITP
D. Subacute infective endocarditis
E.Folate deficiency.

38. hereditary spherocytosis pt , now come with aneamia , low platelet count , but wbc count normal splenomegaly
2 cm below costal margin , what is the cause of anemia ?
A. Hemolysis crisis ( Retic increase )
B. Aplastic crisis ( Retic decrease )
C. Chronic occult blood loss
**
Aplastic crisis----- No jaundice, decrease RBC, Hb, Reticulocyte, initially normal or later decrease platelet
due to parvo virus)
(Hemolytic crisis---follows URTI. jaundice present, increased reticulocyte,normal WBC, decreased
platelet and RBC)

645
39. Parents came to you because their son has hereditary spherocytosis and they want to know what is the chance
that his siblings have the same disease?
25% of his brothers
50% of his sisters
50% of his brothers and sisters autosomal dominant
0 % of his brothers and sisters
50 % of his brothers

40. Hereditary spherocytosis in brother of family, asking the chance of other siblings?
a.25
b.50. ( autosomal dominant )

41. Scenario pointing towards Hereditary spherocytosis , pt wid Hb 4 ,what next management ?
a) packed cell transfusion ( initial )

b) splenectomy ( best )

42. a young patient with history of sickle cell anemia, after along history of flight, came with calf pain, all well wth
respiratory part, which one of the following is the most appropriate next step in Rx?
• O2 therapy
• IVIG…if chest symptoms
• enoxaparine

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 • steroids
.anelgesics…..vasoocclusive disease

43. Focal neuro deficits in a sickle cell patient, next step ?

a) Head CT
b) Plasma exchange

44. Young patient while travelling by airplane had cheat pain

with mild dyspnoea,no other symptoms,has history of sickle
cell trait.What to do next?
Oxygen by mask
Hydration
Blood transfusion
Intubation and oxygen
Splenectomy

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45. A 16 year old female presents with Sickle cell anaemia and heavy menstrual bleeding. What is the best
treatment of choice?
A. Combined Oral Contraceptive Pill (COCP)
B. Inj Depoprovera
C. Mirena
D. IUCD
E. Implanon

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46. An 11-month-old African American boy has a hematocrit of 24% on
a screening laboratory done at his well-child checkup. Further testing demonstrates:

hemoglobin 7.8 g/dL; hematocrit 22.9%; leukocyte count 12,200/μL

with 39% neutrophils, 6% bands, 55% lymphocytes; hypochromia on smear;

free erythrocyte protoporphyrin (FEP) 114 μg/dL; lead level 6 μg/dL whole

blood; platelet count 175,000/μL; reticulocyte count 0.2%; sickle-cell preparation

negative; stool guaiac-negative( FOBT ) ; and mean corpuscular volume (MCV)

64 fL. Which of the following is the most appropriate recommendation?

a. Blood transfusion

b. Oral ferrous sulfate ( as hb is very low ) IDA

c. Intramuscular iron dextran

d. An iron-fortified cereal

e. Calcium EDTA

Normal value 35 microgram/dl ..)

47. A 2950-g (6.5-lb) black baby boy is born at home at term. On arrival at
the hospital, he appears pale, but the physical examination is otherwise normal.

Laboratory studies reveal the following: mother’s blood type A, Rh-positive;

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 baby’s blood type O, Rh-positive; hematocrit 38%; and reticulocyte count

5%. Which of the following is the most likely cause of the anemia?

a. Fetomaternal transfusion

b. ABO incompatibility…mother should be O and baby should be A or B

c. Physiologic anemia of the newborn….appear at 2 to 3 month

d. Sickle-cell anemia…at few ( 4 to 6)month

e. Iron-deficiency anemia…not immediately..may take years

48. ESR is elevated in all of the following except

: a. Multiple Myloma

, b. Sickle cell anaemia,

c. Macrocytic anaemia,

d.pregnancy,

e. chronic hepatitis

49. Woman with 2 children presents to you with malaise and fatigue.This is her 3rd pregnancy.All antenatal
examination is normal except for microcytic anemia with MCV 65.All other investigations are normal.Cause?
Iron deficiency anemia ? Depending upon labs

Thalassemia trait

50. Which one of the following is not a cause of IUGR?

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 Renal disease in mother

Thalassemia trait with Hb 9

Htn taking Methyldopa

Cmv infection

Alcohol intake

In thalassemia , Maternal complication rates of

gestational diabetes, preterm birth, antepartum
bleeding, postpartum bleeding, shoulder dystocia and
puerperal morbidity, and the rates of neonatal
complications: macrosomia, fetal weight <2,000 g,
intrauterine growth restriction (IUGR), stillbirth, low
Apgar score (<7) at 1 and 5 min and NICU admission,
were not significantly different between the two
groups. The rate of pre-eclampsia, however, was
significantly differentu, with RRs of 1.73 (CI 1.01–3.00).

51. -a mother of two children healthy presented to you asking you to have test for hemochromatosis for her and
children as her brother diagnosed with this disease. What is your most appropriate advice?
A-iron blood test for children
B-do test for mother alone
C-refer her and children for DNA test
D-ask for an appointment with the husband and the mother

52. A 35 year old man acutely complained of Right knee pain and swelling right after playing golf. Arthrocentesis
done revealing 25 mL of brown pigmented fluid aspirated. What is the diagnosis?
A. Rheumatoid arthritis
B. Gout
C. Osteoarthritis
D. Pigmented villonodular synovitis
E. Hemochromatosis Achondrosis

53. Man with history of hemochromatosis. He is in intensive care unit. Has flapping tremors. He is confused and
restless. He also has ascites with shifting dullness. Ascites tap done which shows
Cells – 300
LDH –
Which of the following is the most appropriate immediate management?
A) Amlodipine
B) Albumin
C) Lactulose
D) Cefotaxime ( as ascites is infected )

**Spontaneous bacterial peritonitis is a common complication of uncontrolled ascites and is diagnosed by

651
ascitic fluid polymorphonuclear cell count greater than 250 cells per mm3 or positive Gram stain/culture.
Patients who have spontaneous bacterial peritonitis should receive antibiotics within six hours if
hospitalized; in those who are ambulatory, antibiotics should be started within 24 hours.

54. Hemochromatosis scenario asking for most appropriate Ix?

Liver biopsy
serum ferritin &transferrin ..should be transferrin saturation
genotype
U/S

55. A 55-year-old woman came to your clinic due to progressive tiredness, associated with occasional arthralgias for
5 months. Upon examination, you note some skin pigmentation and slight enlargement of the liver. Her father
died due to liver cirrhosis secondary to primary hemochromatosis.
Which of the following is diagnostic result for primary haemochromatosis?

a. Transferrin saturation > 70% (should be >45%)

b. Increased total iron binding capacity
c. Decreased ferritin
d. Decreased serum iron
e. Increased ESR

56. Mother with G6PD now pregnant at 18.weeks.Previously she had a child with cystic fibrosis.What is the
possibility off the current pregnancy to have cystic fibrosis?
0%
25% autosomal recessive
33%
100%

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57. 4 years old child has pallor and jaundice after urti.He has splenomegaly with history of phototherapy at neonatal
period.Diagnosis?
G6PD
HEREDITARY SPHEROCYTOSIS
hemolytic crisis after urti
ITP
**Everything is same for both. But only one is, splenomegaly is hallmark in HS, and in G6PDD it may
preset in severe hemolytic cases

58. . a child with anemia and low platelet after facing with a parvovirus .the retic count is 6 % . What is the possibility of
this condition in her siblings? H.SPHEROCYTOSIS. A.D
1. 25% of boys

2. 50% of boys

3.4. 50% of all siblings *****

5. No sibling gets this condition

59. Hereditary spherocytosis scenario of a lady with blood picture which shows Hb 8.9 and 0.05% retic count. Rest of the
cells are within normal range. Which is the most likely organism for her condition?

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 a. Adenovirus

b. Parvovirus***

60. . 12 yrs old school girl suddenly collapsed at school.she was brought by ambulance with dextose drip 60/ml min.on
exam dolls eye reflex were present but she was not responding to painful stimulus.her
vitals signs were as follows: > R/R 12/min > PR 50/min > SaO2 100% > bp 180/110(?) > if you are working in a tertiary
hospital.What is the Next step of management?

A) Arrange for urgent CT Scan

B) Stop her dextrose infusion and start on saline

C)Give Steroids

D)Intubate the patient

E)Neurosurgical Reference

Raised ICT: increased B.P, decreased B.P, PR increased.cushing reflex..NS will further increase BP.

61. Man came in for motor vehicular accident with multiple rib fractures, widened mediastinum, ___aortic knob (can't
remember the term used) what do do next –
a. pericardiocentesis

b. Intubation and mechanical ventilation

c. 2d echo(aortic rupture)

62. A lady comes with sudden severe headache subsiding after 2 hour + vomiting. Normal ct scan. No fever but neck
stiffness present. No trauma history. Cause?
a. Acute cerebral haemorrhage

b. Subarachnoid haemorrhage

c. Atypical migraine

d. Temporal arteritis

63. .old lady came with lethargy & constipation,u hv done FOBT & some other test & u dx it as a colon cancer,what is the
most appropriate test now ?
a.ct abdomen

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 b.ct colonography

c.colonoscopy

d.usg

E.xray

ans-c

64. Guy takes cocaine .. initially only for a few days .. now taking even before work and affects his work somthat his
employer tells him to take stress leave .. but he doesnt feel he is addicted .. what will you do--
A. ask collateral h/0 from employer

B. discuss his ambivalence to drug

C. supportive psychotherapy

65. thalassaemia:AR..50% will be carrier.. 25% n, 25% affected

66. -Young girl came with parents for check up,labs-HB:9 or 10,rest all normal except APTT raised,HBA2
positive,what to do next?
A.Iron

B.Blood transfusion

C.Folate

C.. raised Aptt can be present in around 8% thalessamia patient. and in mild thalessemia treat with folate. blood
transfusion in thalesamia dose not indicated if hb level above 6, if the baby is doing well.. in sick baby we can
transfuse blood at hb 7

67. lady lethargic anaemia .. mild icterus ... not a vegetarian no menorrhagia .... macrocytosis n megaloblasts .. what
is next i think
A red cell folate level

B iron studies

C intrinsic factor antibodies

D vit b12 levels

68. Patient with known Waldenström's macroglobulinemia is admitted with fever. He has a history of glandular
fever infection and varicella infection in childhood. He is given ampicillin and azythromycin. The next day he
develops rash. Picture: rash is on the abdomen and chest. It doesn’t look like erythema multiforme at all. Most
of the elements are raised papules, but couples of them are pustules. What is the initial next step to identify
cause of rash?
a. swab from the lesion
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 b. biopsy of the lesion

c. bone marrow biopsy

d. drug allergy test.

Rx-prednisolone

69. . Patient with known Waldenström's macroglobulinemia is admitted with fever. He has a history of glandular
fever infection and varicella infection in childhood. He is given ampicillin and azythromycin. The next day he
develops rash. Picture: rash is on the erythema multiforme at all. Most of the elements are vesicular.What is the
initial next step to identify cause of rash?
a. swab from the lesion

b. biopsy of the lesion

c. bone marrow biopsy

d. drug allergy test.

Rx-antiviral

70. waldenstorm macroglobenemia patient came with rigors and fever and right lower lobar pneumonia or some
infection like this admitted and started ampicillin and after minimal time generalised vesicular rash appeared
asking management
A. prednisolone-drug induced

B. immunoglobulin

C. cease ampicillin

D. Ganicyclovir-herpes/CMV

71. 77-pt with chest pain radiate to the back

unstable s&s with sweating &pallor they say in
scenario he had aortic dissection about 4cm
distally from left subclavian artery what is the
rx.
A.iv nitruptusside

B.iv labetalol

C.iv verapamil

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D.surgery interference

657
658
72. beta thalassemia minor- Autosomal Recessive Disorder

what advice to be given to parents regarding child:

a. Repeat cbc

b. tsh

c. thalassemia minor genetic counselling

d. reassure it normal in children

e. rule out hidden lesion (this was exact word)

73. qtn regarding genetics is like mother had thalassemia minor trait what are the chances of thalasemia minor in
children?
A .25%?

B.50%?

C0

74. . A couple who have both beta thalassemia minor trait came to your clinic asking about the chances of their child
acquiring it.
A. 0

B. 0.25….thalassemia major….hb 3.197

C. 0.5….minor/carrier

D. 0.75

E. 1.0

75. RUQ pain, low hb, low mcv, low mchc

A. Thalassemia

B. Hydatid …..eosinophil count should be high

76. Recurrent URTI in girl aged 9 years Hb 9 WBC normal MCV 90 MCHC decreased
a. Repeat CBC/serum ferritin cz mcv is normal and mchc is low
b. TSH
c. Thalassaemia minor genetic counselling
d. Reassure
e. Rule out hidden lesions
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77. A 45-year-old male is diagnosed with hereditary spherocytosis since his childhood.He presented to hospital
multiple times with haemolytic crisis. Decision is made to proceed with splenectomy. After splenectomy for
hereditary spherocytosis,all of the following can be expected except?
a. Persistence of anaemia
b. Persistence of spherocytes
c. Reticulocytosis
d. Rise in haemoglobin
e. Normal RBC life span

78. A child previously treated Viral Infection for 1wk.now come with petechiae on trunk & arm,non blanchable. Lab
Hb -low plt -decrease no mention abt WBC , RBC count
A . Bone marrow aspiration
B. Epstein barr serology
C. coagulation test dx itp
D. platelet Function test
E.urine RE
79. A child previously treated Viral Infection for 1wk.now come with petechiae on trunk & arm,non
blanchable. Lab Hb -low plt -normal no mention abt WBC , RBC count
A . Bone marrow aspiration
B. Epstein barr serology
C. coagulation test
D. platelet Function test
E.urine RE Hsp

**Non branching rash 1.Meningococcal 2.ITP 3.HSP 4.HUS

80. Which vaccination should not be given to a child who is under remission on chemotherapy for CLL? > >
a. Polio –>
b. MMR l> LIVE VACCINE
c. HiB >
d. DPT >

81. old woman presented with c/o lathergy and fatigue. CBC shows hypochromic and microcytic anemia no h/o
abdominal pain or altered bowel habits or bleeding per rectum. What you will advice next?
A) Serum ferritin
b)fecal occult blood
c) hb electrophoresis
d)colonoscopy

82. Preg lady antinatal visit with anemia Hb 9 Mcv low from range ,taking multivitamins already what adv : Iron
infusion
Green leafy vegetable
Hb electrophoresis

83. .a lady her boyfriend left her. She feels sad for long time bored at times. Can't manage her anger sometimes. Now
angry as many course of antidepressants didn't work. Now sleeps and eats well.what in history will help?
A.unemployment for 6 months
. b.alcohol abuse.
C.repeated self harm

84. A 21 year old female presents with lethargy, her lab results reveal a Hb of 9.5 gm/dl, a Ca level of 1.9 (normal is
2.1), INR of 1.5, what would be your management?
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 A. IV vitamin K.
B. Oral iron
C. IV Calcium Gluconate.
D. FFP.
E. Blood transfusion #mar2018

85. 40 year old woman on aspirin and sertaline,now comes with easy bruising,she doesnt seems to understand the
cause except bumpimg into things.. #hematology
1.aspirin
2.sertaline
3.domestic violence
4.myloproliferative disorder
5.anemia

**Serotonin reuptake inhibitors (SRIs) may potentiate the risk of bleeding in patients treated with ulcerogenic
agents and agents that affect hemostasis such as anticoagulants, platelet inhibitors, thrombin inhibitors,
thrombolytic agents, or agents that commonly cause thrombocytopenia. The tricyclic antidepressant,
clomipramine, is also a strong SRI and may interact similarly. Serotonin release by platelets plays an important
role in hemostasis, thus SRIs may alter platelet function and induce bleeding. Published case reports have
documented the occurrence of bleeding episodes in patients treated with psychotropic agents that interfere with
serotonin reuptake. Bleeding events related to SRIs have ranged from ecchymosis, hematoma, epistaxis, and
petechiae to life-threatening hemorrhages. Additional epidemiological studies have confirmed the association
between use of these agents and the occurrence of upper gastrointestinal bleeding, and concurrent use of NSAIDs
or aspirin was found to potentiate the risk. Preliminary data also suggest that there may be a pharmacodynamic
interaction between SSRIs and oral anticoagulants that can cause an increased bleeding diathesis. Concomitant
administration of paroxetine and warfarin, specifically, has been associated with an increased frequency of
bleeding without apparent changes in the disposition of either drug or changes in the prothrombin time. Bleeding
has also been reported with fluoxetine and warfarin, while citalopram and sertraline have been reported to prolong
the prothrombin time of patients taking warfarin by about 5% to 8%. In the RE-LY study (Randomized Evaluation
of Long-term anticoagulant therapy), SRIs were associated with an increased risk of bleeding in all treatment
groups. MANAGEMENT: Caution is advised if SRIs or clomipramine are used in combination with other drugs
that affect hemostasis. Close clinical and laboratory observation for hematologic complications is recommended.
Patients should be advised to promptly report any signs of bleeding to their physician, including pain, swelling,
headache, dizziness, weakness, prolonged bleeding from cuts, increased menstrual flow, vaginal bleeding,
nosebleeds, bleeding of gums from brushing, unusual bleeding or bruising, red or brown urine, or red or black
stools.

86. #aug18 yr old girl presents with malaise, tiredness for mnths.. on labs, hb 8, microcytic hypochromic, inr 1.5,
calcium 1.9..... what’s the inv to reach the diagnosis. (Many labs were given)
a.hb electrophoresis
b.antigliadin antibodies
c.iron studies
d.serum electrolytes

87. After splenectomy for hereditary spherocytosis,all of the following can be expected except?
a. Persistence of anaemia
b. Persistence of spherocytes
c. Reticulocytosis
d. Rise in haemoglobin
e. Normal RBC life
88. WOF is expected to happen after splenectomy for spherocytosis?
a. RBC life span improves
b. Leukopenia

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 c. Reduction in anaemia
d. Reduction of spherocytes
e. Reduction in fragility of RBCs

**In children with HS who underwent total or partial splenectomy, a review found that the hemoglobin
concentration increased from 10.1 ± 1.8 g/dL at baseline to 12.8 ± 1.6 g/dL at 52 weeks postoperatively. In
addition, splenectomry resulted in a decrease in reticulocyte counts and bilirubin levels as well as control of
symptoms. [24] Other postsplenectomy blood changes include the following: Increased hemoglobin level
Decreased reticulocyte count Leukocytosis Thrombocytosis

89. Lead poisoning anemia?

A- Hypochromic microcytic
B- normochromic normocytic
C- C- hypochromic normocytic
D- D- macrocytic

90. -A 2950-g (6.5-lb) black baby boy is born at home at term. On arrival at the hospital, he appears pale, but the
physical examination is otherwise normal. Laboratory studies reveal the following: mother’s blood type A, Rh-
positive; baby’s blood type O, Rh-positive; hematocrit 38%; and reticulocyte count 5%. Which of the following is
the most likely cause of the anemia?
a. Fetomaternal transfusion
b. ABO incompatibility
c. Physiologic anemia of the newborn
d. Sickle-cell anemia
e. Iron-deficiency anemia

91. Preg lady iron def anemia taken multivitamin what to do? A.hb electrophoresis B.folate C.bone marrow D.iron
infusion
92. man with back pain on xray thoracic vertebrae fracture.on bone scan uptake at fracture site only labs anemia.CA
normal. No symptoms of BPH given.what investigation ll lead u to diagnosis
A. PSA
B. bone marrow
C. MRI
D. DEXA
93. A pregnant lady from Vietnam is presenting with pallor, jaundice and hypo-chromic microcytic anaemia. The iron
and the ferritin are decreased. What do you do?
a.Hb electrophoresis
b.Iron studies
c.Detection of blood in faeces
d.Thick an thin blood film

could be git worm...that worm is causing iron deficiency anaemia and this jaundice is due to
obstruction of billiary passage by worm...so fobt will be positive in such cases

94. A 85 year old normocytic normochromic anemic patient with very low hb count(Forgot exact number) having
high creatine/ urea levels how to manage anemia?
Erythropoietin
Parental or oral iron
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 Packed cell transfusion …if very low
Whole blood transfusion

95. another scenario where a girl came with menorrhagia ,looking pale and hypocalcemia there lab value was 1.9
with no S/s.bt another thing was there was micocytic anemia,asking for what to do?
1.hemolytic screen
2.iv calcium injection
3.blood electrophoresis
D. give vit k injection
e.give FFP

96. Scenario of a lady with splenomegaly and rash on the legs thrombocytopenia, borderline anemia and leucocytes
decreased also hb 11 wbc 4000 plat 50000, complaining of fatigue past few months, diagnosis
sle
itp
hsp
aplastic anemia
AML
ITP??

97. 4 yr boy known case of hereditary spherocytosis came with his parents, his mom says he seems getting pale
during 3 months after URTI. physical exam reveals just splenomegaly. Lab data: normal plt, Normal WBC and
Hb:43(nl 100-120). what’s the most important management?
A-steroid
B-ferrous gluconate
C-Packed cell

98. Young boy developed pain in the right knee .. mild progressive marked swelling .. no other systemic symptoms as
I recall Blood results given .. anemia .. low platelets .. normal WBCs What is your diagnosis Juvenile rheumatoid
arthritis
Acute leukemia
Apalstic anaemia
SLE

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664
99. 40 year old woman on aspirin and sertaline,now comes with easy bruising,she doesnt seems to understand the
cause except bumpimg into things.. #hematology
1.aspirin
2.sertaline
3.domestic violence
4.myloproliferative disorder
5.anemia

100. lead poisoning SIDE EFFECT not include :

1-anemia
2-GIT manifestation
3-neurological manifestations august 2018
**correct ans should be liver abnormality

Table 1: Indications for red blood cell transfusion for children

Hb Indication

Hb Red Blood Cell (RBC) transfusion is often indicated, however lower thresholds may be
<70g/L acceptable in patients without symptoms (symptoms may include – tachycardia, flow
murmur, lethargy, dizziness, shortness of breath and cardiac failure) and where specific
therapy (e.g. iron) is available.
Hb 70 - RBC transfusion may be indicated, depending on the clinical setting e.g. presence of
90g/L bleeding or haemolysis and clinical signs and symptoms of anaemia.
Hb RBC transfusion is often unnecessary and may be inappropriate
>90g/L

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 Transfusion may be indicated at higher thresholds for specific situations:
Preterm neonates: Hb thresholds vary depending on post-natal age and respiratory support
(See Neonatal Transfusion Recommendations at RCH)
Children with cyanotic congenital heart disease or on Extra Corporeal Life Support (ECLS)
Children with haemoglobinopathies (thalassaemia or sickle cell disease) or congenital anaemia on a
chronic transfusion program

101. #haema 52year old ptn presented with iron deficiency anemia ( long case was given) wht u will do next? (no
diarrhea, no abdominal pain) (I think Hb ws 7.9 something)
a. Colonoscopy
b. FOBT
c. Iron tablets
d. Blood transfusion

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102. A child presents to ur surgery with c/o joint pains.u find out that he also suffers from iron deficiency
anemia.what could be the most appropriate diagnosis?
a)juvenile rheumatoid arthritis
b)HSP
c)haemophilia
d)thrombocytopenia

103. child with sickle cell anemia came to ER with

joint pain ....retic 6% which infection will cause this ?
A.adeno v
. B.Parvov.
C.CMV
D.EBV

dx hereditary spherocytosis. Ans is C

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104.

105. 9yr old girl presents with pallor patient with picture of microcytic anemia MCV low Serum ferritin low. TIBC
high. Dx
A) iron deficiency anaemia
b. Megaloblastic anaemia
C) sickle cell dx
D. Lead poisoning
E. Thalassemia

106. Hereditary sphero scenario. Cause of abd pain

A. Renal stone.
B.Gall stones.
C.Splenic enlargement

107. Preg lady iron def anemia taken multivitamin what to do?
A.hb electrophoresis
B.folate
C.bone marrow
D.iron infusion

108. 35year old man married with 1 kid, presents with arthralgia, fever 38.9, splenomegaly for 2 weeks. Nothing
about lymphadenopathy. FBC normocytic normochromic anemia. (I forgot but there was something abound blood
shows atypical lymphocytes?) What is diagnosis?
A. SLE
B. HIV
C. CMV
D. Hodgkin lymphoma
E. Acute .... leukemia

109. Case of old woman with iron deficiency anemia, no symptoms no complain, cause?
B. Carcinoma of caecum
C. Carcinoma of.....
D. Carcinoma of stomach
E. nutritional deficiency
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**Iron deficiency anemia Identifying iron deficiency anemia in elderly persons is essential, and the
condition can be corrected. More importantly, iron deficiency, particularly in elderly persons, often points
to an underlying gastrointestinal pathology, including malignancy. [19, 20] Despite the importance of
establishing a diagnosis, iron deficiency anemia represents only 15-23% of cases of anemia among the
elderly

110. old woman presented with c/o lathergy and fatigue. CBC shows hypochromic and microcytic
anemia no h/o abdominal pain or altered bowel habits or bleeding per rectum. What you will advice
next?
A) Serum ferritin
b)fecal occult blood
c) hb electrophoresis
d)colonoscopy
111. Pt with active RA on methotrexate and chronic pyelonephritis ,feels tired and lethargic. labs done which
showed Hb 9.5 g/dl Mch low normal Serum iron decreased S.ferritin normal Tibc decreased What is treatment of
choice
a) packed RBCs
b) iv iron
c) low dose corticosteroid
d) Folic acid
e) erythropoietin injection
112. old pt 67 yr with anaemia with mcv normal iron low ferritin raised tibc low Diagnosis
A – iron deficiency anemia
b- chronic inflammation
c- thalassemia
d-myelodysplastic

113. woman with lethargy ,weakness, night sweat,lymphadenopathy, has got urti some weeks ago , long scenario ,
lab findings Hb –reduced Plt –reduced Blast cell –increased Wcc – upper limit (not increased) Lymphocyte,
eosinophil ,neutrophil (n limit) DX?
A.Acute leukemia
b. Multiple myeloma
c.leukemoid reaction due to inflammation
d.leukemoid reacti0on due to lung ca

**in leukomoid recation there is a reaction following an infection which mimic leukaemia.but here
neutrophil count will be increased. Rarely blast cell andwill be more mature neutrophil cell.
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114. Young patient with lethargy and malaise, FBC shows Hb 10.2 with normal wbc and platelet count.. whats the
best next investigation ?
A vitamin b12
B electrophoresis
C iron study
D FOBS

115. A sheep farmer with h/o anaemia, weight loss, fatigue, RUQ pain, jaundice comes to ur clinic with fever,
itching, shortness of breath. Asking for causative organism?
a. Echinococcus granulosus
b. Coxillaburnetii
c. Brucella melitensis
d. Saccharopolyspora
116. Which of the following will not cause haemolytic anaemia?
A. Pre-eclampsia
B. G6PD def
C. Malaria
D. CLL
E.Folate and B12 def
117. CLD case, anaemia and decreased albumin, peripheral edema, ascites and pleural effusion.(long Labs) what
to give?
a) Albumin
b) Vit K
c) Blood transfusion
d) Packed RBCs
118. A conflict between FOBT or colonoscopy: A 56 yesr old male presents with lethargy, examination shows
anemia, all labs normal ,iron deficiency anemia (low serum ferritin, high transferrin, low serum iron MCV
low)most appropriate next investigation
: A. FOBT.
B. Chromium labelled red cell scan
C.Flexible sigmoidoscopy
D. Hemoglobin electrophoresis
E. Colonoscopy #gastro jm221

119. A patient coming back from Greece. Presents with abdominal pain, loose motion, no fever. (sorry, I don’t
remember the rest) a) Hydatid disease b) Amoebic liver ds. c) Hepatitis A

120. baby after 6 hours of delivery develops jaundice. Cause

A) Neonatal sepsis

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 Hemolytic anemia
C) Beast feeding
121. past history of dvt pt on UFH perioopertively n switch to lmw heparin after 5 days undergone rt hip surgery
develop dvt after 10 days that what to do In investigation only platelets r decreased
A- ffps|
B- vit k
C- cease heparin and switch to other anticoagulant
D- platelets infusion
122. Lady presenting with fatigue…mild pallor present…FBE shows all cell indices reduced…what to check in
patient?
a. Iron studies
B. Vit B12
123. Man with tirdness lethargy cough dyspnea Labs shows Hb 104 Tlc 40 Plt 90 Blast cells 60% Diagnosis ?
Acute leukemia
Bone marrow infiltration by CA lung
CML
CLL
124. Pt came with fever, weakness, fatigue, some infection, lab Ix-Hb reduced, WBC increased, Neutrophil
increased, Dx asked
a. ALL
b. CML
c. Multiple myeloma
125. 23 yr old lady came with weakness on all limbs but especially at lower limbs,diminished reflex ( not sure )
tingling sensation at foot, no other sensory symptoms . HB reduced MCV – 100 ( normal 80- 100 ) WBC, platelet
– normal B12 level- reduced Likely cause ? a. Pernicious anamia ( sorry forgot other opitions

Hematology

Anemia:

.ANEMIA presentations:

.Mild -> Fatigue - loss of energy - tiredness - malaise.

. Severe -> Shortness of breath - lightheadedness - confusion.

. Pallor - flow murmur - pale conjunctiva.

Causes of microcytic hypochromic anemia:

1-iron deficiency anemia

2-thalassemia

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3-sideroblastic anemia

4-anemia of chronic disease

MCV:

NORMAL….80-100

MICRO……LESS THAN 80

MACRO…..MORE THAN 100

IRON DEFIENCY ANEMIA:

CAUSES:

Infants:

Most common cause……diet…prolonged breast feeding without supplementation

Adult:

Most common cause…….GIT bleeding….peptic ulceration

Elderly:

Most serious cause…….cancer colon

Cp:

General manifestation of anemia

Specific manifestation of iron deficiency:

Appetite…..PICA ( strange appetite)

Mouth…….angular stomatitis

Investigations:

CBC:

Decreased Hb, decreased hematocrite, decreased RBC'S

Decreased MCV and MCHC

Most accurate test……bone marrow examination

Iron studies..

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Serum iron, ferritin, transferring……decreased

TIBC…….increased

For diagnosis of the cause:

Stool exam……ancylostoma, occult blood

Endoscopy……peptic ulcer

Colonoscopy…colon cancer….vvvvv imp in elderly

Treatment:

TTT of the cause

Replacement therapy:

How:

Iron rich diet….beef, chicken, leafy greens

Oral iron…..ferrous sulphate, ferrous gluconate

Side effect of iron:

Black stool….. imp

Abdmina pain, vomitin, constipation

Parentral iron:

Indication: intolerable to oral iron e.g:peptic ulcer

Iron dextran, iron sorbitol

Side effect,… anaphylaxis

Transfusion therapy:

How?.....packed RBC's

When:

Hemoglobin less than 7 gm

Marked symptoms of the anemia

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Hemolytic anemia:

Causes:

Hereditary spherocytosis

Paroxysmal nocturnal hemoglobinuria

Thalassemia

Sickle cell anemia

G6PD deficiency

General manifestations:

Jaundice

Hepatosplemegaly

Gall stones

Leg ulceration

Investigations:

CBC:

Normocytic normochromic anemia

Reticulocytic count…..high….vvvv imp

Serum bilirubin….. increased

Serum LDH…..increased

Haptogloin…..decreased….vvvvvvvvvvvvvvvv imp

Hereditary spherocytosis vvvvvvvvvvvvvvvvvvvv imp

Defect…..membrane of the RBC's

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Cp:

Same as hemolytic anemia

Since birth……vvvvvvvvvvvvvvvvvvvvv imp

Marked splenomegaly……vvvvvvvvvvv imp

Complications….aplastic crisis ( parvovirus)….v imp

Investigations:

Same as hemolytic anemia

Specific test…….increased osmotic fragility..vvvv imp

Blood film…..spherocytes

TTT:>

Splenectomy….vvvv imp

ttt of crisis…transfusion…..vvvvvvv imp

Paroxysmal nocturnal hemoglobinuria:

General….manifestation of hemolytic anemia

Complications:

Aplastic anemia

Thrombosis

Pancytopenia

Acute leukemia

Investigations:

As hemolytic anemia

Specific test…..Ham test

Most confirmatory test….flow cytometry CD55, CD58

TTT…..cortisone, and BMT

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Thalassemia:

Disease…..Autosomal recessive……vvvv imp

Defect……beta chain

Types:

Major…..both chromosomes are affected

Minor…..one chromosome affected

Cp:

POSITIVE FAMILY HISTORY

Onset .. not before 6 months

Symptoms of iron overload e.g:cirrhosis

Thalassemic facies:

Depressed nasal bridge

Prominent maxilla

Protruding upper incisor

Pallor

jaundice

investigations:

Same as hemolytic anemia

Most confirmatory test…….Hemoglobin

electrophoresis

Blood film……target cells

Serum studies…. Increased serum iron

TTT:

Repeated blood transfusion

Iron chelation…..deferoxamine

Folic acid
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Splenectomy

Prevetion:…… DNA analysis for the parents

Sickle cell anemia:

Genetics……..Autosomal recessive

Clinical picture:

Same as hemolytic anemia

Vasoocclusive crisis:

Bone infarction……aseptic necrosis of the hip

CNS…..stroke

Lung infarction….acute chest syndrome

Splenic infarction

Renal infarction

Priapism

Hand foot syndrome

How to prevent crisis:?..avoid cold, dehydration,stress

TTT of crisis:

Analgesic……first step

Oxygen…..second step

Antibiotics, Hydration

Exchange transfusion with acute chest syndrome, stroke or priapism

2-aplastic crisis:

Cause…..parvovirus

Cp……pallor……so the patient needs transfusion

Inv…..low hemotocrite and low reticulocytes

TTT……..transfusion

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3-hemolytic crisis:

Cp: pallor, jaundice and red urine

Inv….low hematocrite but increased reticulocytes

TTT…..transfusion

4-sequestration crisis:

Cp: pallor with marked enlargement of the spleen

TTT….splenectomy

Investigations:

Same as hemolytic anemia

Confirmatory test…..Hb electrophoresis….Hb S

Blood film……sickle cells

TTT:

Repeated blood transfusion

Type of blood,……packed RBC's

Iron chelation…..deferoxamine

Folic acid

How to prevent crisis?......hydroxyurea

G6PD deficiency:…..oxidative hemolysis:

Clinical picture:

Same hemolytic anemia….sudden pallor, jaundice, red urine

Causes:

Drugs…..most common

Aspirin, antimalarial, sulpha drugs

Infections

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Meals…..fava beans

Inveatigations:

Same as hemolytic anemia

Specific test…. Asses G6PD enzyme activity

Take care…..after attack G6PD activity is normal but decreased after one month

TTT:

Avoid oxidative stress

Autoimmune hemolytic anemia:

Occurs with SLE, CLL lymphoma , EBV

Specific test……positive Comb's test

TTT:

Cortisone, Immunosuppressive drugs

Cold agglutinin antibody:

Most common cause….mycoplasma pneumonia

Clinical picture:

As hemolytic anemia

Investigations:

As hemolytic anemia

Direct comb's test

TTT:

Avoid exposure to cold

splenectomy

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drugs induced hemolysis:

Cephalosporins-- most common cause

Dapsone

Levodopa

Nitrofurantoin

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Penicillin and its derivatives

Quinidine-

Antimalarial drugs

Aplastic anemia:

Most common cause…..idiopathic

Exposure to radiation (radiation sickness)

Chemotherapy

Environmental toxins (insecticides, benzene, mustards)

chloramphenicol

sulfonamides

NSAIDs and gold

viral infections, including viral hepatitis B, parvovirus B19, HIV and infectious mononucleosis

Autoimmune disease

Clinical picture:

Decreased RBC'S…….anemia

Decreased WBC'S …...infections

Decreased platelets…..bleeding

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Investigations:

CBC……pancytopenia

bone marrow examination….hypocellular fatty tissue…vvvimp

TTT:

The best…..BMT

Supportive….blood transfusion

Megaloblatic anemia:

Causes :

1-vitamin B12 deficiency

Most common cause……vegetarian

Pernicious anemia

Gastrectomy

Organism…..diphyllobothrium latum

2-folic acid deficiency:

Alcoholic…….most common

Drugs: methotrexate, phenytoin cotrimoxazale

Malignany

clinical picture:.

Anemia

GIT manifestation…

Atrophic gastritis

Neurological manifestations..only B12 deficiency:

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Peripheral neuropathy

Sub acute combined degeneration:

Loss of posterior column functions e.g: position and vibration

CBC's:

RBC's…...large MCV …..imp

WBC'S…..large neutrophil and hypersegmented

Platelets….large and decreased

Serology:

Antiparietal cell antibody … only B12

Schilling test…..only B12 deficiency

TTT:

Replacement therapy

Vit B12 deficiency….IM cyanocobolamine

Folic acid deficiency…oral folic acid

Transfusion….packed RBC'S….only severe cases

PERINICIOUS ANEMIA:

. Auto-antibodies against the gastric intrinsic factor required for B12 absorption ………vitamin B12
deficiency.

. Associated other auto-immune diseases e.g. Autoimmune thyroiditis & Vitiligo.

. Peripheral blood smear -> Macro-ovalocytes, megaloblasts & hyper-segmented neutrophils.

. Dx -> Detection of Anti-intrinsic factor Abs

Risk……CANCER STOMACH….VVVVVVV IMP.

Anemia of chronic disease:

Anemia……microcytic hypochromic anemia

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Causes …any chronic disease e.g: RA

Specific test….increased ferritin

Anemia of renal failure:

Main cause…..erythropoeitin deficiency

Type…..microcytic hypochromic anemia

TTT….erythropeitin replacement

Sideroblastic anemia:

Most common cause….lead

Ringed sideroblast

Prussian blue test…(+)

Purpura:

Causes:

Decreased platelet production

Increased platelet destruction….ITP, SLE

Decreased platelet functions: uremia

Vessel …..vasculitis….HSP

Scurvy….vitamin c deficiency…old age

Senile purpura

Immune thrombocytopenic purpura:

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History……URTI 1-2 weeks before attack

Bleeding:

Skin….petechial hge

Generalized

Not raised above the surface

Do not blanch on pressure

mucous membranes:

Epistaxis, bleeding gum

Hematuria

Incranial bleeding….in severe cases

Investigation:

Platelets…..decreased

Bleeding time….increased

Bone marrow exam….increased megakaryocytes with defective budding

Antiplatelets antibodies

TTT:

Majority of cases……nooooooooo ttt

Mild cases….no ttt….avoid trauma and NSAIDs..vvv imp

Moderate cases:

Prednisone…..drug of choice…..first line

IVIG…..second line

Platelet transfusion ….not done only with intracranial bleeding

Chronic cases……splenectomy

Prognosis….excellent

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Hemophilia…..coagulation disorder:

Genetics……..X-LINKED

So boys are the majority of cases

Type:

Hemophilia A….factor 8 deficiency

Hemophilia B…..factor 9 deficiency

Clinical picture:

Bleeding:

Onset….prolonged bleeding after circumcision

Skin….ecchymosis

Joints…..hemoarthrosis….most common site

Repeated hge in the joints….joint damage

Muscle….muscle hematoma

Excessive hemorrhage after minor trauma….vvvvvv imp

Investigations:

Bleeding time….normal

APTT….increased

PT….normal

Factor 8…..decreased with hemophilia A

Factor 9 ….decreased with hemophilia B

TTT:

General measures:

Avoid trauma

Avoid NSAIDs

Specific ttt:

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Factor 8 replacement

Fresh frozen plasma

Desmopressin….increases factor 8 production

Von-Willebrand disease:

Autosomal dominant

Most common hereditary coagulable status

Bleeding prolonged

Investigation:

Bleeding time….prolonged

APTT…..increased

TTT….as hemophilia

Take care:

Girl with prolonged bleeding……Von Willebrand

Boy with prolonged bleeding…..hemophilia Or von willebrand

Purpura….increased bleeding time

Hemophilia….increased APTT

Von willebrand…..increased both

Confirmatory test for:

Thalasssemia….hemoglobin electrophoresis

Sickle cell……..hemoglobin electrophoresis

Hereditary spherocytosis….osmotic fragility

Autoimmune……comb's test

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ITP…….increased megakarycytes

Bleeding after URTI……ITP

)POLYCYATHEMIA VERA (P.vera:(

.Plethoric face.

. Headache - Blurring of vision - dizziness - fatigue.

. Pruritis happening after a hot bath or shower

Splenomegaly…..huge size.

. Hypertension.

++ . peptic ulcerations

Dx -> CBC "MARKEDLY HIGH HEMATOCRITE & low MCV

Increased red cell mass

. Dx -> ABG " Absence of hypoxia…vvvvv imp."

. Dx -> -- Erythropoietin…. Normal or low ….vvvv imp.(

++ . WBCs & ++ Platelets.

. Tx -> PHLEBOTOMY. (HCT < 45%.(

. Tx -> Hydroxyurea – drug of choice.

. Tx -> Give daily Aspirin to prevent Thrombosis

Polycythemia rubra vera vs secondary polycythemia:

Polycythemia rubra vera secondary polycythemia

Oxygen saturation normal hypoxia
erythropoeitin Normal or low increased
.

687
Myelofibrosis:

Cp……..pancytopenia

Bone marrow examination:

Aspiration…….tear drop …vvvvvvv imp

Biopsy….the best…. Fibrotic BM

TTT:

Drug…..hydroxyurea

BMT

Thrombophilia ( hypercoagulable status):

Causes:

Congenital:

Factor 5 leiden deficiency…..most common…vvv imp

Homocystiniemia

Deficiency of factor C

Deficiency of factor S

Deficiency of antithrombin 3

Acquired:

SLE

Antiphospholipid syndrome

PNH

DIC

Malignancy

OCP

Pregnancy

688
Nephrotic syndrome

TTT:

Aspirin ( low dose ) and warfarin

If pregnant….low dose aspirin and low dose heparin

Lymphoma:

Hodgkin lymphoma:

Age….either 15-35 or over 50 ys

Cp: painless enlargement of the lymph nodes

Most common affected lymph nodes…..cervical

Enlarged, discrete, non tender and rubbery

Pain induced by alcohol

Splenohepatomegaly

General manifestation:

Fever, night seating, pruiritis, weight loss and anemia

Intermittenet fever…..pel Ebstein fever

Microscopy …..reed Sternberg cells

Associated with …..HTLN virus

Non-hodgkin lymphoma:

Less common

Associated sometimes with sjogren syndrome

Cp:

Progressive enlargement of the lymph nodes

Gastric lymphoma

Investigation:

689
Biopsy…..excisional ….. is the best

CBC……anemia, eosinophilia

CT and chest x-ray…..enlarged LN

TTT:

Hodgkin…..chemo

Non-hodgkin's ……chemo and radio

Burkitt's lymphoma:…… imp

Cause……Ebstein Bar virus

Age…..kids

Cp….progressive enlargement of the LN

TTT……chemo

.GASTRIC MALT = MUCOSA ASSOCIATED LYMPHOID TISSUE MANAGEMENT:

.ERADICATION OF HELICOBACTER-PYLORIp

. TRIPLE THERAPY (OMEPRAZOLE - CLARITHROMYCIN - AMOXICILLIN.(

.TUMOR LYSIS $YNDROME:

. Ass. with tumors with high cell turn-over.

) . HYPER {phosphatemia - kalemia - uricemia.{

. HYPO {Calcemia.{

. TL$ may lead to fatal arrhythmias, ARF & sudden death.

. Tx -> Allopurinol

DIC = DISSEMINATED INTRAVASCULAR COAGULATION:

.Doesn't occur in healthy pts.

690
. Ass. with sepsis - burns - snake bites - cancer - Abruptio placenta or AF Embolism.

. BLEEDING related to CLOTTING FACTORS DEFECIENCY & THROMBOCYTOPENIApp

++ . both PT & PTT……..

++ .D-dimer & FDP (fibrin degradation products)……

Fibrinogen level…..decreased

Platelet count…….decreased.

. Tx -> REPLACEMENT by FFP FRESH FROZEN PLASMA (Contains both palatelets & clot.factors.(

Complications of blood transfusion:

1-pyrogenic reaction:

Cp…..chills, fever, nausea and vomiting

Cause…..minor bacterial contamination or some pyrogens

2- allergic reaction:

Cp…mild itching, to urticaria

Cause….allergens

TTT: antihistamins, cortisone

3-CHF:

Cause…..adminstration of blood too rapidly to elderly

Prevention: give packed RBC'S instead of whole blood

4- hemolytic reaction:

Cp:

Fever, chest pain and dyspnea

Tachycardia and hypotension

691
Hemoglobinuria and jaundice

TTT:

Stop the transfusion immediately

Normal saline

Iv cortisone

5- transmission of infections:

Hepatitis B

Hepatitis C

HIV

6- hyperkalemia

Due to storage of blood

7-citrate intoxication:

Excess citrate….hypocalcemia

TTT : iv ca gluconate

Complications of massive blood transfusion:

1-hypothermia

2-hyperkalemia

3-hypocalcemia

4-coagulation failure

Most common component that is decreased in stored blood….platelets (short half life)……VVVV
imp

.FEBRILE NEUTROPENIA:
692
.temperature > 38.3c or sustained temp.

. Neutropenia = neutrophil count < 1500 cells/ml.

. All require antibiotics.

. The most common invading organism is PSEUDOMNAS AERUGINOSA.

. Tx -> HOSPITALIZATION,

. BLOOD CULTURES followed by IV CEFEPIME or PIPERACILLIN TAZOBACTAM.

SQUAMOUS CELL CARCINOMA OF THE MUCOSA OF THE HEAD & NECK:

.ALCOHOLIC SMOKER.

Enlarged cervical lymph node

. Dx ->Biposy is a must

Pan endoscopy

Tx -> Radical neck dissection.

.METASTATIC BRAIN CANCER:

. Incidence -> Lung > Breast > Melanoma > Colon.

. Primary solitary brain metastases -> BREAST - COLON - RENAL CELL CARCINOMA.

. Multiple brain metastasis -> LUNG - MALIGNANT MELANOMA.

. Brain metastasis are the most common intracranial tumors

TTT:

.SOLITARY -> SURGICAL RESECTION followed by whole brain radiation.

. Multiple -> Palliative whole brain radiation.

.PAIN CONTROL IN CANCER PATIENTS:

.Use SHORT ACING IV MORPHINE.

.MANAGEMENT OF CHEMOTHERAPY INDUCED NAUSEA & VOMITING:

. SEROTONIN ANTAGONIST Ondansetron

693
general manifestation:

fever, fatigue, weight loss

night sweating, loss of appetite

easy bruising,

recurrent infections

pain in the joints, muscles

lymphadenopathy

hepatosplenomegaly

important notes:

Most common leukemia in kids…acute lymphoblastic leukemia

Most common type of leukemia in the elderly….chronic lymphatic leukemia

Main cp of chronic myeloid

leukemia….splenomegaly

Main CP of chronic lymphatic leukemia

lymphadenopathy

Old age + marked lymphadenopathy…..

chronic lymphatic leukemia or lymphoma

Most common virus causing

leukemia….RETROVIRUSES ( HTLV)

Blast cells…..acute leukemia

(+) myelperoxidase test….acute myelgenous

leukemia

Decreased leukocyte alkaline phosphatase…..chronic myelgenous leukemia

Philadelphia chromosome….. chronic myelgenous leukemia

Most common complication of chronic lymphatic leukemia….blastic crisis

694
Chronic lymphatic leukemia:

‫ ﻣ ﺶ ﻣ ﺴ ﺘ ﺎ ھ ﻠ ﺔ ﻋ ﻼ ج‬- ‫ اﻟﻠﻮ ﻛ ﯿﻤ ﯿ ﺎ اﻟﻄ ﯿﺒﺔ‬-‫ﻟ ﻮ ﻛ ﯿ ﻤ ﯿ ﺎ اﻟﻌ ﻮ اﺟ ﯿﺰ‬

Age….elderly

Main cp…..marked lymphadenopathy

DD…..lymphoma

Association…..autoimmune hemolytic anemia

Prognosis……good

TTT….usually none

Leukemoid reaction:

Marked increase in the WBC'S with immature lymphocytes

Cause……infections e.g: hepatitis, EBV

Leukostasis:

Hyperviscosity due to marked increase in the WBC'S

COMPLICATION…..occlusion of the blood vessels…

Sites….brain, penis, lungs

TTT….PLASMAPHARESIS

Treatment of leukemia:

ALL:

Induction therapy: vincristine and prednisone

CNS prophylaxis: intrathecal methotrexate

Consolidation: vincristine and prednisone

Maintenance: vincristine and prednisone

695
AML:

Induction and maintenance: cytosine arabinoside and daunorubicin

Recurrent cases….BMT

CML:

HYDROXYUREA

Interferon

BMT

CLL:

Usually no ttt

If hemolytic anemia occurs….prednisone

Infectious & Travel medicine

National Immunisation Program Schedule
From 1 April 2019
Australian Government Department of Health
National Immunisation Program
A joint Australian, State and Territory Government Initiative

Age Disease Vaccine Brand

Childhood vaccination (also see influenza vaccine)

Birth Hepatitis B (usually offered in hospital)a H-B-Vax® II Paediatric or Engerix

B® Paediatric

2 months Diphtheria, tetanus, pertussis (whooping cough), Infanrix® hexa

Can be given from 6 weeks of age hepatitis B, polio, Haemophilus influenzae type b
(Hib) Prevenar 13® Rotarix®
Pneumococcal
Rotavirusb
4 months Diphtheria, tetanus, pertussis (whooping cough), Infanrix® hexa
hepatitis B, polio, Haemophilus influenzae type b
(Hib) Prevenar 13®
Pneumococcal Rotarix®
Rotavirusb

696
Age Disease Vaccine Brand

6 months Diphtheria, tetanus, pertussis (whooping cough), Infanrix® hexa

hepatitis B, polio, Haemophilus influenzae type b
(Hib)
Additional vaccines for Aboriginal and Pneumococcal Prevenar 13®
Torres Strait Islander children (QLD,
NT, WA and SA) and medically at-risk
childrenc
12 months Meningococcal ACWY Nimenrix®
Measles, mumps, rubella M-M-R® II or Priorix®
Pneumococcal Prevenar 13®

Additional vaccines for Aboriginal and Hepatitis A Vaqta® Paediatric

Torres Strait Islander children (QLD,
NT, WA and SA)

18 months Haemophilus influenzae type b (Hib) ActHIB®

Measles, mumps, rubella, varicella (chickenpox) Priorix-Tetra® or ProQuad®
Diphtheria, tetanus, pertussis (whooping cough) Infanrix® or Tripacel®

Additional vaccines for Aboriginal and Hepatitis A Vaqta® Paediatric

Torres Strait Islander children (QLD,
NT, WA and SA)

4 years Diphtheria, tetanus, pertussis (whooping cough), Infanrix® IPV or Quadracel®

polio
Additional vaccines for medically at- Pneumococcal Pneumovax 23®
risk childrenc

National Immunisation Program Schedule

From 1 April 2019
Australian Government Department of Health
National Immunisation Program
A joint Australian, State and Territory Government Initiative

Age Disease Vaccine brand

Adolescent vaccination (also see influenza vaccine)

12-13 years Human papillomavirus (HPV)e Gardasil®9

(School programsd) Diphtheria, tetanus, pertussis (whooping Boostrix®
cough)

14-16 years (School programsd) Meningococcal ACWY Nimenrix®

Adult vaccination (also see influenza vaccine)

15 – 49 years
Aboriginal and Torres Strait Islander Pneumococcal Pneumovax 23®
people with medical risk factorsc
50 years and over Aboriginal and
Torres Strait Islander people Pneumococcal Pneumovax 23®

697
Age Disease Vaccine brand
65 years and over Pneumococcal Pneumovax 23®

70–79 yearsf Shingles (herpes zoster) Zostavax®

Pregnant women Pertussis (whooping cough)g
Influenzah Boostrix® or Adacel®

Funded annual influenza vaccinationh

6 months and over with certain medical risk factorsc

All Aboriginal and Torres Strait Islander people 6 months and over

65 years and over

Pregnant women

a Hepatitis B vaccine: Should be given to all infants as soon as practicable after birth. The greatest benefit is if given within 24 hours,
and must be given within 7 days.
b Rotavirus vaccine: First dose must be given by 14 weeks of age, the second dose by 24 weeks of age.
c Refer to the current edition of The Australian Immunisation Handbook for all medical risk factors.
d Contact your state or territory health service for school grades eligible for vaccination.
e Observe Gardasil®9 dosing schedules by age and at-risk conditions. 2 doses: 9 to <15 years - 6 months minimum interval. 3 doses: ≥15
years and/or have certain medical conditions - 0, 2 and 6 month schedule. Only 2 doses funded on the NIP unless 12-13 year old has
certain medical risk factors.
f All people aged 70 years old, with a five year catch-up program for people aged 71-79 years old until 31 October 2021.
g Single dose recommended each pregnancy, ideally between 20-32 weeks, but may be given up until delivery.
h Refer to annual influenza information for recommended vaccine brand for age.

• Contact your State and Territory Health Department for further information on any additional
immunisation programs specific to your State or Territory.
• All people aged less than 20 years are eligible for free catch up vaccines.
• Adult refugees and humanitarian entrants are eligible for free catch up vaccines.

1. Pt had paralysis of lower part of the body had an infectious disease

Lp(ans,gbs)
Nerve conduction….later

2. Pregnant lady with measles presents within 24 hours of rash asking management options included
do nothing
administer immunoglobulin
trace contacts

3. A old man present with new onset of diarrhoea for 3 months and weight loss. Complains for
difficulty in getting up from chair and walking up the start.
a. ---campylobacter jejuni infection
b. ---coeliac disease
c. ---polymyositis
d. ---thyroxicosis

698
4. .35 yrs Man with malaise fever tiredness, has 6 month old boy. Pbf shows atypical
lymphocytes asking dx
Acute leukemia
ebv infection ans
Hodgkin disease
5. A man travelled to Africa but had his necessary vaccinations, malaria prophylaxis, slept under
mosquito nets whiles there but days after his return started complaining of recurrent fever. Whiles in
Africa, he used bottled water and observed sterilization but took twice daily bath with bucket of water
from local lake. Rapid malaria test has proven negative on two occasions. What next?
a) Thin and thick film ans
[ The diagnosis is made on three separate thick and thin blood films but one single test supplemented with
a rapid antigen test may be a practical way of detecting the disease, JM pg]
b) investigate for other infectious disease

6. traveller came back from Africa.have fever(not very high)with tender splenomegaly.no gi
symptoms.hb is 8 g/dl (12-15g/gl).malaria test 3 days before he left was negative.(no history of taking
prophylaxix or net using or any h/o bathing in lake…as in previous recalls).what to do next
a.repeat malarial serology
b.schistosomiasis serology
c.Entamebae histolytica
d.giardiasis

7. African came for refugee health check up.malaria negative two days
prior coming here.mentioned eosinophilia but no fever.what most
appropriate next investigation?
A.stool for ova,parasite. That should have diarrhoea
B.schistosomiasis serology
C.check malaria again. (No fever )
8. Old couple travelled to western australia. Pt in coma, gcs very low,
High temp, Had few mosquito bites while there.. asking cause?
A.Australian ...?
B.Malaria
C.Dengue
D.Ross rive
Dx: A.Murray valley encephalitis( Murray Valley encephalitis virus is a
zoonotic flavivirus endemic to northern Australia and Papua New Guinea.
It is the causal agent of Murray Valley encephalitis. In humans it can cause
permanent neurological disease or death)
9. 50yr old man visits to Bali & after he got back, developed fever with
chills, mild jaundice, diarrhea. On examination, hepatosplenomegaly
present. What will be the fact least indicate malaria?
a. Diarrhoea
b. Daily fever
c. Absence of splenomegaly
d. Jaundice
10. after returning from trader to Cambodia,man returned with fever,chills shivering,diarrhoea.No
hepatosplenomegaly.Which will help exclude the diagnosis of malaria?

699
a. Thrombocytopenia
b. Absence of splenomegaly
c. Diarrhoea
11. African come for refugee health check up. Malaria negative two days prior coming here.mentioned
eosinophilia.but no fever mentioned.what most appropriate next inv u will do?
a. Stool for ova,parasites
b. Schistosomiasis serology
c. Check malaria again

12. 10. Yr old lady with 26 weeks of gestation presents with mild jaundice,fever and right upper
quadrant pain who was travelled from kanya last 2 weeks. What will be the effect on her fetus?

A. Hypoglycemia
B. Hydrops fetalis
C. Low birth weight
13. Patient returned from travel to overseas was taking tetracycline prophylaxis for malaria regularly; 2-
3 days after her return she had bloody diarrhea for 2 days. O/E she has slight tenderness in the left lower
abdomen T 37.5 other than that all normal. Blood culture, stool exam normal. Ask about the cause

a. pseudomembranous colitis
b. giardia
c. E H
d. Shigella
14. presents with abd cramps, bloody diarrhoea. was well previously. recently returned from nepal trip,
was taking doxycycline for malaria prophylaxis . dx?
a. pseudomembranous colitis
b. ulcerative colitis
c. infective colitis
d. ischaemic colitis
e. giardiasis
https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical-
tools/gastroenterology/colitis/pseudomembranous-colitis
15. Chloroquine resistant Malaria prophylaxis in pregnancy?
a. Quinine
b. Artemisinin
c. mefloquine
d. primaquine
16. 55yr old man visited Bali & taking Doxycycline for malaria
prophylaxis & during his trip, he developed fever with chills, malaise, deep
jaundice, pain in RHC with pale stool & dark urine. Investigation given:
Serum bilirubin increased, alkaline phos: markedly increase, AST/ALT
– increased. What will be ur diagnosis?
a) Ca head of pancreas
b) Drug reaction
c) Malaria
d) Cholangitis
700
e) Hep A
17. young had history of fever 40 degree and muscle ache with history of travel to Cambodia .
Examination shows thrombocytopenia and elevated lever enzymes about 200 and more each of them with
elevated urea and yellow eye sclera and no rash and no neck stiffness. What the diagnosis??
a. Malaria
b. Hepatitis A
c. Staphyloccos scalded skin syndrom
d. Dengue fever
18. travel 5 days to combodia, present with moderate dull headahe , jaundice, RUQ pain, full blood
count given
HB ↓
Platelet ↓
Liver Enzyme ↑
??
a. dengue
b. Hep. A
c. Malaria
d. Others
19. Pts came from Brasil 1 month ago. Now come to you. the wife wants to conceive , but they are
concern about Zika virus thats why they haven't had sex since arrive from Brasil. What is your advice?
A)Zika virus isn't STI
B)Safety use a condom.
C) Do Zika virus serology
D) reassure (they are not infected.

If men:wait 3 months from return

Women 2 months
Couple 3 months.
Avoid pregnancy
Use protection

20. pregnant mid trimester with condylomata acuminata,all on the left labia majora,she did cryo but it
increasing number,spresding more,what should u do
.topical antiviral
.surgical excision of the whole left labia majora
.operative cryotherapy contro

701
 .ignore till after delivery

21. A farmer came with malaise, fever, arthralgia, hepatomegaly. NO RASH. Diagnosis?
a. Brucella abortus (ans) jm292
b. Leptospira Pomona jm292
c. Lyme disease jm 287
d. Coxiella burnetii ( Q fever jm 286)

22. Child with vericella treated a few days ago.idont remember name of drug for infected pustules. Now having
ataxia and nystagmus. Most appropriate next investigation will be
1 vericella IgM
2 LP
3 CT ans post viral cerebelitis

https://www.rch.org.au/clinicalguide/guideline_index/Ataxia/

702
23. A mother with her baby 7 months who got his 2 , 4 , 6 months vaccines was in contact recently with
a chicken pox diagnosed child what to do:
A- Varicella vaccine now
B- Varicella IG ( the child was fine ,, not immunocompromised )
C- Reassure her he is immunized
ANSWER Right option should be do nothing or symptomatic treatment

**

What do you give to a child younger than 1 year of age if they were exposed to the chickenpox or zoster virus?

The minimum age for varicella vaccine is 12 months. Vaccination is not recommended for infants younger than 12 months of
age even as post-exposure prophylaxis. CDC recommends that a healthy infant (that is, not immunosuppressed, so not a
VZIG candidate), should receive no specific treatment or vaccination after exposure to VZV. The child can be treated with
acyclovir if chickenpox occurs. Immunosuppressed children should receive VZIG.

https://www.immunize.org/askexperts/experts_var.asp

703
24. Measles outbreak recall—what to do for day care
and staff
A.give ig to unvaccinated staff and children …could be
ans as well
B. exclude all unvaccinated
C. exclude all wz fever
D. take all the infection control measures
E. wash hands/ there was no give vaccine or exclude the
sick
Ref : from nsw site
In jm pg 1043
25. after 3 cases of measles in school. you are keen to find
a way to prevent further outbreak of measles. Which of these
is the most appropriate step to take in this situation?
A-quarantine the children
B-give pamphlets to parents about the vaccination
prevention
C-Give IG to all unvaccinated staff and children
D-Give vaccine to family members
E-told them about hand wash prevention
Answer?b
26. Measles outbreak in a school
A. Vaccinate all children
B. Exclude unvaccinated children from school
C. Ig to all unvaccinated children n staff
ANSwer???????
27. In which of the following, is administration of
immunoglobin as prophylaxis not useful?
A - Hepatitis A
b- Hepatitis B
c- Rubella
d- Mumps ans
e- Varicella

704
28. Young couple wz infertility, female Ix were normal, what in history’ll u ask the male pt 'll be most useful to
guide u to cause of infertility ?
A- Do u drink alcohol so much? ans
B- Did u get chicken pox infection for once while u were young?
C. h/o mumps
29. boy with history of Mumps and history of using
cyclophosphamide, and now using sulfasalazine for some
reason he presented with sperm count 1 million and severely
abnormal what's the cause?
a. Sulfasalazine ans
b. Cyclophosphamide
c. Mumps.(They cause orchitis)
Jm pg 1243

30. The most common complication of mumps in a 5 year old boy is — 1050 jm
a. Diabetes mellitus
b. Orchitis ( in adults)
c. Encephalomyelitis
d. Meningoencephalitis ans
e. Sialectasis
31. child 15 months brought by his mom to clinic , this boy had a rash similar to rubella 1 month ago , last
vaccine he took was at the age of 12 months
what should you do now ?
a- Check IGM for rubella
b- Give only measles mumps vaccine
c- Give MMR
d- Delay his vaccines for a while
https://www.health.nsw.gov.au/Infectious/controlguideline/Pages/measles.aspx#table2

705
Answer?A/DRubella virus specific IgM antibodies are present in people recently infected by rubella virus, but these
antibodies can persist for over a year, and a positive test result needs to be interpreted with caution (wiki)
according to racgp vaccine is at 12 (mmr)and 18(mmrv) mnth and 4yr if 2nd dose missed at 18 mnth

32. Which of the following statements about mumps is correct?

The mumps skin test is a reliable indicator of immunity
Incubation period is 7-10 days(12-25days)
Meningo-encephalitis can precede, occur simultaneously with or follow parotitis ans jm1036
Salivary gland involvement is limited to the parotids
Infertility is usual following mumps orchitis.
33. A 70yo woman presents with recurrent episodes of parotid swelling. She complains of difficulty
in talking and speaking and her eyes feel gritty on waking in the morning. What is the single
most likely dx?
a. C1 esterase deficiency
b. Crohns disease
c. Mumps
d. Sarcoidosis
e. Sjogrens syndrome ans
34. Kawasaki case: child with fever, conjunctivitis, rash, lymphadenopathy, treatment asked
a. Ivig
b. high dose aspirin
c. , echo
Jm 1049

35. Which vaccination should not be given to a child who is under remission on chemotherapy for CLL? > > a.
Polio –> b. MMR l> c. HiB > d. DPT >
Ans B

706
36. It was like he had severe anaphylaxis with egg ...and now came for vaccination
What will u do
A. Do skin allergy test
B. Give test dose vaccine if no problem give full dose Ans
C.Give steroids before mmr
Egg usage got less in vaccinations,now decreased. So can give everyone
37. pregnant lady with measles IGm +.... what to do?? infection can cause miscarriage or premature
delivery but is not associated with congenital malformation ans: contact tracing and symptomatic mx.
jm1043

38. Middle aged lady presented with headache, neck rigidity, her child had fever, cough &amb;
rash recently. LP shows mononuclear cells, glucose reduce
A- Influenza virus
B- Enterovirus —
C- Herpes simplex- only hsv show dec glucose in viruses
D- Meningococcus bcz of lp finding

707
39. paeds missed 12 month immunizations, now 15 months-old-comes to you as GP for URTI?
What to do next?
A. Wait until URTI resolves then give immunization, then come back 3 months after
B. Give immunization now, then at 3 months [ans]
C. Come back at 3 months
D. Give immunization now, come back 1 month later

Catch-up vaccination:
Ensure that all school-aged children and adolescents have had 2 doses of MMR vaccine; the minimum interval
between the 2 doses is 4 weeks.[ Catch up vaccine with 2 doses 4weeks apart is for travellar]

708
40. A mum come with son he has measles rash for 6 days , she is asking about exclusion from school,
the teacher says that all the children at school are immunised. What is your advice?
a- no need to exclusion[ jm1030]
b- exclusion for 4 days
41. In a patient exposed to rubella infection in early pregnancy the proper management is:
To give rubella vaccine
To advise the patient to have immediate termination
To give immunoglobulin and assure the patient
To do rubella titre IgG, IgM and repeat after two weeks ans
To ignore patient's complaint
42. A couple came to you they r in relationship with each other from last 4 yrs now they are planning
for pregnancy what will you check in female partner
a) Rubella ans
b) CMV
c) Parvovirus
d) Toxopalasmosis
e) Varicalla
43. Child with mother came for vaccination. Child got flu. What you should do?
A- Give MMR vaccine except rubella portion
B- Give MMR vaccine except rubella and give it after
child recover from flu
C- postpone vaccination and give it after child recover
from flu
D- Give MMR vaccine now ans jm 73

44. A mother brings her child for MMR vaccination at

12 months of age.Child has got flu-like illness with
temperature 38 ºC. What is the most appropriate next
step?
a. Give MMR vaccine except rubella and give rubella vaccine
once the child recover from flu
b. Postpone vaccination and vaccinate after the child recovers
from flu
c. Give MMR vaccine now ans
d. Tell the mother that MMR is contraindicated
e. Give MMR vaccine except rubella portion

45. pregnant teacher who was vaccinated for rubella

in childhood ( 12 year as I can
remember). recently rubella was diagnosed by GP in a student without laboratory
confirmation. what should be done?
A. nothing
B. check Rubella serology ans
C. confirm rubella in child with lab investigation

709
46. Teacher exposed to rubella positive kid student .. come for consultation .. reviewing her history ..
you find that she is already vaccinated before this pregnancy and IgG was positive after vaccination .. she
is still anxious .. what to do
Tell here she is 100 % immune and no need for further investigation
Repeat IgG titre now
Do US

710
Answer a/b? Handbook ref?

Another ref:

47. A woman gave a birth to a full term baby weighing only 2000 gm with head circumference at 1st
percentile, hepatomegaly and mixed severe jaundice, he has deeply pigmented retina on fundoscopic
examination , and bilateral basal crackles in the lung, wts the causing organism ? :/
a. CMV( microcephaly,hearing defect,motor disturbances,jaundice,hepatospleenomegaly,hemolytic

711
 anemia,thrombocytopenia,30% have mental retardation) jm 279 ans
b. Toxoplasma (detail below this question)
c. Leisteria
d. Herpes Zooster
e. Rubella( cataract,deafness,cardiac abnormalities,IUGR<intellectual disabilities,inflammatory lesions of
brain liver lung bone marrow) jm 1032

Ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4164182/

Congenital toxoplasmosis has a wide spectrum of clinical manifestations, but it is subclinical in approximately 75% of
infected newborns. The severity of clinical disease in congenitally infected infants is related inversely to the
gestational age at the time of primary maternal infection—with first-trimester maternal infection leading to more
severe manifestations. When clinically apparent, it may mimic other diseases of the newborn. In a proportion of
cases, spontaneous abortion, prematurity, or stillbirth may result. Involvement of the CNS is a hallmark of
congenital Toxoplasma infection. The presence of chorioretinitis, intracranial calcifications, and hydrocephalus is
considered the classic triad of congenital toxoplasmosis. Fever, hydrocephalus or microcephaly,
hepatosplenomegaly, jaundice, convulsions, chorioretinitis (often bilateral), cerebral calcifications, and abnormal
cerebrospinal fluid are the classic features of severe congenital toxoplasmosis. Other occasional findings included
rash (maculopapular, petechial, or both), myocarditis, pneumonitis and respiratory distress, hearing defects, an
erythroblastosis-like picture, thrombocytopenia, lymphocytosis, monocytosis, and nephrotic syndrome.

[+JM 280+1182]

48. 14 month old Mark is brought in to see you. He has had high fevers and a mild runny nose for three days but
has still been quite active. Mark's temperature has returned to normal today but he has now developed a red
maculopapular rash on his trunk. The MOST LIKELY diagnosis is:
a) Measles
b) Chicken pox
c) Erythema infectiosum
d) Rubella
e) Roseola infantum Ans jm 1047
49. grand mom worried about vaccine as her daughter is pregnant options r
a DPT ans
b influenza
c rubella
can give in third trimester
50. 5 y old child has recurrent headache 2 month ago, last week he had rash, diagnosed as rubella
O/E u noticed wide base gate wt the most important inv.
A. Rubella serology
B. CT brain ans ( after viral infections,subacute reversible ataxia occurs in children,urgent referral is
needed to exclude others causes)
C. CT chest
51. 20-year-old G1 patient delivers a live-born infant with cutaneous lesions, limb defects, cerebral
cortical atrophy, and chorioretinitis. Her pregnancy was complicated by pneumonia at 18 weeks. What is
the most likely causative agent?
a. Cytomegalovirus
b. Group B streptococcus
c. Oo virus

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 d. Treponemal pallidum
e. Varicella zoster ans[
ref: https://rarediseases.org/rare-diseases/congenital-varicella-syndrome/] +jm 1028

52. 30 year old female was exposed to rubella.Her rubella IgM titer is high.She is 10 weeks
pregnant.Next step?
Reassure and routine follow up
Give IvIg
Give mmr
Offer abortion Ans
Hospitalize and monitor for any signs of infection

Ref: termination of pregnancy is usually offered if there is positive IgM in the first 16 weeks
of pregnancy. Rubella containing vaccinations are contraindicated in pregnant woman and
pregnancy should be avoided for 28 days after vaccination.
<8wks gestation -up to 85% infected with all clinically affected.
<12wks gest - 50-80%infected with clinically affected so I think offer abortion. A
termination of pregnancy is usually offered if there is positive IgM in the first 16 weeks of
pregnancy. Pregnancy
.https://patient.info/doctor/rubella-and-pregnancy

https://www.sahealth.sa.gov.au/wps/wcm/connect/d81813804eedb835b2b8b36a7ac0d6e4/Rubella+Infection+in+Pregnancy_S
ept2015.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-d81813804eedb835b2b8b36a7ac0d6e4-n1mxrZ1

53. A 7yr old is brought to your clinic, Her neck was tilted and fixed to one side. On examination, she had 2
palpable neck lymph nodes. Her chest xray had bilateral pulmonary infiltrates (image not given). Her head
circumference was small for age, fundoscopy showed hyperpigmented retina. She had significant hepatomegaly of
about 5cm from costal margin. What is your diagnosis?
A Congenital rubella
B Congenital CMV ans jm279
C Cerebrohepatorenal (Zellweger's) syndrome
D Combined immunodeficiency
E Hypergammaglobulinemia

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54. 16 month old boy is brought in to see you. He has had fever, rash and a mild runny nose. These
symptoms pass, then a few days later bight red rash appears in the face and a lacy rash on the rest of the
body. What is the most likely diagnosis?
a) Measles
b) Chicken pox
c) Erythema infectiosum ans jm…pervo virus…5th disease
d) Rubella
e) Roseola infantum

55. 15 months baby,last vaccine 6 months old,3 months ago he had rubella
a.MMR vaccine ans
b.ivig
c.wait to next vaccine

714
56. child born with retinopathy with other
features...cz
a. CMV b. rubella c. hemolyic disease d. others

57. 16 weeks pregnant Mother with sore throat

and fever (38 C) serology shows IGM for CMV
positive what will you advise ? A) terminate
pregnancy now B) check foetal umbilical IGM C)
review levels in 2 weeks ans D) give
immunoglobulin now
Ref:
if pregnant lady has IgM positive only ==
Repeat tests 2wks later.............. if
confirmed IgM positive after 2wks==
amniocentesis for PCR ...... if confirmed by amniocentesis == mother has the choice to
terminate pregnancy

58. Teacher exposed to rubella positive student. Came to you for consultation. After reviewing her
history, you find out that she is already vaccinated before this pregnancy and IgG was positive after
vaccination. She is still anxious. What to do?
Tell her that she is 100% immune and there is no need for further investigation…in jm its written 95%
Repeat IgG titre now ans JM 1180…as the time of vaccination not mentioned and we do rubella IGg as
routine invs in first antenatal visit
Do USG
59. Teacher in kindergarten is 10 weeks pregnant ,recently knows that one of the children has
rubella.What is the next step?
Ask for school exclusion of the child followed by reassurance of the teacher
Terminate the pregnancy before week 13
Do IgG and IgM ans
Tell her to come when symptom s appear
60. pregnant lady mid trimester with HPV what to do ??
pregnant lady mid trimester with chicken pox what to
do ?
pregnant lady mid trimester with rubella what to do?
Ø pregnant lady mid trimester with measles what to do ? options
A.do IGM antibodies
B.amniocentesis
C.termination of pregnancy
HPV nothing to be done as doesn't effect fetus. HPV 16 & 18,PAP SMEAR will tell
Explanation:
the precancerous and cancerous stage....if preg wd dysplasia.follow pap smear every 3
month,if pap shows microinvasion then cone biopsy if +ve then manage consevatively in
pregnancy & further treatment after postpartum....is macroinvassion or advance if
pregnancy <24wks radical hysterectomy or radiation,if >24 wks wait untill 33-34wks........

715
 *for measles,,,,,,,,,check igG after exposure and do igG and igM in case of symptoms
**for rubella do IgG as routine check up but IF exposure do igG and Igm both then active
immunization after delivery,,,,,,,,
**for chicken pox check igG after exposure and if its negative and administer i/v
immunoglobulin and if positive reassure and if pt comes with symptoms do chicken pox
serology.....
61. few months child come with weight and height on the 50th percentile and head circumference at
75th percentile when he was born he was on the 50th percentile and head circumfrence at 25 percentile
now he is hypotonic what to do next?
a. cmv serology
b. tsh ?ans
c. toxoplasma
d. rubella
62. A child treated for varicella a few days ago. He was also treated for infected pustules. Now having ataxia and
nystagmus. Most appropriate next investigation will be?
a. varicella IgM
b. LP
c. CT ans
**cerebellar ataxia...commonly occur after variacella, ebv and coxsackie infection.. other
causes may include head trauma, infraction, bacterial infection..ss ::ataxia, nystagmus,
motor incoordination... here next have to do ct first
63. Child with hereditary spherocytosis is pale and has multiple bruises. Blood test: HGB 7.8/ WC
2000/ platelets 70000. What’s the cause?
a) Pneumococus
b) Cytomegalovirus
c) RSV
d) Norwalk virus
e) Parvovirus ans
64. A pregnant lady 15 weeks was exposed to parvovirus.serology test revealed positive
IgM,positiveIgG.WHAT TO DO?
1.repeat serology within weeks
2.viral culture of amniotic fluid
3.USG ans explanation: Even it has 30-50 percent transmission rate from mother to fetus still
high percent fetus born normal! So we prefer to monitor if hydrops or even fetal anemia
has ocurred or not by doppler(usd). Its only to see degree of anemia, we do fetal blood
sampling . Once hydrops is confirmed then prenatal testing is warranted otherwise not. JM
1181
4.fetal haem

716
717
ü One with increased retic count and
8. One with decreased retic count, given normal value 2-3%
Options are the same
Parvovirus(decreased)
CMV(increased)
**Hemolytic anemia due to acute cytomegalovirus infection in an immunocompetent adult:

718
65. Hereditary Spherocytosis Child with URTI. Pallor no jaundice, Retics hight 6% , low Hb , Low Platelet.
On exam child had Pansystolic murmur at left sternal border. Cause
A Parvovirus ans
B. Hep A
C. ITP
D. Subacute infective endocarditis
E. Folate deficiency

Explanation:its dt anemia

66. Spherocytosis recalls with parvovirus and inheritance (what percentage of children will be affected)
Ans.AD 50%

67. Pregnant lady exposed to a child with parvovirus and she is IgG positive ? What is next?
1)reassure
2)IgM

68. A 23-year-old G1 with a history of a flulike illness, fever, myalgias, and lymphadenopathy during her
early third trimester delivers a growth-restricted infant with seizures, intracranial calcifications,
hepatosplenomegaly, jaundice, and anemia. What is the most likely causative agent?
a. Cytomegalovirus
b. Hepatitis B
c. Influenza A
d. Parvovirus
e. T. gondii ans jm280+1182

69. A child with anemia and low platelet after facing with a parvo virus .the retic count is 6 % . What is
the possibility of this condition in her siblings?
1. 25% of boys
2. 50% of boys
3. 25% of all siblings
4. 50% of all siblings
5. No sibling gets this condition
Answer??

70. old recall of hereditary spherocytosis with severe anemia

and low reticlocyte.asking a cause

719
1.aplasia due to parvo ans
2.hemolysis
e
71. Hereditary spherocytosis question ,with 72. Heriditary spherocytosis question ,with
recurrent infection ,systolic murmur at lateral history of recurrent infection ,systolic murmur
sternal border .. at lateral sterna border ..
Hepatospleenomegaly Hepatospleenomegaly ..lab given
reticent 1 % reticulocyte .1 %
Hb decrease Hb decrease
No jaundice No jaundice
Wbc normal Wbc normal
Platelets normal .. Platelets normal ..
What's the treatment? What's the treatment?
A. Iron therapy A. Iron therapy
B. Ferrous gluconate B. Whole blood transfusion
C. Platelets C. Platelets
D .prednisone D .prednisone
E . Immunoglobulins ans E . Immunoglobulins
**invs is pcr
Explanation: for aplastic anemia secondary to parvovirus in HS, 1)supportive treatment 2) RBC transfusion c) rare
cases will need immunoglobulins.
**if packed rbc in option go for it if not go for ig.

73. A pregnant lady 15 weeks was exposed to parvo virus.serology test revealed negative IgM,negative
IgG.WHAT TO DO?
1.repeat serology within weeks ans jm 1047
2.viral culture of amniotic fluid
3.USD
http://www.sahealth.sa.gov.au/wps/wcm/connect/04ab65004ee541dda794afd150ce4f37/Parvovirus+in+pregnancy
_Clinical+Guideline_final_Dec14.pdf?MOD=AJPERES

74. A G2P1 came at 12 weeks of pregnancy for the second time. The first visit was at 4 weeks of
pregnancy, now in her lab tests: CMV IgM (+). What is the appropriate management?
a. Check her previous sample for Ig G and Ig M
b. Do amniocentesis
c. Do blood test again for Ig G ans
d. USG in 18 weeks
75. Lady came with CMV IgM positive at 16 week pregnancy how will you manage?
1) Offer termination
2)Take foetal blood sample
3) Repeat serology test for mother after 3 weeks ans
76. Lady with symptoms of CMV infection and is also positive for IgM antibodies. Next step:
A. Offer termination of pregnancy?ans should be usg or amniocentesis
B. Vaccination
C. Immunoglobulin
D. Do nothing
77. Man comes up at 4 am due to tongue swelling. He had chronic hay fever and shell fish allergy. He also takes
ACEI for hypertension he went to Asian restaurant the previous evening. What is the cause of his tongue swelling?
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http://www.racgp.org.au/.../dec.../ace-inhibitor-angioedema/

Accidental shellfish ingestion

C 1 esterase deficiency
Idiopathic anaphylaxis
78. A boy presented with rash on cheeks for 1 day and diagnosed with
Slapped cheek syndromd(P19). Many mothers of his class mates at school
are pregnant. What to do
A. Nothing
B. Withdraw him from school
C. With draw from school and notify school authorities
D. Inform health services
E. Serology for all pregnant mothers mashaba anfa
**parvo virus is nt infectious anymore if the rash appears

79. Pregnant lady with regular check ups. her first trimester usg was
normal at 24 weeks her fundal height was small for gestation and on usg it
was small (iugr) and also asymmetric.what will u do to know the cause?
a. tsh Ans
b. abort
c. parvo virus serology
d. blood transfusion
**In parvo, hydrops fetalis develops, so supposed to be
more fundal height. Hypothyroid causes IUGR. May be A.
**Symmetrical iugr causes chromosomal anomalies...torch infection...drug abuse...alcohol
use...maternal anemia...
***** Asymmetrical iugr causes r maternal ds... such as pre eclampsia.. chronic htn..ut
anomalies

80. mother presented with child with hereditary spherocytosis. Becoming progressively pale for last
two month..blood picture of very low anaemia(42) and there low in reticulocyte count. But wbc and
platelet were normal. bilirubin normal ,What the cause?
a) aplasia
b)unexplained haemolysis
c)folate deficiency
d) parvo 19 virus.Ans
81. hereditary spherocytosis pt , now come with aneamia , low platelet count , but wbc count normal
splenomegaly 2 cm below costal margin , what is the cause of anemia?
A. Hemolysis crisis
B. Aplastic crisis ?ans
C. Chronic occult blood loss
**as no mention of jaundice
82. mother presented with child with hereditary spherocytosis. Becoming progressively pale for last
two month..blood picture of very low anaemia(42) and there was change in reticulocyte count. But wbc
and platelet were normal.bilirubin normal ,What the cause?
a) aplasia ?ans
b)unexplained haemolysis

721
 c)folate deficiency
d)dysthymia
83. mother presented with child with hereditary spherocytosis. Becoming progressively pale for last two
month..blood picture of very low anaemia(42) and there low in reticulocyte count. But wbc and platelet were
normal. bilirubin normal ,What the cause?
a) aplasia
b)unexplained haemolysis
c)folate deficiency
d) parvo 19 virus ans
84. Rashes similar to syphilis except> A. Roseola
> B. Discoid eczema> C.Tinea coporis
> D.Guttae psoriasis> E.Atopic eczema ans

85. 14 month old Mark is brought in to see you. He has had high fevers and a mild runny nose for three days but
has still been quite active. Mark's temperature has returned to normal today but he has now developed a red
maculopapular rash on his trunk. The MOST LIKELY diagnosis is:
a) Measles
b) Chicken pox
c) Erythema infectiosum
d) Rubella
e) Roseola infantum ans
86. A 10w gestation pregnant woman contact with a boy with Roseola. Serology check of IgG and IgM
are negative, what is next:
a. Reassure ?ans http://www.pregnancy.org/article/pregnancy-and-roseola-virus
b. Recheck IgG and IgM 2 weeks later
c. Do Ultrasound at 16 weeks
Pregnant women get exposed to the virus all the time. By the time they are pregnant most
women carry the antibody which means they had the disease already, so they are immune
and cannot get it again. There are only very few reported cases where Roseola has
affected the fetus, so the risk to the fetus after exposure is generally considered very low,
especially when the vast majority of women are immune.

87. A pregnant lady comes after taking care of her friends son who was later diagnosed as having EBV
infection. She’s worried. What is your management?
-Ultrasound for hydrops
-Check serology for antibody titres
-Reassure — However, the lack of consistent patterns justifies reassurance for mothers who have been
exposed to measles,2 mumps,2,4,7 adenoviruses, respiratory syncytial virus (bronchiolitis),19,32 Epstein-
Barr virus (infectious mononucleosis)1,33 and human herpesvirus
6 (roseola). http://www.aafp.org/afp/2000/0515/p3065.html
-Tell her to come if any symptoms arise

88. Pictures of Hand foot mouths disease.school exclusion

1. 7days
2. until rashes dried ans jm 1035

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89. Boy with hand-foot-mouth disease asking when he can return to school:
a. after 7 days,
b. when lesions are crusted,
c. when lesions have disappeared,
d.tomorrow.
90. hand foot & mouth disease symptons ,,, coxsackievirus A16
Rx
Reassure ans jm 1035
Antiviral
**symptomatic treatment
91. scenario of Hand foot mouth disease and cause asked…coxsacie virus

92. child with fever and blisters in the palm and sole and mouth ,there is lymphadenopathy
> A. Coxsackie’s ans
> B. Kawasaki
> C. Herpes

93. diagnosis?

Ans: HFMD

94. 35 year old female patient developed fever with neck stiffness. Csf shows increase monocyte...pr
0.45 ......Glucose 3.6(normal)His son has recently sore throat fever and rash all over his body Most imp
cause of infection in mother?
Meningococcal
Pneumococcal

723
 Hsv
Enterovirus ans

Explanation: Hsv n entero both can cause

But entero is most common cause in viruses
**csf glucose 2.5 and 4.4mmol/L (45-80mg/dl)
95. child present with rash in body and oral cavity. the rash is flat and pus like fluid is seen. dx?
-staph. aureus, coxakie virus, herpes simplx, varicella

96. mother came with her child 3 years old he can't eat because of oral small ulcer he also has ulcer on
his fingers and toes his temp 38 deg what is the cause
Hsv
Coxsakie ans [hfmd]
Adenovirus
Group b haemolytic
Corona virus

If pus like fluid staph.hfm disease no pus like fluds??

97. child with fever, conjunctivitis, rash lymphadenopathy, abdominal pain . Initial Investigation
(Kawasaki disease
a. Aso titre
b. ESR
c. Echo http://www.rch.org.au/.../Kawasaki_Disease_Guideline/...
D. Ana

98. 3 year child with five day fever, sore throat has prescribed Amoxicillin and developed rash in her body. She
has lymphadenopathy, red eyes and tips of fingers are desquamated. What next?
a. Blood culture
b. immunonogluniln essay
c. echo ans…kawasaki
d. urine exam
99. child with macular generalized rash with cracked lips oral mucosa involved
bleeding from hand feet genitalia. Labs thrombocytosis .And leucocytosis.Most appropriate asked—
Echo ans
Urineculture and pcr
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Blood culture
100. pic of a child with rash on abdomen(was typical drug allergic rash) developed after being put on
antibiotics amoxicillin and some other cant remember for tonsillitis and fever and LDN. No improvement
what to do next:
a. add gentamycin
b. add erythromycin
c. stop both antibiotics ans(EBM)
d. wait and watch
101. Woman sore throat, bronchitis, two weeks ago, took amoxicillin for it, now presents with purpuric
raised rash around ankle and dorsum of foot, rash does not blanche and coalesce together
Hypersensitivity vasculitis ans (
Inf mononucleosis
HSP

Explanation: the Rash of EBM is maculopapular ( its a non raised rash) while the rash of hypersensitivity
vasculitis is raised as described in the question.

102. History of flu like symptoms .. mild pharyngitis .. generalized tiredness .. malaise .. 38.5 fever for 2
weeks .. small enlarged LN in a lot locations .. mild hepatosplenomegaly (sure that time) .. LONG labs are
given .. positive is low WBCs .. low normal RBCs and normal platelets
Evidence of ATYPICAL lymphocytes .. Monospot test is negative
What is your diagnosis
a. IMN
b. EBV ans

103. pic of maculopapular rash history of sore throat , fever and treated by amoxicillin , what to
do next?
- stop amoxicillin
- EBV serology

104. 4 year old child presents with 3 cm mass closer to angle of mandible(unilateral). Child was treated
for tonsillitis 1 month ago. Which of the following is best next?
Give her first dose of antibiotics
Review in 1 week ans.
Needle aspiration

Explanation: ts ebm after antibiotics due to tonsillitis i think and its viral can resolve spontaneously
only symptomatic treatment.Or can b inflamed lymph node in that case again we must follow up
even larger after 3 weeks then we should do fnac

105. A child with history of infectious mononucleosis 6 months ago now comes with lethargy and
tiredness, poor school attendance, sore throat. What’s the management? > a- Blood exam and urine
microscopy ?ans> b- Ignore (psychotic) > c- Recurrence of infectious mononucleosis

** The test is used to detect proteins in the blood called heterophile antibodies that are produced
by the immune system in response to an Epstein-Barr virus (EBV) infection, the most common
cause of mono. In the urine, EBV DNA was detected in 15 out of 16 (93%) patients in the first
sample obtained and detected between 3 to 50 days during the clinical course of the disease. In
four patients EBV DNA was detected in the urine up to 3 months after full recovery.
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106. Hypersplenism is associated with all of the following except?
a) Lymphoma
b) Polycythemia vera
c) Infectious Mononucleosis (IM)
d) Hereditary spherocytosis
e) CHF ans
107. A 31-year-old woman presents at the hospital for a pre-employment physical examination prior to beginning
her year as a medical intern. She is sexually inactive and denies alcohol use. She had infectious mononucleosis
while in college and received the recombinant hepatitis B vaccine before starting medical school. Which of the
following would describe her hepatitis B serologic profile?
A. Hepatitis B surface antigen positive, core antibody positive, and surface antibody negative
B. Hepatitis B surface antigen negative, core antibody positive, and surface antibody positive
C. Hepatitis B surface antigen positive, core antibody negative, and surface antibody negative
D. Hepatitis B surface antigen negative, core antibody negative, and surface antibody positive [ans]
E. Hepatitis B surface antigen negative, core antibody negative, and surface antibody negative.
HBV has a central core and a surrounding envelope. Your immune system makes IgM antibodies to
the core of HBV during the active stage of infection. Hepatitis B core IgM antibodies begin to
appear in your blood several weeks after you are first infected with HBV. People who have had
the hepatitis B vaccine will not have the core antibody in their blood.
108. Pregnant woman exposed to infectious mononucleosis.What will you do next?
Reassure ?ans
IgG and IgM

109. Childcare teacher in her first trimester came to you. She's concerned about being exposed to the
child of one of her friends last week. Physician had remarked the diagnosis of infectious mononucleosis
for the child without doing any serology. Best next?
a. Reassurance
b. IgM&IgG test for teacher
c. USG for teacher
d. IgG test for the child
110. Man coming back after short trip from endemic area for only 5 days with severe Jaundice ..fever ..on
examination you find tender liver and enlarged 5 cm under costal margin ..you do investigations
Found Very high ALT , AST , GGT,ALP Diagnosis :
Active viral hepatitis A ans
b) Active viral hepatitis B
c) Malaria 7 to 14 days for falciparum and for
others 12-40
d) INFECTIOUS mononucleosis
111. A man come fr Indonesia got Jaundice (at
there ) since 2 days before he come back. Also
got RHC tenderness & liver 5 cm palpable.
Headache& myalgia also +. No fever. Plt count
normal. Many lab given & liver enz slightly
increase. Dx ?
a. Hep A
b. Hep B
c. Dengue
d. Malaria

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e. Ross river fever
112. Middle aged man recently returned from africa, presents with haematuria n spleenomegaly, hb is 8.
He tested his malaria which was negative 3 days before he left africa. Whats diagnosis.
A. Retest malaria immunoassay
B. Schistosomiasis
C. Giardiasis
113. Patient has history of anal pain since 3 months. He arrived from Somalia recently. O/E: Diagnosed
as anal fissure. what is the most expected predisposing factor?
- Rectal Cx
- Hemorrhoids
- Rectal schistosomiasis
- Peri-anal abscess

114. A 14 year old comes to you with a 3 month history of loose stools associated with abdominal pain.
On physical examination, she is noticed to have anal excoriations. No anaemia / passage of blood in
stools. History of pin worm infestation at the age of 3 present for which she was treated. Her ESR is 70.
The most likely diagnosis is ?
a. Crohn’s disease
b. Giardiasis
c. Campylobacter
d. Clostridium perfringens
e. Pseudomembranous

115. Scenario of Bali travel after 10 days develop fever ,Chills Jaundice increase ALK , GGT , mild increase
of AST and ALT
a. Malaria
b. cholangitis
116. 3year child with five day fever, sore throat has prescribed Amoxicillin and developed rash in her
body. She has lymphadenopathy, red eyes and tips of fingers are desquamated. What nex t?
a. Blood culture
b. immunonogluniln essay
c. echo ans
d. urine exam
117. Male went to Thailand. Had sex with many prostitutes.. Now develops fever, sore throat, arthralgia.
On examination generalized lymphadenopathy, spleenomegaly and mild pharyngeal erythema.
Labs- Lymphocytosis
Mono-spot- Negative
Diag?
a EBV.
b. HIV [seroconversion illness ...JM pg 261]
c. Malaria
A
From JM: acute seroconversion illness- usually occurs within 6 wks of infection.characterized by
Fever,night sweats, malaise, severe lethargy, anorexia, nausea, myalgia, arthralgia, headache,
photophobia, sore throat, diarrhea, lymphadenopathy, generalized maculoerythematous rash
and thrombocytopenia, the main symptoms are headache, photophobia and malaise/ fatigue.
Neurological manifestations, including meningoencephalitis and peripheral neuritis, can occur.
Acute HIV infection should be considered in the DDx of illnesses resembling glandular fever.
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118. which of the following help you to make a diagnosis of viral laryngitis rather than that of bacterial
origin ? a) exudates ans b) tender lymphadenopathy c) change in voice
Explanation: [ this is the correct recall - 96. How will you differentiate viral tonsillitis from bacterial tonsillitis?
a. Hyperaemia
b. Lymphadenopathy
c. Exudates over tonsil
d. Low grade fever
e. Laryngitis]
Low grade fever is in favor of viral etiologies.

Centor criteria
— The Centor criteria are a widely used and accepted clinical decision tool [38-40]. These criteria are:

●Tonsillar exudates
●Tender anterior cervical adenopathy
●Fever by history
●Absence of cough
The likelihood of having GAS increases with the number of Centor criteria. However, the Centor criteria are most
useful in identifying patients for whom neither microbiologic tests nor antimicrobial therapy are necessary. Patients
with fewer than three (0 to 2) Centor criteria are unlikely to have GAS and, in general, should not receive either
antibiotic treatment or diagnostic testing.
119. Patient with known Waldenström's macroglobulinemia is admitted with fever. He has a history of
glandular fever infection and varicella infection in childhood. He is given ampicillin and azythromycin. The
next day he develops rash. Picture: rash is on the abdomen and chest. It doesn’t look like erythema
multiforme at all. Most of the elements are raised papules, but couples of them are pustules. What is the
initial next step to identify cause of rash?
a. swab from the lesion??
b. biopsy of the lesion
c. bone marrow biopsy
d. drug allergy test

120. Rx of infectious mono ?

Amoxicillin
Antiviral
Symptomatic ans
121. A man presented with fever malaise and lymphadenopathy. History of travel one week before to
Thailand, history of prostitution. On labs mono-spot negative , atypical lymphocytosis.asking
diahnosis
a. EBv
b. CMV
c. HIV jm260
122. A pregnant lady comes after taking care of her friends son who was later diagnosed as having EBV
infection. She’s worried. What is your management?
-Ultrasound for hydrops
-Check serology for antibody titres
-Reassure
-Tell her to come if any symptoms arise ans

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[http://www.sahealth.sa.gov.au/wps/wcm/connect/a646d3004ee45c18ba8abfd150ce4f37/Epstein-
barr+virus_Feb2015.pdf?MOD=AJPERES&CACHEID=a646d3004ee45c18ba8abfd150ce4f37]

123. A lady with painful, white (?) vulvar ulcer. Next ?

a. biopsy from ulcer dx lichen sclerous
b. swab from ulcer for PCR
c. Urine test
d. VDRL
Jm 1178 pg
124. Male came from Thailand 2 months ago .. presenting now with marked confusion and marked
lymphadenopathy more at the axillary and inguinal groups(may be mild hepatosplenomegaly .. not sure)
.. CT showed bilateral periventricular lesions (no details mentioned) .. what inv to do next
Test for HIV Ans
Test for IMN
Test for Malaria
MRI of the brain
D/d : neurocysticercosis
125. A guy came back from Angola, high fever, you check for malaria, took antimalarics, twice negative
results for malaria in 24 hours apart, the test has 98% sensitivity, 96% specificity, what to do next?
a)Check for different disease
b)Repeat blood smear-thick and thin after 24 hours
c)test in high peak of fever
Is it B or C?
126. A young student presents with fever, generalized lymphadenopathy, splenomegaly, ulcers of tonsils
and skin rash. Blood film shows large lymphocytes with air bubbles, WBC – 13×109/L, lymphocytes are
decreased. DS?
a) Glandular fever
b) HIV…jm261
c) Strept infection
d) HSV
127. A 24 yrs old male presented with fever, malaise, and sore throat for last 12 days. Examination
showed white tonsillar exudates, generalized lymphadenopathy, maculopapular rash (not vesicular), rash
on palms and soles and excoriating lesions around anus. Which of the following is the likely diagnosis?
a. Glandular fever
b. Secondary syphilis ans
c. Pemphigus
d. Steven Johnson’s syndrome
e. Herpes simplex infection

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128. A child come with multiple ulcer in tongue, buccal mucosa and tonsil, there was also a small ulcer
on his lip. High fever present. Diagnosis?
a. Herpengina…by coxsackie virus a
b. Herpes simplex stomatitis ans
c. Glandular fever

129. 14yrs old boy,One of your long term patient since birth, presents to you at your surgery afterDog
bite at home, when he was playing with it , accidentally fell over the animal and provoked it.O/E There
were Two deep puncture wounds. No deep structural injury.His last immunization for tetanus was at 4
yrs of age according to his File.You advise him to get the wounds cleaned and apply non-Adherent ,
absorbent plaster by theOffice nurse and give him prophylactic antibiotics for 5 days. As the bytes are
deep puncture wounds you decided to give him tetanus injections-as well. Which one is the BEST
vaccination?.
1.DTPa(Diptheria,Tetanus,Pertussis acellular)** Ans JM1481 as immunization complete no need of IgG
2.Tetanus Toxoid
3.Adult Tetanus and Diphtheria Toxoid
4.Tetanus immunoglobulin + Tetanus toxoid?
5.diphtheria toxoid +whole cell pertussis + Tetanustoxoid (DPT) booster

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130. Simon aged 4 months is diagnosed with pertussis. What is the MOST APPROPRIATE management of
Simon's parents?
a) Immediate booster immunisations for pertussis
b) A 10 day course of erythromycin ?
c) Commence a 3 dose pertussis revaccination schedule
d) Arrange nasopharyngeal swabs
e) Immediate immunisation with pertussis immunoglobulin
Prophylaxis table: Prophylaxis is aimed at preventing spread to infants <6 months.
Antibiotics No antibiotics

Close contact with confirmed case of pertussis whilst index case Contact with index case while no longer infectious ( >
infectious (< 21 days of cough and < 5 days effective antibiotics) 21 days of cough and >5 days effective antibiotics)
AND OR

First contact was within 14 days (or within 21 days for infants < 6 First contact was > 14 days (or > 21 days for infants <
months) 6 months)
AND

Children:

• Age <6 months OR

• <3 doses pertussis vaccine OR
• Household member age <6 months OR
• Attend childcare in same room as infant <6 months

Adults (regardless of immunisation status)

• Expectant parents in last month of pregnancy OR

• Health care worker in maternity hospital or newborn nursery OR
• Childcare worker in close contact with infants <6 months OR
• Household member aged <6 months

131. Indigenous Australian never travelled abroad developed cough 3 wks.He has a 3 mon old infant,
does not want him to get affected.what should be done now???? A.Nasopharyngeal PCR (below 3 wk).
B.pertussis serology Ans. C.Throat culture D.Mycoplasma serology. E.Tuberculin skin test.

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132. Pertussis infection of child, have a sis of 24 mnth fully vaccinated and all the members of the family
treated with erythromycin, wats next best option?
A.Reassurance
B.Azithromycin for 5 days ans

133. Mother comes with child with pertussis rash. He

has a 5 month old sister. Doc gives dpt booster
vaccine to all family members. What to do
a- reassure the sister will not get affected by pertussis
as she is taking vaccinations
b- give erythromycin to all family members Ans
c- give erythromycin only to the boy
Correct ans should be treat the boy and baby sister

Explanation: high risks contact-of pertussis should be treated

with same medication dose and duration of pertussis(jm
7th 1051)

134. 2 yr old have pertussis, have 5 month sister,

after Rx ?
A. DPTa for sister
B. DPTa for adult of unknown hx of vacc.
C. Erythromycin
D. Parents & Grandparents Vaccine…..and erythromycin to sister
135. 2 yr old have pertussis, have 5 month sister, after Rx ?
A. DPTa for sister
B. DPTa for adult of unknown hx of vacc.
C. Erythromycin
D. Parents & Grandparents Vaccine ?Ans
136. 1. 26M, tractor injury, completed 4 course tetanus vaccine & multiple booster dose, last vaccine
was 6 yrago, deep ulcer with soil in wound (unclean), mx? →
a) · TIG
b) · DPTA
c) · IM procaine penicillin
d) · TIG + DPTA
e) Nothing
137. Man has soiled lacerated wound. He had simple scratch wound 5 days ago for that he received a
dephtiria tetanus toxoid and no other relevant history of vaccination asking most appropriate step after
debridement?

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A. Tetanus toxoid plus tetanus
immunoglobulin.
B. Tetanus/Diphteria vaccine
C. Tetanus immunoglobulin
D. No more treatment needed
138. A man with soiled wound with no
immunization in the past against Tetanus.
What to do:
1. TT +Ig
2. TT + Ig + Penicillin
3. TT
4. TT + penicillin
5. Ig
139. A 56 year old farmer presented with
a lacerated wound from a farming
equipment.he had superficial wound 5
weeks ago and received tetanus toxoid..what is the next most appropriate step for tetanus prophylaxis?
A penicillin for 5 days
B.give TIG
C.Give ADT vaccine
d.IM cephalosporin 1 g
e. TIG + vaccine
140. MVA accident, man came here with found out Influenza A virus. What will you give to the pt?ula.
He has been fully immunised. After given antibiotic, what would be your next step to prevent further
infection?
A) Wound debribement
😎 Internal fixation
C) External fixation
D) Tetanus vaccination
E) Dislocation correction
141. Child 5 years of age got superficial abrasions and lacerations after falling in a garden bed. he has
h/o 2 DTPa vaccinations. most app step after cleaning the wound?
a. give Tetanus toxoid and topical antibiotic cream
b. give tetanus toxoid and oral penicillin
c. give tetanus toxoid and immunoglobulins
d. DTPa and booster after 2 months
e. DTPa and immunoglobulins
142. Unknown history of vaccination before but 5 weeks before got tetanus vaccine after minor injury,
now got laceration what next?
A ig
B dtp and Ig
C. TT +Ig
B. Toxoid
E. Antibiotic or reassure
E ??
It should be toxoid if clean minor wound otherwise tt plus ig
E we give if pt present within 4 weeks of tetanus vaccine
for unvaccinated people 3 doses .. .this pt had one incidental dose 5 weeks back so now TT+Ig then after 6
month but for lacerated wound TT+Ig may ve given.if suspected heavy contamination.

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143. Child has pertussis . Has younger sister at home , <6 month. Parents against antibiotic. What to do ?
Report child service
Give antibiotic against parents will
Tell to bring child if cough starts
Send for counseling?? Ans

144. 3 years old child has cough and in school pertussis case is confirmed. He is vaccinated for pertussis
2 doses already, has one sister of 5 months old at home. Mother comes to you for advice what to do
now:
a. Tell her that child is immunized and no need of anything now
b. Test 5 month child with PCR now
c. Give all family DTPa
d. Give 5 months child DTPa
Correct ans is missing…should be antibiotic to the both babies [Aug 2016]

145. Boy with pertussis for 2 weeks

Treat+isolate
Treat and isolation not needed
**we do school exclusion not isolation in pertussis
146. 9 month baby with fever, clear nasal discharge, coughing with vomiting.Crackles and sneezes
present.Diagnosis?
Pertussis
Viral bronchiolitis ans
Pneumonia

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147. 3 yr child got pertussis, family got ab prophylaxis but not his 5 month old sister who has completed
her vaccination
a. advise mmr vaccine at 12 months
b. advise dtpa boosters for parents & grandparents ?Ans
c. give dtpa vaccine to family adults who are of unknown
immunization status
d. avoid child care till age of 6years

148. scenario of whooping cough in a 5 month old

child.child is not cyanosed.Asking what will be your action.
a) reassure mother it is not pertussis
b) prescribe oral abx for 5 days and discharge the baby
home.
c) admit and observe ans JM 1051

149. Regarding pertussis, which of the following

statements are true?
> a- Incubation period is 7-10 days (7 to 14 days…max 21
days)
> b- Triple vaccine cannot be given with another live virus
vaccine (can be given)
> c- Pertussis vaccine should not be given to a child with
neonatal convulsions (dtpa can be given in febrile
convulsion..not sure about neonatal convulsion)
> d- Erythromycin reduces the severity of signs and symptoms (it reduces the infectiousness not s/s)
150. A 7 mo old child presented with two weeks of paroxysmal coughing and vomiting, but is relatively happy
between paroxysms. You suspect she may have whooping cough (pertussis).He received clarithromycin. He lives at
home with his mother, father and older brothers, aged 3 and 5 years. Neither of her brothers have been
immunised against pertussis. Which of these is the best management strategy?
A.Arrange to have 7 months old child admitted to hospital and isolated immediately
B.Report the family to the child protection agency in your state for failing to immunise their children
C.Provide vaccination ASAP to 3 and 5 years brother
D.Prescribe clarithromycin for the brothers & give vaccination to the whole family
E.Provide booster vaccination for the parents
151. 7 months old child presented with two weeks of paroxysmal coughing and vomiting, but is relatively happy
between paroxysms. You suspect she may have whooping cough (pertussis). He received erythromycin. He lives at
home with his mother, father and older brothers, aged 3 and 5 years. Neither of her brothers have been
immunized against pertussis. Choose the correct option from the list below.
a. Arrange to have 7 months old child admitted to hospital and isolated immediately
b. Report the family to the child protection agency in your state for failing to immunize their children
c.Vaccinate immediately to 3 and 5 years brother
d. Prescribe oral erythromycin for whole family
e. Nothing to do
https://www.rch.org.au/clinicalguide/guideline_index/Whooping_Cough_Pertussis/

School exclusion:

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Unimmunised ( < 3 doses) household and close childcare contacts less than 7 years of age must be
excluded from school or child care for 14 days from the last exposure to infection OR until they
have taken 5 days of effective antibiotics. —— RCH

152. child with history of prolonged cough was diagnosed as pertussis and started treatment. His young
sister, 5 months has no immunization history. After giving erythromycin for all family members, what also
will be done?
A- Giving another antibiotic to all family(can not remember its name)
B- Give booster dose of DTAP to all family members
C- Give booster dose of DTAP to his 5 month sister only
D- Do nothing
153. 3 y/o comes with cough and fever during pertussis outbreak. He tests positive for pertussis. He has
sister of 5 months and mom is worried. Besides treating him with erythromycin, what is next mx
A. Tell mother the 5 m/o is safe because she has received two dose of vaccination
B. Give only symptomatic family members erythromycin
C. Give 5 m/o sister erythromycin ?ans
D. Isolate the 3 y/o from family
#sep2017
154. pregnant female with genital herpes how to differentiate 1ry from recurrent herpes simplex:
1.HSV Igm now
2.HSV specific serology now ans
3.PCR
[ uptodate]

155. Female with burning face pain and redness

Trigeminal neuralgia
Herpes simplex
Varicella zoster

156. A pregnant woman came with urinary retention.When you tried

to insert catheter,you find painful vesciles band diagnosis is
confirmed as herpes simplex.What to give?
Oral acyclovir ans
IV acyclovir
Iv famcyclovir
Topical acyclovir
157. middle-aged woman complaining of burning pain in the
maxillary region during last 24 hours. There some redness over the
area of the projection of the maxillary sinus. Nothing said about nasal
symptoms. Dx?
a. Maxillary sinusitis
b. Trigeminal neuralgia
c. Cluster headache
d. Varicella infection
e. Herpes simplex infection
158. A 41 year old lady with increasing dyspareunia and burning sensation in vagina not responding to
clotrimazole came to you. On examination you found redness of vulva with a painless small ulcer on labia.
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 What to do next?
A) VDRL thinking of syphilis. https://www.rch.org.au/clinicalguide/guideline_index/Vulval_ulcers/
B Vaginal Cytology
C) Vaginal swab for bacterial culture
D) PCR for Herpes simplex
159. A case of recurrent herpes zoster infection. Tzanck prep(for herpes simplex and for chickenpox)
done showed multi nucleated giant cells. which treatment is best for resistant viral infections
A. High dose acyclovir
B. foscarnet Ans
C. valaciclovir
D. Ganaciclovir
Explanation: This phosphonic acid derivative (marketed by Clinigen as foscarnet sodium under the trade
name Foscavir) is an antiviral medicationused to treat herpes viruses, including drug-
resistant cytomegalovirus (CMV) and herpes simplex viruses types 1 and 2 (HSV-1 and HSV-2)

160. What investigation to do to diagnose active herpes simplex infection in a pregnant lady?
a. Serology
b. Viral culture for HSV
c. HSV PCR from swab of lesion
d. Urine examination
** active lesions : pcr, serology to differ primary and secondary. so here C
161. Eye problem not solve with clorampenicol...
a) chlamydia Ans b) Herpes simplex C ) bacterial
Explanation: CHLAMYDIA INFECTION WILL NOT RESPOND TO CHLORAMPHENICOL ,however,HERPES
SIMPLEX STILL DOES RESPOND TO
CHLORAMPHENICOL https://www.google.com/url?sa=t&rct=j&q=&esrc=s...,
http://wellpilot.com/.../herpe.../treatments/chloramphenicol

162. pt on sulphasalazine , now got PAINFUL ulcers , plus gingivitis , paletels normal , rbc normal , wbc
may be dec i forget , but was dec , other ev thing was normal cause
a.suplasalzaine toxicty(ans)
b herpes simplex ulcers
c acute leukemia

163. A child was presented to you with fever & rash/ulceration in his mouth (gum, tongue, buccal
mucosa, lip). O/E his tonsils looked red too. + lymphadenopathy. Diagnosis?
a. Herpes stomatitis

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 b. Herpangina ..similar to hfmd
c. Herpes simplex Ans

164. What investigation to do to diagnose active herpes simplex infection in a pregnant lady?
a. Serology
b. Viral culture for HSV
c. HSV PCR from swab of lesion ans
d. Urine examination
[we use pcr for detection of active infection AND serology for
differentiation between 1ry and 2ry]
165. A picture of a child's arm with 2 lesions looking like pustules. The
mother used topical antiseptics but they were of no use, what's your
diagnosis?
a) Herpes simplex
b) Impetigo.(antiseptic didn’t work..now need antibiotic)
c) Mulloscum contagiousum
d) Warts
166. in an area there is typhoid outbreak.a girl comes with 2 days of
diarrhoea and abdominal pain.routine stool is normal.what will u check.
a.blood culture
b.antibody
c.stool culture
d.urine culture

167. A 40 year old Vietnamese man who arrived in Darwin 6 weeks

prior, presents with 5 days of headache, fever and malaise. What is the MOST LIKELY diagnosis?

e) Malaria
f) Typhoid fever
g) Dengue fever
h) Filariasis
i) Meningococcal meningitis

168. A man comes to you as he will be travelling to Fiji. He already has vaccination against hepatitis A and
typhoid. What other vaccinations should be recommended?

A) Tetanus, diphtheria and whooping cough

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B)Yellow Fever

C) Hepatitis B

D) Polio
169. 31 years woman who is in her third trimester , came in with one day history of injury by metal gardening
equipment. She had her last tetanus vaccine at age 26. What is the most appropriate next step in management? .)

a. Do nothing
b. ADT now
c. DPTa now
d. Immunoglobulin
e. ADT at the age of 36
170. #Tropical_Medicine A group of college students are admitted to the ED with bruises over their skin, dark
coloured urine and shock one week after they were back from camping in a forest. Which one of the following is
most likely cause?

a. Giardia lamblia
b. E. coli
c. DIC
d. Staph aureus
e. Ross river fever

171. Salmonella outbreak has been declared in the community. A girl presents to you with watery diarrhea for 3
days. What is the best test out of the following to diagnose her condition?
a. Blood culture
b. Urine culture
c. Stool culture
d. Throat swab
172. A pt of paucibacillary tuberculoid leprosy has completed 6 months of MDT.the response to therapy is good
but the lesion is not healed completely..Accordingly to WHO criteria

1...continue dapsone for 2 more months

2...test for drug resistance

3..continue the treatment for 6 more months

4..stop the treatment n watch

#aug2016
173. A four year old girl has had a temperature of 38.5o C for two days and has not wanted to eat her food.
Yesterday she developed a sore throat and small, painful ulcers inside her mouth. Today she has small blisters on
the palms of her hands and soles of her feet which are painful but not itchy.What is the most likely underlying
cause?
A Coxsackie virus [Ans -HFMD]
B Herpes simplex virus
C Staphylococcus aureus
D Streptococcus pneumoniae
E Varicella zoster virus

739
174. Husband and wife traveled to Jakarta and stayed in city hotels for 3 days. They did not travel to
rural areas. After returning, wife found husband developed backache, fever, headache, eye pain and pain
in right upper quadrant. What investigation will you do to reach diagnosis?
a) Thick and thin blood film
b) PCR antibody to rule out HIV
c) Japanese encephalitis antibodies
d) PCR for Flavi virus
175. Vietnamese man came with fever , headache , body ache , cough ,,and easy bruising .all lab results
were normal except for platelets 20000, most likely diagnosis is
a leptospirosis
b hep a
c malaria
d acute cholecystitis
e dengue fever
176. All causes acute urinary retention ( aur) in female except ?
1.fibroid
2. Herpes simplex virus.. Genital herpes may cause AUR both from local inflammation as well as sacral
nerve involvement...reference uptodate
3..Hpv ans
4. Spinal Spinal tumor
5. Retroverted Gracie uterus
177. sheep farmer trip to thailand weight loss 10 in the 6 months jaundice ruq pain itching dark urine
dx?
a. hydadit cyst
b. amebiasis
c.pancreatic cancer
d. cholelithiasis
178. pic of lesions in forearm (looked like impetigo but might even be dried blisters :/ ) asking when
can go back to school? a) immediately b) 48 hrs after starting antibiotics Ans c) after 5 days
179. 5 yr old girl with rash/crusted lesion(in another recall) on forearm not relieved by antiseptic
organism asked.( the rash was def impetigo)
j) Herpes
k) Staph aureus Ans
l) Varicella

180. pic of face of young girl with 3 ulcers on Rt cheek (

crust , no bullae ) ? impetigo.
Mother said ulcer not improved with antiseptic. What
will u give ?
Bactroban Ans
Acyclovir
No need of antibiotic
Clean daily
181. Mother brought his young child who presented with four lesions on his right face. She tried antiseptic but the
ulcers like lesions showed no improvement. What is your most appropriate treatment?
A. Mupirocin (Bactroban)
B. Topical hydrocortisone

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 C. Topical acyclovir
D. Topical idoxuridine

182. Child with hematuria he had rashes about a week ago diagnosis asked
A)IgA nephropathy
B) Minimal change nephrotic syndrome
C)post streptococcal glomerulonephritis
D)hemolytic uremic syndrome
183. Anna, a 3 year old child, develops pustular lesions on her face which subsequently form a honey-
colored crust and start spreading. You diagnose impetigo. Which of the following statements would be
included in your advice to her parents?
a) Since Anna is otherwise well, she may attend her child care centre
b) There is no danger of spread to family members
c) Topical treatment will not usually be sufficient to achieve cure
d) Anna must be isolated until the lesions have completely resolved
e) Lesions should be adequately covered to reduce self-inoculation Ans jm1052
184. 6 month old baby brought to you by the mother with crusted patches on face. Otherwise well. The
mother had used iodine antiseptic with no
improvement. Whats the treatment?
a) Bactroban Ans
b) Erythromycin
c) Beclomethasone
d) Acyclovir cream
e) Acyclovir syrup

185. Dx asked…
a. Bulus impetigo
b. HZ
c. Napy blister

186. Pic of deroofed red lesion in 5 year old girl forearm brought by her mother because these lesions
are itchy,no fever Asked for DX?
A scabies
b impetigo
C measles

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187. Mother brings 10 month old boy after noticing pus discharge at meatus and prepuce only partially
retractable. Asking ttt
-Topical betamethasone -Topical mupirocin
-Oral amoxicillin jm 1224 may be balanitis

188. child with maculopastular rash on hand and

underarms with mild fever-investigation was
,a np swab
,b-blood
c-culture Ans??????[?impetigo?]
,d-biopsy
**could be scarlet fever as well
189. A child picture given identify the picture
,,CAUSE
A.staph aureus Ans [Dx:?boil?]
B.Strep
C.Herpes
D.EBV
E.HIV

190. 152.[HB page 164]

Ans?2nd pic a
191. Patient varicella zoster skin infection,ulcerated,some chronic features, Mx?
a. oral antibiotics
b. cover the wound
c. topical cream
d. analgesic…may be varicella zoster
e. famicyclovir
Ans D/
192. 8 yr boy, fever 39, Hx of tonsilitis 1 week ago, Now fever n rash, toxic looks pale
1. Blood culture
2. Amox ?Ans, scarlet fever
Phenoxymethylpenicillin (dose according to age) for 10 days with rapid
resolution of symptoms, although resistance is increasingly common.
Children can return to school 24 hours after taking antibiotics and feeling

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 wel
Jm ch#93
193. Mother brought her 2 year old child who had fever for 3 days, you prescribe paracetamol. N 2 days
there were poor response to paracetamol and on the examination you find bilateral conjunctivitis,
erythema of the oral cavity and redness in the palms. In lab test: high ESR. What is the best next
management?
a. Start prednisolon immediately
b. Admit the child and prescribe Aspirin and Immunoglobulin and do Echo ans kawasaki
c. FBE
194. 17yrs male come for sore throat and treated with amoxillin.He had no H/O of allergy.After 7 days ,he come
for following picture,Dx?
A.Delay hypersensity reaction..should be mildly elevated
B. Steven _Johnson ?Ans if exactly this picture its b but there should be some prodromal feature before it.
C. fixed drug eruption

195. #nov 2016

196. School exclusion for scabies ?

Ringworm, scabies, pediculosis (head Exclude until the day after appropriate treatment has Not
lice) commenced excluded

*** Begin antipruritic dermatitis treatment immediately after each course of antiscabetic creams:
(a) moisturize before and after showering (b) avoid irritants such as too much soap and
excessive sweating (c) apply appropriately potent topical corticosteroids to the rash for the next
2-3 weeks

197. You are a doctor in aboriginal community and treat a large group of children suffering from scabies
with Permethrin and after 3 weeks some children still suffer from scratching their skin . what to do next (
Nothing Mentioned about Crusted lesions )
A- Oral Ivermectin
B- Topical Ivermectin
C- Topical corticosteroid
D- Repeat permethrin
ans is === > D

198. Pic of scabies with scenario of constant scratching the lesion. Asking diagnosis with word options
.no option for parasite.
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 Bacterial
Viral
Ans?????
199. Mary is an attendant at a local accommodation centre and has an intensive itchy rash on her wrists
and arms that has been present for the past few days. She has recently bought a watch and wonders if
this is the cause of the problem. The most likely Dx?
A) popular urticaria
B) Tinea
C) contact dermatitis
D) eczema
E) Scabies ?Ans
200. child with vesicle in foot, face, axillae, o/e scratch mark between fingers. dx?
a. HFM
b. scabies Ans
201. many scabies cases in children in a remote indigenous community.after treating patient what most
appropriate to do?
1-all children should stay away from school
2-close all swimming pools
3-treat all household contacts Ans
202. The skin lesions shown on the photograph were found on
the hands of a 73-year-old nursing home patient. She
has been noted to be The most appropriate
treatment would be
a. Topical steroids
b. Erythromycin
c. Prednisone 60 mg
d. Miconazole cream
e. Benzene hexachloride Ans infected scabies
203. Homeless middle age female picture of rash over wrist this rash on both wrists and groin tx
Cortison crean
Tar
Benzylbenzonate Ans
204. .A healthy fit 21 yo girl went for a backpacking adventure through the forests and bushes of
southern Queensland. She was bitten by what she thinks were tics on her shoulder. Over some time it
became blackish, her entire shoulder area was black. She had a history of fever and chills. What is the
diagnosis?
Ross River Fever
Q Fever
Lyme Disease ??????Ans bulls eye rash
Dengue/scrub typhus[in another recall]?Ans jm 135
Malaria
{Queensland tick typhus?}

#sept 2016, 2017;JM 286,287,275

205. Farmer with fever hepatomegaly and lymphadenopathy malaise no rash all lab elevated. GGT alp
alt.
Lyme disease
Brucellosis Ans 285

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 Q fever
Cholecystitis
206. A man on the rural area sometime shearer presents with fever,rash,asthritis,hepatomegaly
dx-hydatid cyst/Q fever/brucellosis
Correct Answer is C.

Q fever
Clinical features
• Incubation period 1–3 weeks
• Sudden onset fever, rigors and myalgia
• Dry cough (may be pneumonia in 20%)
• Petechial rash (if persisting infection)
• ± Abdominal pain
Persistent infection may cause pneumonia or endocarditis.

DxT fever + headache + prostration=Q fever

Hydatid cyst: patient may be asymptomatic.

Brucellosis:
Fever (undulant), sweats, myalgia, headache, lymphadenopathy.
Possible:
• arthralgia
• lymphadenopathy
• hepatomegaly
• spinal tenderness
• splenomegaly (if severe)

207. A farmer came with malaise, fever, arthralgia, hepatomegaly. NO RASH. Diagnosis? 2015
a. Brucella abortus ?Ans
b. Leptospira Pomona
c. Lyme disease
d. Coxiella burnetii
208. A farmer, with fever, hepatomegaly and lymphadenopathy, malaise, no rash all lab elevated ggt, alt,
ast, alp. Dx?
a- brucellosis
b- q fever
c- lyme disease
d- cholecystitis
209. Farmer with f/o meningitis, CSF findings are TC-820/cc, Monocytes- 70%, Polymorph-30%, Cytology
showed Gm +ve Rod……
A. Brucellosis
B. Pneumococcus
C,Listeria
D.Anthrax
210. a case of meningitis-neck stiffness, headache, fever.. CSF with increased monocytes, neutrophil,
high protein, low glucose.. what is the organism ??
a. listeria monocytogenes
b. Mycobacterium tuberculosis
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c. echovirus
d. Streptococcus
211. AOF is cause of the neck stiffness, except:

1. Meningitis

2. Botulism

3. Phenothiazine toxicity

4. Tetanus

5. Pneumonia

B. Neck and peripheral weakness (“floppy baby”)

Pneumonia may cause neck pain, stiffness, or torticollis secondary to compensatory muscle spasm, or
referred pain.

212. Aboriginal guy with presentation of multiple arthritis recently , a week ago his wife noticed big
round rash on his back. Mx
a- methotrexate,
b- prednisone [Dx RA?/lyme disease…doxycycline
c-Nsaid). Ross river..maculopapular rash

213. 20 yr old man from Egypt is in Australia visiting relatives. He presents with a history of urinary
problems over the past two weeks, with frequency, dysuria fever and terminal hematuria.he has also
noted occasional hemospermia. On examination he appears pale( a little) , with a temp of 37.8 degrees. A
urine specimen is positive for blood and protein. which one of the following is most likely diagnosis?
A ) urinary ameobiasis
B ) urinary bilharziasis
C) urinary calculus
D) urinary TB
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E) urinary leptospirosis

214. A 44 yrs old man went on holiday to Sudan 5wks ago. He now presents with red urine and fever.
Exam: hepatomegaly. What is the most likely dx?
A. Malaria
B. Brucellosis
C. Leptospirosis
D. Schistosomiasis
#july19
215. Patient comes from trip. Sheep framer. Now jaundice and pain. What will u do first?
a. USG
b. CT
c. MRI
d. LFT
216. a abboiter worker came with fever prostitution she has neck stiffness nd headache and dry cough
what is dx
a.brucellosia
b anthrax
c.leptospirosis
d.psitacosis
both psittacosis and leptospirosis have these symptoms, but since it says abattoir, it most likely
leptospirosis since it transmitted from cattle, but psittacosis is transferred from birds and poultry so thats
another dilemma

217. A 10 year old child is brought by his mother because of pain over the joints of hands and feet for
the past 5 days. On examination vital signs are normal but temperature is 37.8 C. He presents with a
maculopapular rash on trunk and arms and lymphadenopathy. What is the most likely diagnosis?
a) Dengue fever
b) Malaria
c) Juvenile rheumatoid arthritis
d) Ross river fever
e) Brucellosis
Alpha virus
Fever+polyarthritis+maculopapular rash

218. OCT 2017\\ female came with symptoms fever myalgia, rash,, 1week ago, went camping in
Queensland, got bitten by tick, bite site got red and tick was removed. o/e axillary lymphadenopathy ,
black scab at bite site,etc. Dx?
f) Lyme disease
g) Scrub typhus
h) Q fever
i) ross river fever

tick bite> lyme disease will cause doughnut rash

May cause arthritis facial palsy too.

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 219. an aboriginal male patient come as he is suffering of joint pain and edema his wife
discovered rash over his back with elevated margin aalso P R prolonged in ECG ttt
1 NSAID
2 penicillin [?Ans dx ?Rheumatic fever]
3 methotrexate
4 prednisolone

Management Admit to hospital

Paracetamol (± codeine) for fever and joint pain
Single dose of IM benzathine penicillin G or 10 days of oral
penicillin V
Arthritis can be treated with aspirin or naproxen
Sydenham chorea requires no treatment in most cases
(carbamazepine and valproate if required)
Carditis requires bed rest and urgent echocardiogram. Diuretics
or fluid restriction may be necessary. Consider ACEI and/or
glucocorticoids for severe carditis

220. A previously healthy 25-year-old basketball player came in due to swelling of the right limb for 1
week. On examination, his right arm including his hand and forearm are dusky, swollen and edematous.
He has non-tender axillary lymphadenopathy. He noticed that his pet cat is also unwell. What is the most
likely diagnosis?
a. Cellulitis- non tender LAP with fever
b. Cat-scratch disease- tender lymphadenopathy, low grade fever, pustules 1448
c. Subclavian vein thrombosis- no lymphadenopathy(if present painless) and fever***Ans
d. Cervical rib
C (correct answer here) there are some distractions in this questions like basketball player
and pet unwell. but most important thing the patient does not have any fever also no
tender lymphadenopathy

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 Explanation: athlete +fever for few days+ lymphadenopathy usually painful+
Animal/cat sick+ limb swelling= Cat scratch disease

No fever+no lymphadenopathy(if present painless)+limb swelling+athelet/volleyball

player+ No animal sick= subclavian vein thrombosis
221. Man had cat scratch on his arm then developed vesicular rash on the arm with lymph node swelling
Asking about the possible cause? Cat scratch disease bartonella hanselae
#note_this
#paeds
Sand-peper rash: scarlet fever
Red tongue : sacrlet fever/kawasaki disease
Maculooapular rash: measles / kawasaki disease/ dengue fever/ rubella/rose river fever
Vesicular rash: chicken pox/hand,foot and mouth disease
Rose-spot rash: typhoid
Initial investigation of cough: chest xray
Hirshprung disease: full thickness biopsy
Celiac disease: biopsy
Duchenne ms dystrophy: ms biopsy
LYME disease: doughnut shaped rash

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#Rocky mountain spotted fever:

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751
Male genital system
1. Recall of child with testicular swelling.The exact scenario was a
child with acute scrotal pain and swelling .On examination both
testes were separately palpable and non tender.Swelling and
redness was present over the pens.What is the most likely
diagnosis?
a. Torsion of testis
b. Edidodymorchitis
c. Strangulated incarcerated hernia
D. Hydrocele
d. Idiopathic scrotal edema
(Deep perineal pouch involves in this)

2. 25 years old man came for follow up of orchidopexy
for testicular torsion requesting for testicular Tumor screening
because his left testicle is slightly low and larger than right physical exam normal
a. Tumor markers
b. Usg
c. Reassure

Many people find that the right testicle is slightly larger and the left
hangs lower.

3. 4yr old child was brought by parents with complain of acute
bilateral scrotal swelling, not tender. On palpation, testes were
not enlarged & non tender.

a) Incarcerated inguinal hernia

b) ) Idiopathic scrotal odema
c) Epididymoorchitis
d) Hydrocele
e) Testicular torsion

752
4. A 30yr old man with a painless swelling on his right testis. separate from the testes, on the upper pole of testes.
vas can be felt separately. The swelling is soft, non tender. What to do?
A. Trans inguinal excision
B. Tumour marker
C. Re assessment after 3months (dx-encysted cord/epididymal
cyst.so reassure 1st.then review in 3-6 month if asymptomatic.after
3-6 months do usg & tumor marker)
jm 1216
D. Fnac
E. Biopsy
5. 15 yr came with swelling in rt testis has dragging pain.otherwise
normal.on examination testis r palpable but there is a swelling over
testis with only seen when standing and strain(most probably. What is
appropriate
a.no inv
b.usg dx-vericocele
jm 1224
c.tumor marker
d.fnac

753
6. 8yr old child with few days scrotal swelling, scrotum is red, and swelling extends to perineum and
penis. No fever, no pain, no tenderness. Child is doing fine.
a) orchitis
b) acute scrotal oedema
c) atopy

754
7. Inguinal hernia. What will lead u to go for urgent surgery?
(contro)
A. Swelling
B. Pain (older): sudden, severe, constant pain
C. Irreducibility (if sudden sever pain then it will be the
answer)(child)

irreducible hernias should be operated on soon after presentation.

Although irreducibility is not an indication for urgent operation, it is the
step before obstruction supervenes. In addition, irreducible hernias are
usually painful.

8. Pic of swollen testis of a child with no symptoms but looked

hydrocele.mother concerned what to do next?
Needle aspiration
Alfa feto protein
Reassure .. persistent processus veginalis.reassure upto
12months of age.if still presist,do surgery.
US

755
 9. A young man developed testicular swelling following
trauma to the testis during a game. Subsequent review
showed no trans-illumination and no tenderness. What
physical finding will lead to a diagnosis? Jm 1225

( Dx: testicular tumor)

a. Palpable para-aortic lymph nodes
b. Palpable inguinal lymph nodes
c. Can get above swelling

Ans : usg

10. 22yrs old male swelling of Rt testis and left

is normal.USG show testicular tumour of
Right testis.After AFP,what next ?

A.PSA
B. CEA
C. hCG
D.CA 19-9

11. Man with swelling 1.5 cm in scrotum, testes & cord palpated normally , no pain or urinary symptoms ,
whats is the definitive treatment ?

756
DX: epididymal cyst
A)trans scrotal surgery(best)
B)aspiration by needle (after observation or reassure)
C)Reassure now & check it after 3 mO (initial)
D)trans inguinal surgery (for testicular cancer)

757


758

759
12. Young man, palpable smooth scrotal mass on left side. Palpable testicles Thickened cords. Dx?
c. Epididymal cyst
d. Hydrocele(testes impalpable) jm 1223

13. A patient presented with a unilateral scrotal swelling suspected to be a varicocele. Which of the clinical
findings will help in making the diagnosis?
a. Clearly palpable spermatic cord
b. There is associated trans-illumination
c. There is no trans-illumination
d. There is fullness in the posterior part of the testis with an impalpable cord

14. 20 year old man with complaint of painful scrotal swelling after he collided with colleague whiles
playing soccer 2 weeks ago. The left testis is normal but the right testis has 8 cm mass. Cord was
normal but testis could not be palpated. What is likely to be the finding on examination?
a) Swollen or enlarged supra aortic lymph nodes ..jm1227
b) failure of transluminance (exact word)
(both for testicular cancer and hematocele)
c) Inguinal lymph node

15. 30 yr old male with scrotal swelling since few days.on examination scrotum is tender and swollen.
testis and cord is thickened and enlarged. on rectal exam anterior tenderness.
orchitis

760
 epidydimitis
hernia
hydrocele.
ans: epididymoorchitis

16. Most consistent with hydrocele

Transillumination
Can't feel testes separately

17. Pic of swollen testis of a child with no symptoms but

looked hydrocele.mother concerned what to do next?
Needle aspiration
Alfa feto protein
Reassure
US. If less than 1 year reassure
Is greater than 1 yr than surgical drainage

761
#2015file

18. middle age man present with swelling in
inguinal area that moves down to the
scrotum & return back, bulge during
coughing.. asking diagnosis??
a.direct hernia
b.spermatic cord lipoma
c.femoral hernia
d.encysted hydrocele?
e.testicular cancer

19. Child 8 years old with sudden onset of

painful red and swollen scrotum, penis and
perineum.On examination:Testis is normal,
no fever , Diagnosis?
a-Torsion testis
b-Incarcerated hernia
c-Epididymo-orchitis
d-idiopathic scrotal edema
e- Hydrocele

20. most complication of untreated varicocele (scrotum):

A/ impotence
B/ testicular atrophy
C/ infection
d/ hydrocele ( also cause decrease fertility )

Over time, the valves may not open and close normally, allowing blood to pool. ... The pooling blood around the
testicle increases the pressure, which may cause the shrinkage. Infertility is another strong possibility for those who
don't get varicocele treatment. Untreated varicoceles of large veins can cause overheating

762
21. Male with smooth test. swelling unilat. At upper pole you can feel spermatic cord and vas separately
Test. A or B?
A Epidydemal cyst
B Spermatic cyst
C Hydeocele
D Varicocele
Jm 1214

22. Patient coming for the elective

surgery for
uncomplicated varicocele who has
well had undergone an elute stent
insertion and currently on clopidogrel.
What to do?
Cease clopidogrel 3 days before
operation
Cease clopidogrel 19 days before
operation
Reassess the need for surgery
Defer the operation to 1 month and cease Clopidogrel before the operation

23. Pic of varicocele. Pt has scrotal swelling which subsides with lying down. What is most imp inv
A ct abdomen
b us grion

It should be usg scrotum

24. Pic of child with inguinal swelling from birth recently enlarged
Inguinal hernia b. Hydrocele c. Varicocele
#may2016 jm 1226

25. - Image of bilateral gynecomastia, more on the left side.

Male, 54 years, heavy drinker, 2 to 3 liters per day. He is having diffuse abdominal distension and
bilateral parotid swelling and hand tremor. He is also having small Testicular swelling. Diagnosis?
Malignant teratoma
Hepatic liver disease
Leydig cell tumour
Colon cancer

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There should be testicular atrophy but there is may be testicular edema due to generalized swelling

26. History of orchidopexy, infertility, sperm count 1 million, what next

A- Scrotal usd
B- Testerone
C- FSH, LH

27. Man with swelling 1.5 cm in scrotum. testes & cord palpated normally, no pain or urinary
symptoms, what is the definitive treatment?
Trans scrotal surgery
aspiration by needle (If epidid. Cyst)
Reassure now & check it after 3 mo.
trans inguinal surgery (If test. Tumor if young …almost less than 30) see snerio in exam
dx: epididymal cyst

28. adult male with pic of U/s-there is complex mass, swelling ofscrotum,what to do
a.biopsy
b.CEA
c.alpha feto protein
d.surgery
#May

29. 8 yr old child with scrotal pain, swelling and redness for 24 hours. Most appropriate next step?

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 • a. USG
• b. Surgery
• c. Aspiration

30. 20 year old man with complaint of painful scrotal swelling after he collided with colleague whiles
playing soccer 2 weeks ago. The left testis is normal but the right testis has 8 cm mass. Cord was
normal but testis could not be palpated. What is likely to be the finding on examination?
a) Swollen or enlarged supra aortic lymph nodes (we need to do ct as deep structure)
b) failure of transluminance (exact word) ……..tumor or hematoma
c) Inguinal lymph node

31. Young boy who was kicked by a friend, while playing football, Noticed Redness & with swelling of
right scrotum.Rt testes & spermatic cord are palpable,Lt Scrotum & Spermatic cord are palpable.Next
Inv-
A.USG
B.Biopsy of Scrotum
C.Sample for tumor marker

32. Young male 25 yrs presented with pain in scrotum from last 2 days. On exam testes is swollen red and
with tender thick spermatic cord. Whats next
a) surgical exploration
b) ultrasound
c) PCR urine
33. pict of swelling of left scrotal children ( I don't remember age ), typically was Varicocele . Without any
problem. asked next investigation to reach Dx ?
a) review after one month…**leave and review(jm)
b) USG (racgp)
c) cystoscopy
d) venogarm
e) no need investigation

Varicocele in children

A varicocele describes the varicosity of the pampiniform venous plexus of the spermatic cord and is present in 15% of
males of all ages.11 Venous dilatation impairs normal countercurrent thermoregulation of the testis, which may
cause testicular atrophy as well as subfertility due to oligospermia. Most varicoceles are asymptomatic, but some
cause testicular ache (or ‘dragging’). The vast majority are left-sided due to left–right differences in gonadal and
renal venous anatomy.11

On examination, the hemiscrotum is redundant and the varicocele feels like a ‘bag of worms’. Examination is
performed when the patient is first standing, then lying. When lying, the varicocele empties but may be made to fill
with a Valsalva manoeuvre.

Investigation

765
An ultrasound is useful to accurately measure testicular volume and confirm the clinical diagnosis of varicocele in
lower grade cases. Rarely, a retroperitoneal malignancy may present with a varicocele. For this reason, some
practitioners always order a renal ultrasound in newly presenting varicocele cases. However, clinical assessment for a
renal mass, hypertension and haematuria is more important than ultrasound to address this rare association.

When to refer

Varicoceles associated with symptoms or a greater than 10% discrepancy in testicular size should prompt a non-
urgent referral.

Surgical treatment

Intervention is indicated when there is a greater than 10% discrepancy in testicular volume or if symptoms are
sufficient to offset the risks of elective surgery. Whether those without these indications should also be treated to
protect future fertility remains controversial.12 Elective surgical correction by ligation of the testicular vessels
(Palomo procedure) is very effective and now most often performed laparoscopically.13 Interventional radiology
approaches are also efficacious and may be standard in some centres.

34. inguino scrotal swelling completly disappear on lying flat

?
saphena varex
direct hernia
varicocele
lymph node
hydrocele
#aug2015

**indirect hernia can come to scrotum..not direct one

A direct inguinal hernia protrudes through a weakened area in the
transversalis fascia near the medial inguinal fossa within an
anatomic region known as the inguinal or Hesselbach's triangle, an area defined by the edge of the rectus abdominis
muscle, the inguinal ligament and the inferior epigastric artery. These hernias are capable of exiting via the
superficial inguinal ring and are unable to extend into the scrotum.

766
35. Pic. Of scrotal u/s in 30 yr old male ask for best next ? cyst(testis palpable and hydrocele impalpable)

A) aspiration…if symptomatic
😎 excision…best
C) reassure & recheck after 3 monts
#SURGERY

As cystic finding in usg and testes could be

palpated it's epididymal cyst. No complains
or symptom so follow up

Epididymal cyst

36. 50-male with suspected

varicocele,what you see in
examination to confirm the diagnosis ?
a.palpable with transillumination
b.impalpable with transillumination
c.palpable and spermatic cord can be felt
d.fullness and congestion in posterior part of testes with impalpable cord…couldn’t take it cause cord isn’t
impalpable...
#surgery

37. 20 year old man with complaint of painful scrotal swelling after he collided with colleague
whiles playing soccer 2 weeks ago. The left testis is normal but the right testis has 8 cm mass.
Cord was normal but testis could not be palpated. What is likely to be the finding on
examination? a) Swollen or enlarged supra aortic lymph nodes b) failure of transluminance
(exact word) c) Inguinal lymph node

38. Pic of red and inflamed scrotum in 25 yr old male , cause ?

a. Gonorrhea
b. chlamydia
c. e coli
d. proteus
e. some another bug
20 May 2016 ·

767
39. 40 y old male complaints of rt scrotal pain, O/E rt
testicular tenderness and redness
Wt inv
A. US testis
B. Urine analysis
Tumar markers
#May

40. adult male with pic of U/s-there is complex mass,

swelling of scrotum,what to do
a.biopsy
b.CEA
c.alpha feto protein
d.surgery
#May

41. 25 yr male present with scrotal pain for 24 hrs..afebrile

red tender testis..what will you do?
u/s
aspiration
surgery (dx: sudden onset, so torsion testes)..usually
associated with vomiting not fever
#august

42. Picture of baby with enlarged testis, absent scrotal

rugae, enlargement extending upto upper pole of testis
and above. DX?
Hydrocele
Varicocele
Inguinal hernia ,# may

768
43. Q.11 2 year old with 24 hour of scrotal swelling and pain. O/E tender scrotal swelling with spermatic
cord
A)Refer
😎 Antibiotics
C)U/S scrotum
D) Aspirate
#july2016 #surgery #peads
24 hours of scrotal swelling and pain ?????? could it be testicular torsion?????
if yes then refer cuz us is unreliable

44. A man was brought by his wife for mass in right scrotum which was completely asymptomatic. The man
says that it's painless . On exam mass on upper pole of testes vas can be felt soft non tender testes can
be felt separate what to do next
Tumor markers
Aspiration
Transinguinal excision
Reasssess in 3 months…dx epididymal cyst
Biopsy

45. 9)Man with urinary retention mass above the pubic symphysis DRE showed enlarged prostate with
palpable median sulcus palpable Catheter inserted what is the most appropriate next step?
A-trans rectal ultrasound
B-PSA
C-MRI
D-CT
E-urine culture…there should be microscopy with it
Should nt it be E next step to rule out uti in er management of a case of bph????

46. A 72 year old man with a recurrent history of urinary tract calculi presents to his GP with a four month history of
painless haematuria and increased frequency. He also complains of recent weight loss. On examination the
patient looks thin and pale. Initial investigations reveal: haemaglobin: 110g/ L, WCC: 6x 109/ L, urea: 6.5 mmol/
L, creatinine: 86umol/ L, (PSA): 3 ng/ ml. Urinalysis shows: blood + + +, protein +, nitrites negative. What would
be the most appropriate diagnosis?
Urolithiasis
b) Transitional cell carcinoma of bladder
c) Prostate carcinoma
d) Renal cell carcinoma
e) Squamous cell carcinoma

769
47. Man comes with nocturia, frequency. On dre prostate is smooth and enlarged,a mass is palpable 6cm
from pelvis, wat investigation will you do?
PSA
Ct scan
Usg
48. Old man with frequency , urgency and nocturia and unable to pass urine now.On exam, distended
bladder and he was catharized. On PR exam, enlarged smooth prostate , median sulcus palpable.What
to do next?
1) Serum Ele and Cr
2) Cystoscopy
3) PSA
Amc Sam DRE has already been done, thats why we know it's enlarged. We already know PSA wont be accurate after
doing a DRE so it can't be next, which is what the question is asking. Chronic retention can cause renal function
impairment, which is more immediately threatening that possible prostate cancer, given he has no metastatic signs.
HIs kidney function is the more pressing condition to treat on an immediate basis, not to check if its cancer
immediately, of which, only a biopsy is definite.
, in addition a smooth and enlarged median sulcus is already a good indicator that its not cancer but BPH. The stem
is about the management of BPH thus the debate between surgical or pharmacological intervention and that can
only be determined by assessing the renal function.

49. 4) TRUSA man aged 64 yr. his psa is 3.8ng now.last year it was 2 or 1.8.he did 12 biopsies this time and
one showed a focus of adenocarcinoma and gleason score 4 . management asked?
A) radical prostatectomy
B)external beam radiotherapy
C) orchidectomy
D) continued surveillance

770
771
772
773
65 year old asymptomatic male requested for screening of prostaticca.psa level 3.6 on biopsy of prostate small focus
of adenocarcinoma without involvement of LN and surrounding structues.gleason score 7.asking about appropriate
mx?
a.radical prostatectomy
b.active survillience
c.external beam radiation
d.brachytherapy

Old male had urinary problem, 2 months back pain.On examination tenderness @L4/L/5, DRE shows hard irregular
large prostate..
Next?
CT lumbar spine
PSA
TRUS
Pet scan
Next is psa. Diagnostic is trus with biopsy

45 years male presents with urgency and dribbling of urine at the end of micturition on DRE the prostate is enlarge
and median sulcus is properly palpable. On physical exam there is a pubic mass(urine retention). No nocturnal
frequency (if not otherwise evening coffee). What is next investigation?
PSA

774
Cystoscopy
Microscopy culture
CT scan

Long term complication of prostate surgery

A. Impotence
B. Retrograde ejaculation
C. Urinary incontinence

Initial incontinence. Long term rettrogate ejaculation

recall of measles outbreak, what to do for day care and staff

a. give Ig to unvaccinated staff and children

B. exclude all unvaccinated

C. exclude all wz fever

D. take all the infection control measures

E. wash hands/ there was no give vaccine or exclude the sick ones

775
after 3 cases of measle in school. you are keen to find a way to prevent further outbreak of measles. Which of these
is the most appropriate step to take in this situation?

A-quarantine the children

B-give pamphlets to parents about the vaccination prevention

C-Give IG to all unvaccinated staff and children

D-Give vaccine to family members

E-told them about hand wash prevention

50Y old Farmer with lacerated wound.6 weeks ago has taken DPT for superficial wound,has no other immunization
history.Now what to do
1.TT
2.Tig
3.Tig and DPT

776
4.TT and Tig

(DPT-child; dpt-adult)

50Y old Farmer with lacerated wound. 4 weeks ago has taken DPT for superficial wound,has no other immunization
history.Now what to do
1.TT
2.Tig
777
3.Tig and DPT
4.TT and Tig
(The primary series for adults consists of three doses.First and second dose are given 4 weeks apart and third dose

is given by 6 to 12 months.)

case of polycystic kidney disease on annual follow up presented with hematuria and GFR 20 asking what of the
following would help you to find if there is lower urinary tract obstruction

a.renal us
b. CT abdomen (not pelvis)
c. IVP
d. retrograde urethrogram/cystoscopy
e. another test with contrast

A retrograde urethrogram (RUG) is a diagnostic procedure performed most commonly in male patients to diagnose
urethral pathology such as trauma to the urethra or urethral stricture. [1,

Yes if upper tract ivp -- key investigation but in those who have creatinine level <1.5 If ivp inadequate then
retrograde pyelography done Allergic to IVP- CT urography Ultrasound--initial test Cystoscopy-- lower urinary tract
obs ( as it is not mentioned so I choose D) Retrograde urethrogram-- lower urinary tract especially in trauma case
Cystoscopy with retrograde pyelography- urethra prostate bladder upway to kidney Can be done with elevated
creatinine so can be alternative to IV

778
You are called to the ward to review a 72-year-old man who is pyrexial at 38.0°C, 8 hours following an anterior
resection for rectal adenocarcinoma without defunctioning stoma. He is asymptomatic and pain-free with an
epidural.A urinary catheter inserted in theatre is draining concentrated urine. He has a history of chronic airways
disease controlled with inhalers. He has no respiratory distress, but both lung bases sound quiet. The most likely
explanation for the patient's pyrexia is-
A. Epidural abscess
B. Systemic response to surgical trauma
C. Basal atelectasis (ans)
D. Infective exacerbation of chronic airways disease
E. Urinary sepsis

It is Atelectasis. Points in favor: 1) Post operative 2) H/O COPD, which can facilitate the development of atelectasis.
Probably that's why atelectasis developed within 8 hours of operation. 3) lung base is quiet. 4) pt. age > 60y * Pt. has
no respiratory distress, probably because atelectasis maybe asymptomatic.

779
Postoperative pyrexia (2)You are called to see the same patient 7 days postoperatively as he has become unwell and
pyrexial with a temperature of 39.0°C. The patient has generalized abdominal discomfort. The abdomen is tender
with generalized guarding and rebound. The chest is clear to auscultation. The patient's catheter and epidural were
removed 2 days ago. The most likely explanation for the patient's pyrexia is-

A. Deep vein thrombosis

B. Infective exacerbation of chronic airways disease
C. Pulmonary embolus
D. Anastomotic leakage
E. Pre-existing chest infection

55y old lady known with insulin dependent DM, has had right leg amputation 5yrs previously, now blood pressure
175\90, normal regular pulse, BMI 32, LDL 2.8, s. triglyceride 4.5,hba1c was 8.5,fasting glucose was 9.5.Which of the
following is important to keep her other left leg from amputation?

a.Meticulous foot care

b.Control her blood pressure

c.Tight glycaemic control

780
d.Reduce LDL

e.Reduce her body weight

child was taken drinks at party ant 2 yrs he was vomiting and de temperature was 35.9
Whats the most appropriate thing to do
A-Drug screen
B-alcohol
C-glucose****
D-Diazepam

Alcohol accidental consumption must have lead to

hypoglycaemia in children resulting in drowsiness

Children’s bodies absorb alcohol quickly. This can occur in

less than 30 minutes. Alcohol affects the central nervous
system. Symptoms can include confusion, vomiting, and
seizures. The child may have trouble breathing and flushed
or pale skin. Alcohol reduces the gag reflex. This can cause
choking. Alcohol may also cause low blood sugar in
children. This can result in a coma from the alcohol or the
low sugar.

schizoaffective disorder on risperidone, and lithium. Went

to party n took alcohol, cocaine n
ecstasy
Now presenting with hyperreflexia, tremors, irritability,
drowsiness, agitation, temp 37.8, bp
150/?
Wat nxt investigation
Alcohol level,
drug screen,
lithium level,
ck level

A 2yr old patient has with fatty diarrhea has was brought in by the patient, failure to thrive , physical exams reveals rash
in the limbs. What is the diagnosis .
A, cystic fibrosis,
b. Dermatitis
c. Coliec disease***
d. Amoebiasis
e.(Rash so coeliac).

Dermatitis herpetiformis (DH) is the skin manifestation of coeliac disease which occurs as a rash that commonly
occurs on the elbows, knees, shoulders, buttocks and face, with red, raised patches often with blisters. It affects
around one in 3,300 people.

781
DM 1 pt after a penetrating injury developed swelling of ring finger, it was tender esp on flexor side pt had problem with
extension of the finger ... What to do next
A. IV cephalothin(exact wording)
B. Iv flucoxacillin***
C. Surgical exploration
D. Iv cephalothin with physiotherapy

782
E. Iv flucoxacillin with physiotherapy

A 3yr old with complain of anorexia and diarrhoea for the past 2days and fever. On examination Temp 39, tenderness and
guarding in Left iliac fossa. What is diagnosis
Mesenteric adenitis
Appendicitis
Giardiasis
Amoebic dysentery

783
3 year child was complaining of colicky abdominal pain and anorexia for 7 days, then 2 days of diarrhea and other feature
now presented to you his there was tenderness all over the abdomen with guarding, temperature 39. What is the most
likely diagnosis?
A-perforated appendicitis
B-mesenteric adenitis
C-norovirus gastroenteritis
D-giardiasis
E-campylobacter gastroenteritis

In an athlete woman with anorexia nervosa. You should consider all the following except?
a. Amenorrhoea
b. Pericarditis
c. Metabolic alkalosis
d. Tetany

Child with reduced attention and occassional, non-rythmic outburst

a) Asperger

B)Tourette

204.Child with normal development at 2years, but parent worried about language. Arranges toys in straight line, sustains
attention, only interested in younger sibling
a) Asperger b) Tourette

Bulimia nervosa associated with which of the following:

A- Trichitillomania
B- kleptomania
C- pathologic gambling
D- pyromania
E- intermittent explosive disorder

juvenile pyromania, asking for cause—

a.for attention,
b. curiosity about fire.
C. for revenge

Pyromania management?
a. Exposure and response
b. CBt

784
Which one is not a basic inv for anorexia nervosa

A) Electrolytes
B) Dexa scan
C) LFT
D) ECG
E) U/E

2 ..only after 6 months of symptoms

Child with nephrotic syndrome treated with steroid developed hypertension, diffuse abdomen

pain and vomiting for 1 week ,afebrile what is the most likely cause?
A- acute pancreatitis
B-acute pyelonephritis
C-renal vein thrombosis

Although renal vein thrombosis (RVT) has numerous etiologies, it occurs most commonly in patients with nephrotic
syndrome (ie, >3 g/day protein loss in the urine, hypoalbuminemia, hypercholesterolemia, edema).

child with nephrotic syndrome treated with steroid developed hypertension , diffuse abd pain and vomiting for 1
week ,afebrile
A acute pancreatitis
B acute pyelonephritis
C renal artery stenosis (pre existing)

if abdominal pain , vomiting, oliguria and pulmonary embolism( pulm htn): renal vein thrombosis

if systemic htn: renal artery stenosis is usually asymptomatic except htn

nephrotic syndrome case asking about itital treatment

a.restrict fluid at home
b.restrict fluid at hospital
c. steroid

785
50. 5o y old woman complain pain in mid thoracic region + weakness of legs progressing over 2 past
months O/E found spastic paraparesis Dx

786
 1-multiple sclerosis
2-tabes dorsalis
3-motor neuron disease
4-spinal cord compression
5- parasagital meningioma

51. Multiple sclerosis presenting early is often misdiagnosed as?

A. Polyneuropathy
B. Encephalopathy
C. Conversion d/o
D. Hysteria
52. A 40 year old male patient having weakness in facial muscle
including frontals, he is having swallowing difficulties, Coughs
when he tries to drink water.What is the most likely
Diagnosis?
A- Bell’s Palsy
B-Ramsay Hunt Syndrome
C-Multiple Sclerosis
D-Basilar Artery Stenosis
E- Brainstem infarct …if excluding frontalis

53. Pt was stable after mi had thigh Hematoma enoxaparin and clopirodgel taken asked how ill u manage
next
a.compress haematoma
b. stop enoxaparin clopidogrel
c. inject anti thrombin in thigh
4. give ffp
(Then iject anti thromboin)

54. . A man with numerous painful vesicles on penile shaft. A test done showed multi segmented giants
cells. What is the possible organism or diagnosis
A. Tzanck prep for viral organism
B. Syphilis
C. Lymphogranuloma
D. Shingles
E. Haemophilus ducreyi

Tzanck cells (acantholytic cells) are found in:

• Herpes simplex[1]
• Varicella and herpes zoster
• Pemphigus vulgaris
• Cytomegalovirus
The Tzanck test has been largely replaced by DFA for identification of the herpes virus [2]
It is shingles. Multi nucleated giant cells on Tzanck smear

787
55. a mother presented with her 4 yr child with c/o upper respiratory tract infection, afebrile when u
examine the child, he has bruises, no rash no petechiae some bruises old what will you suspect
1.hsp (no history of joint pain nd rash)
2.thrombocytopenia
3.non accidental injury
4 factor 8 deficiency

56. 4 yr child brought by mother at 18 months she says baby start rolling over at 5 months sitting at 7 to 8
months standing and walking at 12 months nd so nd now babbling but no proper words. Her
audiometry is normal. Baby respond to voices and growth is also normal. What is ur advice to mother?

a) Normal growth
b) Delayed speech
c) Delayed milestones

57. 75 years old male, asymptomatic

BM report: increased lymphocytes Immunohistochemistry:

Positive CD19, CD56
Treatment?
A. No treatment
B. Rituximab + CVB
C. Rituximab + Prednisolone
D. Cyclo-phosphamid

788
 • Symptomatic myeloma (all three criteria must be met):
1. Clonal plasma cells >10% on bone marrow biopsy or (in any quantity) in a biopsy from other tissues
(plasmacytoma)
2. A monoclonal protein (Myeloma protein) in either serum or urine (except in cases of true non-
secretory myeloma)
3. Evidence of end-organ damage felt related to the plasma cell disorder (related organ or tissue
impairment, commonly referred to by the acronym "CRAB"):
§ HyperCalcemia (corrected calcium >2.75 mmol/l, >11 mg/dl)
§ Renal insufficiency attributable to myeloma
§ Anemia (hemoglobin <10 g/dl)
§ Bone lesions (lytic lesions or osteoporosis with compression fractures)

Note: Recurrent infections alone in a patient who has none of the CRAB features is not sufficient to make the
diagnosis of myeloma. Patients who lack CRAB features but have evidence of amyloidosis should be considered as
amyloidosis and not myeloma. CRAB-like abnormalities are common with numerous diseases, and it is imperative
that these abnormalities are felt to be directly attributable to the related plasma cell disorder and every attempt
made to rule out other underlying causes of anemia, kidney failure, etc.

https://www.ncbi.nlm.nih.gov/pubmed/27531777

789
58. Patient went intramedullary wire fixation for tibia fracture..pain exaggerated on passive dorsiflexion of
his big toe..what management should proceed? Dx: compartment syndrome

A.review after weeks

B.put on more analgesic
C.leg elevation
D.4th option forgot may b invx like X ray
E.stabilize with plaster cast

59. Q)Family history of father and paternal aunt died at 50 years of age.
Patient complaint of wide based gait and verbal dysfunction. What is your next management?
A. Genetic counseling (huntington cus autosomal dominant)
B. Lumbar puncture
C .Serum cooper and ceruloplasmin
D. MRI
E. CT head

60. after 3 cases of measles in school. you are keen to find a way to prevent further outbreak of measles.
Which of these is the most appropriate step to take in this situation?
A-quarantine the children
B-give pamphlets to parents about the vaccination prevention
C-Give IG to all unvaccinated staff and children
D-Give vaccine to family members
E-told them about hand wash prevention

61. Excised BCC send to patho lab.what is the most prognosis value for this??
A. thickness of the lesion….for mmelanoma
B. no cancer cell all around the margin
C. inflammation of the lesion
D. amt Solar keratosis
Margins for bcc.Thickenss for melanoma.

62. you are a doctor in rural hospital in north Australia and a patient comes after 30 mints was bitten by a
brown snake in his left ankle , the patient has no symptoms , and there were simple scratches over the
skin of the ankle with no marks of the snake teeth , the tertiary hospital is 150 km far away , what is the
urgent next step to do:
A- Call for helicopter ambulance to the tertiary hospital to be supervised
B- Give anti- venom ampoule now and another ampoule after symptoms appear
C- Tell the patient to go home as no tooth bits remarks and no symptoms
D- Urgent apply for a tourniquet in the upper part of left thigh.
E- No option mentioned to manage the scratches locally or bandage locally

790
 (First aid 1 Keep the patient as still as possible. 2 Do not wash, cut, manipulate the wound, apply ice or use a
tourniquet. 3 Immediately bandage the bite site very firmly (not too tight). A 15 cm crepe bandage is ideal: it
should extend above the bite site for 15 cm (e.g. if bitten around the ankle the bandage should cover the leg to
the knee). 4 Splint the limb to immobilise it: a firm stick or slab of wood would be ideal. 5 Transport to a
medical facility for definitive treatment. Do not give alcohol)

(Note 1: The use of prophylactic adrenaline is controversial and some authorities reserve it for a reaction to the
antivenom. It is best avoided with brown snake envenomation and with coagulopathy.

Note 2: Do not give antivenom unless clinical signs of envenomation or biochemical signs (e.g. positive urine, or
abnormal clotting profile).

Note 3: One ampoule may be sufficient but three or more may be needed, especially if coagulopathy.)

63. Ovarian cancer screening question – friend was diagnosed with ovarian cancer, wants to be screened,
you examine her but is normal, what advise do you give her –

A-ultrasound,
b- reassure,
c- tell her that there is no screening for ovarian cancer

64. Pt. 35 yr old completed her family on OCP asking about screening for ovarian cancer. H/o ovarian
cancer in mother or some relative. Most appropriate advice?
• a. CA125 every 2 year and USG
• b. BRCA1 and BRCA2 gene study
• c. Advice for sterilization as OCP increase risk for ovarian cancer

65. 25yr old whose friend diagnosed of ovarian CA. Asking for screening. No other complaint.
a) reassure her that she has no risk JM-254
b) screen for ovarian CA gene
c) pelvic USS
d) bimanual pelvic exam

66. 4.Man came with 3 cm painful tendermass over inguinal ligament , appeared after he returned from a
hiking trip
A inguinal hernia
B femoral hernia
C Iymph node

Femoral hernia and lymh node both are below inginal ligament and lymph node will have fever as well

791
67. Femoral hernia scenario ask about best inv? a) Xray abd b) CT abd pelvis c)Usg of swelling
68. Pt with orchidopexy asking for testicular cancer screening

a)us
b)reassure
c)ct
d)self testicular examination
ans: testicular exam by doctor

69. A young 27 year old man present with concern of having testicular cancer and wants to know about
screening for testicular cancer on examination everything normal , on testicular examination right
testis is slightly lower than left testis, what will u advice regarding screening?
A. Reassure
B. Self-examination
C. PSA
D. Digital rectal examination
E. Come back in 3 months’ time

70. picture of gynecomastia, pt has parotid swelling and swelling in testis , what is the cause of
gynecomastia (contro)
a) testis cancer
b) testis teratoma
c) parotid tumor
gynaecomastia is related with teratoma.. and testis teratoma is metastasis to parotid gland

792
71. Young man with testicular cancer AFP -ve BHCG +ve and mets to his para aortic lymph nodes what is 4
cm what is best management
a. Surgical removal of testes and lymphnodes
b. Radiotherapy
c. Chemotherapy
Dx: seminoma
Ans: orchidectomy with radiotherapy

793
#uro

72. 13#Sept 2017 Testicular tumor. AFP raised , what other marker will u check ??

(HCG

LDH)

73. A man who has had a bilateral orchidopexy presents to your clinic. He is asymptomatic and has no
family history of testicular cancer. He is worried about developing testicular cancer. What is the FIRST
step:
A. No intervention required
B. Ultrasound
C. Biopsy inguinal approach
D. Biopsy scrotal approach
E. Tumour markers
**Physical examination and then reassure that means no active intervention ...so going with A

74. 15A 35-year-old man who is taking radiation therapy for a lymph node metastasis from a testicular
cancer operated 2 years ago, presents with rectal bleeding. Which one of the following could be the
most likely cause of his rectal bleeding?

A. Colon cancer.
B. Rectal cancer.
C. Anal fissure.
D. Haemorrhoid.(if took radiation5 yrs ago)

794
 E. Radiation proctitis….

75. 16Middle age man presents with swelling in inguinal area that moves down to the scrotum & return
back, bulges during coughing, completely disappear when patient lies flat... asking diagnosis??
Varicocele / indirect inguinal hernia reducible
spermatic cord lipoma (inguinal) direct inguinal hernia
encysted hydrocele
testicular cancer
#gynob

76. 1730. mother came with her 6 months old child with scrotal swelling . she is concerned about the
swelling of his son. On examination the swelling is partially reducible. [ there was a pic of swelling, left
sided swelling was larger than the rt]. What is the most appropriate inv for this?
A. no inv is required
B. USG of testes
C. XRAY

795
77. Regarding unilateral undescended testis, which of the following is most commonly associated?

a) Malignancy
b) Varicocele
c) Inguinal hernia
796
 d) Hydrocele
e) Torsion of the testis
19#SEPTEMBER

78. . That recall of child with testicular swelling. The exact scenario was child with acute scrotal pain and
swelling. On examination both testes were separately palpable and non tender. Swelling and redness
also over the penis. What is the most likely diagnosis?

• a. Torsion of testis
• b. Epididymo-orchitis
• c. Strangulated incarcerated hernia
• d. Hydrocoele
• e. Idiopathic scrotal edema
79. Child 8 years old with sudden onset of painful red and swollen scrotum, penis and perineum.On
examination:Testis is normal, no fever , Diagnosis?

a-Torsion testis
b-Incarcerated hernia
c-Epididymo-orchitis

797
 d-idiopathic scrotal edema
e- Hydrocele

80. 21Picture of baby with enlarged testis, absent scrotal rugae, enlargement extending upto upper pole of
testis and above. DX?

Hydrocele
Varicocele
Inguinal hernia ,# may

81. 22Child 6 months e mass in testis increases in size and partially reducible ....1st step
A. Us
B urgent surgery
Ans surgery within 2 weeks

82. 23which sign consistent with hydrocele---

-trans illumination
CANT FEEL SEPARATELY

798
83. 24A 15 yrs old boy comes to the ED with sudden onset of severe lower abdominal pain for 4 hours. O/E
there is tense tender swollen testes situated at a higher level. What is the Dx?
Torsion of testes.
Neoplasm of the testes
Hydrocele

799
 Varicocele
Epididymo-orchitis

Is it Torsion?

25#SURGERY

84. pead hernia in scrotum pic what to do now?

Usg
Afp
No inv needed

85. 26Pic of swollen testis of a child with no symptoms but looked hydrocele mother concerned.what to do
next?

1.needle aspiration
2.alpha frto protein
3.ultradound
4.reassure

86. 2 year old brought by mother with groin swelling when he cries. On exam, child is fine and no swelling.

a) reassure mother
b) herniotomy
800
 c) abd USS
d) review if swelling reoccurs

Ans: a

87. scrotal swelling in 67yr male,wht physical examination will help u dx hydrocele-

a-tranillumination positive
b-spermatic cord not palpable
#july
88. football player hit and came in with testicular mass, painless. What to expect on exam :
a) no transluminescence
b) hernia with cough
c) raised AFP and B-HCG
d) large inguinal lymphnodes
e) palpaple paraortic lymphnodes
#august

89. 4yr old child was brought by parents with complain of acute bilateral scrotal swelling extending into
perineum and penis.it was red but non tender. On palpation testes were not enlarged and non tender.
A.incarcerated inguinal hernia
B.idiopathic scrotal edema
C.epididymoorchitis
D.hydrocele
E.testicular torsion
# sep

90. 40 year old obese man presented to you complaining of a lump that appear during lifting head toward
the abdomen and raising his legs but disappear when lying flat , on examination there was a lump
extended from the umbilical upward to the xiphisternum . what is the most appropriate management
for this patient?
A-abdominal binder
B-mesh repair of hernia
C-herniorraphy

801
 D-weight loss
A diastasis recti may appear as a ridge running down the midline of the abdomen, anywhere from the xiphoid
process to the umbilicus. It becomes more prominent with straining and may disappear when the abdominal
muscles are relaxed

91. 22-a pic of 5 yrs old w small swelling above umbilicus but it is eccenteric , her mom
brought her to u and she is worried about her daughter , on exam the swelling is soft no
redness no pain "no other mention about otherthing " what is ur diagnosis ?
1. epigastric hernia
2.lipoma
3. epidermoid cyst
4. Umbilical hernia

92. Epigastric hernia ,best examination

1-standing and cough

2 lying and cough

3-leg elevation

802
Because an epigastric hernia is often small or barely visible, the doctor may have you stand and cough to see the
bulge more clearly as it pushes forward. ... In harder to diagnose cases, your doctor may take an ultrasound or CT
scan, to take an internal look at the abdominal wall between the breastbone and naval.

93. . Epigastric hernia picture of a 56 year old man which extends from umbilicus to xiphisternum. He
looked morbidly obese and had a waist circumference of 110 cm

Asking for appropriate advice for the patient.

A. Weight loss therapy
B. Abdominal binder
C. herniorraphy with mesh repair
D Hernioplasty
E Observation

94. Epigastric hernia picture of a 56 year old man which extends from umbilicus to xiphisternum. He looked
morbidly obese and had a waist circumference of 110 cm
Asking for appropriate Mx for the patient.
A. Weight loss therapy
B. Abdominal binder
C. herniorraphy with mesh repair
D Hernioplasty
E Observation
95. )1prostate ca scenario.DRE was irregular & enlarged prostate,next inv?
A)PSA
B)PET SCAN
C) TRUS

96. 2)A man is having a check up for prostate cancer last two years PSA was 1.5mg/ml, now PSA is
3.8mg/ml, then 12 slides of biopsy done and only one foci showed adenocarcinoma. Gleason score is 4.
How will you manage this patient?
A.TURP
B.radical prostatectomy
C.active surveillance
D.EBRT

803
 If age >70 active survilliance

If age <70 radical prostactemy

97. 45 yrs old man with no family history of prostate cancer comes for screening advice and counselling .
He insist he wants a DRE. A digital rectal exam showed a normal sized prostate with normal non
nodular sulci. What is the next important step
A. Reassurance
B. PSA after 2 weeks
C .TRUS
D. Abdominal usg

98. Man with urinary retention mass above the pubic symphysis DRE showed enlarged prostate with
palpable median sulcus palpable Catheter inserted what is the most appropriate next step?
A-trans rectal ultrasound
B-PSA
C-MRI
D-CT
804
99. man with irregular enlarged prostate on Dre . dx asked… psa
trus ans
/ pet scan

100. Long term complication of prostate surgery

A. Impotence
B. Retrograde ejaculation ans
C. Urinary incontinence

Retrograde ejaculation is the most common long-term

complication of TURP and can occur in as many as 90% of cases.

This is where semen doesn't come out of your penis during sex or masturbation, but flows into your bladder
instead. It's caused by damage to the nerves or muscles surrounding the neck of the bladder, which is the point
where the urethra connects to the bladder.

Retrograde ejaculation isn't harmful and you'll still experience the pleasure associated with ejaculation (orgasm).
However, your fertility may be affected, so you should speak to your surgeon if this is a concern.

101. Initial complication after TURP

urinary incontinence ans
Retrograde ejaculation
Erectile dysfunction
Infection

The most common adverse effect of radical prostatectomy is erectile dysfunction

102. man 55yrs..no family history of prostate cancer.. overallhealthy..family history positive for
colorectal cancer now came for prostate screening? What advice would you give

Informed consent…after informing pros and cons

**Assymptomatic men aged 50 to69 choose to have PSA testing after being councelled on pros and cons of
testing.should be tested after every 2 yrs and core biopsy if PSA >3

103. . 58 year old man presented with severe lower back pain and tenderness in the lower lumbar, he
has weight loss of 10 kg and on examination, there was tenderness over L4-L5 vertebra, On DRE the
prostate was enlarged and irregular, what is the most appropriate test that lead you to the diagnosis?
A-PSA
B-PET SCAN
C-spinal CT
D-spinal MRI
E-TRUS ans

805
104. 47 years old patient presented to you in clinic for the screening of prostate cancer. He is worried as
his father had died of prostate cancer at the age 75. which of the following screening test would you
suggest?
A) PSA and DRE
B) PSA only ans
C) Prostate biopsy
D) Reassurance
E) Advice him to do PSA in 10 years

• Men considering a PSA should be given information about the benefits and harms of testing.
• Men with an average risk who have decided to undergo regular testing after being informed of the benefits and
harms should be offered PSA testing every 2 years from age 50-69. If the total PSA concentration is greater than
3ng/mL then further investigation should be offered.
• Men over 70 who have been informed of the benefits and harms of testing and who wish to start or continue
regular testing should be informed that the harms of PSA testing may be greater than the benefits of testing in
their age group.
• Men with a father or one brother who has been diagnosed with prostate cancer has 2.5 – 3 times higher than
average risk of developing the disease. If these men have decided to undergo regular testing after being informed
of the benefits and harms, they should be offered PSA testingevery 2 years from age 45 to 69.
• Men with a father and two or more brothers who have been diagnosed with prostate cancer have at least 9 to 10
times higher than average risk of developing the disease. If these men have decided to undergo regular testing
after being informed of the benefits and harms, they should be offered PSA testing every 2 years from age 40 to
69.
• In a primary care setting, digital rectal examination is not recommended for asymptomatic men in addition to
PSA testing however this may be an important assessment procedure if referred to a urologist or other specialist
for further investigation.
• Mortality benefit due to an early diagnosis of prostate cancer due to PSA testing isn’t seen within less than 6-7
years of testing so PSA testing isn’t recommended for men who are unlikely to live another 7 years (subject to
health status).
• A PSA testing decision aid for men and their doctors is under

105. Old man with Hx of radiotherapy for prost cancer. Recently has complains for fresh bleeding per
rectum. What's Dx?
A) Cancer colon
B) Radiation prostatic ans (within 12 monts of radiation) is associated with diarrhoea,tenesmus,mucous
discharge,abdominal pain
C) cancer rectum
D) haemorroids

806
106. Prostate cancer, Gleason score 7, T3 N0 M0 , treatment?
a) orchidopexy

b) radical prostectomy

c) external beam radiotherapy ans

T1 and t2 localized

T3a extracapsular extension

T3b seminal vesicles involved

T4 fixed to external structures ie is external sphincters

807
107. .55 yrs (I guess) old man concerned about prostate cancer…have no symptoms and no family
history…dre has been done and its normal..what will you do?
a. ressure him
b. do psa after 2 wks ans

108. question about man 64 yr old prostate cancer ..gleason score 4 ..small focus
of adenocarcinoma
Radical prostatectomy
External beam radiation

https://emedicine.medscape.com/article/2007095-overview

109. 65 years old male has prostate cancer localized to prostate.. Rx

Radical prostectomy ans

Transurethral prostectomy
Active surveillance
External beam radiation
Ablation

110. 42 y man w/o sign and symptom and family history of cancer ask about prostate cancer screening,
what is your advice?
Only DRE is enough
PSA is the investigation of choice but after 50 (after discussing the pro and cons)
PSA has a high false positive

What are the tests for prostate cancer?

808
 • Blood test for PSA. This test is controversial as a screening test because: – PSA levels may be elevated from causes
other than prostate cancer – there is debate about what constitutes a ‘normal’ and an ‘abnormal’ PSA level when
screening. The test is often repeated if it is only mildly elevated – the PSA test does not discriminate between those
cancers that will cause harm and those that will not (see ‘What is prostate cancer?’ section above). • Digital rectal
examination, where the doctor inserts a finger into the anus to examine the prostate, is no longer recommended in
addition to PSA testing.

111. Which of the following cancer is most common to metastasize to bone ?

a) Prostate Cancer (2nd most)
b) Stomach Cancer
c) Breast Cancer ans
d) Lung Cancer
e) Cerebral Cancer

Jm page 257 breast >prostate>lung>hodgkin>kidney >thyroid >melanoma

112. Elderly man with dysuria and nocturia, has back pain, PSA 10.
Prostate cancer `ans
Bladder cancer
BPH
113. 19 yo boy has been brought to the
ED following a car accident, the pt
wants to do urine, but he can’t pass the
urine, also the blood is coming from his
urethra... what to do:

1- Intra urethral catheter

2- Cystoscopy
3- Supra pubic catheter
4- U/S

809
 5- Retrograde something like that...

Renal and Male pathology

810
1. Child with URTI,protein+, rbc+ on urinalysis, came back 2wk
later, urine, rbc+ of non glomerular origin, no cast. Which
investigation?
A- Urine culture
B- ASTO
C- USD
D- DMSA
E- Renal Bx

2. An old aged gentleman with signs of pyelonephritis. His GFR is

less than 20. What would be your choice of antibiotic in this
case?
A. Gentamicin.
B. Amoxicillin. Hi
C. Trimethoprim
JM-301,pyelonephritis---JM-247…

811
all question ans---amoxicillin…so GFR—low all time choose amoxicillin…
Trimethoprim-sulfamethoxazole is often administered for uncomplicated pyelonephritis in young women. However, for
reasons described below, trimethoprim-sulfamethoxazole may not be effective in patients with renal insufficiency. ref.
Clinical Journal of American Society of Nephrology

3. A case of severe UTI. There was chills, high fever and pain. GFR is low (20 ml/min) what of the following would you
prescribe to the patient
a. trimethoprim
b. vancomycin
c. nitrofurantoin (CKD)
d. amoxicillin (With Clav.or Genta.)
e. gentamycin (CKD)

812
4. 65 year old male with UTI, with CRF, GFR less than 20,what is the most appropriate antibiotic-
a.amoxicillin
b.nitrofurantoin
c.trimethoprim
d.cephalexin

5. Person with urinaray tract infection and GFR,20 what to give

a.Amoxilcillin
b.Trimethoprim/sulphamethoxazole
c.Gentamycin
d.Nitrofurantoin
**don’t follow this explanation

6. Old age , fever sign of pyelonephritis, BP 90/60, confused and dysuria, pus in urine in urinalysis, u send for culture,
GFR<20 *management ?
A. Amox
B. Trimeth. &Sulfa
C. Gentamycin
D. Ciprofloxacin
Pyelonephritis …low GFR---always choose cipro..if nt in option thn amoxicillin..

813
7. Child presented with UTI, on ultrasound right kidney smaller in size than left. What next investigation
a) dtpa
b) dmsa
c) urine culture
d) ct

8. Young Male with suspicious testicular mass.Blood for tumour marker done.Next?
A.CT….
B.USG
C.Biopsy
D.Aspirated tumour mass

9. 22yrs old man came inquiring of testicular Ca.Since friend was Dx with it.on exam,Left testicle was larger than rt.Dx? --
--ans- normal(rt. testis is larger than left)..
A. Klinefelter----small testis
B. Testicular Ca ---swelling
C. Hypogonadism----small testis
D. Normal

10. Similar scenario..Inx asked-(No option for tumour marker)?

A.USG -----best
B.CT
C.Orchidopexy
D.Bx of testes

11. Couple came for infertility consultation.Women has regular mens& was normal on Inx.Man has small testes
&azoospermia.Dx-
A.Klinefelter
B.Hypogonadism
C.Cryptorchidism

OB Triad
Turner Syndrome (Primary amenorrhea+Web
neck+Streak gonads)
Klinefelter Syndrome (Testicular
atrophy+Gynecomastia+Azoospermia)
Down Syndrome (Short stature+Mental
retardation+Endocardial cushion cardiac defects)
12. 15yr male, scrotal pain 24hour, tender, restless, red scrotal skin
A- USG
B- CT
C- Aspiration
D- Surgery

814
dx—Testicular torsion

13. Young male, scrotal pain, fever, thick cord. Which will help for Dx
A- UD
B- CT
C- FNAC
D- Urine PCR
dx- Epididymo-orchitis

14. Had kidney transplant from cadaver. No urine output up to 7 post op days, requiring dialysis. What is the cause
A- Acute rejection
B- Block catheter
C- Ureteric obstruction….….if no option for atn take this one
D- Donor venous thrombosis
E- Acute tubular necrosis

15. History of orchidopexy , infertility, sperm count 1 million, what next

A- Scrotal usd
B- Testerone
C- FSH, LH

16. Pt with history of hematuria, CT given ( not sure, there is lesion on

right side). Asking which will increase risk of DVT if he undergoes Sx
a- Spider nevi on chest
b- Nicotine stains on fingers
c- Bilateral varicose veins
d- BMI

**if obesity in option choose that one

815
17.Indian student, 2 months dysuria, hematuria, frequency. All urine test normal except RBCs and pus in urine. Urine
culture (-). Dx?
a)Cystoscopy
b)Renal biopsy diagnostic for renal tb
c)Urogram
d)Repeat urinalysis
e)Chlamydia PCR…next and best for chlamydia and next for renal tb

B✅

Diagnosis ➡ Renal Tuberculosis !!

Next investigation ➡ Cystoscopy !!

Definitive ix ➡ Renal Biopsy! ✅

17. Old patient with backache, hematuria, nitrite positive on urine

dipstick. Wbc high on RE.
Diagnosis.
A. Uti
B. Bph
C. prostate ca

18. A patient presented with macroscopic hematuria. 6 months back he

was diagnosed as c-ANCA positive vasculitis causing hematuria and
started on Prednisolone and Cyclophosphamide. The RBCs on
examination are 20% dysmorphic and 80% normal (or maybe opposite
not sure). What is the most appropriate next step?
a. Repeat renal biopsy
b. Stop cyclophosphamide
c. CT abdomen
d. Renal USG
e. Cystoscopy

19. 6yr old boy with urti and prot+rbc in urine. After 2 weeks urine exam shows non glomeraular rbc. Next investigation?
A. Asot,
B. urine culture,
C. usg…

20. Man 1 week after prostatectomy, his wife came to consultation bcz he is acting different, more irritated, aggressive,
showting…what in the history will help u reach dg?
A) Worsening symptoms at night (I marked this thinking about delirium),
B) marked interpersonal aggression
and other options I cant remember.
Disorientation
21. Child with URTI . urninary incontinenence history,with Blood+ no protein in urine test no cell,no leucocytes,no
nitrates.repeat after 1 week RBcs of non glomerular origin next step?
urine culture
renal biopsy
DMSA
Ultrasound
ASOT

816
22. 6yr old boy with urti and prot+rbc in urine. After 2 weeks urine exam shows no glomeraular rbc. Next investigation?
A Asot
B urine culture
C us…

23. 8 years old child with URTI , RBCs and protein in urine .No nitrate . Asking Most appropriate test?
A. Urine culture
B. ASOT
C. Ultrasound
D. Renal Biopsy

**depending on scenario…if non glomerular origin go for urine culture.

817
 if glomerular origin and occurs with first 2-3 days its iga nephropathy and do renal biopsy
and if occurs after 1 to 2 wk its psgn and to aso titre

24. 5 years old child with the history of URTI, urinalysis show protein +++ and blood + at that time. Now at followup, URTI
resolved, urinalysis show blood +, no cast, no nitrites. What is the next investigation to do?
• USG
• CT
• DMSA
• Urine culture

25. .Child presented with UTI, on ultrasound right kidney smaller in size than left. What next investigation
222. dtpa
223. dmsa
224. urine culture
225. ct

26. Child 4years, BP 90/50(if BP high), haematuria+++, protein++ Dx?glumerulonephritis

27. UTI in a child treated with Amoxill + Genta for 5days. But fever doesn’t subside. What is the cause of this refractory
fever?
Perinephric abscess

28. Pt treated for cystitis.had antibiotics for 24hrs, now devlopd fever, rigor,loin pain. what next?
a.u/s bladder (USG KUB)initial
b.ct abdomen (BEST)§§§§
c.cytology
Dx—perinephric abscess..inv---CT abdomen….jm-246

818
29. Old lady having rectocele but not cystocele, has been facing intontinence of urine while she laugh or speak loud and
that’s reason she use to sit by washroom whole day , urinalysis was not significant , what most appropriate to do in
this :
a. ct abd pelvis
b. urodynamic studies
c. usg pelvis
d. reassure
Dx---Stress incontinence

30. Left sided scrotal swelling, testis is normal and cord is palpable and separated as well, minor swelling is seen above
testis , right side is normal all, what is likely diagnosis in 32 years old male:
a. testicular ca
b. epididymial cyst….(dragging sensation). jm-1223
c. seminomas
d. teratoma

31. Patient with history of orchidopexy and

corrected with surgery want to conceive.
Semen analysis count one million with reduced
motility.
A.serum testosterone
B.FSH LH

32. Young male 25 yrs presented with pain in

scrotum from last 2 days. On exam testes is
swollen red and with tender thick spermatic
cord. Whats next
a) surgical exploration
b) ultrasound
819
 c) PCR urine

33. child with nephrotic syndrome treated with steroid developed hypertension , diffuse abd pain and vomiting for 1
week ,afebrile
a) acute pancreatitis
b) acute pyelonephritis
c) renal artery stenosis

**usually renal artery stenosis has no

symptom except htn

Ø Old age with symptoms of dysuria and

urgency,PSA is normal was done last week but
patient developed pain at thoracic region
a) PSA
b) bone density
c) total bone uptake

34. Old age x-ray given with fracture at T8? ESR

increased,calcium is normal
a) bone marrow examination
b) PSA-initially
c) bone density

35. Case of polycystic kidney disease on annual follow up presented with hematuria and GFR 20 asking what of the
following would help you to find if there is lower urinary tract obstruction
a. renal usg
b. CT abdomen
c. IVP
d. retrograde pyelogram
e. another test with contrast

36. Renal tb question with sterile pyuria and symptoms of hematuria and frequency. What should b done to confirm dx?
A Ct
B Biopsy

37. A man comes with abdominal distension and bilateral ankle edema. He has a history of hypertension which is treated
with Ramipril. On examination, his BP is 165/95mmHg. His urine examination shows protein (+++) and hematuria (+).
What is the diagnosis?

a. Acute interstitial nephritis

b. Nephrotic syndrome
C. Glomerulonephritis/Ig A nephropathy

**Patient with BP 165/90 along with proteinuria,hematuria,ankle edema and abdominal swelling.Diagnosis?
a)Nephrotic syndrome b)Interstitial nephritis c)CCF d)Cirrhosis of liver
Nephrotic disease----2 type….1.focal segmental glumerolusclerosis

820
38. Woman about 25 years comes with bilateral flank pain, fever, protinuria,hematuria etc, has had 2 episodes over past
twelve months, one of her three sisters has the same, what is your diagnosis
A. Nephritis
B. Glomerulonephritis
C. Hereditary glomerular nephritis (x linked ,male predominant and associated with deafness)
D. PKD

39. Pt on Hiv drug- Indinavir since 6 months now present with loin pain and hematuria. What to do next?
a. USG
b. IVP
c. Non contrast CT
d. Triple phase ct
Radio lucent-----indinavir------usg
Radio opaque---ca containing stone….inv---abd xray (next)

40. A PA chest xray of a man demonstrating widely spread reticulonodular shadows. The patient has a history of bilateral
loin pain and hematuria. His serum Calcium is elevated. What's the next investigation you would request?
A. ACE levels.
B. CT chest.
C. CT abdomen----confirmatory.
D. Renal biopsy.
E. Urinalysis.
Lung involvement ---open lung biopsy

41. A case of severe UTI. There was chills, high fever and pain . GFR is low<20
ml/min). what of the following would you prescribe to the patient
a. trimethoprim

821
 b. vancomycin
c. nitrofurantoin
d. amoxicillin
e. gentamycin

42. Lady with abdominal pain and fever, Dx as UTI, started amoxicillin and gentamicin. Improve but still pain + & low
grade fever. Culture came back coagulate –ve staph
A- Continue
B- Add vancomycin (coagulase negative is staph.epidermidis and saprophyticus)
C- Switch to fluclox
D- Increase dose of amoxicillin

** Vancomycin is generally the cornerstone for treatment of infections due to S. epidermidis and other CoNS, because
80-90% of strains responsible for nosocomial infections are resistant to semi-synthetic, penicillinase-stable penicillins,
such as oxacillin and nafcillin.

43. 30 yr old lady presenting with urinary incontinence and nocturia ..difficulty in micturition , no urine with cough .. no
fever , no burning micturition , on examination there is partial vaginal wall prolapse .. What’s the cause of her
urgency
a) UTI
b) Detrusor instability
c) Stress incontinence

44. When to confirm UTI in child?

a) E. Coli are more than 10*5 in urine (collection method and unit not mentioned)
b) Significant organism in supra pubic aspirate ans
c) Organism found over external meatus
JM 248 Kaplan 149

UTI cannot be diagnosed on symptoms alone.

There is no indication for culture of urine from a bag specimen.
In children that can void on request an MSU is an adequate sample. In younger children a clean
catch is often adequate. In septic infants an SPA or catheter urine may be required.
Urinary dipstick testing is only a screening test for UTI. It has poor sensitivity and specificity
especially in children less than 3 years of age.
Finding a UTI in a sick child does not exclude another site of serious infection (eg meningitis).
Remember that 2% of young children will have asymptomatic bacteruria and this may not be
the cause of this acute presentation. Organisms may spread from urinary tract to elsewhere
including meninges - this is rare but documented in babies less than 4 weeks of age. Do not
omit an LP in a young baby if you are considering meningitis just because you have found a
UTI.
Prior antibiotic therapy may lead to negative urine culture in patients with UTI. The laboratory will
test for antibacterial activity in the urine
MSU …A pure growth of > 10*8 CFU/litre indicates infection. A pure growth > 10*5 may indicate
early infection and requires a repeat specimen
822
 JM 248 AND KAPLAN 149

2)VESICOURETERAL REFLUX : child may present with recurrent UTI

Backflow of urine frm bladder to kidney
Predisposition to pyelonephritis> scariing >reflux nephropathy >(HTN ,proteinuria,renal insufficiency
to end stage disease>impaired kidney growth)
First 4 grades will resolve medically but grade 5 requires surgical treatment

3) OBSTRUCTIVE UROPATHY presents with upper abd.pain or flank pain,pyelonephritis,recurrent

UTI,failure to thrive..
Diagnosis :< VCUG.
A VCUG, or a voiding cystourethrogram, is a minimally invasive test that uses a special x-ray
technology called fluoroscopy to visualize your child's urinary tract
TREATMENT ;decompress bladder with catheter
Intravenous antibiotic……transuretheral ablation or vesicostomy
POTTER sequence;present with pulmonary hypoplasia
45. Child from daycare with post streptococcal Glomerulonephritis.When can she return to school?
a.Immediately after discharge ANS (better to restrict activity)
b.After throat swab is done for all students
c.After prophylaxis for all students
d.After microscopic hematuria resolves

POST-STREPTOCOCCAL GLOMERULONEPHRITIS
Diagnostic triad :discoloured urine +periorbital edema+oliguria
Edema HTN and hematuria acc to Kaplan
1 to 2 week after streptococcal pharyngitis and 3 to 6 wk after skin infection
Diagnosis:rbc cast in urine 1 to 2+ proteinuria
Complement level is LOW
Best test is anti Dnase antigen
GABHS antigen and ASOT

TREATMENT : HOSP ADMISSION

Bed rest
Fluid
Daily weighing
Penicillin if GABHS positive
Salt and water restrictin and carbohydrate rich diet( for follow up do bp and rft hematuria may last
for years ) JM881 Kaplan 152
46. child , macroscopic haematuria no previous urti no edema , his urine protein + rbcs +++ , he had the same problem 4
months ago and resolved completely ,, dx ?
igA nephropathy –
glomerulonephritis –
haemolytic uremic syndrome

823
IGA NEPHROPATHY: URTI AND GIT INFECTION OCCURS AFTER 1 TO 2 DAYS OF INFECTION …COMPLEMENT
LEVEL IS NORMAL
GROSS HEMATURIA IF PROTEINURIA <500MG è NO TREATMENT
IF .500MG è GIVE ACEI AND ARB IF. 1 GM è GIVE GLUCOCORTICOID KAPLAN 153 AND JM 869

47. 7 YR OLD BOY FAILED HEARING TEST family history of renal problems and few maternal uncles are deaf.microscopic
hematuria present
ALPORT SYNDROME

X linked, sensorineural hearing loss and ocular abnormalities present most commonly dot and fleck
retinopathy and ant lenticonous

48. 8 yr old boy from camping trip c/0 diarrhea and vomiting.after 24 hr presented with rigors and chills fever, traces of
blood in stool. sbp 50mmhg. plt 20,,hb 9. Diag??
A)HUS ans kaplan 154
B)DIC
c)ITP

Bloody diarrhea
5 to 10 days after infection oliguria,pallor ,irritability,oliguria may cause ARF
Hb 5 to 9 platelet 20,ooo to 100,000/mm3
No antibiotic if E coli present( worsen HUS)
Fluid electrolyte
Treat HTN
Ffp and plasmapheresis if no diarrhea and no cns problems

49. 6 month old boy after bath, his mom felt a hard mass in left hypochondria, non tender
Wilm's tumor (>2-3YRS)
Neuroblastoma (<2-3YRS)
Polycystic kidney disease (Always Bilateral)
Hepatoblastoma (<5YRS)

824
Kaplan pg 154, JM253 and 254

50. Middle aged man had nephrotic Syndrome. Getting steroid. Now he has Generalised abdominal pain & vomitting. Gfr
reduced.
1. Perforated PUD
2. Renal vein thrombosis ans

Nephrotic syndrome complications: a) Infection b) SBP c) Thromboembolism

51. 32 years old man hypertensive with nephrotic syndrome having abdominal pains A-renal vein thrombosis B-acute
glomerulonephritis

52. Child with Nephrotic syndrome treated with Steroids developed hypertension, diffuse abdominal pain and vomiting
for 1 week. Afebrile. Cause? Acute pancreatitis Acute pyelonephritis Renal artery stenosis

53. Another case of a child with hematuria. He had rashes about a week ago. Diagnosis asked
a. Post-streptococcal glomerulonephritis
825
 b. IgA nephropathy
c. Minimal change Nephrotic syndrome
d. Hemolytic uremic syndrome
proteinuria 40mg/m2/hr +3,+4 or .3 g/day
albumin<2.5 g/L
edema
hyperlimidemia
Rx: bed rest
high protein and low salt diet, fluid restriction
prednisolone for 4 to 6 weeks then taper over 2 to 3 months
consider biopsy if no improvement within 8 weeks of treatment.
Kaplan pg 156

54. Which is most commonly associated with undescended testes?

Varicocele
Testicular ca ans-risk/fate/complication
Hydrocele
Torsion of testis
Inguinal hernia

Kaplan 157…. untreated or delay in treatment increase risk for malignancy (seminoma)

55. 25 yr male , hx of orchidopexy for testicular torsion a few time back , came requesting for testicular tumor screening
bcoz now this got left testicle slightly low and larger than right ,physical examination normal, next inv ?
a. Tumor markers
b. usg tumor
c. reassure
d. ct/mri e. biopsy

It is entirely normal for one testicle to be bigger than

the other. Many people find that the right testicle is
slightly larger and the left hangs lower.

https://www.medicalnewstoday.com/articles/321234.php

826
 best initial test for testicular torsion
technetiumm99
colour doppler---to see vascularity

56. 4 yrs old boy with nocturia he has hasn’t developed single dry night what to do
A) desmopressin
B) wait for spontaneous resolution (ans) JM1008 upto 5 yr normal
C)decrease water intake at night

57. A boy 8yrs with h/o nocturnal enuresis wants to go camping.Management ?

Conditioning apparatus
TCAs
Desmopressin nasal spray (ans) JM1008

58. A 4 year old child brought by his parents . Complaining of bed wetting at night. He is dry during day . he is well .
parents say he usually has it most of the nights. Management.
a-trial of bed wetting alarm
b-reassure it is normal (ans) Treatment is usually not recommended for children younger than 6 or 7 years.
c-desmopressin
https://emedicine.medscape.com/article/1014762-overview#a1

59. 4 Nocturnal enuresis 4yr child initial investigation?

A)urine culture
b)u/s.
C)urine dipstick.
D)urine analysis (ans) initial screening test

60. 4yo with enuresis nocturnal 4=5 times a week. Daytime

dry, next what
a. urine dipstick (ans)
b. renal ultrasound
c. urine culture
d. urea, creat and electrolytes

61. nocturnal enuresis 4 yr old asked initial test

1. urine analysis (ans) (initial test)
2. urine culture (best)
3. usg

The word enuresis is derived from a Greek word (enourein)

that means “to void urine.” It can occur either during the
day or at night (though some restrict the term to
bedwetting that occurs at night).
Nocturnal enuresis:Causes of bedwetting
Not all of the causes of bedwetting are known.
Some of the possible factors are:
Genetic tendency. Bedwetting does tend to run in families.
If one or both parents wet the bed when they were children,
then it is quite likely to occur in their children.
Smallish bladder capacity.
Deep sleeper.

827
Laboratory studies that may be helpful include the following:
Urinalysis (the most important screening test in a child with enuresis)
Ensure the urinalysis is performed on a concentrated urine specimen. Dilute specimens with a specific
gravity under 1.010 might not reveal infection.
If the urinalysis findings suggest cystitis, urine culture and sensitivity testing
Blood tests usually are not needed
Kidneys continue to produce a lot of urine at night (most people make less urine when they are asleep).

62. girl history of nocturnal enuresis presents with urti, comes back after that, all normal except hypertension and
non-glomerular erythrocytes and no cast on urinalysis. What investigation to confirm diagnosis?
a)renal US, (ans)
b)ct
https://emedicine.medscape.com/article/981898-workup#c3

Glomerular hematuria:
Example of dysmorphic red blood cells consistent with renal or glomerular hematuria. The presence of red
cell casts in the urinary sediment is strong evidence for glomerular hematuria.

Non-glomerular hematuria
Nonglomerular etiologies can be further subdivided by whether the process is located in the upper urinary
tract (kidney and ureter) or lower urinary tract (bladder and urethra) (Figure 2). In general, urologists are
concerned with structural and pathologic conditions that are visible on imaging and/or endoscopic
examination

2.urinary incontinence : & uterovaginal prolapse

www.aafp.org/afp/2000/1201/p2433.html

Overactive bladder=Detruser instability=unstable bladder=common cause of urge incontinence.

63. …65yr. old female developed bed wetting, mild uterus prolapse noted, cause asked
A. stress incontinence
b. detrusor instability (ans)
c. uterus prolapse
d. others
https://www.racgp.org.au/afp/2012/november/overactive-bladder-syndrome/

828
1. Over active bladder syndrome
Presentation
It usually presents with a sudden urge to urinate that is very difficult to delay and may be
associated with leakage. Other features include:

Frequency of micturition.
Nocturia.
Abdominal discomfort.
Urge incontinence (more common in women).[1]
There are no specific physical signs and the diagnosis is usually made from the symptoms and
confirmed with urodynamic studies.
Detruser instability (urge incontinence/overactive bladder syndrome )

64. Lady age 70 may b who wets her bed daily take 4 cans of beer daily at night n with mild vaginal prolapse, Cause?
Beer she takes (ans)
Urge incontnence
Stress incontenence
Uterovaginal mild prolapse

65. Q.very Old lady with stress incontinence..no recto or uterocele…no UTI….what is next?
a-urodynamic study (ans)
If the stem would have said incontinence then evaluation would be next. Dx is given here already, stress
incontinence.....due to weak sphincteric fxn,,, but urodynamic studies haven't been done yet which is necessary to
assess the level of sphincter incompetence.... A first
b-ascending urethrogram
c-surgery
d-pelvic floor exercise

66. A woman with incontinence on laughing, sneezing, what investigation will u do to get the diagnosis?
a. bladder scan for overflow
b. urodynamic studies () JM 872 (ans)
Do we do Urodynamic study for stress incontinence????

Stress incontinence
Stress incontinence is the leaking of small amounts of urine during activities that increase pressure inside
the abdomen and push down on the bladder. This occurs mainly in women and sometimes in men (most
often as a result of prostate surgery).Stress incontinence is most common with activities such as coughing,
sneezing, laughing, walking, lifting, or playing sport. Other factors contributing to stress incontinence
include diabetes, chronic cough (linked with asthma, smoking or bronchitis), constipation and obesity.
Stress incontinence in women
Stress incontinence in women is often caused by pregnancy, childbirth and menopause. Pregnancy and
childbirth can stretch and weaken the pelvic floor muscles that support the urethra causing stress
incontinence during activities that push down on the bladder.
1) During menopause, oestrogen (a female hormone) is produced in lower quantities. Oestrogen helps to
maintain the thickness of the urethra lining to keep the urethra sealed after passing urine (much like a
washer seals water from leaking in a tap). As a result of this loss of oestrogen, some women experience
stress incontinence during menopause.

67. A 70 year old lady with stress incontinence. Urodynamic studies done after Pelvic floor exercises what’s the best
management for her?
a) Tension-free Vaginal Tape(ans)

829
b) Weighted cones in vagina
c) Burch's colposuspension/ bladder neck suspension(f urodynamic study shows genuine stress incontinence d/t urethral
sphincter weakness)----to treat stress incontinence
d) Local oestrogen cream
A new minimally invasive suburethral sling (“tension-free vaginal tape”) has been shown to cause less
postoperative morbidity than traditional surgeries while achieving long-term (five-year) cure rates
greater than 86 percent.18 The sling is placed during surgery under local anesthesia on an outpatient
basis. While the tension-free vaginal tape sling is a nonabsorbable polypropylene mesh, and concern
may exist regarding erosion and/or infection of this material; to date, no such cases have been
reported.

68. 68 years old lady with urinary incontinence on coughing and staining, she is obese with diet controlled DM. Her
urodynamic studies positive in low volume study. She has mild rectocele but no cystocele. She has been advised to do
pelvic floor exercise which she found to have some improvement but she feel socially embarrassed for urinary
incontinence. what would be your best next management? 1. weighted vaginal cones 2. weight reduction 3.
Colposuspension.

69. An 85 year old lady with stress incontinence, whenever she laughs or sneezes presents with rectocele which is
reducible.What is most important management in this patient after bladder exercise has failed. 1.Weighted Vaginal
cones 2.Imipramine 3.Surgery for rectocele 4.Bladder neck-suspension surgery 5.Vaginal tape

70. old lady with stress incontinence=== treatment offered was pelvic floor exercise.she came back again ,not satisfied as
still experiencing stress incontinence, asking most appropriate next.
a) vaginal cone
b)estrogen cream
c) surgery march 2017
A set of specially designed vaginal weights can be used as mechanical biofeedback to augment pelvic muscle exercises12

(Figure 4). The weights are held inside the vagina by contracting the pelvic muscles for 15 minutes at a time. As the
muscles strengthen, heavier weights are used.

71. 68 year old lady with urinary incontinence on coughing and staining, she is obese with diet controlled DM. Her
urodynamic studies positive in low volume study. She has mild rectocele but no cystocele. She has been advised to do
pelvic floor exercise which she found to have some improvement but she feel socially embarrassed for urinary
incontinence. what would be your best ---colposuspension.

https://www.google.com.au/url?sa=t&source=web&rct=j&url=http://onlinelibrary.wiley.com/doi/10.1111/j.1464-
410X.2004.04809.x/pdf&ved=0ahUKEwj46L76if7WAhUGH5QKHY61Bg4QFghFMAQ&usg=AOvVaw2nzsEab8j01gQ5iFJhwL9

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w

72. Old lady with urinary incontinence...she has nocturia...difficulty in micturition...no urine come with cough..no fever,
no burning micturition….on examination there is partial vaginal wall prolapse...
What's the cause of her urgency
UTI
Detrusor instability (ans)
Stress incontinence

73. Stress incontinence case in an old lady with prolapse

Pelvic floor exercise (ans)
Imipramine

74. A man complaining of dripping of urine

a. urethral stricture
b. stress incontinence (ans) ans-bph
c. cancer bladder

75. an 85 yrs old lady with stress incontinence when ever she laughs or sneezes with rectocele reducible but no
enterocoele wats most appropriate management bladder exercise failed?
vaginal cones
immipramine
surgery for rectocole
Bladder suspension —-Bladder suspension means bladder neck sling suspension as in amedex pic

76. . A 70 year old lady attends with stress incontinence. The best management for her is:
A Pelvic floor exercise-initially
B Tension-free Vaginal Tape (TVT)
C Heavy cones in vagina
D Burch's colposuspension
E local estrogen cream

77. Old lady with hx of prolapse now has urgency but no stress incontinence investigation
Urodynamic study———You never go for dynamics if problem is in front of you
Umc (ans)…urinary microscopy & culture
Recurrent UTIs may be related to a variety of sources including kidney stones, fecal incontinence, urinary incontinence,
urinary retention, cystocele, rectocele, enterocele or uterine prolapse.
Anti cholinergic
B

831
 http://www.racgp.org.au/afp/2012/november/overactive-bladder-syndrome/

Table 2. Investigations for overactive bladder syndrome

Initial investigations42
Urinalysis to exclude infection, haematuria and glycosuria
Urinary tract ultrasound and measurement of postresidual volume
Frequency/volume chart for at least 3 days
Bladder diary for a minimum of 3 days

Secondary investigations19
Urine cytology
Urodynamic testing
Cystoscopy
Imaging of upper urinary tract or spine

78. 75 yrs old lady with severe urge incontinence. She manages to accidentally urinate 10times during the day and can't
make it to the bathroom. She is annoyed by this. Urodynamic studies confirm detrusor instability. What is the best Rx
a) pelvic floor muscle exercise
b) Anticholinergic (ans) page 872 jm…(best)
c) Retropubic suspension
d) ant. Colporrhaphy

Medication Summary
The goal of therapy is to improve the symptoms of frequency, nocturia, urgency, and urge incontinence.
Treatment options include anticholinergics, antispasmodic agents, and tricyclic antidepressants (TCAs).
In patients with stress incontinence, alpha agonist treatment results in contraction of the internal urethral
sphincter and increases the urethral resistance to urinary flow. Sympathomimetic drugs, estrogen, and
tricyclic agents increase bladder outlet resistance to improve symptoms of stress urinary incontinence.
Pharmacologic therapy for stress incontinence and an overactive bladder may be most effective when
combined with a pelvic exercise regimen. The 3 main categories of drugs used to treat urge incontinence
include anticholinergic drugs, antispasmodics, and TCAs.
When a single drug treatment does not work, a combination therapy such as oxybutynin (Ditropan) and
imipramine (Tofranil) may be used. Although their mechanism of action differs, oxybutynin and imipramine
work together to improve urge incontinence.
The goals of pharmacotherapy are to improve overactive bladder (OAB) symptoms, reduce morbidity, and
prevent complications. Anticholinergics are the first-line agents used to treat OAB. Other treatments
approved for use in OAB include the beta3-receptor agonist mirabegron (Myrbetriq) and detrusor
injections of on a botulinum toxin A. Individuals with genital atrophy may benefit from topical estrogen
therapy. In select cases of refractory OAB, tricyclic antidepressants may be helpful.

79. .63 yr old lady presenting with urinary incontinence and nocturia ..difficulty in micturition , no urine with cough .. no
fever , no burning micturition , on examination there is partial vaginal wall prolapse .. What’s the cause of her urgency
a) UTI
b) Detrusor instability(ans)
c) Stress incontinence

Ø A middle aged Australian woman,multipara, c/o inability to control her bladder past 3 months. She is afebrile.
Coughing , sneezing and laughing causes dribbling of urine.How do you define the exact cause of her
incontinence?
Urine Analysis
Urine C&S
Urodynamic Studies(ans) page 872 urodynamic studies to confirm genuine stress incontinence

832
Voiding Cystourethrogram

80. 72 years old man urgency. Urine culture is negative. Ttt

Anticholinergic drug
Prazosin——-Depends on full stem if it's BPH then it will be Prazosin.
Bladder training (urge incontinence)
Pelvic floor training
Urge incontinence

Urge incontinence is a sudden and strong need to urinate. You may also hear it referred to as an unstable
or overactive bladder, or detrusor instability.

In a properly functioning bladder, the bladder muscle (detrusor) remains relaxed as the bladder gradually
fills up. As the bladder gradually stretches, we get a feeling of wanting to pass urine when the bladder is
about half full. Most people can hold on after this initial feeling until a convenient time to go to the toilet
arises. However, if you are experiencing an overactive bladder and urge incontinence, the bladder may feel
fuller than it actually is. This means that the bladder contracts too early when it is not very full, and not
when you want it to. This can make you suddenly need the toilet and perhaps leak some urine before you
get there.
Often, if you experience urge incontinence you will also have the need to frequently pass urine and may
wake several times a night to do so (nocturia).
Bladder ca : page 868 jm
Bladder cancer risk factors
Smoking
Smoking is the single biggest risk factor for bladder cancer.

81. which one of the Followings malignancies have been approved except
A.Promiscuity (exact word) and Ca Cervix….
B.Betel chewing and oral cancer
C.Schistosomiasis and bladder cancer
D.Nickel and hepatocellular carcinoma (ans) nickel causes lung ca

Ø old guy with nitratus +ve and heamaturia and back pain on urine test with leucocytosis and RBC, diagnosis
a. uti
b. bladder cancer

**nitrite positive means gm –ve organism..in cancer there shouldn’t be leucocyte

82. Women has painless hematuria she was using phenolphthalein a few weeks ago..what next?

833
Urine routine cs…
CT abdomen
Cystoscopy

Initial---urine microscopic
If next Cystoscopy …

Substances and Medications Affecting Urine Color

Artificial food colouring
Beets
Berries
Chloroquine (Aralen)
Furazolidone (Furoxone)
Hydroxychloroquine (Plaquenil)
Nitrofurantoin (Furadantin)
Phenazopyridine (Pyridium)
Phenolphthalein
Rifampin (Rifadin)

83. postmenopausal female came to you with complaint of difficulty during sex, she also has rectocoel on examination?
A) vaginal pessary
B) vaginal repair
C ) vaginal estrogen(ans) Hormone replacement therapy for postmenopausal women

Rectocele: Bulging of the front wall of the rectum into the vagina. Rectocele is due to weakening of the pelvic
support structures and thinning of the rectovaginal septum (the tissues separating the rectum from the vagina).
Also called a proctocele.
Causes of rectocele

Some of the events that may weaken or thin the rectovaginal septum and cause a rectocele include:
Vaginal (normal) childbirth
Giving birth to multiple babies
A long and difficult labour

Assisted delivery during childbirth, including the use of forceps

Tearing during childbirth, particularly if the tear extended from the vagina to the anus
Episiotomy (a surgical cut made to enlarge the vaginal opening during childbirth to avoid injury to mother and
baby), particularly if the cut extends to the anus
Hysterectomy
Pelvic surgery
Chronic constipation
Straining to pass bowel motions
Advancing age, as older women are more prone to rectocele.

Treatment for rectocele

Generally speaking, a rectocele with no obvious symptoms doesn’t need medical treatment, but it is wise to pay
attention to diet and other lifestyle factors that contribute to constipation. Treatment options may include:
High-fibre diet
Fibre supplements
At least six to eight glasses of water per day
Stool softeners (don’t use laxatives)
Instruction on how to help yourself to pass a bowel motion; for example, you may be advised to gently press a
finger against the rear wall of the vagina while toileting
Don’t strain on the toilet
834
 Hormone replacement therapy for postmenopausal women
Pelvic floor (‘Kegel’) exercises
Insertion of a pessary – a ring-like device worn high in the vagina that helps to support the pelvic organs.
Surgery for rectocele
Surgery may be needed if the rectocele doesn’t respond to other treatments and is causing symptoms.

84. sterile pyuria with weight loss and hematuria . what is Dx ?

a. RCC
b. Bladder cancer
c. Renal T.B (ans)
www.nejm.org/doi/full/10.1056/NEJMra1410052?rss=mostViewed#

causes of sterile pyuria

Genitourinary TuberculosisThis condition can infect the kidneys, ureters, bladder, prostate, and genitalia.25 Genitourinary
tuberculosis can cause renal calyceal destruction, calyceal obstruction, or hydronephrosis, or all of these conditions.

85. A patient presents with symptoms of dysuria and hematuria.She has a history of weight loss fro
m a few months with malaise.On U/E Rbcs and pus cells present.Your diagnosis?
a)Renal cell carcinoma
b)Renal tuberculosis (ans)
c)Bladder carcinoma

Early granulomatous kidney disease may present as proteinuria, pyuria, and loss of kidney function. Isolated hematuria is
another possible manifestation of renal TB. Lower urinary symptoms occur whenever the disease spreads down to the
ureters and bladder. Urinary symptoms suggestive of urinary tract infection, accompanied by pyuria and hematuria with
no bacterial growth, suggest urogenital TB, Ultrasonography, computerized tomography, and magnetic nuclear
resonance will demonstrate grossly distorted ureters

86. old guy with nitritus +ve and heamturia and back pain on urine test with leucocytosis and RBC, diagnosis
a. uti (ans)
b. bladder cancer

painless macroscopic hematuria >>> cancer , how to approach this one???

835
Bladder ca—inv—urine cytology(initially)…..thn cystoscopy….(next best)
CT IVU---gold standard

87. Another case of a child with hematuria. He had rashes about a week ago. Diagnosis asked
a. Post-streptococcal glomerulonephritis (ans)
b. IgA nephropathy
c. Minimal change Nephrotic syndrome
d. Hemolytic uremic syndrome

88. nephro 5¤ A child deep red-coloured urine, slight Oedema, on Urine RE RBC ++, Protein +
Dx?
a. IgA nephropathy…in young adult
b. Reflux nephropathy
c. Interstitial nephritis….in elder people taking multiple drug
d. APSGN….by exclusion
e. Nephrotic syndrome

89. Middle aged man who is hypertensive and just treated for his helicobacter pylori with triple therapy. Now comes with
urine protein and haematuria with 3-4renal cysts seen on USG. Diagnosis?

836
a. PKD ans
b. IgA Nephropathy
c. Nephrotic syndrome
d. Acute Interstitial NephritiS ….think about it as well
after ppi,only few cyst,htn +ve and after ppi

**More than 100 different medications may trigger AIN. Many

of these medications fall into the following categories:
antibiotics nonsteroidal anti-inflammatory drugs (NSAIDs),
which are often used as pain relievers proton pump inhibitors,
which are medications used to treat excess stomach acid

**Symptoms of interstitial nephritis The most common

symptom of interstitial nephritis is a decrease in the amount a person urinates. In some cases, urine output may increase.
At times, people can have no symptoms. Other symptoms of interstitial nephritis include: a fever blood in the urine
exhaustion confusion fatigue nausea vomiting a rash water retention swelling weight gain from water retention feeling
bloated elevated blood pressure

90. Girl presented with proteinuria and traces of blood in urine after falling from a tree , asymptomatic
Reaction to trauma (ans)
Nephrotic
IgA nephropathy
Thin membrane GN

91. Male, 30 yrs painless heamaturia after URTI ?

Post streptococcal,
glomerulonephritis,
IgA nephropathy,
Nephritis

92. NEPHRO 5 years old child who was a case of nephrotic syndrome and initially responding with steroid now he has
stopped responding to steroids and developed microscopic heamaturia and hypertension , what is the diagnosis:
1- FGN (ans)
2- superimposed PSGN
3- IgA
4- membranous GN

The most common clinical presenting feature of FSGS (>70% of patients) is nephrotic syndrome,
characterized by generalized edema, massive proteinuria, hypoalbuminemia, and hyperlipidemia.
However, the natural history of FSGS is variable and can range from edema that is difficult to manage, to
proteinuria that is refractory to corticosteroids [2] and other immunosuppressive agents, to worsening
hypertension and a progressive loss of renal function.
https://emedicine.medscape.com/article/245915-overview#a1

93. You are evaluating a 7 year old child with irritability and low urine output. His blood pressure is 150/90, and the
urinalysis shows proteins ++, RBC ++
What would be the next step in management?Dx---PSGN

837
1Antihypertensive treatment (ans)
2.Methylprednisolone IV
3.Low protein, low salt and increased water intake
4.Low protein, high carbohydrate and low salt diet (and fluid restriction for
psgn)
5.High protein, low salt, low carbohydrate and decreased water intake

** low salt ,low fluid and high protein diet for nephrotic syndrome

94. nephrotic syndrome case asking about initial treatment

a.restrict fluid at home
b.restrict fluid at hospital….for psgn
c. steroid (ans)

95. Man with alcohol hx and smoking. Had peripheral oedema and swelling
over abdomen. Protein +++ blood +
A. Nephrotic syndrome (ans) (membranous nephropathy)
B. Alcoholic cirrohosis
C. Ccf

96. Woman about 25 years comes with bilateral flank pain, fever, proteinuria,
hematuria etc, has had 2 episodes over past twelve months, one of her
three sisters has the same, what is your diagnosis
A. Nephritis
B. Glomerulonephritis
C. Hereditary glomerular nephritis
D.PKD (ans) page 169 kaplan paeds & 269 kaplan medicine

838
https://www.healthline.com/health/polycystic-kidney-disease#overview1

97. Middle aged man had nephrotic Syndrome. Getting steroid. Now he has Generalised abdominal pain &vomitting. Gfr
reduced.
1. Perforated PUD
2. Renal vein thrombosis (ans)

98. .A lady develops severe occipital headache plus she also has a hx of pkd and migraine, her ct comes normal and
physical and neurological exam what should be the next step in ix to lead to dx?
a. Mri
b. Ct angiogram (ans) can be aortic aneurysm APKD page 269 kaplan medicine
c. Lp

What are the complications of polycystic kidney disease?

In addition to the symptoms generally experienced with PKD, as cysts on the kidneys grow larger there may be
complications.
Some of these complications can include:
weakened areas in the walls of arteries, known as aortic or brain aneurysms

99. pt with chronic renal failure on dialysis bp is high before dialysis and normalise during dialysis and is high again after
dialysis procedure over,what is the mx-?
1-recheck dry weight
b-give diuretic

839
3-start antihypertensive

100. on dialysis other recalls:)

A man with renal failure who needs to have haemodialysis. He has no problem during dialysis, but his
BP INCREASES at the end of dialysis.What could be the reason?
A- allergic reaction to the dialysate fluid
B- over dialysis
c- ACE inhibitors overdose
D- Hypokalaemia

101. A man with renal failure and need to have haemodialysis. He has no problem during dialysis, pre dialysis bp is
150/90…but after
840
that his BP DECREASES to 80/60 at the end o f dialysis, …hes anemia of 8gm/dl… What could be the reason?
a. allergic reaction to the dialysate fluid (wheezing and dyspnoea expected)
b. over dialysis
c.anemia(First-use syndrome of Hemodialysis)

841
842
102. Patient on dialysis, BP increase after dialysis what to do?
- Antihypertensive
- Furosemide
- Check body weight

103. patient non compliant on dialysis came after 5 days last dialysis with dypnea and weakness what is you next
action:
a-call dialysis unit
b-ABG
c- ecg
d- xray chest

104. Patient on dialysis, no dialysis for 5 days, now presented with dyspnea and weaknesses what is
management?
a. Furosemide
b. ABG
c. -ecg

105. Adult with loin pain radiated to groin hx of renal stone. What to do to prevent recurrence after this episode—I
chose hydrochlorothiazide**

106. A 35-year-old lady presented with sudden severe right sided flank pain associated with hematuria. CT scan
confirmed 7 mm kidney stone with one small ureteric stone which later on passed out.Pain was well managed by
opioids. You are planning to send this patient home and patient seeks advice on how she can prevent recurrence of
kidney stones. All of the following help to reduce the recurrence of urolithiasis except?
a. Increase fluid intake to make up to 2 litres of urine per day
b. Thiazide diuretics
c. Oral citrate
d. Allopurinol
e. Spironolactone

107. patient with ckd creatinine 0,2 (normal less then o.1)admitted (reason I forgot)…creatinine raised to 0.35 after 2
days,,,cause no other history that was stem
1: renal artery stenosis 2: urine retention
3 urine infection 4: dehydration

843
 **it depends on the reason pt was admitted for

108. women feeling anxiety palpitation, sweating when she enter into shopping mall, she doesn’t touches door and other
things of mall, she believes she will infected by HIV VIRUS,if she touches, HER gp tell her hiv DOESN’T spread in dis way, DX?
a.ocd
b.generalised anxiety disorder c.panic disorder with agarophobia

**Mysophobia, also known as verminophobia, germophobia, germaphobia, bacillophobia

and bacteriophobia, is a pathological fear of contamination and germs. The term was
coined by William A. Hammond in 1879 when describing a case of obsessive–compulsive
disorder (OCD) exhibited in repeatedly washing one's hands.

109. a 12 year boy brought by his mother complaining that everyone in school called him fat , his weight is at 90th
percentile and height 50th percentile. She said its happening when he was six years old. What is ur next investigation
of choice
a. chromosomal analysis
b. early morning serum cortisol
c. plasma growth hormone
d. thyroid stimulating hormone

844
** question bank says always rule out first TSH. If TSH comes normal then rule out out Cushing syndrome doing early
morning cortisol& overnight dexamethasone test

110. . 7 yrs old boy developed facial swelling and limb oedema after urti. Urine examination showed protein ++++,
rbc+. What next to do
a. urine cs
b. renal biopsy
c. renal usg
d. serum biochemistry
dx:nephrotic syndrome: hypoalbumenia and hypercholesteromia

111. young man with 25% of pneumothorax following knife stab . vitals stable , no resp. distress but reduced entry of
air in the same side . mx ?
A- admit and observe
b- do cxr
c- thoracotomy
d- removal of knife under GA followed by underwater drain
e. removal of knife only

112. the pt in emergency room with a knife in lt chest, what will u do?(condition stable except HR:100)
a) remove the knife and deep suture
b) remove the knife after chest xray
c) send to OR and remove the knife and then insert chest tube
d) insert chest tube in ER and then remove the knife

113. Knife in back of chest BP 85/50 HR 110 SPO2 98% after starting iv and 02 by mask what next
1.urgent CT
2. Intubae
3. cross match
4. remove knife.

114. 2-man with stab injury , with knife in the chest ,posteriorly in the 4-5 ics, in midclavicular line.after stabilizing
vitals in ed, what is the next most appropriate step-
a.remove knife
b.intubate
c.drain
d.fas tusg.

845
e.ct

115. patient was brought to emergency

room after a fight causing a stab with a
knife in the chest. patient BP is normal
but his O2sat is mildly decreased he is
calm , he only has mild dyspnea , on
examination he has dullness to
percussion , decreased air entry on left
side with trachea deviated to the side of
the injury ( not the opposite ), what
should you do ?
a- Give O2
b- Chest tube
c- Thoracocentesis
d- IV fluids
e- Just cover the wound and send him home

Kidney tumours

116. Young boy with intermittent pain in flank and radiating to thigh for two years, now pain is continuous with
vomiting, a mass felt below left hypochondrium, dx
a. Wilms tumour
b. Nephroblastoma
c. Ureteropelvic junction obstruction*

117. 6 month old boy after bath, his mom felt a hard mass in left hypochondria, non tender
a. Wilm's tumor
b. Neuroblastoma*
c. Polycystic kidney disease

118. wilms tumor.......definitive investigation....ultrasound or CT scan *?

119. 5y child with recurrent abdominal pain , vomiting 2y ago last attack you feel mass in RT hypochondria . what is the
diagnosis?
a. neuroblastoma
b. wilm’s tumour
c. pelvi ureteric obstruction*

** Symptoms of UPJ obstructions include:

• The renal pelvis and/or kidneys are dilated (hydronephrosis)

• Urinary tract infection.
• Abdominal mass.
• Vomiting.
• Poor growth in infants (failure to thrive)
• Back pain.
• Flank pain.
120. 4 yr old boy with recurrent abdominal pain and vomiting since 2 yrs.on examination there is a mass in right
hypochondrium.Most likely diagnosis?
a.pelviureteric obstruction*
b.wilms tumour
c.neuroblastoma
846
121. 2 year old child, had episodes of vomiting associated with abdominal pain, mother also noticed a mass in Rt
hypochondrium
Diagnosis asked
Wilm’s tumour
Neuroblastoma
Pelviureteric junction obstruction*

122. A 5 year old boy with a 3 year history of vomiting and abdominal pain.Now he presents with abdominal pain and a
right upper quadrant mass.What's the most likely diagnosis?
a. Wilms tumour
b. Neuroblastoma
c. Hepatoblastoma
d. PUJ obstruction*
e. Uti

123. An obese patient with history of dull flank pain, fever and haematuria, CT given of Renal cell carcinoma. Asking
what will increase his risk of DVT if he undergoes an operation?
a. Nicotine stain of fingers
b. Atrial fibrillation
c. Bilateral varicose veins
d. BMI
e. Spider naevi on chest

If not obese than C

124. An old patient who recently had MI and stent placement and using aspirin and clopidogrel comes with
haematuria on CT scan 1 cm mass in kidney is found which is strongly being suspected to be renal cell carcinoma.
What you will do?
Nephrectomy
Hemi nephrectomy
repeat CT scan after 12 months..*
Biopsy

125. Man with hematuria throughout urine and bilateral kidney palpable , blood investigation urea and creat high :
a. PKD*
b. Bladder cancer
c. Renal cell carcinoma

126. . A patient presents with symptoms of dysuria and hematuria.She has a history of weight loss from a few months
with malaise.On U/E Rbcs and pus cells present.Your diagnosis?
a)Renal cell carcinoma
b)Renal tuberculosis*
c)Bladder carcinoma

127. patient complaints of dysurea and blood in urine, but no fever, urine analysis shows ++blood, ++ pus cells,
bacterial growth is -ve, what’s the aetiology:
a. TB nephritis??
b. perinephric abscess
c. renal cell carcinoma
847
 d. cancer bladder

128. Patient presents with cough productive of blood stained sputum. He has been having ankle pains and painful
wrist. Urine microscopy showed RBC casts. What is the diagnosis?
a. Systemic lupus erythromatosis
b. Bronchial cancer
c. Wegner’s granulomatiosis*
d. Renal cell carcinoma

848
symptoms of good Pasteur

129. .fundoscopy of hypertensive retinopathy with increased hypertension

and urinary symptoms like dysuria ( maybe) and 5 kg weight loss.
a.renal failure
renal artery thrombosis (rcc causing renal vein thrombosis and wt loss…leading to
htn and hypertensive retinopathy)
c.hypertension
d.irrelevant*

130. A 4-year-old boy is brought by his mother because she is concerned

about the abdominal distension of her child. She informs you that child has also
been suffering from low grade fever, lost his appetite and complains of pain in his
limbs very often. On examination child is pale and there firm, non-tender irregular
abdominal mass that crosses the midline. Which of the following is the most likely
cause of the child's presentation?
a. Polycystic kidney disease
b. Hepatoblastoma…jaundice
c. Neuroblastoma*
d. Acute lymphocytic leukemia
e. Nephroblastoma…haematuria

131. 6 month old boy after bath, his mom felt a hard mass in left
hypochondria, non tender
A.nephroblastoma
B.Neuroblastome

132. renal tumour lower lobe of kidney 1cm, 70 yrs old woman asymptomatic on accidentally ultrasound finding
a. Biopsy
b. Total nephrectomy
c. Partial nephrectomy (if u think its malignancy)
d. Counselling
E. Observation and reassurance*(if u think its benign)

**<4cm partial nephrectomy

4-7 cm try to do partial if not possible then total
>7 cm total nephrectomy

Total nephrectomy is the treatment of choice in the following situations:

o Tumor size ≥7 cm
o Those tumors that have a more central location
o Suspected lymph node involvement
o Tumor with associated renal vein or inferior vena cava (IVC) thrombus
o Direct extension into the ipsilateral adrenal gland

partial rather than total nephrectomy:

o A solitary kidney
o Multiple, small, and/or bilateral tumors
o Patients with or at risk for chronic renal disease

133. 18renal tumour lower lobe of kidney 5cm, 62 yrs old woman asymptomatic on accidentally ultrasound finding
what you will do next?

849
 a. Biopsy
b. Total nephrectomy
c. Partial nephrectomy
Observation and reassurance
Renal Tumor***

134. 21.84 yrs lady renal tumour lower lobe of kidney 1cm, asymptomatic on accidentally ultrasound finding. she also
had a drug eluting stent 4 months ago and she is on Asprin and clopidogrel. whats next appropriate management?
Biopsy B. Total nephrectomy C. Partial nephrectomy D. Counselling E. Observation*

850
135. renal tumour lower lobe of kidney 1cm, 70 yrs old man next
a. biopsy
b. total nephrectomy
c. partial nephrectomy

136. 65 Pt with abdominal Pain with CT done suprarenal mass 5 cm wt to do

1 biopsy …as no surgery in option

2 partial nephrectomy
3 total nephrectomy
4 mibg

851
#June

137. 55 years old man with heterogeneous 3cm upper kidney mass
a. Partial nephrectomy
b. Complete nephrectomy
c. Review after 1 year CT scan
d. Reassure

852
138. A patient on peritoneal dialysis who was going well suddenly declined to have dialysis. On examination she was
having slight temperature and mild tenderness in upper abdomen. What finding you will most likely find in this
patient?
a. Disorientation
b. Depressed mood
c. Blunted affect Nephro#

139. #NEPHRO CKD female patient is on dialysis, she is coping with her life & families well. Today all in a sudden she is
refusing to do dialysis. What’s the reason for this type of behaviour?
Blunted Effect
B.Depressed mood
C.Command Disorder

140. Dialysis pt after 5 days in emergency with weakness and dyspnea what next
a. Call dialysis unit
b. Frusemide
c. Ecg
d. Abg

141. pt with chronic renal failure on dialysis bp is high before dialysis and normalise during dialysis and is high again
after dialysis procedure over,what is the mx-?

853
 a. 1-recheck dry weight
b. b-give diuretic
c. 3-start antihypertensive

142. A man with renal failure who needs to have haemodialysis. He has no problem during dialysis, but his BP
INCREASES at the end of dialysis.What could be the reason?
a. allergic reaction to the dialysate fluid
b. over dialysis
c. - ACE inhibitors overdose
d. Hypokalaemia

143. A man with renal failure and need to have haemodialysis. He has no problem during dialysis, pre dialysis bp is
150/90…but after that his BP DECREASES to 80/60 at the end of dialysis, …he anemia of 8gm/dl… What could be the
reason?
a. allergic reaction to the dialysate fluid
b. over dialysis
c. c.anemia

144. Patient on dialysis, BP increase after dialysis what to do?

a. Antihypertensive
b. Furosemide
c. Check body weight

**if option like increase dialysis time take that one

145. Patient on dialysis, no dialysis for 5 days, now presented with dyspnea and weaknesses what is management?
a. Furosemide
b. ABG
c. CXR

146. Pt on dialysis, htn controlled but now htn reoccur after dialysis and bp normal during treatment.
what next?
a) add htn
b) give frues daily
c) sedate before dialysis

** correct ans should be increase dialysis time

147. Had a kidney transplant from cadaver no urine output for 7 days requiring dialysis. Whats the cause
A. Acute rejection (otverzhenie)2nd day
B. Blocked catheter (& days urine didbn pass through catheter)
C. Ureteric obstruction
D. Donor venous thrombosi
E.Acute tubuar necrosis

148. pt on renal dialysis he is normotensive in dialysis but after dialysis he is hypertensive mx:
a antihypertensive
b- frusemide before dialysis
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2813124/

Treatment of hypertension in hemodialysis patients::

1) Free water restriction is a therapeutic option for hypoosmolar states, not volume overload. A more appropriate
therapy for these patients would be to restrict dietary sodium intake. A two gr sodium diet is commonly
recommended.
854
 2) Drug therapies :

The majority of patients with end stage renal disease on chronic dialysis need antihypertensive drug therapy.
Several classes of antihypertensive drugs are available and all EXCEPT diuretics are effective in controlling
hypertension in hemodialysis patients.

In patients with left ventricular hypertrophy, ACEI may be effective in causing regression, although the trial sizes
have been limited.
Calcium channel blockers (CCBs) are the most widely prescribed class of drugs in patients on hemodialysis.
Calcium channel blockers appear to be more effective when the plasma volume is expanded. They do not need
additive doses after hemodialysis.

Angiotensin converting enzyme inhibitors and beta blockers appear to be attractive agents due to their
independent cardiovascular benefits.

149. Pt become Hypertensive after dialysis. Which drug will you choose
A. Losartan
B. Amlodipine
C. Frusemide
D. Carvidelol

150. 55 years old gentleman on 3 sessions haemodyalisis weekly ,he missed his last 2 sessions ,presented to the ED
with acute shortness if breath ,fatigue and lethargy ..he still have some urinary output .....his chest auscultation
revealed bibasal crackles ...whats your initial management plan:
A-direct haemodialysis
B-ABG
C-Chest X Rays
D - peritoneal dialysis
E- frusemide
** The fact is we should call (arrange) the dialysis unit...and meanwhile do ECG, abg and cxr...so if option a is TO CALL
THE DIALYSIS UNIT I will go for that but no peritoneal dialysis for sure!cz it's not an easy and rapid procedure!

855
Depends on scenario…if everything is normal in examination just reassure

151. Male for army ; during investigation found hematuria ; what the cause ??
a. PKD
b. IGA nephropathy
c. Thin basement membrane incidental finding

C , if not then B
**Thin basement membrane disease (TBMD, also known as benign familial hematuria and thin basement membrane
nephropathy or TBMN) is, along with IgA nephropathy, the most common cause of hematuria without other
symptoms.

152. patient has blood + protein trace in urine. Next visit, same urine analysis, urine microscopy and culture shows no
growth, rbc of glomerular origin and no cast. probable diagnosis?

856
 1.iga nephropathy
2 nephritic syndrom
3 transient bening hematuria
4 cronic kidney failure
5 thin basement membrane nephropathy

153. A 32-year-old man presents with loin pain and

hematuria. He is HIV positive and on an anti-HIV
treatment regimen including indinavir. Which one of
the following is the most appropriate next stepin
management?
A Intravenous pyelogram (IVP).
B Ultrasound (US).
C Non-contrast CT scan.
D KUB X-ray.
E Triple-phase CT scan

154. Man with pain in right abdomen for several hours. Now radiating to right groin. All examination are normal apart
from small swelling in right inguinal area that comes and goes. Patient looks to be in severe pain. Investigation
a. Xray KUB
b. Ct adomen
c. Usg right groin
155. #june2019
pt with loin pain no proteinuria , RBC +++ in urine, no fever or renal angle tenderness, most appropriate next step?
A)Xray KUB
B)CT KUB
C)Urine Culture
D) USG

156. known case of polycystic kidney disease with lower urinary tract obstruction,
what investigation will you do to evaluate
A CT abdomen
B US kub
C Retrograde pyelogram
D Cystoscopy

157. Young man presented with loin pain , urine examination showed hematuria . what is the most appropriate next
step?
A X-ray
B-abdominal ultrasound
C-CT abdomen
D-MRI
E-urine culture
A or C? Please explain

158. ***Man with pain in right abdomen for several hours. Now radiating to right groin. All examination are normal
apart from small swelling in right inguinal area that comes and goes. Patient looks to be in severe pain. Investigation

Xray KUB

Ct abdomen

Usg right groin

857
Ortho
1. slipped capital femoral epiphysis scenario. Treatment asked
jm 734. hb 2.150. http://www.racgp.org.au/afp/2012/june/survival-
radiology-for-gps/

ANS:OPEN REDUCTION AND INTERNAL FIXATION USING

SCREW/PIN
Slipped capital femoral epiphysis One problem of the displaced capital
epiphysis of the femoral head (SCFE) is when some patients develop
avascular necrosis despite
expert treatment. Diagnosis
of the condition before major
slipping is important. This
necessitates early
consultation with the
teenager experiencing hip or
knee discomfort and then
accurate interpretation of X-
rays.
Clinical features • Adolescent
10–15 years, often obese •
Most common in the
oversized and undersexed
(e.g. the heavy prepubertal
boy) • Bilateral in 20%
Normal Limp and irritability of
hip on movement •
Anterior hip (groin) pain •
Knee pain • Hip rotating
into external rotation on
flexion and often lies in
external rotation (ER) •
Most movements restricted,
especially IR Any adolescent
with a limp or knee pain
should have X-rays (AP and
frog view) of both hips (see
FIG. 65.6 ). Otherwise, this
important condition will be
overlooked. SCFE is graded I
to IV.

2. A 13 year old obese child

presents with painful right
knee and right hip pain with
difficulty walking and reduced
abduction and internal
rotation. What is your

858
 diagnosis?
a) Juvenile arthritis – before 16 yo.joint effusion ,pain on movement,
b) Septic arthritis of the hip-jm 734
c) Avascular necrosis of femoral head –jm 735 pain more in groin area,most common non traumatic due to
steroid and alchohol abuse.coagulation prob or vessel injury like chemo therapy, Traumatic causes
d) Cartilage dysplasia - Ar
e) Slipped capital femoral epiphysis– 10-15yo
ANS:E

3. 4 year old child came with limping, T 38, all knee examination normal but hip movement was markedly restricted.
Dx....
septic arthritis
Tenosynovitis
Perthes Disease
C.Juvenile arthritis
D. Knee synovitis
ANS:A

4. 8 years old bot comes with c/o right knee pain .Unable to put weight on right leg.Temperature 39, o/e mild
tenderness over the knee , no swelling and restricted movement of the hip due to the pain. Asking for diagnosis
A. Septic arthritis
B. Perthes Disease
C.Juvenile arthritis
D. Knee synovitis

5. . 4yr old child had history of diarrhoea for 4days.Mother didn't pay attention until next day child couldn't walk
&says hip is sore.Dr tries to examine hip & child refuses and cries.On Exam,Full range of motion of hip,knee &
ankle.Temp 39 c.What is Dx
A.Perthes disease
B.SCFE
C.Septic arthritis
D.Teno synovitis of hip.
ANS:C UNLESS PROVEN OTHERWISE

6. Around 12 years old boy had abdominal symptoms..pain and diarrhoea for past 4 days..since today morning
reluctant to walk and reluctant to use hip..diagnosis.
859
 A.septic arthritis
B. Osteomyelitis jm 799
C. Slipped femoral epiphysis
ANS:A

7. 6yr old boy presented with C/o pains in leg more @

night.He had URTI for 2 wks now with cervical
lymphadenopathy. Most propable diagnosis for leg
pain?
A general myalgia
B growing pain
C perthes disease
ANS:B
perthes age cut off is 7yrs.. and SCFE its 12yrs adolescent
obese male .. it has to be Growing Pain which is a
neuralgic pain which are like cramps. amedex

8. 10 y/o with hip pain and limping came to you. Limited

motion of hip noted on abduction and internal
rotation. Xray is given.
1. Irritable hip(transient synovitis) .. if xray normal jm
746,744

Treatment. Refer early. Treatment is bed rest or the use

of crutches and analgesics. Follow-up X-ray is needed in 4 to 6 months to exclude Perthes disease. Aspiration
under general anaesthetic may be needed to exclude septic arthritis.

2. Septic arhtritis
3. Perthe's disease
ANS:3 IF ABNORMAL XRAY

PERTHES DISEASE

9. A 13 year boy came to you limping. All examinations normal, USG showed synovial fluid, Dx?
a. Perthes disease
b. Irritable hip –(TRANSIENT SYNOVITIS) Ultrasound shows fluid in the joint
c. Osteoarthritis
ANS:B

860
10. 10 yrs boy came to you with a problem in his leg , he cant
seem to abduct it. he has limitation in joint movement ,
xray normal, us synovial fluid 8 mm , ESR 10
diagnosis
A Osteosarcoma
B Juvenile OA- jm 362
C Perthes disease
D Irritable hip syndrome
ANS:D

11. The commonest cause of hip pain in a 3-year old child?

a) Transient synovitis jm 744-- 3-8 yo
b) Perthes disease rarely – 2 t0 18 rare
c) Slipped upper femoral epiphysis
d) Arthritis
e) Tuberculosis
ANS:A
hip pain in children Hip disorders have an important
place in childhood and may present with a limp
when the child is walking. These important
disorders include: • DDH • congenital
subluxation of hip and acetabular dysplasia •
transient synovitis • Perthes disease • septic
arthritis/osteomyelitis • SCFE • pathological
fractures through bone cyst

12. WOF is true about Perthes disease?

a- Recurrent limp in preschool child
b- Painless limp and x-ray reveals of definitive changes
ANS:b
https://www.rch.org.au/uploadedFiles/Main/Content/ortho/factsheets/PERTHES-DISEASE.pdf

Perthes disease
o Avascular necrosis of the capital femoral epiphysis.
o Age range 2-12 years (majority 4-8yrs)
o 20% bilateral
o Present with pain and limp(rch)
o Restricted hip motion on examination
Ø 11 yrs boy with knee pain he remembered he got
injured while playing 3 wks back, on ex, localized
tenderness, xray: periosteial elevation and new bone
formation dx?
Ostomyletis
Osteosarcoma
Perthe's disease
OA
ANS:B IF NO FEVER
http://www.radiologyassistant.nl/en/p494e15cbf0d8d/bone-tumor-systematic-approach-and-differential-
diagnosis.html
861
v OSTEOSARCOMA:SUN RAY APPEARENCE

862
v OSTEOCLASTOMA:SOAP BUBBLE APPEARENCE
v

v EWING SARCOMA:ONION PEEL v OSTEOCHONDROMA:GROW AWAY FROM

APPEARENCE EPIPHYSIS

v OSTEOID OSTEOMA:NIDUS FORMATION v OSTEOMYELITIS:SEQUESTRUM

863
 v

13. Ara,5yr old present with a painless limp,you suspect Perthes'sdisorder,which of the following statements is
Correct?
A)hip mobility is usually reduced,particularly adduction and external rotation –internal rotation.
B)ultrasound is required to make a definitive diagnosis- by xray
C)the white blood count and C reactive protein are usually raised
D)progress is assessed with serial radio logical examination
E)Osteotomy is the treatment of choice
ANS:D
RX OF PERTHES: REFER,REST,CRUCH

14. Young boy 13 years of age presents with limp and limited internal rotation. He is on the 95th percentile for
weight and 50th percentile for height. Which of the following is the likely diagnosis?
a. Tenosynovitis – 4 -8 , all esp abduction and ir
b. Septic arthritis – any,all
c. SCFE – 10 -15 , all esp ir
d. Perthes– 4 – 8,abduction, ir
ANS:C

15. 28 years old lady returned after a holiday from Asia and present with some skin lesion , tenosynovitis on left
forearm. She also complains of pain and swollen left knee. Vital stable. Diagnosis
1. Post viral arthritis
2. Gonococcal arthritis
864
 3. Reactive arthritis – jm 382
4. Streptococcal arthritis.
ANS:2
B: The classic triad of polyarthralgia, tenosynovitis and painless vesicopastular skin lesions
are consistent for disseminated gonococcal infection.

16. .Pt. with De quervain's tenosynovitis and was on some medicine treatment but no relief. So surgical procedure
was done. Later he developed weakness on wrist extension and some other features. Cause?
jm 720
a. Radial N entrapment due to tenosynovitis
b. Radial N entrapment due to splinting
c. Medial nerve
ANS:B

Complications
Although de Quervain tenosynovitis features a simple tendon entrapment and the treatment is quick and
straightforward, complications of surgical treatment can be profound and permanent. [19] Careful attention to
surgical technique at the initial release is paramount to avoiding complications.
Superficial radial nerve injury is the most irksome complication. Sharp injury, traction injury, or adhesions in the scar
can cause neuritis in this high-contact area, greatly limiting hand and wrist function. This complication is best
avoided through careful blunt dissection of the subcutaneous tissue and gentle traction.
Persistent entrapment symptoms are possible if the tendon slips of the abductor pollicis longus are mistaken for the
tendons of the abductor pollicis longus and the extensor pollicis brevis. In such a case, the extensor pollicis brevis
tendon may remain entrapped within the septated first dorsal compartment. Should repeat cortisone injections
fail to relieve symptoms, careful surgical re-exploration may allow a previously overlooked tendon to be released.
Subluxation of released tendons is possible. [20] With wrist flexion and extension, the tendons of a widely released
first dorsal compartment snap over the radial styloid. This complication is best avoided by carefully limiting the
release to the thickest middle 2 cm of the first dorsal compartment or by reconstructing a loose roof to the
released sheath. Reconstruction of the sheath with a slip of local tissue may relieve symptoms.

https://www.youtube.com/watch?v=RPPynbZjC7Q

17. Pt on warfarin with fever. Swelling in thigh. What

investigation to do
A) D dimer
B)CT angio
The diagnosis is based on the clinical manifestations and on
imaging studies (computed tomography), which show
enlargement of the muscle affected9.
Doppler not given
HERE B BUT IF DOPPLER GIVEN THEN THAT IS MOST
APPROPRIATE
https://www.mdcalc.com/wells-criteria-dvt

18. Athlete with twisting knee injury, now can't flex the knee beyond a point. Jm 769.

865
a. ACL injury
b. patella injury
c. collateral ligamet injury
d. medial meniscal injury
e. lat meniscal injury
ANS:D AS MEDIAL MENISCUS TEAR
Jm782
If you've torn your meniscus, you might have the
following signs and symptoms in your knee:
o A popping sensation.
o Swelling or stiffness.
o Pain, especially when twisting or rotating your knee.
o Difficulty straightening your knee fully.
o Feeling as though your knee is locked in place when you try to move it.

19. Hx of gradual poor vision of few days in unilateral eye of young athlete after he had an impact on that side of the
face.
a. blow out fracture
b. retinal detachment – jm 895
c. lens displacement
d. vitreous haemorrhage– jm 895

ANS:B??

866
20. Pain/Loss of sensation in lateral upper arm, outer forearm, and thumb and
index finger
a. C4 C5 injury
b. C5 C6 injury
c. C8 T1 injury
ANS:B
21.A young man comes with weak shoulder abduction, and elbow extension,
loss of sensation over deltoid, cause? Jm 1462,688
a. C5 nerve palsy– only shoulder
b. Brachial plexus injury (superior trunk c5 and c6) c5 – t1
c. C7 nerve injury
d. Carpal tunnel syndrome
ANS:B

867
22.Football player with multiple neck injuries in the past ,slept on chair last night.Upon waking up he has weakness
in abduction of right arm and shoulder,loss of sensation of lateral arm.Cause?
C5 nerve injury
Brachial plexus injury
Radial nerve injury
Axillary thrombosis
ANS:A

23.60 year old with shoulder pain, difficult to raise his arm some sensation on outer serface of the arm lost , and
weak at elbow after her Fell asleep in front of tv , Diagnosis?
brachial plexus injury
radial nerve injury
ulnar nerve injury- claw hand
median nerve injury-
ANS:A

24.Some hand surgery (dt remember type of sx) torniquate applied at wrist after sx finished patient developed
numbness at base of thumb, loss of all extensors of hand( wrist drop), rest symptoms i dt remember,cause
radial injury due to torniquate
radial injury due to surgery itself
rest options i dt remember but they were nerve injuries
ANS:A

25.lady had de-quervan synovitis. She has some surgery(?) and after tourniquet application on hand she develops
pain on wrist& fingers extension and loss of sensation on base of thumb. Cause
a. surgical injury on radial nerve
b. surgical injury on ulner nerve
c. tourniquet injury on radial nerve
d. tourniquet injury on ulner nerve
ANS:C

868
26.A patient came in with weakness of wrist and finger extension. Tendon reflexes were normal. No other
abnormalities noted. Where is the lesion?
a. Anterior interposes nerve
b. Median nerve
c. Ulnar nerve at the elbow
d. Radial nerve
e. Posterior interosseus nerve
ANS: D ———

Posterior interosseous nerve injury cause weakness

in only finger extension but radial nerve for both
finger and wrist extension.
Finger extension – Radial nerve (also wrist and
elbow)
Finger flexion – 2,3 by Median nerve 4,5 by Ulnar
nerve

27.which nerve will recover well and function well after dissection?
a.digital nerve of finger
b.sural nerve
3.ulnar nerve
4.sciatic nerve
5.post.int.branch of median nerve
sural nerve?

http://www.orthobullets.com/hand/6066/peripheral-nerves-injury-and-repair?expandLeftMenu=true
http://www.medscape.com/viewarticle/423216_6

Graft Material

Autogenous nerve graft is the most commonly used material for bridging nerve gaps. Ideally, the donor
nerve provides a suitable environment for regeneration and results in acceptable donor morbidity. The
sural nerve meets many requirements for nerve tissue quality and donor site morbidity and has become
the standard autogenous graft for bridging large upper-extremity nerve gaps.
Nerve grafting
autologous graft
indications
o ≥ 3cm gap
o digital nerve defects
o at wrist to common digital nerve bifurcation - use sural nerve
o at MCP to DIP level - use lateral antebrachial cutaneous nerve
o at DIP level - use AIN, PIN or medial antebrachial cutaneous nerve
outcomes
gold standard for segmental defects > 5cm

28. A patient cannot extend his wrist and fingers. Where is the lesion?
a. Ulnar nerve
b. Radial nerve
c. Median nerve
d. Posterior interossei nerve

869
e. Anterior interossei nerve
ANS B

29.Female typist, came with pain in wrist. Unable to do opposition of thumb n index finger. Also complaint of
numbness. What is ur Dx?
a. Ulnar N. Lesion
b. radial N. Lesion `
c. median N.Lesion – no pain jm 717
d. carpal tunnel syndrome – median nerve
ANS:D
Thumb opposition:carpal tunnel
pincing and ok sign: ant
interosseous nerve
pincer grip: ulnar nerve
30.Footballer with h/o diarrhoea few days back and neck injury few months back, fell on sleep last night with arm
over chair, woke up in the morning with loss of sensation over lower half of arm, mid part of forearm, weakness
in wrist extension. Whats the possible reason?
a. brachial nerve palsy
b. neck injury
c. C5 injury
d. radial nerve palsy.
ANS:D

31.24 years old man who used to be Australian football player presented with pain in his shoulder that persisted for
about 3 weeks. He has a history of multiple neck injury. He had an episode of diarrhoea before this pain. On
examination there is only loss of extension
of elbow. Cause?
a. C5 nerve injury
b. Brachial plexus injury
c. Radial nerve injury
d. Axillary nerve injury- ulnar nerve
ANS:b

Ø pt 60 years old, with some shoulder pain.

Felt asleep in front of tv yesterday and in the
morning presents with more pain on
shoulders, on examination, shoulder
movements r painful, abduction is painful
and slight sensation reduction on upper
arm, has elbow extension and wrist
weekness and low sensation in outer
forearm. used to be a football player had
multiple past neck injuries, cause: a-brachial
plexus injury b- radial nerve injury c- ulnar
nerve injury d- median nerve injury e-
axillary nerve injury

870
32..patient with shoulder weakness on abduction and loss of sensation on upper arm ( no other signs or symptoms) ,
last night he slept on the chair, he was a football player and had several neck injuries, where the lesion ?
a. C5
b. brachial plexus
c. radial nerve
ANS:A

33. Ulnar nerve level of injury…hand reduced sensation 4&5, cannot hold pen
a-wrist
b-c8,T1
c-elbow
d-axilla (HB-3.039)
ANS:c (Medial side of forearm), Wrist ( motor Intact)

If dip involved elbow level injury…. If no dip

then wrist level injury

34.A 42 year old carpenter complains of numbness in the little and ring finger of his left hand. On examination there
is weakness of abduction of his little finger and weakness of flexion of the terminal phalanx of his little and ring
fingers. The appreciation of light touch and pin prick is decreased over his ring and little fingers and the adjacent
medial border of his hand. Which one of the following is the most likely site of the causative lesion?
a. Median nerve in the forearm
b. Ulnar nerve at the elbow
c. C8 nerve root in the neck

871
d. Ulnar nerve at the wrist
Radial nerve in the spiral groove
ans:2

35.Scenario about C6 nerve root compression. Numbness in thumb and index finger . weakness of ----- muscles and
decreased brachio radialis reflex and power.
a. CE radiculopathy
b. Median nerve(palmer)(c5 to t1)
c. Ulnar nerve
d. Radial nerve(dorsal)(c5 to t1)
ANS:D

36.A 17 y old man is brought to A & E after shielding himself from a machete attack. He has incisional injuries to the
medial aspect of his elbow & medial epicondyle. O/E he is unable to flex his ring and little fingers at the MCP
joints & is unable to abduct or adduct his fingers. There is no loss of sensation. Which nerve is affected?
A. Median nerve
B. Medial cord
C. Radial nerve
D. Deep ulnar nerve (Motor Deep)
E. Superficial ulnar nerve (Sensation Superficial)
ANS:D

37.42 year pt after some trauma to elbow last year now with increased carrying angle ,which one can be found in
examination
a.flection of MCP+PIP ,DIP spared
b.hyper extention of MCP + flection of PIP,DIP (Claw Hand)…late claw hand in ulnar nerve injury at elbow. The
early presentation should be weakness in flexion of dip
c. fibrosis and nodularity of palmar fascia- duputren contracture.
d. thickened and waxity of posterior hand skin
ANS:B
When present at birth, it can be an indication of Turner syndrome[1] or Noonan syndrome. It can also be
acquired through fracture or other trauma. The physiological cubitus valgus varies from 3° to 29°.
Women usually have a more pronounced Cubitus valgus than men. The deformity can also occur as a
complication of fracture of the lateral condyle of the humerus, which may lead to tardy/delayed ulnar
nerve palsy.

38.A patient can't move finger and wrist, which nerve is affected?
> A. Median
> B. Radial
> C. Ulnar
> D. Posterior Introsseous Nerve(only finger)
> E. Anterior Introsseous Nerve(radial 3 fingers only)
ANS:B

39.pt with weakeness of rt hand and arm..loss of sensation on outer aspect of arm..history of neck injury 10 yr
back..loss of flexion of elbow and extension of wrist
C7 injury
Radial nerve injury
T1 injury and some other
ANS:B
872
40. pt 60 years old, with some shoulder pain. felt asleep in-front of tv yesterday and in the morning presents with
more pain on shoulders, on examination, shoulder movements r painful, abduction is painful and slight sensation
reduction on upper arm, has elbow extension and wrist weakness and low sensation in outer forearm.used to be
a football player had multiple past neck injuries, cause:
a-brachial plexus injury??
b- radial nerve injury
c- ulnar nerve injury
d- median nerve injury
e- axillary nerve injury
ANS:A?
AXILLARY (ABDUCTION & SENSATION OVER DELTOID&OUTER FORE ARM) +RADIAL (EXTENSION OF WRIST+ELBOW)

41.Man cannot flex his wrist or his fingers or his extensor policis brevis.The small muscles of hand are normal.where
is the lesion
a.Ulnar nerve at elbow(Small muscles of hand)
b.radial nerve
c.median nerve at elbow??
d.posterior interoseus nerve(lesion causes finger drop)
e.anterior interoseous nerve( causes only flexion 3 median nerve)
ANS:C?BUT EPB IS SUPPLIED BY RADIAL NERVE.

42.loss of finger grip in index and thumb.what nerve

A. radial
B. ulnar supplies the adductor policies and dorsal interosseous muscle which is responsible for pincer grip
C.anterior interosseous==brach of median nerve only for ok sign and thumb opposition
D. carpel tunel

if an individual is unable to pinch their index

finger and thumb, a pathological indication
of damage to the anterior interosseous
nerve between the two heads of the
pronator muscle is concluded. This is known
as anterior interosseous nerve syndrome
(AINS).
Posterior interosseous nerve===radial nerve
ANS:B

43.Man having numbness of index and thumb

brachioradialis reflexes bit low power in
muscle 5/5
Thoracic outlet syndrome - jm 723
Carpel tunnel-brachioradialis reflex not
affected
Cervical spondylosis-jm 703
ANS:C

873
C6 nerve root is most commonly involved in cervical spondylosis and its sensory changes like
paresthesia and numbness occur in outer
forearm thumb and index finger and reflex affected is biceps
plus brachioradialis

44.old man developed pain in the buttock while lifting an object , pain radiated
from buttock to sole of foot.what will be associated?
a. weakness of sensation on inner leg
b. weakness of sensation on outer leg
c. loss of ankle reflex- s1
e. loss of knee reflex- l3 l4
ANS:C

45.a man fell on his outstretched hands and has a painful wrist with some restriction of movement, x-ray done to
him showed the following picture. What is the most appropriate treatment? Jm 1468
Dx- colles #
a. Apply crepe bandage and early mobilisation – for simple
b. Screw fixation
c. slab and early mobilisation
d. Plaster cast
e. plate
ANS:D
Plain radiograph
AP and lateral wrist x-rays usually suffice. The fracture appears extra-
articular, and usually proximal to the radioulnar joint. Dorsal angulation
of the distal fracture fragment is present to a variable degree (as opposed
to volar angulation of a Smith fracture).

https://radiopaedia.org/articles/colles-fracture

874
46.A patient presented to you with pain in his wrist after a fall
on outstretched hand. X-ray is shown. After management, when
will you request him to come back for a review?
A- 2 days
B- 2 Weeks
C- 2 Months
D- No need for further review
E- one month
Jm 1469-check X-ray at 10–14 days; position may be lost as swelling
subsides and plaster becomes loose

ans:2 wk

47.24 year old male with a history of fall on an outstretched

hand with pain and swelling. XRay was given, (showed scaphoid
fracture. Very clear fracture line throught the middle) jm 1456
Non union complication avascular necrosis
What is the best treatment option for this patient
a. Crepe bandage
b. Plaster cast
c. Analgesics
d. Compression screw
e. Plate fixation
ANS:B

875
48.Patient complaining of soreness on lateral
epicondyle at the end of work,the patient
attributes it due to computer mouse
clicking.On examination , tenderness on
lateral epicondyle .Asking treatment?
Dx – tennis elbow
A-lateral epicondylectomy
B-finger immobilization splint – no as must do
exercise
C-lateral epicondyle immobilization splint
D-bracing under lateral epicondyle
ANS:D
Initial: REST and and analgesia
Long term: bracing

Counterforce bracing

Counterforce braces are used in an attempt to reduce the tension forces on the wrist extensor tendons,
and this orthotics may be superior to lateral epicondyle bandages in reducing resting pain. [17] The
brace should be applied firmly approximately 10 cm distal to the elbow joint. Use of a counterforce
brace may decrease pain and increase grip strength at 3 weeks in individuals with lateral epicondylitis.

49.A man in brought to the ER after brawl hit to the side of left eye. On examination, you have found an orbital floor
fracture. Which of the following is the accurate predictor of this diagnosis?
A-Sub conjunctival haemorrhage
B-inability to open his mouth
C-loss of sensation of his cheek
D-decreased visual acuity
ANS:C

50.Direct below injury to Zygoma, fracture on Xray, what is the most probable findings clinically: jm 1458- malar #
1. Loss of sensation in cheek
2 facial muscle weakness – close to ear,comes from acoustic meatus
3 CSF rhinorrhea – base of skull #
4 loss of visual acuity-
ANS:1

876
51.what of the following is the most consistent finding of orbital floor fracture:
a.vertical diplopia (2nd common)
b.horizontal diplopia
c.inability to open the jaw
d.loss of sensation on the ipsilateral cheek

http://www.racgp.org.au/afp/2012/april/maxillofacial-trauma/

http://www.racgp.org.au/afp/2012/april/maxillofacial-trauma/
http://emedicine.medscape.com/article/1284026-overview#a10

877
52.Woman with back pain after lifting heavy thing has Shooting pain in buttock radiate to back of calf. What do you
think any other additional finding the patient have?
Diminished ankle reflex– s1
Diminished knee reflex – l3l4
week extension of foot – l5
D-urine incontinence -
E-may be stiffness

ANS:A S1 NERVE ROOT LESION JM 747

53.58 years old male patient had pain in the back after
gardening, going down right left leg and knee and. Foot.
Straight leg raising examination was painful. All other
neurological examination normal. What is the most
appropriate thing to do for this patient?
Jm 404 back pain
A-MRI spine(If assuming the best one, or xray)
B-X-ray lumbar spine
C-CT lumbar spine
D-ultrasound
E-Symptomatic treatment only(JM 404, 412)
ANS:E

878
54.straight leg raise test asking which lost?
ankle jerk
knee jerk
c)flexion of hip
d) flexion of knee
ans:a

https://l.facebook.com/l.php?u=https%3A%2F%2Fwww.ebmconsult.com%2Farticles%2Fstraight-leg-raising-
test&h=AT18GBZ42NEWWUyQ4S2u5IQhXZ6wRCGxUbYrqyH2PKMfFVXONtSyLYB9Dg89_eqGsDqayeQXjXgHXQiqZl
G8wQIm0RA0iqjUvXfbc5LRajvrbcj_sOIJLAeAmCDNeHK20bCFrg

55.A 38-year-old woman develops lower back pain radiating down her right leg whilst performing DIY. She describes
a severe, sharp, stabbing pain which is worse on movement. Clinical examination reveals a positive straight leg

879
 raise test on the right side but otherwise the examination is unremarkable. Appropriate analgesia is prescribed.
Of the following, what is the most suitable next-step in management?
a. Check ESR
b. Arrange physiotherapy jm 420
c. Refer for MRI
d. Perform a vaginal examination
e. Lumbar spine x-ray
ANS:B

56.young man HIT by a squash ball while playing, apart from headache which resolved by analgesic he complained of
decreased in vision. On examination, his visual acuity was 6/12 in the left eye; right eye was 6/6 asking the most
likely cause?
A-vitreous hemorrhage ===sudden
B-retinal detachment===gradual
C-zygomatic fracture
D-orbital floor fracture
ANS:b

57. 8 year old child with persistent night pain in his left legs , on examination there was no restriction in active
movement and no swelling or tenderness what is the most appropriate next step?
A-X-ray left hip
B-ultrasound
C-bone scan
D-bone marrow examination
E-OTHER option be careful and check options well for this question
ANS:A
Dx: growing pain, reassue

58.A man came with pain on elbow after a long work in a kitchen ..doc dxed it as lateral epicondylitis ..what is the
mech?
flexion wrist
extension wrist
extension of elbow
rest two opt were movement of wrist.
ANS:B

Patient doing extension, doctor doing flexion

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59.Dupiytren's contracture pic. Cause of injury
asked
FIBROUS HYPERPLASIA OF PALMER FASCIA

60.Growing pain..NO INVESTIGATION

REUIRED (JM 745)

61.Photo of fracture head of humerus old

lady...what can happen because of this
(axillary nerve C5 C6)
1-loss of bicep power(shud be biceps reflex,
deltoid power)
2-sensory loss of little finger==ulnar nerve
3-forearm sensory loss===
ANS:1

62.A man in brought to the ER after he received a

kick to the side of his face. On examination
you have found an orbital floor fracture.
Which of the following is the accurate
predictor of this diagnosis?
a. Inablity to open the mouth
b. Subconjunctival haemorrhage
c. Anesthesia on cheek
ANS:C
63.Young boy 13 years of age presents with limp
and limited internal rotation. He is on the 95th
percentile for weight and 50th percentile for
height. Which of the following is the likely diagnosis?
a. Tenosynovitis
b. Septic arthritis
c. SCFE
d. Perthes
ANS:C

64.MVA with fractured ribs 6th to 10th ---Positive pressure ventilation recall
65.MVA patient comes to ED. His vital stable and having difficulty breathing due to pain and fracture ribs (3-7) Asking
next immediate step of management.
a. morphine
b- chest tube with underwater drain
c- needle thoracotomy
ANS:A
66.A patient riding a horse in the rural area fell off the horse and sustain fracture of the ribs (5-11), femoral and
humeral fracture. X-ray shows small pneumothorax. Vitals stable and saturation 96%. She is to be air lifted to a
tertiary hospital. Before lifting her to the hospital after stabilizing the femoral and humeral fractures, what should
you do?
a.Needle aspiration b. chest tube insertion c. oxygen therapy d. strap the chest
ANS:B
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67.Patient of RTA rib fracture 3 to 7 what is management now..
1,surgical fixation
2, banding to prevent paradoxical movement
3,intubation and positive pressure ventilation
4,chest tube
ANS:3 HB 119

68.CT chest pic MVA with severe pain and difficulty breath due to pain.Decreased breath sounds bilaterally and
dullness to percussion.Asks about the cause of pain?
Hemothorax
Pneumothorax
Pneomediastinum
Fractured ribs
ANS:D
69.knee injury after football. pt cant rotate medialy his legs if thighs are fixed.
anterior cruciate ligament injury.
medial meniscua
lat meniscus (Internal Rotation, Adduction Force causing)
patella
ANS:C
70.painful knee.swollen tender.
aspirate.
antibiotic
rest
ans:a
71.old male fall . on xray no fracture , but have pain
in left hip and painful leg in left leg stress test..
next
a.bone scan…1473
b.MRI,,,,jm 735 subcapital fracture
**The Bone scan will focus only on the outer layer of the bones while the MRI will further determine the extent of
the damage

72.supracondylar fracture X ray given, patient controlled analgesia

given but he still has pain, next step of management? A.reductionB.
Ulnar nerve decompression C. Add analgesics D. Send to OT
ANS:A

Ø Supracondylar fracture with swollen elbow and numbness of

fingers.Immediate management after analgesics?
A)X ray
B)Fasciotomy
C)Reduction
D)Ulnar nerve decompression

882
Ø 14. Young boy, accident with slipped fall during skiing. Very marked
swollen elbow, very painful. On examination, absent peripheral
pulses, numbness cold and clammy. At emergency department,
what is your next step of management?
A. Ulnar nerve decompression
B. Reduction
C. Refer to OT
D. Simple analgesic
E. X ray

https://radiopaedia.org/articles/supracondylar-fracture

https://www.rch.org.au/clinicalguide/guideline_index/fractures/Supracondylar_fracture_of_the_humerus_Emergen
cy_Department/

73.A 65 y.o. complains of pain in the anterior aspect of the pelvis after the fall. On X-ray –
fracture of one of the anterior pubic rami. What is the management?
a. Bed rest for 2 weeks
b. Mobilize with brace
c. Mobilize as tolerated
d. Surgical fixation
ANS:a

883
a. 70 year old woman fell, fracture of radius . O/E swollen wrist
. xray slight displacement
A) PIN
B) ORIF
C) Closed reduction and pop cylindrical
D) Closed reduction and back slab
ANS:C

pop cylindrical is full cast from all sides

884
b. which is NOT sign of zygomatic bonne fracture?
a. Horizontal diplopia
b. Vertical diplopia
c. Enophthalmos
d. unstable TMJ
e.Unable to open mouth
ANS:d. A can be too.medial wall fracture may cause horizontal diplopia.

https://patient.info/doctor/zygomatic-arch-and-orbital-fractures

c. 73b.a baseball player got hit on zygomatic bone. What the most complaints he’s having right now?
a) diplopia
b) unable to open his jaw

885
 c) face paralysis…should be ipsilateral cheek
d) difficult to chew
ans:A
d. 73c. A patient presented with history of getting
punched repeatedly around the eye in a brawl and now
has “jiggly” vision with swelling. Which is the most
common cause for his presentation?
A- orbital floor fracture
B- zygomatic fracture
C- nasal bone fracture
D- maxillary fracture
E- ruptured globe
ans:A

74.28-year-old man is brought to the emergency department after he had an accident while he was driving and had
his right ankle injured. On exam, his vital signs are stable. The right ankle joint is laterally displaced and there is a
laceration over the joint. Which one of the following is of greatest importance as the most initial step in
management?
Wound debridment.( even if pulse absent both cases A.wound debridement first
B. Tetanus immunisation.
C. Intravenous antibiotics.
D. Reduction of the displacement- - do within 6 hr
E. X-ray of the joint. (Isnt the ans either)
Check nice guidelines

REDUCTION èantibiotic è tetanus è X-ray

886
75.A 9 years boy fall from ladder sustains an injury clavicle . X
ray done shown below . What is the appropriate step of
management?
A. coracoclavicular ligament repair
B. Intramedullary wire
C. Arm sling
D.some other conservative method
ANS:C

Dx: clavicle fracture

http://www.rch.org.au/clinicalguide/guideline_index/fractures/Clavicle_fractures_Emergency_Department/

Ø Clavicle fracture pic.Fracture in the middle displaced overriding.what Is the management? a-Fixation to
coracoid bone b- Intramedullary wire c-arm sling d-repair supraspinous tendon
Ans: ORIF(wire, plate and screw)

887
76.A female with wrist fracture who showed good healing in the xray at 6 weeks now comes for review at 8 weeks.
She has no major complaints except for mild intermittent pain. What is the most appropriate next step?
a. Arrange for a splint to give additional support
b. Repeat xray now

Ø Colles fracture recall but with different options xray at 6 week followup was normal and now pt having mild pain
and tingling sensations what to do
A. Xray again Frst
B. splint for few days more 2nd
C. occupational therapy to check on him — 3rd
D.exercise analgesics
E. MRI to see ligament (contro)
C Occupational therapy. This is a case of Carpal Tunnel Syndrome post fracture. It happens because of
adhesions of of flexor tendons to median nerve and deep planes (near the fracture). In this case
occupational therapy will help to mobilise and improve function. Studies that might help but doesn’t
appear are USD to evaluate elastography of tendon and nerve conduction studies.

Wrist fracture/scaphoid fracture needs delayed x-ray evaluation of treatment to avoid non-union.

77.worker two days aching and swelling in left upper limb and hand?
Biceps rupture,
svc obstruction.
Cellulitis
ans:a ans subclavian vein thrombosis

888
The stem is deficient and need more details As worker
biceps rupture is possible but without hand swelling
. SVC obstruction associated with neck and face
swelling. Cellulitis more about redness hotness any
history of wound more sign of inflammation. If only
features present in original stem and one more
option of subclavian vein thrombosis present I'll
choose it

78.xray of tibial and fibular fracture with lacerated wound, what is the most important in the management?
a. internal fixation
b. external fixation
c.debridment
d. tetanus prophylaxis
ANS:C

79.50 years old lady presented with fall on outstretch hand

came to hospital with pain on pushing the thumb
downward .. xray done it was clearly normal (nothing
mentioned about cast).. then after 4 wks she present
with mild intermittent pain what to do now??
a.refer to orthopedic
b.give analgesia
c.cast the hand for 6 wks
ANS:A

80.Most appropriate next step in woman with painful

hammer toe ??
a.Not to wear tight shoes
b.Surgery
ANS:A

Next step is avoid tight shoes

Most appropriate is surgery

Mainly involve the second toe with extended MTP joint, hyper-flexed PIP joint and extended DIP joint.
Painful corns will appear over the prominent joint.
They respond well to surgery if problematic-and are not helped by good footwear.

81.manual worker with swelling of whole rt upper limb compared to the other side after heavy work by saw
machine:
• Muscle sprain
• Subclavian vein thrombosis
ANS:B

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http://emedicine.medscape.com/article/424777-treatment#d10
82.women work as a cleaner, come with elbow pain and pain in extensor surface pain in forearm in rt hand, she is rt
handed.
dx?
-stress fracture of head of radius
-torn of extensor muscle head origin…(tennis elbow)
dislocated joint
ANS:B

83.pt with marked toe deformity, wt next appropriate

Surgery
Foot wear
ANS:B
84.Boy aged 12 years playing sports regularly. He came
with c/o pain in his right knee. He thought that he had injury while playing the game on his knee. His knee is often
locked. What is the reason behind it?
Tear of medial meniscus….locking occurs in meniscus tear
Tear of anterior cruciate ligament
Tear of collateral ligament
Patella fracture
ANS:A

85.pregnant at 37 wks..sprained ankle badly..u applied crepe

bandage and and advised to keep foot elevated..what is
the best advice u can give regarding pain management?..
a. avoid codein
b. avoid all pain medicines unless it is intolerable
c.avoid NSAIDS (Closure of PDA)
d. use topical medicine
e. don’t take any medicine
ANS:C
86.case of cevical injury may be 2nd vertebrae and displacement you have put a tight collar stabilized patient ,
(cyanosis or failed respiration) what will
u do while transfer to hospital
ETT if generalized swelling
CPAP
Tracheostomy
Cricothyroidotomy
ANS:D
take ororacheal intubaion first
https://lifeinthefastlane.com/ccc/airway-
cervical-spine-injury/

87.Child comes to you with complains of pain in the right knee. You notice that he is limping while walking. He has
mild temperature. On examination you notice that there is decrease movements in the right hip. USG shows that
there is widening of joint space. Which of the following it the most appropriate management?
A) Antibiotics
B) Analgesics
C) Immobilise===tenosynovitis going to perthes disease
D) Steroids

890
ANS:C
Ans: refer early if in option
Perthes:

88.fixed gastrocnemius muscle swelling (no picture

given)
what is the most appropriate
a.Fnac
b.incisional biopsy
c.mri===soft tissue sarcoma
ANS:C

89.injury in foot , old recall , dislocated ankle jt . no option of wound debritement. What emergency management ?
a ) do realignment of the ankle joint in er
b ) refer to orthopaedician

http://www.racgp.org.au/afp/2010/januaryfebruary/sports-ankle-injuries-assessment-and-management/

90.Patient hit his eye by squash ball what is the sign of # Base of orbit
A Diplopia when gaze forward
B Diplopia when gaze outward and upwards
C pain with opening mouth
ANS: B
Orbital rim fracture – This is a fracture of the bones forming the outer rim of the bony orbit. It usually occurs at the
sutures joining the three bones of the orbital rim – the maxilla, zygomatic and frontal.

891
‘Blowout’ fracture – This refers to partial herniation of the orbital contents through one of its walls. This usually
occurs via blunt force trauma to the eye. The medial and inferior walls are the weakest, with the contents
herniating into the ethmoid and maxillary sinuses respectively.
Any fracture of the orbit will result in intraorbital pressure, raising the pressure in the orbit, causing exophthalmos
(protrusion of the eye). There may also be involvement of surrounding structures, – e.g haemorrhage into one of
the neighbouring sinuses.

91.Picture of dupuytren contracture and normal blood glucose next step

A. Physiotherapy(1)
B. Remove flexor retina column(3)
C. Steroid injection in tendon(2)
ANS:DEPENDS ON PIC
surgical resection/fasciectomy
indications
MCP flexion contractures > 30°
PIP flexion contractures
painful nodules are not an indication for surgery

http://www.orthobullets.com/hand/6058/dupuytrens-disease

92.40yr man, numbness of 4th& 5th fingers, weak thumb& index opposition, flexion of wrist and fingers are normal
a. CT brain

892
b. Wrist X-ray
c. MRI brachial plexus
ANS:B

93.40yr man, numbness of 4th&

5th fingers, weak thumb&
index opposition, loss of
princer grasp, flexion of wrist
and fingers are normal. What
is the most likely site ?
A- Cervical neck lesion
B- Carpal tunnel nerve
entrapment
C- brachial plexus
D- Nerve entrapment elbow
E- Cervical region

I think it's C8T1 lesions or lower brachial plexus

lesions( Djerine Klumpke). Numbness of 4th
and 5th digits shows ulnar nerve involvement
and impaired thumb opposition shows
median nerve involvement but these two
signs are both supplied by C8T1 ... since
combined median and ulnar nerve lesions are
rarer than C8T1 lesions ... I think the answer is
C( but not the whole brachial plexus) or A or E
(but these answers don't describe specific
C8T1 sites) Reference ... OHCM 456

94.5th metacarpal bone fracture

a. Back slab
b. K wire
ANS:A JM 1471

95.Case of woman who broke her wrist, came back in 6 weeks, Xray
shows satisfying union, then she cames back in 8 weeks with
persisting pain, what to do next-
A- bone density
B- repeat xray
C- mri for tendon investigation
ANS:b
Dx: regional pain syndrome

If pain from day 1 or very beginning: post traumatic chronic

wrist pain : do mri
If new pain: regional pain syndrome: mri

893
96.Supracondylar fracture with swollen elbow and numbness of fingers.Immediate management after analgesics?
X ray
Fasciotomy
Reduction…if xray is already done
Ulnar nerve decompression

97.xray supracondylar fracture arm, most imp step in management?

Plaster cast
Reduction under GA
Sent to OT for reduction

Ø which is NOT sign of zygomatic bone fracture? a. Horizontal diplopia b. Vertical diplopia c. Endophthalmos d.
Instable TMJ e.Unable to open 👄

fractures of ( maxillary sinus , zygomatic arch , lateral orbital rimàZygomaticomaxillary Comples

(ZMC) fracture which is known as a Tripod Fracture & wall ). A ZMC fracture vl gv a mixed picture
of Diplopia Vertical/oblique/horizontal depending on which part of the tripod was impacted
severely , Enophthalmos , difficulty in opening of mouth and infraorbital nerve damage from
pubmed

98.Supracondylar fracture x-ray. A child presents with swollen elbow after fallen with an outstretched arm. P/E
shows pale, pallor and painful forearm. What would be the next management:
a. Neurovascular assessment in every 4 hours
b. Close reduction and reassess the neurovascular status urgently==avascular necrosis(IF TYPE 2 IN XRAY)
c. Immediate open reduction and neurolysis(IF TYPE 3 IN XRAY)

99.45 yrs Severe pain in submandibular area with

swelling and intraoral redness Appropriate inv.
a.Xray Mandible
b.OPM --- Orthopantomograph(OPG)
c.Ct Neck
ANS; INTRAORAL XRAY

894
100. 45 year old male with severe pain in submandibular area with swelling and intraoral redness.Appropriate
investigation?
X ray mandible
CT neck
101. Which is the most common type of shoulder dislocation???
1. Anterior,
2. Posterior,
3.Inferior
102. Inferior dislocation of shoulder joint pic, whats on exam, loss of sensation on medial aspect of arm, loss of
sensation on lateral aspect of arm, paralysis of biceps,

103. 5 years old boy came with his parents. He unable to pronate his hand
a) pulled elbow
b) ulna dislocation
c) shoulder dislocation
ANS:B.IF CANT
SUPINE=PULLED ELBOW

104. This man fell down from height open armed. Diagnosis
Anterior dislocation of shoulder
posterior dislocation of shoulder

105. Nuchal scan is performed between the 11th and 13th week of
gestation, because the accuracy is best in this period. After a difficult
forceps delivery, it is noticed that the baby hangs his arm to the side,
and cannot move it. What is the likely cause?
a) Fracture humerus
b) Erbs palsy - C5, C6

106. The MOST COMMON fracture to occur in a baby during birth is:-
a) Humerus
b) Femur
c) Clavicle
d) Pelvic
e) Cervical spine
ANS:C
107. WOF is damaged in mid humerus fracture
a. Axillary nerve
b. Radial nerve
c. Median nerve

895
ANS:B

108. clinical test used for the diagnosis of the medial meniscus injury?
A. Posterior drawer test B. Varusloading test C. Anterior drawer test D.Patella apprehension test E. McMurray
test
ANS:E
109. Football player suddenly feel acute moderate pain in his rt knee while playing after hours the pain subsides
but effusion expanded after some day when the swelling and pain settled sometimes he felt his leg is giving away
some time his knee is locked (conto)
Dx
Med meninscial injury
Fracture patella
Med meninscial and medial cruciate ligament
injure
Ant cruciate ligament injury
ANS:A

http://www.medbullets.com/step2-3-
orthopedics/20553/meniscus-tear

110. Football player suddenly feel acute moderate

pain in his right knee while playing, after hours the
pain bubsided but effusion expanded,after some days when the pain and swelling were setteled, some times he
feels his leg is giving away and some other times his knee is locked DX?
A)antcruiciatelig injury
b)med menscial lig→ if effusion develops within 24 hours

896
 c)medmenscial +ligamentous lesion → effusion develops immediately and the pain would be more severe
d)fracture patella
ANS:B
111. Football-player has an injury while playing after that there was effusion in his knee and became swelling.
Rupture lateral meniscal ligament
Rupture Ant. cruciate Ligament (within 30 mins)
Rupture post. cruciate ligament
Fracture patella
ANS:B
112. image of dupuytren's contracture, which of the following is the most likely to be found (contro)
a. chronic alcohol use
b.history of vibratory machine overuse
c.DM

113. Xray given (joint space is a bit narrow , may be little displacement) Football player , can’t stand , painful
ankle joint movement , ask diagnosis ?
Fibula fracture
Fibula fracture with fracture articular surface of tibia
Fibula fracture with fracture articular surface of tibia & joint displacement
Fibula fracture with joint displacement (amedex)

897
 Fibular fracture with ? mortise

High ankle sprain and syndesmosis

injury

898
114. In osteoporosis (osteoarthritis) of hip, which movement is
usually restricted first?
a. Flexion of hip
b. Extension of hip
c. Adduction of hip
d. Abduction of hip

115. 30 y/o F w/ DM1 since 20 years of age has painful foot. XR

w/ osteopaenia and decreased joint space. Dx
a. -OA
b. -Neuropathic joint
c. -RA
d. -Osteoporosis
e. -SLE

Charcot joint, also known as a neuropathic or neurotrophic

joint, refers to a progressive degenerative/destructive joint
disorder in patients with abnormal pain sensation and proprioception.

clinical presentation

Patients present insidiously or are identified incidentally, or as a result of investigation for deformities.
Unlike septic arthritis, Charcot joints although swollen are normal temperature without elevated
inflammatory markers. Importantly they are painless.

899
116. . 40 yo woman gardener presents concern for osteoporosis, mother has osteoporosis at age 70. Her medical
hx is hip fracture for car accident some year ago. What is best advise?
- Dexa
- Calcium and vit D supplement
- Educate lifestyle and dietary modifications ans
- bisphosphonate

900
**Does the patient have any of the following risk factors associated with vitamin D deficiency?
Housebound or in residential aged care facility • Patients >65 • Indoor worker • Long sleeve clothing, staying in the
shade • Dark skinned • Vegetarians • Diabetes • Renal/liver disease • Pregnancy or breast feeding • Gastrointestinal
disorders e.g. Crohn’s, Coeliac, gastrectomy • Obesity

117. 25-year-old man came to ER with history of back pain L4-L5 level. He denies any history of back injury.
Previously, he was drug abuser and Hepatitis C positive. Physical examination is normal. He has an erythema at
the back which is painful. Which of the following is the most appropriate? Jm 404
a. HIV serology
b. CT spine
c. MRI spine to r/o osteomylitis
d. Kaposi sarcoma
e. Erythema multiforme

118. A 35 year old man acutely complained of Right knee pain and swelling right after playing golf. Arthrocentesis
done revealing 25 mL of brown pigmented fluid aspirated. What is the diagnosis? A. Rheumatoid arthritis B. Gout
C. Osteoarthritis D. Pigmented villonodular synovitis E. Hemochromatosis Achondrosis
Ø Pigmented villonodular synovitis
From Wikipedia, the free encyclopedia

Pigmented villonodular synovitis (PVNS) is a joint disease characterized by inflammation and overgrowth of
the joint lining. It usually affects the hip or knee.
901
in general, pigmented villonodular synovitis often manifests initially as sudden onset, unexplained joint
swelling and pain; the joint swelling is disproportionate to the amount of pain the patient feels at first.
Age:20 to 50 yrs
Realted to specific job and activity
PVNS is radiologically diagnosed by magnetic resonance imaging (MRI). The disorder is difficult to identify
and is often not diagnosed for four years or more after presentation due to nonspecific symptoms or a
general paucity of symptoms.[6]
Pathology
The synovial fluid of the joint is often grossly hemorrhagic.[10]
PVNS, under the microscope, looks as the name of the condition suggests; it is composed of nodules and/or
villi and has an abundant number of (pigmented) hemosiderin-laden macrophages
Once PVNS is confirmed by biopsy of the synovium of an affected joint, a synovectomy of the affected area
is the most common treatment

119. Which of the following is not considered an extra-articularmanifestation of Rheumatoid Arthritis?

a) Osteoperosis
b) Peripheral neuropathy
c) Cutaneous nodules
d) Pericardial effusions
e) Hepatomegaly

902
120. .old man had back pain, sometimes it wakes him up from sleep. No
injury history.what is the cause?
a)mechanical back pain (as no leg symptom)
b)lumber disc prolapse
121. 30yrs old carpet layer presented with 6 months history of knee
pain,on examintaion mild swelling and tenderness on pressing
patella.next investigation
X ray knee
ultrasound knee
arthorscopy

ans shud be aspiration knee and nsaid, later cs inj

Dx is prepatellar bursitis
if aspiration not given go for usg

Aseptic prepatellar bursitis

Signs and symptoms

Lateral section of the knee

The primary symptom of prepatellar bursitis is swelling of the

area around the kneecap. It generally does not produce a significant amount of pain unless pressure is
applied directly.[4] The area may be red (erythema), warm to the touch, or surrounded by cellulitis,
particularly if infection is present, often accompanied by fever.[5]:p. 608 Unlike arthritis, except in severe
cases prepatellar bursitis generally does not affect the range of motion of the knee, though it may cause
some discomfort in complete flexion of the joint.[6]:p. 360 Flexion and extension of the knee may be
accompanied by crepitus, the audible grating of bones, ligaments, or particles within the excess synovial
fluid.[7]:p. 2

There are several types of inflammation that can cause knee pain, including sprains, bursitis, and injuries to the
meniscus.[9] A diagnosis of prepatellar bursitis can be made based on a physical examination and the presence of
risk factors in the person's medical history; swelling and tenderness at the front of the knee, combined with a
profession that requires frequent kneeling, suggest prepatellar bursitis.[2] Swelling of multiple joints along with
restricted range of motion may indicate arthritis instead.[5]:p. 608

A physical examination and medical history are generally not enough to distinguish between infectious and
non-infectious bursitis; aspiration of the bursal fluid is often required for this, along with a cell culture
and Gram stain of the aspirated fluid.[6]:p. 360 Septic prepatellar bursitis may be diagnosed if the fluid is
found to have a neutrophil count above 1500 per microliter,[5]:p. 608 a threshold significantly lower than
that of septic arthritis (50,000 cells per microliter).[6]:p. 360 A tuberculosis infection can be confirmed
using a radiograph of the knee and urinalysis.[12]

122. Man has been having pain on lower back, tenderness in lumbar region on point pressure. Dx:
a. Lumbar disc prolapse (that’s all I remember)
b. Incomplete

123. Old man, back pain one week ago while working in the garden, now came with point tenderness, low grade
fever, what is the likely dx
903
 A. Discitis (fever present)
B.herniation
C.sepsis
D.vertebral fracture (no fever)

124. 65years complaining back pain after gardening o/e point tenderness in lumbar vertebrae what will you do
next
MRI
bedrest …vertebral fracture
continue activity

125. pt has colles fracture treated 2 months ago. Her xray at follow up at 6 weeks was normal. Now c/o pain and
tingling sensetions at the site of fracture what u will do next?
1. repeat xray
2.Mri to see ligaments-to rule out vic( vascular injury compartment syndrome)
3 exercises
4.analgesia — regional pain syndr jm 723
5.brace
126. Older woman with pain in proximal muscles of shoulder and pelvic girdle. ESR elevated (I think in 50s).
Management?
a. Prednisolone ANS-polymyalgia rheumatica
b. Paracetamol
c. NSAID

127. Patient went intramedullary wire fixation for tibia fracture..pain exaggerated on passive dorsiflexion of his
big toe..which management should proceed (contro)
a. -review after weeks
b. -put more analgesic
c. -leg elevation-
d. -4th option forgot may b invx like xray-best inx for compartment is MRI, rx is surgery to open the compartment,
fasciotomy
e. -stabilize with plaster cast
128. A 49 year old female presented with progressive back pain. She has a history of Breast Ca (and Sx done at her
35yr age) and lumbar osteoarthritis. What of the following clinical features will help you decide the investigation
(MRI) to do?
a. Past history of breast Ca
b. Back pain without trauma
c. Past history of vertebral osteoarthritis
d. High blood pressure
e. Radicular Pain radiating to the buttock

129. Humerus dislocated X-Ray in a man while skateboearding. Asking what will he most likely experience?
a. Posterior dislocation of the humerus head
b. Tingling and numbness in the inner aspect of arm
c. Tingling and numbness in outer aspect of arm ANS
d. Other ones

Injury of axillary nerve (axillary neuropathy) is a condition that can be associated with a surgical neck of the humerus
fracture. Injury in this nerve causes paralysis (as always) to the muscles innervated by it, most importantly deltoid
muscle

904
130. ankylosing spondylitis scenario. Asking treatment.
A. hydroxychloroquine
B. Methotrexate
C. Sulfasalazine
D. Steroids
E. tumour necrosis factor inhibitor-ex-adalimumab,infliximab,etanercept

The signs and symptoms of ankylosing spondylitis often appear gradually, with peak onset being between 20 and 30
years of age.[9] Initial symptoms are usually a chronic dull pain in the lower back or gluteal region combined with
stiffness of the lower back.[10] Individuals often experience pain and stiffness that awakens them in the early
morning hours.[9]

905
131. 40 yrs old present with low back pain, tenderness over L4/5 area, with sharp pain down the leg and foot,
neurological examination is normal, what ivx?
a. Lumbosacral spine Xray
b. Lumbosacral spine MRI
c. Lumbosacral spine CT
d. Lumbosacral spine something???(sorry I forget)
e. Observation

906
132. Person with pain tenderness swelling of knee presented joint aspiration shows gram posi diplococi
(streptococcus pneumonie, enterococcus)wat next
a. Do xray
b. Start ceftriaone vanco — suspecting septic arthritis, (ceftro for
gram negative,vanco for positive), actually rx is IV di/flucoxacillin
c. Do arthroscopy for pain relief
Treatment for septic arthritis:

133. A boy come with high fever (38.5) and swollen knee, pain at
the medial tubercle of the knee, what treatment will you give?
a. Penicillin G
b. Penicillin G + gentamicin
c. flucloxacillin
d. Erythromycin

134. Man came with knee pain lat side,pain comes up with walking
in broad base or running in slope,on examination u find pain
extending the flex knee and tender in 30° flexion.. xray normal
a. Lat.menisci tear(pain in lat side of knee and on internal rotation)
b. Stress fracture of lat epicondyle
c. Ilio tibial tract strain — up and downhill jm 774
d. Patellar femoral pain syndrome(anterior knee pain)— joggers
knee jm

135. what will increase pain in lateral epicondylitis

a..pronation***
b..supination

136. pic of boutonnières deformity. ..

Mechanism of injury asked
Ans-Flexion of the pip joint,hyperextension of DIP joint***

137. Supracondylar fracture with swollen elbow and numbness of fingers.Immediate management after
analgesics? Jm-1465
A)X ray
B)Fasciotomy
C)Reduction****-already diagnosed as supracobdylar # if not dx then do xray first ,preferred RX is in OT
D)Ulnar nerve decompression

907
138. Young boy, accident with slipped fall during skiing. Very marked swollen elbow, very painful. On
examination, absent peripheral pulses, numbness cold and clammy. At emergency department, what is your next
step of management? Dx: supracondylar fracture (contro)
A. Ulnar nerve decompression
B. Reduction
C. Refer to OT (amedex)
D. Simple analgesic-then x ray,then rx based on the type of #
E. X ray

Clinical signs that indicate urgent orthopaedic review in the ED include:

absence of radial pulse
ischaemia of hand: pale, cool
severe swelling in forearm and or elbow
skin puckering or anterior bruising
open injury
neurological injury

8. Do I need to refer to orthopaedics now?

Indications for prompt consultation include:
Associated absence of pulse or ischaemia
Open or impending open fracture (large anterior bruise)
Associated nerve injuries
Gartland type II & III fractures
Associated same arm forearm or wrist injury
Flexion supracondylar fractures
Unable to achieve or maintain reduction (including if ED is not experienced in fracture reduction, splinting or casting)

139. Patient with history of bluish discoloration of fingers specially in winter but after taking Nifedipine, patient is
feeling better but still has pain, what to do next?
Steroids
Azathioprine
Hydroxychloroquine if 2nd to sle jm 305
Cyclosporine
Cyclophosphamide

Ans: nsaid
***** if 2nd to RA: methotraxate

140. Middle aged woman with pain in right thigh worse at night n morning.( But gets better after 10 mins of walk:
wrong stem). Hx of bilateral knee OA. Next Investigation?
a. X ray right hip
b. Bone scan
c. X ray lumbosacral spine***
D. MRI
E. Doppler Usg

141. child presented with multiple bruises in back,X ray_periosteal bone formation (as multiple sites.cause?-
Nonaccidental injury(my ans)
Osteogenesis imperfecta…. bruises not common

908
**A periosteal reaction is the formation of new bone in
response to injury o r other stimuli of the periosteum
surrounding the bone.[1] It is most often identified on X-
ray films of the bones.
A periosteal reaction can result from a large number of
causes, including injury and chronic irritation due to a
medical condition such as hypertrophic osteopathy,
bone healing in response to fracture, chronic stress
injuries, subperiosteal hematomas, osteomyelitis, and
cancer of the bone. It may also occur as part of thyroid
acropachy, a severe sign of the autoimmune thyroid
disorder Grave's disease

142. 11 mths old child come with bruises on the back multiple areas of subcortical bone formation. Agitation
present.
A rickets
B infantile cortical osteosis
C haemophilia
D osteo imperfecta
e non accidental injury
**Infantile cortical hyperostosis is a self-limited inflammatory disorder of infants that causes bone changes,
soft tissue swelling and irritability. The disease may be present at birth or occur shortly thereafter. The
cause is unknown. Both familial and sporadic forms occur. It is also known as Caffey disease or Caffey's
disease.
https://radiopaedia.org/articles/caffey-disease-1

143. man,back pain after lifting heavy object, radiates back of thigh upto sole. SLR positive at 30 degrees.
expected clinical finding?
a. loss of knee reflex, L3-L4
b. loss of ankle reflex-sciatica, S1
c. sensory loss outer thigh — meralgia paresthetica-lat cutaneous nerve L2-L3,
d. sensory loss, anterior thigh-femoral nerve and its branches
e. ,weak knee extension L3
JM 747,741

909
910
144. The patient comes with morning stiffness of both wrists for 1 to 2 hours and both wrists pain. (not mention
other joint pain). Now patient is concern and comes with this wrist joint pain. Her lab results as follow.
Hb à reduced
MCV à slightly reduced (nearly below lower margin level)
ESR à 70 (sure for this level)
a. NSAIDs
b. Prednisolone
c. Hydroxychloroquine-sle best choice
d. Methotrexate-best choice for RA-aft 6 weeks of NSAIDs
e. Etarnarcept — Initially NSAIDs and best Methotrexate
145. A 26-year-old man is stabbed in the arm in pub brawl.
There is no evidence of vascular injury, but he cannot flex
his three radial digits after that event He has injured the
A)Posterior intessous ligament
B)Radial nerve
C)Median nerve (I choose)
D)Musculocutaneous nerve
E)Ulnar nerve

146. A 12-year-old male presents with acute onset of

inability to walk and severe pain in the groin, thigh, and
knee. There is no signs of fever He is and appears nontoxic
but is obviously distressed. Examination shows an
externally rotated thigh and apparent limb shortening. What is the MOST likely diagnosis?
a. Osteosarcoma
b. Slipped capital femoral epiphysis jm 734
c. Septic arthritis of the hip
d. Toxic tenosynovitis of the hip
e. Osgood-Schlatter’ s disease

147. long history about 55 yr postmenopausal female pt concerned about risk of osteoporosis , she had done an
oesohageal operation and still complaining of some GiT problems, her t score cevical 2.5 and Lumbar T score -2.5,
they give lab their ca level is normal and vit d level is normal and no mention in the Q about any menopausal
symptoms,what is your most appropriate management ?
a. alendronate (is a bisphonate with gi side effects)
b. ca plus vit d
c. Strontium ralonate-only CI in renal or vascular diseases-jm986

148. A postmenopausal woman with back pain; DEXA -2.5. She had normal Calcium level but low vitamin D level.
What is the treatment of choice?
a. Ranoxifene
b. Vitamin D
c. Oral calcium
d. Alendronate****

149. Women with Osteoporosis on HRT for 5 years, bone density score for spine vertebrae is -1.7 and for femoral
head is -1.2.What is next?
a.Nothing
b.Continue same
c.Change HRT to Alendronate
d.Add Alendronate
e.Vitamin D and Ca supplement

911
150. 70 yrs lady has previous 2 times H/o vertebra # or something like this and now again with the same issue..all
her vitD,Ca, Albumin all level ok, she is on raloxifene 25 mg, what to do now
A.continue current treatment
B. increase Raloxifene dose to 50 mg(if gi problem present)
c.stop raloxifene and start Alendronate(ans)
D. continue raloxi and add Alendronate
E. once weekly injection

Raloxifene

Raloxifene is a selective oestrogen receptor modulator (SERM) that has been shown to prevent
postmenopausal bone loss (Table 2). It has beneficial oestrogen-like effects on bone, but also has anti-
oestrogen effects on the breast and endometrium. A RCT has demonstrated that raloxifene increases
BMD in the spine and femoral neck and reduces vertebral fractures.32

151. long history about 55 yr postmenopausal female pt concerned about risk of osteoporosis her t score cervical
- 2.6and Lumbar T score 1.6 they give lab their ca level is normal and vit d level is normal and no menopausal
symptoms,what is your most appropriate management
a. alendronate*****( could be given if there is no oesophageal or GIT history or current infection)
b. ca plus vit d( should be given for prevention )
c. HRT( is ist choice in postmenopause women with menopausal symptoms)
JM 986

152. A woman presented with back pain. She’s had mastectomy done. MRI shows metastatic vertebral lesion.
What is the best treatment for the pain?
a. Morphine*
b. Radiation***
c. NSAID
d. Tamoxifen

912
153. colles’ fracture scenario and xray, management ask?
a. open reduction and internal fixation
b. plaster cast
c. reduction and apply below elbow plaster cast jm 1468

154. Displaced colles fracture 155. undisplaced colles fracture

156. Man having numbness of index and thumb brachioradialis reflexes bit low power in muscle 5/5
A. Thoracic outlet syndrome
B. Carpal tunnel???/
C. Cervical spondylosis(involve c5-6 and c6-7) jm 691

157. 33 year of woman who had done TAH and BSO, t score femur -2.5 and vertebra -1.5, what to give
a. oestrogen therapy
b. oestrogen and progesterone
c. vit D and Ca
d. alendronate

158. gout scenario of gout with CRF, treatment ask

913
a. allopurinol
b. colchicine
c. naproxen
d. prednisolone????

Usual first medication of gout

acc to HB is indomethacin
(NSAID e gi side effects,)
allopurinol which is given
ONLY after 4 weeks of an
acute attack.
Colchicines is usual not given it
also is contraindicated in
kidney problems
NSAIDS contraindicated in cvs
and renal cases.

159. . Gout scenario with no

history of renal failure, pt
taken allopurinol 100mg now present with gouty tophi, tx? Jm 373
a) paracetamol
b)colchicine
c)increase allopurinol***(can be increased upto 300mg)
d) naproxen

160. one xray of bamboo spine, history of back pain not relieved by taking analgesics, asking for tx?
a. methotrexate
b. sulfasalazine
c. surgery
d. refer to ortho
1st line AS is NSAID
2nd line: TNF inhibitor INFLIXIMAB
insufficient effect ad:MTX or sulfasalzine.
161. painful knee with fever. INV
a. arthrocentesis
b. xray knee
c. MRI knee
d. ESR

162. 22 year old male pretend with right knee pain while jogging, and relieved by rest, on exam knee movement
is normal and no limitations to joint mobility, no fever, no swelling, no deformity, x ray is normal too. Dx?
A. Stress Lateral epicondyle fracture
B. Lateral meniscus injury
C. Patellar femoral pain syndrome 772 JM
D. Septic arthritis
E. Osteoarthritis

163. Xray of bamboo spine not relived by paracetamol what next

a. physiotherapy and hrydrotheray-nxt is

914
 b.salfasalazine
c.Infliximab
d.Methotrexate
ans: nsaid

164. spine x ray of bamboo spine.history of not responding to

paracetamol and paracodeine Treatment asked?
a. Naproxen –NSAIDS first,then TNF blockers and IL1 and finally MXT
and sulphalasize
b. Infliximab****
c. Methotrexate
d. Prednisone

165. Pic of tophi on fingers. Renal failure (+). Rx.

a. Allopurinol
b. Naproxen
c. Colchicine

Usual first medication of gout acc to HB is indomethacin (NSAID

e gi side effects,)
allopurinol which is given ONLY after 4 weeks of an acute attack.
Colchicines is usual not given it also is contraindicated in kidney
problems
NSAIDS contraindicated in cvs and renal cases.

166. almost similar pic of anthology crash fracture. I saw there was compression fracture of vertebra. scenario
was an old lady with history of fall come to you with back pain,there was no neurological deficit ,but fracture was
there , got two ques one was asking wat will u do next-
a. mri
b. bed rest
c. continue activity

167. 40 year old woman after lifting some heavy thing ,

develops pain in the right buttock and tenderness in her back at
L4-5, has difficulty and restrictions of movement in extension
and flexion and rotations , what will you give beside analgesic?
a. spinal x ray( >60 yrs, osteoporosis, more chances of
vertebral #, femoral# which may remain silent .
after doing xray he can continue activity)
b. spinal mri( gold standard if pt has numbness)
c. bed rest
d. referral to orthopedics
e. keep active***
Dx: vertebral dysfunction
Ø .other was asking acetaminophen and NSAIDS fir about rx-
b. nsaid
c. alendronate

915
168. Old man with back pain. Xray given which shows collapse
of L4 or L3 as well as osteopenic bones. Lumbosacral x ray was
done. Which of the following is the next best step?
a. MRI-first exclude mm
b. PSA
c. DEXA***
d. Bed rest

169. Fracture of neck of humerus clear pic with scenario asking

clinical feature ?
a. Paralysis of biceps muscle
b. numbness of lateral aspect ,
c. numbness(can't recall the exact word) of medial hand

The surgical neck of the humerus is a constriction below the tubercles of the greater tubercle and lesser
tubercle, and above the Deltoid Tuberosity.
It is much more frequently fractured than the anatomical neck of the humerus. A fracture in this area is
most likely to cause damage to the axillary nerve and posterior circumflex humeral artery. Damage to
the axillary nerve affects function of the teres minor and deltoid muscles, resulting in loss of abduction
of arm (from 15-90 degrees), weak flexion, extension, and rotation of shoulder as well as loss of
sensation of the skin over a small part of the lateral shoulder.

170. Another scenario was baby cries when movement with left hip . On examination all movements are normal .
Most probable diagnosis , options were
a. developmental dysplasia of hip ,
b. slipped capital femoral epiphysis. . .

In postmenopausal women with h/o breast ca with vertebral fracture chose alendronate
and if alendronate couldn’t be given raloxifene
In GI complications chose zolendronic acid
In steroid use or in cases with less dosage chose zoledronic acid.

171. another similar scenario,old lady with back pain ans T score showed osteoporosis, lady has esophageal ulcer
and dysphagia, what will you prescribe to her?
a. Alendronate
b. Ca vit D
c. Zolindronic acid- Zoledronic acid (Zometa) is used to treat high levels of calcium in the blood that may be caused
by certain types of cancer
d. Nsaid

Gastrointestinal adverse effects are the most common and upper gastrointestinal disorders
or oesophageal abnormalities are considered a contraindication to oral bisphosphonate
use. . Zoledronic acid is an intravenous infusion that is administered once per year for
osteoporosis treatment and prevention.

172. osteoporosis scenario . vertebral n non vertebral -2.5 each. Gerd present - zolidronic acid (IN BONY METS)
173. 2 scenarios of osteoporotic women, one had previous Breast Ca, other one had sterilisation due to
menorrhagia asking treatment at both, almost same answers
a) Alendronate
916
 b) I.V. Zoledronic acid***(once 6 month, preferred than alendronate coz of dosage) annual acc to jm
c) Vit D

174. Old woman with steroid use (peptic ulcer, gi bleeding)taking risedronate 3 months has
frequent #Thoracic vertebrae, what next?
a. changes to alendronate?
b. increase it
c. continue
d. change to IV zolendronic acid?

Combination approaches involving co-administration of bisphosphonates with other antiresorptive

medicines (eg. strontium) or anabolic medicines (eg. teriparatide) are not recommended.

175. Old lady with back pain after falling, complaining there is pain in her rt lumbar region radiating upto toe,on
exam there was no neuro deficit,wat will be your mx?
a. Xray
b. Mri
c. Continue activity
This radiating pain is simply referred pain. If it was radicular pain then there should be some
neurological deficit (eg. Loss of sensation in particular dermatome, loss of jerk)...in our
ques it is simple radiating pain with no neurological deficit so I will do simple xray as this
pt is supposed be in red flag bcz she is old (>50 yrs)

176. Pt has bilateral knee osteoarthritis...now comes with pain in lateral side of one thigh. Inv?
a. Xray hip- osteo hip causes pain in medial aspect of thigh
b. Xray lumbosacral spine — meralgia paresthetica — compression of a nerve(lat fem cut n) that
causes pain in lateral aspect of thigh
c. Xray thoracic spine
d. Bone scan

917
177. Another rta q!!!! Pt with neck pain, now stiffness due to
pain, triceps jerk lost, inv says disk prolapse.asking which one
a. C5-6-biceps,brachioradialis
b. C6-7-
c. C7-T1
JM 688

178. Dupuytren contracture pic. Rx

a. Corticosteroid inj
b. Physiotherapy
c. Sx
d. corticosteroid inj-needling, collagenase inj etc, if fails
e. surgery.

179. A 43-year-old male presented with acute non-radiating back pain since last 2 days.Pain started after lifting heavy
weight at work.Physical examination is significant for localized tenderness at L4-L5 level.Neurological examination is
completely normal.What is the next best step in the management of this patient?
a. X-ray spine
b. MRI scan
c. CT scan
d. Analgesics for pain and restrict normal activity-bed rest
e. Analgesics for pain and encourage normal active

180. A lady whose mother has osteoporosis and had Fx. Femoral head asking advice for herself. She works as a
receptionist and not having healthy diet.
a. Check Ca level
b. Check vit D level-bcos she is comin under risk for low vit d
918
c. Bone mineral density

https://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&cad=rja&uact=8&ved=0ahUKEwjX_Ma
Qh_nWAhVqy1QKHRDACDUQFgg1MAI&url=https%3A%2F%2Fwww2.health.vic.gov.au%2FApi%2Fdownloadmedi
a%2F%257BB7FD55F3-0E01-4D80-8A37-0EDC6DF1894D%257D&usg=AOvVaw35Zvtav4Dp1V9j7sBUqWKb

181. Cast after wrist Fx. What is the earliest sign of tight cast?
a. Itch under the cast
b. Pain
c. Swelling in fingers
d. Color changes in fingers

First tingling and pain, swelling,

182. A 43-year-old male presented with acute non-radiating back pain since last 2 days.Pain started after lifting
heavy weight at work. Physical examination is significant for localized tenderness at L4-L5 level.Neurological
examination is completely normal. What is the next best step in the management of this patient?
a. Aspirin
b. Aspirin+ codeine
If only these two options then select aspirin.use paracetamol if given.

183. Anthology vertebral fracture picture with 40 years lady with sudden severe pain radiation to thigh and toe
with no neurological deficit next investigation
a. Spine Xray
b. MRI….investigation
c. Bed rest
d. Analgesia…management
e. Continue activity
MRI is usually the study of choice to detect the extent of
damage to the spinal cord. MRI is the most sensitive tool
for detecting lesions of both neural tissue and bone.

184. Same vertebral fracture picture in old lady with lower

back pain radiating to buttock, All exams normal. What’s the
best management here
a. Bed rest
b. Continue activity
c. MRI spine-FRACTURE + RADICULAR PAIN go for MRI
d. Corset
e. Observation

185. 58 year old lady worried for postmenopausal fracture

due to osteoporosis,,,she was treated for ca breast 4 years
back,,,,u did scan and T value -
2.6 treatment….Next initial
management ?
A. CAL/VIT D
B. ALENDRONATE
C. HRT
D. RELOXIFEN- always in case
of postmenopausal women

919
186. Colles fracture image below, how to manage?
a. Plaster
b. back slab
c. sling

187. Figure 2 Colles Fracture

188. Old woman with steroid use taking risedronate 3months has
frequent #Thoracic vertebrae ,what next?
a. changes to alendronate
b. increase it
c. continue - If BMD remains low (T-score ≤–2.5) and/or there are incident
vertebral fractures, continue treatment
d. change to IV zolendronic acid-since she is taking corticosteroids
-very good site

920
Ans: teriparatide

921
http://www.racgp.org.au/download/Documents/Guidelines/Musculoskeletal/osteoporosis-guidelines.pdf

189. 58 years old male patient had pain in the back after gardening, going down right back of left leg and knee
and. Foot. Straight leg raising examination was painful. All other neurological examination normal. What is the
associated symptom??
a. Pain in ant. Thigh
b. B- loss of ankle jerk -sciatica
c. C- loss of knee jerk

190. An old man with history of gout is brought to you following a painful knee. He also has chronic renal failure.
The knee is tender to touch and warm. On aspiration you see polymorphs, turbid fluid and birefringent crystal
(negative or positive not mentioned). Which of the following is the correct treatment of choice?
a. Indomethacin
b. Allopurinol
c. colchicine
d. Prednisolone
e. Codeine

191. 8)A 25 years old soccer player got injured in his knee during a game. Initially there was pain that subsided
after hours. After some days effusions started to expand. Finally when the swelling settled he feels sometimes his
knee is locking in full extension and sometimes his leg gives away. What is the diagnosis?(contro)
a. Only ant cruciate ligament injury -
b. Med meniscus injury -ans
c. lateral collateral ligament injury
d. Medial collateral ligament injury and medial meniscus injury
** Subacute effusion (after 24 hours) + locking/ clicking + Mc Murray +ve—> Meniscus
injury
Valgus stress in 30 degrees flexion —> Laxity/ instability (described as leg gives away) =
MCL injury Ans: D

192. Adolescent presenting with swelling in lower femur with xray scenario of elevated periosteum, calluses of
new bone formation without involving epiphysis, he had mid injury while playing few days back-
a. osteomyelitis
b. osteosarcoma, -elevated periosteum-codmans triangle,new bone formation,sunburst/hair on end
appearance,commonly after an injury.

922
c. Osteoclastoma-after fusion of
epiphysis,usually long bones,

193. 15. 72 years old Man come with low

back pain . On investigating X ray , found
L4-L5 compressed fracture .Many lab
investigations: low Hb around 85 , mild
leukocytosis , ESR 108 , What will you do
to know the cause of fracture ?
a. PSA
b. Bone marrow examination
(Low back pain + old age + ESR more than
100 = M.myeloma )
c. MRI spine
d. Spine X ray

194. Sport man ( ?football ) he injuried his knee

during playing , cannot flex knee , knee is swollen,
red , very painful , temperature normal , Next
appropriate
a. Arthrogram
b. Arthroscopy
c. MRI knee
d. CT knee
e. Aspiration of knee ( no USG option )

923
I chose MRI

195. 3 year old child, knee pain ,limping...on examination tenderness on knee,, No definite swelling,no fever..next
step(Hb: low..Plt..low..Esr:high)
A: aspiration of knee
B: xray of knee***
C:bone scan
D:bone marrow examination (best is bone marrow suspecting bone marrow)
E: FBE
If question says no tenderness or movement restriction in knee then answer will
be examination of hip joint.
If obese, 10-15 yrs, painful limping and irritability of hip movement may b
bilateral+knee pain> SCFE>xray hip
3-8yr+sudden onset of hip pain +limping+h/o trauma or recent urti> transient
synovitis> xray hip (normal findings)+usg
924
4-8 yrs+ painless limping+aching+may b knee pain can b bilateral+problm in
abduction and internal rotation> perthes> xray hip>refferal
2 -10 years ALL there is not only knee pain but other systemic symptoms too
196. A diabetic foot ulcer, diabetes controlled, dorsalis pedis and peripheral pulsation was felt, and culture was
taken. Picture nearly the same but less severe and less oedematous). What to do?
A. X ray foot***( done aftr antibiotic course if ulcer is not healing, if more than 6 wks then MRI)
B. Doppler US
C. Angiography
D. WBCs count

197. A pt had knee injury knee is swollen, & medial ROTATION PAINFUL. cause TEAR OF??
A. ACL
B. PCL
C. Medial meniscus
D. Lateral meniscus jm 769

925
198. ).Indigenous 15 year with Flitting (migratory) joint pain and rash in back next inv.(rheumatic fever)
a.ESR
b.Throat swab***.
c.ECG
d.Full blood count
e.CXR

199. 82) pt with arthralgia and back rash ?

investigation asked?( (incomplete stem)
a. Rheumatoid factor
b. Ana ****

200. )Septic arthritis scenario,60 yrs old man,fever

38,painfull knee & swollen knee,whats next?
a.aspiration knee**** Aspiration first to rule out
infective arthritis and start antibiotics if needed.
.xray can be done later
b.antibiotic
c.xray knee
for (children JM 364)

201. 65 years complaining back pain after

gardening o/e tenderness in lumbar vertebrae L3,L4 & limited flexion & extension,after giving analgesics what is
ur next mx?
bedrest

926
 continue activity****
refer to orthopaedics
corset
no MRI in option
ans.a (old+lumber tenderness,unsuspecting vertebral #)

202. female pt comes with wrist pain & stiffness for 1-2 hr ,this condition for last 5-6 years,on lab inv high
ESR,what is the best mx?
a.NSAIDs
b.Prednisolone….. if age below 25 to 40 then SLE and typical pain is wrist pain
c.methotrexate

927
203. injury of the knee(which ligament affected when pain on medial twisting)?
a. Medial meniscus
b. Lat meniscusjm pg 769 table signs point 4

204. 205) lateral epicondylitis, what would make it hurt more?

a. Pain on resisted wrist extension (jm 715)
b. Or passive flexion of wrist

928
205. )32 year old with history of hysterectomy and oophorectomy ,done for menorrhagia.She has -2.8 Z
score.What to give?
Vitamin d
Calcitriol
Estrogen
Estrogen and progesterone
Alendronate
osteoporosis scenario with T score -2.5 ,low normal ca ,and low vit D. What to give??
a) Alendronate
b) Calcium
c) Calcitrol
d) Ralixofen

206. X ray of shoulder dislocation asking about most appropriate statement

Loss of sensation of medial part of arm
Loss of sensation of lateral part of deltoid**
#of head of humerus

207. Q225) X-ray of ant shoulder dislocation asking about consistent sign
Loss of sensation over deltoid****
Loss of biceps reflex

208. 40 / m gardening. Pain L4/L5 , pain radiating to buttock .. no neuro deficit ..

X-ray spine***
b. Ct spine
c. Mri spine
d. Observation
E. Pet scan

209. Q300)83 yrs old female compression vertebra X-ray (fracture) was given i think from anthology . what will u
do ?
a. bed rest and analgesia*****
b. continue activity
c. MRI spine

210. Q301) Low back pain , 58 yrs old man , felt tenderness at Lumbar spine (levels mentioned maybe L1L2) no
neuro deficit. wt will u do
a. X-ray( if ask about investigation)
b. mRi spine
c. continue activity*****

211. A case of lateral epicondylitis. Treatment?

Lateral epicondylectomy
Immobilization of the fingers
Analgesic****
Sling below elbow
Brace at the elbow

929
First choice analgesics then brace below the elbow

212. Patient complaining of soreness on lateral epicondyle at

the end of work, the patient attributes it due to computer
mouse clicking. On examination, tenderness on lateral
epicondyle. What is the most appropriate treatment?
a. Lateral epicondylectomy
b. Finger immobilization splint
c. Lateral epicondyle immobilization splint
d. Bracing under lateral epicondyle
e. Analgesic

213. A couple comes to the GP clinic for infertility treatment.

All investigations of wife was normal. Husband is on
medications for arthralgia. What will be your advice?
a. continue methotrexate and hydrochloroquinone(HCQ)
b. cease methotrexate and continue HCQ.***
Methotrexate may cause an increased risk for infertility, not
birth defects. Low sperm count has been seen in some men
using methotrexate
c.cease both drugs
d. continue methotrexate and stop HCQ

214. .lateral epicondylitis-long h/0 working on table.pain in

lateral epicondyle-wats da cause-
a.Tendon injury***
b.bursa inflammation

215. Middle aged man came with the complaint of weak in hand grip; numbness in 4th and 5th finger; pain in his
shoulder radiating down to his inner aspect of his forearm. Triceps jerk is lost. What is your Dx?
A. Brachial plexus neuralgia****(c8, t1)-
B. Nerve root compression- here c7-c8, mostly c5-c6 & c6-c7 is common for this plus no neck pain.
C. Ulnar neuropathy

216. 11 month old infant is brought by his mother. Mother is quite concerned. X ray shows subperiosteal new
bone formation in multiple areas. What is your Dx?
A. Non accidental injury
B. Osteitis imperfect****
C.osteosarcoma

217. . A boy come with high fever (38.5) and swollen knee, pain at the medial tubercle of the knee,,what
treatment will you give?(dx -septic artritis)
a. Penicillin G
b. Penicillin G + gentamycin
c. flucloxacillin****(septic arthritis)
d.Erythromycin

http://www.aafp.org/afp/2003/0901/p917.html

Acute sepsis can affect any joint at any age, although it is more common in children. It evolves over hours or days
and can rapidly destroy a joint structure. It is an emergency in the hip joint of children. Check for IV drug use. The
commonest organisms are S.aureus and N. gonorrhoea.
930
Diagnosis - blood culture and synovial fluid analysis and culture.
Treatment -
drainage and washout of the joint
IV followed by oral antibiotics e.g. di/ flucloxacillin.
septic arthritis hip joint
218. 4 year old child came limping, Temperature is 38 degrees, all knee examination normal but hip movement
was markedly restricted, what is the diagnosis?
a)Septic arthritis***
b) Tenosynovitis(follows urti)
c) Perthes-no fever

However, the diagnosis of infectious arthritis rests on the isolation of the pathogen(s) from aspirated joint fluid.
While any joint can become infected, the most commonly involved joints in nongonococcal septic arthritis are the
knee and hip, followed by the shoulder and ankle (9).

219. year old male with a history of fall on an outstretched hand with pain and swelling. XRay was given, ( showed
scaphoid fracture. Very clear fracture line throught the middle)
What is the best treatment option for this patient
a. Crepe bandage
b. Plaster cast**** jm 1470
c. Analgesics
d. Compression screw
e. Plate fixation

220. Case of woman who broke her wrist, came back in 6 weeks, Xray shows satisfying union, then she came back
in 8 weeks with persisting pain, what to do next-
A- bone density
B- repeat xray****-Dx sympathetic dystrophy- Most commonly, pain, swelling, redness, noticeable changes in
temperature and hypersensitivity (particularly to cold and touch) occur first
C- mri for tendon investigation
Dx: post traumatic chronic wrist pain
Inv: mri jm:733

221. . 50 years old man who suffers from rheumatoid arthritis and who has been treated with prednisolone for 3
years developed peripheral neuropathy of the lower extremities. This neuropathy is most likely due to
a. arsenic poisoning
b. thiamine deficiency
c. development of necrotising arteritis ***
d. ruptured intervertebral disc
e. vitamin B12 deficiency

this is a rare disease, and doctors don’t know what causes it. However, autoimmunity is considered to play
a role in this disorder. Autoimmunity occurs when your body forms antibodies and attacks your own
tissues and organs.

You’re more likely to develop this disease if you have an autoimmune condition, such as rheumatoid arthritis (RA) or
systemic lupus erythematosus (SLE).

222. A 32 year old woman presented with bilateral joint swellings of her proximal interphalangeal joints
associated with a 45 minutes period of early morning stiffness of joints. She has obvious rheumatoid nodules and
a high rheumatoid factor assay. Which of the following is the best treatment of choice.
931
a. infliximab
b. sulfasalazine
c. methotrexate****
d. prednisolone
e. Hydroxyurea

223. 58yrs old man, drag left foot, reflexes on left lower limb are increased, planter flexion & dorsiflexion are 4/5,
weak ankle movements, equivocal plantar reflex, upper limb and face are normal exam.Lesion site
a. Common peroneal nerve
b. Cervical spinal cord
c. L5,S1 nerve root
d. Cerebral cortex
e. Brain Stem

224. A 12 years old girl presents with a sudden history of loss of sensation on the lower limbs associated with
decreased reflexes and progressive ataxia . Which of the following is most likely the cause of her condition
B12 deficiency( old age )
Friedreich´s ataxia**** (young age 7-15)- Foot deformity, scoliosis, diabetes mellitus, and cardiac involvement are
other common characteristics.
Charcot marie tooth diseases- Patients usually do not complain of numbness. This may be because patients with
CMT disease never had normal sensation and, therefore, simply do not perceive their lack of sensation ,
hammertoes, genetic, abnormal gait, Inverted champagne bottle legs,EMG ,no cure,physio
Dermatomyositis -accompanied with rash(painful and itchy violet) with muscle weakness.ck inc

225. Pt with 2 ulcers, one on leg above medial melleolus and other on plantar surface of foot over the head of
2nd metatarsal. Burger test positive of that limb. H/O claudication while walking, and rest pain as well. And pulses
and not palpable for this limb. Asked reason behind the pain?
a) Ulcer
b) positive Burger test
c) Osteomyelitis

932
226. Tennis player , came with injury. Pain while examination. 1 . Partial rotator cuff tear2. Clavicle-acro
dislocation 3. Gleno dislocated 4. Biceps head injury?

227. Serum calcium 2.9mmol/l. What Ix next

a. PTH
b. 25 Cholecalciferol
c. Evaluation of Hypercalcemia

http://www.aafp.org/afp/2003/0501/p1959.html

933
228. . Clavicle fracture pic.Fracture in the middle displaced overriding.what Is the management?
a-Fixation to coracoid bone
b- Intramedullary wire-if displaced
c-arm sling-if not displaced
d-repair supraspinous tendon

229. Old man

with a fracture between T8 and T10 showed increased
uptake on x ray. Labs were given with anemia and very
high ESR. What is the next investigation?

Plasma electrophoresis bcos looks like mm-if esr >100

PSA
Osteolytic lesion: multiple myeloma
Sclerotic: ptostate cancer

In MM bone lesions are lytic in xray but in metastasis of prostate cancer its sclerotic !!
If the increased uptake was only defined to fracture site then A
but increase uptake means sclerotic ...so i m with prostat cancer

230. 14 months old child,fever,irritability sudden onset of left lower limb pain,refuses to stand asking diagnosis
a.osteomyelitis-not necessarily joint b. septic arthritis-joint swollen

PAEDS 1
1. Newborn baby born to a diabetic mother at 36/40. Weight 4240g, APGAR 7/10, found to be cyanosed on his
hands and feet, also jittery. Axillary temperature was 37.2. He improved after aspiration and 100 % O2. The most
likely diagnosis is:
A. Hypoglycaemia-improved with o2
so cant be hypoglyc
B. Meconium aspiration
C. Heart disease
D. Lung disease
E.hypoxia

2. Child, post viral ITP. Non blanchable

petechial rashes. No other abn finding
or bleeding. On FBE
Hb n WBC normal. PLATS 35×10 9. Treatment?
a. Strict bed rest
b. Steroids——if active bleeding
c. Immunoglobulins—— if active bleeding

3. 9 months old infant with deformed occipito-temporal region of skull and prominent frontal region, what to do?
a. Change sleeping position

934
 b. CT
c. Ultrasound
d. MRI
e. Resaaure

4. 14 yo boy, delay at school for 1 yr, starts passing stools in his pants, reason (contro)?
Developmental delay, sexual abuse, inflammatory bowel disease

5. an infant who was delivered prematurely at 28 weeks with birthweight of 1100 grams. After delivery he was
given surfactant and intubated and kept in a ventilator for 3 days, now the baby present with spastic paresis in
his lower limbs. Cause?
a. prematurity
b. respiratory distress syndrome
c. intrapartum hypoxia
d. low birth weight
e. intrapartum infection

6. 15 years old girl, came with (fever, sore throat, swollen neck glands) Otherwise no medical illness, not on any
medications, no travel history. Asking (something like) what symptom will actually tell you the definite
diagnosis? (exact option) (contro)
a. Diffuse pharyngitis-ebv pharyngitis common jm pg 278
b. Temperature 38.5
c. Swelling of ankle

935
 d. generalized maculopapular rash
e. splenomegaly

but it can be pointing towards URTI, tonsillitis, nasopharyngitis... If we choose spleenomegaly along with symptoms
already in stem point more towards EBV

7. A 37-year-old female gives birth to her 2nd child. At the 10th day the child becomes jaundiced. His
mother tells the doctor that her first child had jaundice after birth and then developed bilateral cataract
after the jaundice. What is the diagnosis?
a) Congenital rubella
b) Neonatal hepatitis
c) Diabetes Mellitus
d) Syphilis
e) Galactosaemia

8. 4ys old child brought by mom has stridor, cough T 37.5, no other complaint, chest exam was normal, no
wheezes. His younger brother 2 ys old has Hx of asthma
What to give
a. salbutamol by face mask with spacer
b. oral prednisolone-croup
c. inhaler prednisolone
d. Na cromoglicate

936
937
9. 7 weeks child with high fever ,vomiting increased until it is now
after every meal ,no other signs, urine exam revealed 5*10*9 cells
what next :
a. Oral cipro

b. Oral amoxi

c. IV gentamicin-thinking uti severe infection===acute
pyelonephritis
d. IV cephalosporin
Jm 251

10. neonate found apnea in sleeping brought by parents to ER no HR

apnea with no bruises his death is pronounced next
A.Mention on his death paper as cot death(sids)
B.Inform child protection cervice
C. Refer him to forensic autopsy jm1075
D. Call the coroner — first call coroner and notify police then autopsy done
E.Arrange funeral for neonate instead of parents

11. 2 year old child presenting, mother concerned as he still doesn’t walk. On neuro exam he had exaggerate reflex
of lower extremity. He was born gestation age 26 weeks. At delivery he was given gentamicin and
dexamethasone for respiratory. Cause of his current symptoms?
a. Gentamicin toxicity-ototoxic
b. Antenatal infection
c. Preterm delivery ANS
d. Antenatal hypoxia
e. Something else
premature birth and evn intrauterine hypoxia are risk factors for cerebral palsy

12. Child 4 yo presenting with 6 episodes of respiratory infection in past 9 months. Cause?
a. IgA deficiency ===>6 in one year
b. Exposure to kindergarten ans
c. Don’t remember the rest
Normal for children to get 6viral infections/year

13. A woman delivered a preterm baby in her 2 nd pregnancy with 3100gm weight. Apgar at 1 st min is 6 and at 5 th
min is 9. Over the next few hours he develops grunting and Tachypnea and subcostal recession. He was started
on o2 at 4 hours of age but not relief. What is the most likely cause?
a. Birth asphyxia
b. Meconium aspiration
c. Tension pneumothorax
d. Transient tachypnea of newborn
e. Hyaline membrane disease

14. A child complaint coz problem at school . can’t give attention to lessons , and behavior problem. Snoring at night
but no wake up from sleep, sleep well but difficult to awake in the morning, on examination , moderately
enlarged tonsil but not inflamed
a. Give oral amoxillin for 4 weeks
b. Beclomethasone spray ===adenoid jm pg 832
c. Oral loratadine
d. Methylphenidate
938
 e. Other irrevelant drug

15. worried mother come with children to have antibiotic for meningitis.as boy visited child care where a girl dx as
meningitis from mon –Wednesday.but that child visit just on Friday.what to do?fever of child not mentioned.
a. Inform her about sign symptom of disease
b. Send her to imergency department
c. Give antibiotic

16. Child present with fever, neck stiffness, anterior fontanelle full , lymphocytes 5400cumm(n <5) , glucose is
normal ,no organism on gram stain, meningitis like scenario
a. Intravenous phenytoin
b. Rectal diazepam
c. Intramuscular morphin
d. Oral paracetamol- suspecting viral meningitis, glucose not
reduced and lymphocytes + , rx is symptomatic as it is self
limiting
e. Intravenous dexamethasone

17. Child present with fever, neck stiffness, anterior frontanalae full,
lymphocytes 5400cumm (n <5), glucose is reduced, no organism
on gram stain, After giving antibiotic and (fluid?), What will need
to give? (exact option) A. Intravenous phenytoin B. Rectal
diazepam C. Intramuscular morphine D. Oral paracetamol E.
Intravenous dexamethasone

18. child with fever drowsiness n cold extremities

Rash was mentioned asking treatment
a. Iv cefatholin-ideally ceftriaxone or cefatoxime
b. Iv gentamicin
c. Oral penicillin-not oral always iv for meningitis
d. Oral roxithro was there

939
 Jm pg 297- dx meningococcal meningitis

19. A child with fever drowsiness n cold extremities abd. Tenderness & abd. pain
Rash was mentioned asking 4 the treatment
a. IV Cefatholin
b. IV gentamicin
c. iv penicillin may be meningitis
d. Oral roxithro

20. 6 weeks old baby with non bilious vomiting he is thin and his growth is slow but look alert , his arterial blood
gases showed metabolic alkalosis. what will be your initial step in the management ?
a. Abdominal US
b. Oral rehydration
c. Iv rehydration and fluid balance (first) and then surgery-nil per oral-hps

21. 9 months old child irritable screaming bile stain vomiting and diarrhea. Her sis is suffering from gastroenteritis.
Usg shows shadows in right upper quadrant(mass In rt. upper quadrant)
What to do next
a. Air enema- (both therapeutic n diagnostic)dx intususception....bile staining late sign....proceeding rs or gi
Infection
b. Stool cuture
c. Urine culture
d. Observe

22. henoch schonlein purpura pic asking for management-nsaids,symptomatic rx and steroids-pred

940
23. Child after cold sores developed pin point lesions on the trunk and limbs of lesions were unblanchable. Labs
given. Clinical examinations were normal.(contro)
Hb – 86g/dl
WCC – normal (SURE)
Platelets – 35x10
What is your next step?
a. Bone marrow aspirate
b. Coagulation studies
c. Platelet function test
d. Urine microscopy + Culture — if hsp but hsp not pin point petechiae
e. EBV serology
Jm pg 435

• The clinical diagnosis of ITP depends on there being manifestations of thrombocytopenia without other
abnormal findings, in particular no pallor, lymphadenopathy or hepatosplenomegaly.
• Confirmation rests on the adequate exclusion of other causes of thrombocytopenia. The most important
conditions to exclude are acute leukaemia, other marrow infiltrative conditions and aplastic anaemia. An FBE
(including blood film) will usually confirm the diagnosis.
• A bone marrow aspirate is an invasive procedure with some morbidity in children who bruise easily, and is
only necessary if the diagnosis is uncertain. It is rarely necessary in uncomplicated ITP

24. child scenario of meningitis with fever, nausea and vomiting, head tilted to the right. wat investigation?
a) Lumbar puncture-if not mentioned as meningitis
b) blood culture-if alrdy meningitis mentioned
c) CT
d) sputum culture

25. 4 y child with colicky abdominal pain and two three episodes of mild diarrhea, abdomen tender and guarding

941
 a. Messentric adenitis\\\\perforated appendicitis
b. Entero virus-mostly resp illnesses
c. Rota virus
Correct ans missing…could be appendicitis

26. 1 year old child diagnosed with bacterial meningitis was admitted to
hospital.blood culture taken and iv ceftriaxone started.after 1 day of
admission child had a seizure of <1 min duration.long labs were given
sodium and bicarbonate low.all others were in normal range.what is the
cause of seizure?
a.SIADH(if bicarbonate low normal or normal)
b.dehydration(by exclusion)
c.adrenal failure(k high)

27. child with nephrotic syndrome treated with steroid, developed hypertension , diffuse abd pain and vomiting for
1 week ,Afebrile-
A acute pancreatitis
B acute pyelonephritis
C renal artery stenosis

28. child with signs and symptoms of meningitis develops seizures, generalised lasting for 5 minutes. His lab values
are normal except for sodium of 120mmol/l. What to do next?
A IV mannitol
B 0.9% normal saline
C 3% hypertonic saline-bcoz of seizures, if only meningitis and no seizure then give 0.9 %
D Fluid restriction
E Diuretics

29. Baby 6 weeks age, persistant vomiting (non bilious) since 2 weeks and constipation, abdominal examination
can’t be done perfect as baby was crying,but seems normal.what to do?
a)add food thickener
b)USG abdomen-hps

30. 8 year old child with persistent night pain in his left legs , on examination there was no restriction in active
movement and no swelling or tenderness what is the most appropriate next step?
A-X-ray left hip
B-ultrasound

942
 C-bone scan
D-bone marrow examination
E-Reassure****growing pains r usually bilateral but could be unilateral as well
Jm 1020

31. scenario of child with pain at nigh in his legs for several months ( his age is 5 yr the pain improved in the morning
,,,, with sore throat and bilateral lymphadenopathy X ray normal. what is your dx?
a.growing pain
b.perhtes dis
c.SCFE
d.irritable hip

32. 1 yr old child growing well , good feeding , stand with assistance , sits unsupported , say some some sound like
BABA , on exam. He had a systolic murmur ,whats next ?
A) refer him to pediatric cardiologist *****
B) reassure her innocent murmur (innocent murmur)
C) send for urgent echo
D) tell her that he could have a cong. Heart disease
Jm 1021

33. Mother coming to u asking about her 7 years old son who
played football with his friend one week ago, 2 days ago he
got red rash and diagnosed with meningitis, what will u do
about prophylaxis?
A) give ciprofloxacin 500 mg Oral to child immediately
B) give ciprofloxacin to whole family
C) counsel mother that its not spread through this contact
only****
D) say mother to bring when symptoms develop

Who requires prophlylaxis?

• Index Case (if treated only with penicillin)

• All intimate, household or daycare contacts who have been exposed to Index Case within 10 days of
onset.=meaning 10 days prior to onset also
• Any person who gave mouth-to-mouth resuscitation to the Index Case.

34. mother bring her child because child friend who slept in their house diagnosed meningitis, mx?
give cipro to child
cipro to whole family—— if house has children <12 months or <4 years and inadequately immunized
do lumbar puncture
blood culture
pg 1069

https://www.rch.org.au/clinicalguide/guideline_index/Contact_chemoprophlaxis_table/

35. A 7yr old is brought to your clinic, Her neck was tilted and fixed to one side. On examination, she had 2 palpable
neck lymph nodes. Her chest xray had bilateral pulmonary infiltrates (image not given). Her head circumference
was small for age, fundoscopy showed hyperpigmented retina. She had significant hepatomegaly of about 5cm
from costal margin. What is your diagnosis?
A Congenital rubella-also present at birth
B Congenital CMV****-rx ganciclovir
943
 C Cerebrohepatorenal (Zellweger's) syndrome-present at birth,dies within 1st year,no cure, rx just symptomatic,
dx is inc levels of long chain fatty acids in blood, pex dna test
D Combined immunodeficiency-rx is stem cell transplant-bone marrow transplant
E Hypergammaglobulinemia-inc IgM and red other IGs….gamma globulin testing…rx Ig replacement

36. 2 yr old girl with vulval discharge, O/E labia red, whitish discharge. Culture reports enteric organisms. Cause? a)
sexual abuse b) poor perineal hygiene-vulvovaginitis c) UTI d) chronic constipation

37. 8 mo old baby, parents concerned not babbling yet. Appears to respond well to sounds on examination. MX?
a) tell its normal variant
b) review in 6 mo….take audiological assessment if present
c) arrange speech pathologist referral
d)ENT consu

**if option includes audiologist referral for audiologic assessment take that..and for preterm baby its normal
https://www.childrens.health.qld.gov.au/wp-content/uploads/PDF/red-flags-a3.pdf

944
38. A 15 month old child is brought to you by his parents. He was born at 36 weeks by normal vaginal delivery and
his birth weight was 2500 gms. At 8 months a mother and child health centre test for hearing was done, which
was normal. The parents say that he babbles but does not speak any words yet. On P/E, the child appears
normal. What will you suggest?
a. Reassure the parents that this is a normal variant
b. Reassess at 18 months
c. Repeat mother child test for hearing
d. Arrange for audiometry testing

39. 8yr old child brought by his mother , he complained from episode of staring suddenly that occur along with
fidgeting of right hand and movement of right arm head twitching to right side, sometimes chewing and lip
smacking each episode last for 60-90 second then the child remain dizzy and confused for 1-2 minutes after the
episode . These occurs in 3-4 days and then the child back to his normal activity and behaviour for several weeks
. what is the most likely diagnosis? ??????
A- Temporal lobe epilepsy ??? ( usually 60-90 secs and child remains confused after episode) JM(partial seizure)
B- Juvenile myoclonic epilepsy ????(gen seizure)
C- Absence seizure (not absence seizure bcoz ab seizure is usually only few secs 5-10 secs and continue normally
after episode)(gen)
D- other don’t remember

40. lady brings her her 11 month child as she is afraid he is not normal as he cant sit unsupported till now , she tells
you that he stayed in ICU for 6 weeks when he was born as he was delivered at 32 weeks with a weight of 1.5
kgs. what is the most important question to ask to guide you ?
When did he start to roll from prone to supine***
If his brother had similar problem ?
If he had prolonged jaundice when he was in ICU

41. Primigravida gave birth at term to 3200 g baby,normal vaginal delivery without any complications and there was
slight meconium staining of liquor.Baby was normal at birth with normal heart rate.After 1 minute,suddenly
stopped breathing.HR decreased.Cyanosed.No response on stimulation.What is the most appropriate next step?

945
 a. Intubate
b. Nasopharyngeal aspiration of meconium-is alrdy done at birth
c. Bag and mask ventilation

42. child with croup scenario, 38 fever and coryza, harsh cough, respiratory stridor on rest using collateral
muscles look like moderate
A. Prednisolone oral
B. nebulized adrenaline-looks like severe
C.dexamethasone
d.inhaled steroid
https://www.rch.org.au/clinicalguide/guideline_index/Croup_Laryngotracheobronchitis/

43. child 7 years old came with fever 38.7 looks tired and lethargic and has grunting on examination his chest is clear
what is the diagnosis??
a. Epiglotitis jm 1082
b. Croup
c. Broncholitis
d. Pneumonia

44. 2y.o. Boy vomits after feeding, cries, lost 200g in previous week. Blood analysis shows metabolic alkalosis. What
is the investigation?
A) CT
B) Barium enema

946
 C) Ultrasonography
D) Endoscopy

45. Baby normal delivery. No analgesia to mother. Meconium stain slight. 1 min later central cyanosed and did not
breath. What to do? Aspirate first then
A. Bag and mask
B. Intubation

46. Child with fever 39.8 e abdominal pain. on examination looks unwell resp rate 30 heart rate 120 treatment
a)oral amoxillin
b)oral roxithromycin- atypical pneumonia-bcoz of abd pain
c)iv penicillin ????
d) iv flucloxacillin ( used for staphylococcus aureus )

947
47. Female worried about baby : how to prevent from sudden infant death syndrome.
a. Sleep with baby
b. . keep baby in supine position

48. Mother living in mining town comes with her daughter for normal blood test. Her daughter’s
test show lead level 0.72 what will be your next appropriate step?
948
 a) n children: Blood lead level of 5 µg/dL or 0.24 µmol/L or greater requires further testing and
monitoring. The source of lead must be found and removed. A lead level greater than 45 µg/dL or 2.17
µmol/L in a child's blood usually indicates the need for treatment.
b) Assess IQ testing of child
Educate mother about environmental risks-

49. 2yrs old child with asthmatic symptom, which

investigation help dx?
A) Improvement with salbutamol
B) Chest x-ray
C) Lung function test-only aft 6 yrs
D) ABGS

50. -3 year child was complaining of colicky abdominal pain and anorexia for 7 days, then 2 days of diarrhea and
other feature now presented to you his there was tenderness all over the abdomen with guarding , temperature
39. What is the most likely diagnosis?
A-perforated appendicitis ( refer mantrel score )
B-mesenteric adenitis
C-norovirus gastroenteritis
D-giardiasis
E-campylobacter gastroenteritis

51. child long term asthma controlled with SABA and inhaler, urine show ketone ++ glucose ++, blood glucose 8.5,
next inv?
1. OGTT
2. HbA1C
3. FBS

949
52. 9yrs old child long term asthma controlled with SABA and steroid inhaler. During blood test ketones
and high sugar found. RBS 8.wat will you do to "FOLLOW UP"?
A.FBS
B. OGTT
C.HBA1c

53. 2 yr old baby, fever, neck stiffness, immunization complete 2, 4, 6 month complete. Apart from antibiotics
which will u give?
à IV dexamethasone (looka like meningitis ,steps- o2 access +iv line,
Blood culture,within 30 mins prior to hospitaluisation
Bolus saline
Lumbar puncture
Dexamethasone
Ceftrixone
For meningococcal infection-rash-purpurici Rx is benzylpenicillin.

54. 6 month of infant born preterm was took by mother who is worried for its low intake now. Weight percentile
charts is given. (contro)
At birth - 1.3kg
1 month- 2.6kg
3 month 4kg-
4 month 5kg- should double
6month 6kg-
What will be your most appropriate explanation to mother in regard of the baby’s weight?
a. Your baby is growing excessively
b. Baby is growing normal
c. Baby weight is low but it is acceptable
d. Baby growth is poor but will need access after one month
e. Your baby growth is suboptimal and need further investigations

55. 2 year old child. Respiratory rate 30. Heart rate 120. Fever 39.7. one day history of fever, vomiting, abdominal
pain. On examination mild abdominal tenderness but no rigidity. Chest xray is given ( looks like pneumonia).
Which of the following is the most appropriate initial antibiotic?
a. Amoxicillin
b. Roxithromycin

950
 c. Augmentin oral
d.IV penicillin
e. IV flucloxacillin

56. 9 year old patient comes with his parents because of multiple times upper and lower respiratory infections. Lab
values are given. (Hb decrease, MCV decrease)
a. Red cell folate
b. Serum B 12 level
c. Serum ferritin
d. Hb electrophoresis
Forget the last option
If repeated infection: sickle cell anaemia if hemolytic otherwise iron def
https://www.rch.org.au/clinicalguide/guideline_index/Anaemia_Guideline/

57. Child got hepB vaccine 2 times, stopped because of flu. Now, no fever, what next
A- Give 1 now, & catch up
B- Give 1 now & recommence new
C- No now

58. Child aged 4 years is brought by his mother. He has recurrent abscess. His weight is under 10th percentile. On
examination, his tonsil is enlarged, and has recurrent staphylococcal abscess and healing scars of abscess in
different parts of the body. Which of the following is related to him?
a. Neutrophils deficiency –Chronic granulomatous disease (CGD) aka primary immunodeficiency
disease (PIDD)
b. Lymphocytes
c. Complements

Inv: dihydrorhodamine 123 (DHR) test

The most common form of CGD is genetically inherited in an X-linked manner, meaning it only affects boys. There
are also autosomal recessive forms of CGD that affect both sexes.

Therapeutic options for CGD include prophylactic antibiotics and antifungal medications, interferon-gamma
injections, and aggressive management of acute infections. Bone marrow transplantation can cure CGD

59. 14 month baby who has history of roll over on 4 month, sitting without support from 8 month , claps hand, plays
peak a boo, now has started walking without support, moves things from one hand to other , babbling but no
words...
a. normal development
b. Gross motor delay
c. Fine motor delay
d. Social delay
951
 e. Speech delay

60. 8yrs old child with neck lump ... asking inv
a. Usg
b. Ct

61. Child firm neck lump after some gap of urti... on xm evrything normal.. no other lymphadenopathy anywhere
else. What to do
a. Review after 1 week
b. Biopsy
c. Fnac

62. Irritated child with 39 fever, abdominal pain, vomiting with tenderness but no rigidity. Asking what will help in dx
(contro)
a. Cxr
b. Blood culture
c. Usg –looks like mesenteric adenitis since no guarding.
d. xray abdomen

63. Rta q. Iv colloid given twice still in shock. What is most appropriate next

952
 a. Laparotomy
b. Fast usg
c. Ct abd

64. Baby with hematuria, urea creatinine normal,had similar episode before which resolved within 48 hrs. Now prot
1+ rbc 4+ dx?
a. Iga neph===2 days hx
b. Acute psgn====2 weeks hx
c. Hus
d. Nephrotic syndrome
e. Hemorrhagic cystitis

The classic presentation for the nonaggressive form (in 40–50% of the cases) of iga nephropathy is episodic
hematuria, which usually starts within a day or two of a non-specific upper respiratory tract infection (hence
synpharyngitic), as opposed to post-streptococcal glomerulonephritis, which occurs some time (weeks) after
initial infection.

65. 8yrs boy with eneuresis, going camping

Desmopressin nasal spray
953
66. . 9 years old girl had enuresis . what to do next?
A) DMSA
b) cystoscopy and urodyanamics-urethral obstruction and neurogenic bladder
c)nothing
initial urine analysis or culture or blood sugar\\\\\ urodynamic study…in complicated cases

67. Recall of child with testicular swelling.The exact scenario was a child with acute scrotal pain and swelling .On
examination both testes were separately palpable and non tender. Swelling and redness was present over the
pens.What is the most likely diagnosis?
Torsion of testis
Edidodymorchitis
Strangulated incarcerated hernia
Hydrocele
Idiopathic scrotal edema bcos red it cant be hydro
https://www.rch.org.au/clinicalguide/guideline_index/Acute_scrotal_pain_or_swelling/

68. sore throat with runny nose, on xm redness in throat and minimal enlargement of cervical nodes, mx?
a. Reassure===phyrangitis(viral)
b. antibiotic
**swab should be the answer,, according to center criteria

69. meningitis complication? First is hearing loss,epilepsy,concentration

memory and vision loss

70. JIA recall-ANA titre was 1:160.asked dx

71. 18month old baby with limp . Anti Ana antibodies 1:160 titres
something improved with NSAIDs .
1.juvenile rheumatoid arthritis ,
2.osgood
3.ankylosing spondititis
4.SLE

954
72. fetal heart rate was 60 and after emergency LUCS,the heart rate
remained 60 despite resuscitation.What maternal investigation will help
you with diagnosis.
Factor V Leiden
Lupus anticoagulant
Anti ro/1a—— neonatal lupus
Protein C
Ø Pregnant woman at term.Fetal heart rate 60/min.Emergency LUCS
done.Baby's heart rate is 60/min.What antibody will you look for in
mother?
Factor V leiden
Lupus anticoagulant
Anti Ro
Anti smith

Ø Pregnant woman at term.Fetal heart rate 60/min.Emergency LUCS done.Baby's heart rate is 60/min.What
antibody will you look for in baby?
Factor V leiden
Lupus anticoagulant
Anti Ro
Anti la
Anti smith

73. child with history of asthma and he was aknown case of nut allergy, both parents are smoker, develop wheeze ,
hoarseness of voice and other chest symptoms relieved by salbutamol. What is the most likely preventive measure for
such subsequent episode?
A-avoid all type of nuts in foods
B-prevent exposure to passive smoking from parents
C-remove all carpets from house
D-remove cats and dogs

74. Kid with nocturnal enuresis, planning for camping. What to do?
a. Say not to go
b. Alarm
c. Desmopressin
d. Reduce fluid in the evenings
If under 6 yr reassure and wait as its normal

75. A child with DM 1 not taking Rx when he is in school. What to do?

a. Insulin glargine-it’s a long acting insulin
955
 b. Recommend a nurse

He needs only basal insulin control when he is in school.

At home he takes insulin.
In that case A
Glargine.

76. Paraumbilical hernia picture. Asked what is the most appropriate step in P/E to Dx?
Becomes larger or tense when the infant cries or
strains.\\\\sugery any age but best after 6 months

77. picture of child 4 yrs old with paraumbilical hernia ,

mother saying asymptomatic , small ,long period
whats management:
a- Aspiration
b- Surgery
c- Reassurance

78. Neonatal jaundice case was there..baby had

phototherapy at birth and after 6 wks age parents
taking him because of dark urine, pale stool… Dx?
Looks like conjugated bilirubin. Dx: biliary atresia

Symptoms
Babies with biliary atresia usually seem healthy at birth. Most often, symptoms start to occur between 2 weeks
and 2 months of life. Symptoms may include:
• Yellowish skin and eyes (jaundice)

• Dark urine

• Light-colored stools

• Swollen belly (abdomen)

• Weight loss

79. 9 month baby with fever, clear nasal discharge, coughing with vomiting.. crackles and wheezes.. Dx?
a. Pertusis
b. Viral Bronchiolitis
c. Pneumon

impetigo school exclusion

vericella schoole exclusiom

956
Condition Exclusion of cases Exclusion of contacts
Amoebiasis (Entamoeba histolytica) Exclude until there has not Not excluded
been a loose bowel motion
for 24 hours
Campylobacter Exclude until there has not Not excluded
been a loose bowel motion
for 24 hours
Chickenpox Exclude until all blisters have Any child with an immune deficiency (for
dried. This is usually at least example, leukaemia) or receiving
5 days after the rash appears chemotherapy should be excluded for
in unimmunised children, but their own protection. Otherwise not
may be less in previously excluded
immunised children
Conjunctivitis Exclude until discharge from Not excluded
eyes has ceased
Diarrhoea Exclude until there has not Not excluded
been a loose bowel motion
for 24 hours
Diphtheria Exclude until a medical Exclude family/household contacts until
certificate of recovery is cleared to return by the Secretary
received following at least
two negative throat swabs,
the first not less than 24
hours after finishing a course
of antibiotics and the other
48 hours later
Hand, foot and mouth disease Exclude until all blisters have Not excluded
dried
Haemophilus influenzae type b (Hib) Exclude until at least 4 days Not excluded
of appropriate antibiotic
treatment has been
completed
Hepatitis A Exclude until a medical Not excluded
certificate of recovery is
received, but not before 7
days after the onset of
jaundice or illness
Hepatitis B Exclusion is not necessary Not excluded
Hepatitis C Exclusion is not necessary Not excluded
Herpes (cold sores) Young children unable to Not excluded
comply with good hygiene
practices should be excluded
while the lesion is weeping.
Lesions to be covered by a
dressing, where possible
Human immunodeficiency virus (HIV) Exclusion is not necessary Not excluded
infection
Impetigo Exclude until appropriate Not excluded
treatment has commenced.
Sores on exposed surfaces
must be covered with a
watertight dressing
957
Influenza and influenza-like illnesses Exclude until well Not excluded unless considered
necessary by the Secretary
Leprosy Exclude until approval to Not excluded
return has been given by the
Secretary
Measles* Exclude for at least 4 days Immunised contacts not excluded.
after onset of rash Unimmunised contacts should be
excluded until 14 days after the first day
of appearance of rash in the last case. If
unimmunised contacts are vaccinated
within 72 hours of their first contact with
the first case, or received normal human
immunoglobulin within 6 days of
exposure, they may return to the facility
Meningitis (bacteria, other than Exclude until well Not excluded
meningococcal meningitis)
Meningococcal infection* Exclude until adequate Not excluded if receiving carrier
carrier eradication therapy eradication therapy
has been completed
Mumps* Exclude for 9 days or until Not excluded
swelling goes down
(whichever is sooner)
Pertussis (whooping cough)* Exclude for 21 days after the Contacts aged less than 7 years in the
onset of cough or until they same room as the case who have not
have completed 5 days of a received three effective doses of
course of antibiotic pertussis vaccine should be excluded for
treatment 14 days after the last exposure to the
infectious case, or until they have taken
5 days of a course of effective antibiotic
treatment
Poliomyelitis* Exclude for at least 14 days Not excluded
from onset. Re-admit after
receiving medical certificate
of recovery
Ringworm, scabies, pediculosis (head Exclude until the day after Not excluded
lice) appropriate treatment has
commenced
Rubella* (German measles) Exclude until fully recovered Not excluded
or for at least 4 days after
the onset of rash
Salmonella or Shigella infection Exclude until there has not Not excluded
been a loose bowel motion
for 24 hours
Severe acute respiratory syndrome Exclude until a medical Not excluded unless considered
(SARS) certificate of recovery is necessary by the Secretary
produced
Streptococcal infection (including Exclude until the child has Not excluded
scarlet fever) received antibiotic treatment
for at least 24 hours and
feels well
Tuberculosis Exclude until a medical Not excluded
certificate is received from

958
 the treating physician stating
that the child is not
considered to be infectious
Typhoid fever (including paratyphoid Exclude until approval to Not excluded unless considered
fever) return has been given by the necessary by the Secretary
Secretary
Verotoxin-producing E. coli(VTEC) Exclude if required by the Not excluded
Secretary and only for the
period specified by the
Secretary
Worms (intestinal) Exclude until there has not Not excluded
been a loose bowel motion
for 24 hours

* Vaccine-preventable disease
Note: In this schedule, ‘medical certificate’ means a certificate of a registered medical practitioner

80. Moluscum = no exclusion just cover and send

81. .picture of impetigo in baby’s hand---asking school

exclution?
Ans.immediately after starting antibiotic (was only
appropriate opton)

82. Diabetes type 1with renal impairment... Baby risk

A. IUGR
B. MACROSOMIA

83. To see prevalence of HCV in child born to HCV positive

mother
A. HCV AB at 18 month
B. HCV Ab just after birth
C. HCV PCR in mother
D. HCV PCR in neonate(3 and 6 mon)

84. A newborn baby developed mixed jaundice on first day

of his birth. On examination his head circumference is
below 3rd centile. He has hepatosplenomegaly and
generalized petechiae. His eye exam revealed normal
cornea but pigmented retina. Which inv. will u do
towards diagnosis

a) urine test for virus-looks like cmv-all features of cmv
test =urine pcr, rx-antivirals
b) auditory evoked potentials

c) CT brain

d) liver biopsy


85. 7 days old infant presented to you complained with poor feeing and bile stain vomiting. His birth was at 38 weeks
gestation and weight 2600g. He is breastfeeding with no immediate post natal complications. The child has a history
of passing meconium on day 4 of birth. Now, he had mild jaundice and abdominal distension present. What is the
appropriate diagnosis?
a) Hirschsprung's Disease -The main symptom is a newborn's failure to have a bowel movement within 48 hours
after birth
959
 b) Meconium Ileus-seen in cf
c) Duodenal Atresia-double bubble, early 1st day bilious vomiting
d) Necrotizing Enterocolitis
e) Volvulus

86. Mother of a week old infant complains of a fleshy lump at the umbilicus after the cord fell off. The lump is noted
to give some discharge . Which of the following is the appropriate management?
a. apply silver nitrate
b. Apply podophyllin-for molluscum
c. Excise the lump
Jm 1025 pg
87. lady brought her baby born normal now on 6 weeks having hypotonia and areflexia off all limbs,poor sucking and
progressive difficulty in respiration.diagnosis
a. spinal muscular atrophy- muscles don’t work properly, causing muscle weakness and wastin, Sometimes,
feeding and swallowing can be affected. Involvement of respiratory muscles (muscles involved in breathing and
coughing) can lead to an increased tendency for pneumonia and other lung problems
b) pradder willi syndrome - rare genetic disorder affecting development and growth, has an excessive appetite,
which often leads to obesity-no resp difficulty,blond baby
c) early cerebral palsy

88. vaccination recall. Mother does not wanted to vaccinate. Options were
a. Don’t vaccinate
b. Call her husband to talk again
c. Refer her to social welfare worker - specially if aboriginal
d. Believe on your own professional skill and take some legal issues something like that

89. Child treated for tonsillitis still has 3cm lump under mandible angle. Painless. No lymphendopathy, no fever,
otherwise well.
a) Aspirate biopsy
b) Ultrasound
c) EBV serology
d) CT head and neck
e) Review in 1 week

90. Pneumonia child 2 yr , RR 30 /min , HR 120/min , fever 39 degree , no respiratory distress , what initial treatment
?
a. Oral amoxicillin / clavilunate
b. IV flucoxallin
c. IV benzyl penicillin
d. Oral roxithromycin

960
91. 12 year old child with BMI 25 and growth chart showing Age vs BMI,plotted showing him above the 95%
curve.Diagnosis?(actually coming under 95th,if so then overwt)
a. Normal
b. Overweight
c. Obese***(below 5% is under weight. 5-85% is normal. 85-95% over weight. above 95% is obese.)

961
92. Growth chart of 7 years old child whose BMi is 18.5
a. Normal,
b. healthy
c. slightly over weight
d. over weight****
e. obese

93. parents bring their child 6 years old he was more than 95% On growth chart .He always sit infront of tv and has
limping in leg ?!
1-reassurance that his obesity is familial
2- diet modification together with exercises
3-diet only
4 – prevent him tv
5-refer to orthopaedic*****( it is slipped capital femoral epiphysis)

94. 10 month old child with 3 mnth history of vomiting parents were feeding him thick feed as well not settling
percentile was 50th Head percentile, and everything was normal: asking investigations
A) BRAIN CT
B) Chest xray
C) Bone DMSA scan
head percentile is normal , Increased INTRACRANIAL PRESSURE LEADS TO vomiting

95. mother comes with 12 month old infant with increase head size from 25 percentile at birth to 75 percentile now
and on examination child is hypotonic
what will you do next?? (contro)
a.CT SACN head
b.check CMV infection
c..TSH
D.head ultrasound
e.rubella test

96. A mother comes with 10 months old baby whose growth is normal but head circumference increased from 25 th
percentile at birth to 75th percentile now baby is feeding well but can't roll over or support himself hypotonic
next investigation
a.TSH
b.USG head
962
 c.Ct scan
d.MRI

97. A blank growth chart for a child was given. Parents brought their baby because they are concerns of his weight
gaining. The baby was preterm 32 weeks and birth weight was 1.6 Kg. (and weight in 2, 3, 4 month all were
under 5 percentile). His weight: 6 kg now. What would you say to parents?
> a. Suboptimal weight gain and need to review in 1 month
> b. Poor gaining and need to do investigation
> c. Slow gaining weight and no need to worry****

https://www.breastfeeding.asn.au/bfinfo/whochart.html

98. 12 month old child with his head circumference plotted on a growth chart..there a big increase till almost 100
percentile (over few months)..he asked for the investigation:
CT( if closed),
USG( if open fontanella than go for US and if closed than go for CT

Ant fontanelle-18-24 mnths

Post fontanelle-2 months
Percentile < 3: Microcephaly
Percentile >= 3 and < 97: Normal head circumference
Percentile >= 97: Macrocephaly

Normal at birth 33-35cm

963
 Every month 2cm inc upto 3 months
Every 2 months 2 cm inc upto 6 months

The general guidelines that are usually given for weight loss and weight gain are:
a baby loses 5-10% of birth weight in the first week and regains this by 2-3 weeks2
birth weight is doubled by 4 months and tripled by 13 months in boys and 15 months in girls1
birth length increases 1.5 times in 12 months1
birth head circumference increases by about 11 cm in 12 months1

99. mother come with 12 months old infant with increase head size from 25 percentile at birth to 75 percentile now
and on examination child hypotonic what will you do next??
a. CT SCAN head b. check CMV infection c.TSH –cong hypothyroidism D. head ultrasound e Rubella test

100. Scenario of a normal developing boy aged 4years. Born 3.8kg normal delivery to a normal mother with no
known medical history. Child is also a fussy eater but mentioned that growth chart (Weight below 10th centile
and Height is below 25th percentile Growth curve is up going since birth). Mother is concerned that the child is
not developing like his older sister.
A. Refer Dietician
B. Refer Paediatrician
C. Reassurance to mother that child is normal.****
D. Do hand & wrist X-ray.
E. Review in 3 months.

101. Growth chart given

Premature baby with birth weight of 1.5 kg
3 months 3kg
4 months 4 kg
6 months 6 kg
Asking to plot in the growth chart and
A.Normal growth***
B.Suboptmal growth
C.Overgrowth

102. A Kid presented by a flu like symptoms (Fatigue, Fever, Lack of appetite, Sore throat), enlarged cervical LNs
and pharyngeal ulcers, so what’s the causative organism?
B. EBV****
C. Adenovirus
D. Influenza virus

964
 (Influenza Symptoms--Pain areas: in the muscles
Cough: can be dry or with phlegm
Whole body: chills, dehydration, fatigue, fever, flushing, loss of
appetite, or sweating
Nasal: congestion, runny nose, or sneezing
Also common: body ache, chest discomfort, head congestion,
headache, nausea, shortness of breath, sore throat, or swollen lymph
nodes

Adenoviruses can cause a wide range of illnesses such as

Common cold
Sore throat
Bronchitis (a condition that occurs when the airways in the lungs
become filled with mucus and may spasm, which causes a person to
cough and have shortness of breath)
Pneumonia (infection of the lungs)
Diarrhea
Pink eye (conjunctivitis)
Fever
Bladder inflammation or infection
Inflammation of stomach and intestines (gastroenteritis)
Neurologic disease (conditions that affect the brain and spinal cord)

103. A mother brought her 2 years old girl with history of blood stained vaginal discharge which regularly stained
the girl’s underwear. What would you do?
a. Parform Chlamydia and gonorrhea tests
b. Reassure the mother that is normal
c. Report to the child agency about sexual abuse****
d. Foreign body
e. Crohn's disease
If there is redness in vaginal area it is vulvovaginitis
If there is pure red discharge or any STI symptoms or indications go for child abuse
If there is offensive discharge than go for foreign body

104. Child 5 yrs fell on garden bed has multiple superficial lacerations he has hx of 2 doses of vaccine at 2 nd 4
mntgs wht next
Dpt and booster after 2 mnths
Tetnus toxoid nd ig
Dpt and ig

http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-
home~handbook10part4~handbook10-4-19

105. Regarding Sudden Infant Death Syndrome (SIDS), which of the following statements is CORRECT?
a) Positioning a baby prone (on its front) to sleep may reduce the risk
b) The incidence is greater in female infants
c) Maternal smoking has not been shown to be a risk factor
d) Breastfed infants are at greater risk
e) Infant overheating may be a risk factor****jM 1074-75)

106. mother concerned with SIDS since her friend’s baby died due to this … best advice for mother..
Ans- don't sleep with baby (JM 1075)
965
107. 5yr old child with go URTI 1week now pt is pale but no jaundice and spleen 2-3 cm palpable
a)aplastic crisis( no jaundice,decreased rbc,hb,reticulocytes, initially normal or later decreased platelet)-mainly
due to parvovirus b
b)hemolytic crisis???( follows urti,jaundice, normal wbc,decreased platelet and rbc)

108. child with rectal prolapse.O/E 50 percentile wt & height.h/o first cousin with cystic fibrosis.what h/o will be
most valuable for him??
a. His recent stool pattern
b. Family h/o cystic fibrosis***-cf causes sticky membranes-constipation-straining-rectal prolpase
c. His sister treated for hookworm

109. 7 days old baby presented with jaundice since 4 days of life his birth was at term not complicated and he is
breastfeeding serum bilirubin was 240 (normal 200) with 120 direct bilirubin liver is 1 cm palpable below costal
margin what is most app.
Tfts.
Abdominal usg for liver & biliary tree**** (Biliary atresia, and direct bilirubin increases in B.atres)
Coombs test
Stop breastfeeding & follow up (in B.M.Jaundice, jaundice is since 4days, and indirect bilirubin is high)
Phototherapy

110. Baby presented with jaundice on day 8 started on day 4 .TB 200 DB 120, INv
a)physiological jaundice
b)stop breast milk review after 1 week
c) USG abdomen
d) Phototherapy

111. 7 days old neonate was brought due to jaundice, started on day 4, bilirubin level 240umol/L (direct –
120umol/L). How will u manage?
a. USG abdomen***biliary atresia since direct bilirubin
b. Phototherapy(>290)
c. cessation of breastfeeding for 1 week & follow-up

966
112. An 8 months old baby who's father is a nomadic farmer presents with a rare folic acid deficiency. Mother
claims child is feeding well. Mother was a known well controlled epilepsy patient on anticonvulsant therapy
Which of the following is the possible cause
of this condition.
A. Cow milk feeding.
B. Goat milk feeding.– due to the time here
C. Possible side effects from mum's
medications**** folic acid antagonists
such as antiepileptic medications, sulfa
antibiotics, or methotrexate
D. Nutritional anaemia.
E. Rare genetic mutation

The low concentration of many essential

nutrients, especially folate and iron in goat’s
milk make it an inadequate sole source of
nutrition. This also highlights the importance
of taking a full feeding history at baby check-
ups.

113. A child with fever and hx of sore throat . he developed pain in wrist later developed arthralgia n swelling in
ankle joint. skin rash present . what's the most initial step of management ?
a. ESR
b. Full blood examination
c. throat swab**** ( Rheumatic Fever)
d. USG

114. 9 yrs old with type 1 diabetes. on small n intermediate acting insulin. every morning high glucose levels.
what to do ?
a. check blood glucose levels at 3 am****
b. check early morning insulin levels
c. increase the evening intermediate insulin
d. give insulin before breakfast
e. give another dose before sleep

967
 The Somogyi effect is most likely to occur following an
episode of untreated nighttime hypoglycemia, resulting in
high blood sugar levels in the morning. People who wake
up with high blood sugar may need to check their blood
glucose levels in the middle of the night (for example,
around 3 AM). If their blood sugar level is falling or low at
that time, they should speak with their health-care team
about increasing their food intake or lowering their insulin
dose in the evening. The only way to prevent the Somogyi
effect is to avoid developing hypoglycemia in the first place

115. recall of duchenne muscular dystrophy .

which of the following regarding Duchenne muscular
dystrophy is incorrect?
A ) the usual age of symptoms onset 2-6 years
B ) Genetic inheritance is usually X-linked recessive
C ) Approximately 25% of pt die by the age of 20***(more
than 25%)
D ) A lordotic , waddling gait is a feature
E ) Female carriers are usually asymptomatic

Duchenne muscular dystrophy is also known as

DMD. It is the most common type of muscular dystrophy.
Signs and symptoms of DMD
DMD is usually first diagnosed at about three to four years old, although symptoms are common earlier than
this. Early signs of DMD include:
'Toe-walking' - children start walking on their tip toes.
Larger than normal calf muscles - called pseudohypertrophy.
Many children with DMD don't walk until after 18 months of age.
A 'waddling' type of walk.
Inability to run or climb stairs.
Affected children develop an unusual way of getting off the floor, called a 'Gowers sign'.
Some children with DMD also have delay in their speech development.
DMD is a progressive disease. Children affected by DMD generally lose the ability to walk by 12 years of age,
after which they need to use a wheelchair. The muscle degeneration in DMD affects all muscles of the body
including the breathing muscles and the muscles that hold the spine straight.
Diagnose by A blood test will reveal a CK level which may be 50 – 100 times greater than normal.
DNA study and muscle biopsy test
Inheritance
DMD affects about one boy in every 3,500. Girls are usually not affected but can be carriers. Problems with the
dystrophin gene, causing DMD, can happen even without a family history of DMD.
Where there is a known family history of DMD, families are encouraged to have genetic testing to find out the
risk of having a child with DMD. Your family doctor or neurologist can help organise for you to have this test.
Treatment
Treatment Physiotherapy
Regular physiotherapy is important to keep your child mobile, healthy and comfortable.
Why is genetic counselling important?
Soon after the diagnosis of DMD it is essential that genetic counselling is arranged, together with appropriate
tests for those members of the family who are at risk of being carriers. Genetic counselling provides information
on the inheritance pattern, risks to other family members, and the ‘prognosis’ (likely outcome of the disorder).
Family members that are found to be carriers of the condition can discuss with a genetic counsellor family
968
 planning options to reduce the risk of passing the condition on to future children. This may include utilising new
technology called pre-implantation genetic diagnosis which is used in conjunction with IVF.

116. A 3yr old boy presents wit hx of ambulation delayed till 16 months of age, toe walking, calf hypertrophy and
proximal hip girdle muscle weakness. His pediatrician , considering a mild static encephalopathy did not request
screening for myopathy but referred him to an orthopedic surgeon, who found that his ck levels are elevated,
indicating need for referral to a neurologist. His older siblings are ok. Diagnosis?
A. Dupuytren contracture
B. Cerebral palsy
C. Polymyositis
D. Duchenne muscular dystrophy****
E. Becker muscular dystrophy

117. 4year old boy with nocturia.still he hasn’t developed a single dry night.wat to do –
a.desmopressin
b.wait for spontaneous resolution*** Your child is at least six years old (we do not recommend treatment before
this age as many children get better spontaneously and treatment is less effective)rch
c.decrease water intake at night

118. a 10 yr old child had seizure at home.after that he became unconscious and remain.he was brought to ed via
ambulance.blood glucose 2.wat will u give
a.im glucagon???
b.iv dextrose
c.iv glucagon
d.iv normal saline

in home and in ambulance: im glucagon

in hospital: iv glucose

969
119. 18 month old baby was brought by its parents, they complained that their baby continued crying at night.
What advice will you give?
A. Add thickener to milk***( insufficient milk )-for GERD
B. Give cow’s milk
JM pg996

970
120. 2 yr old boy, BW 20 kg, developed abscess on thigh, incision and drainage done. What is important to do in
this child apart from wound debridement?
A. RBS***
B. Dietician advice

121. A boy who swallowed blade, xray taken & on Xray (given) seems like two razor blades, no abdominal pain,
no rigidity, how will u manage?
a. lactulose
b. gastroscopy
c. colonoscopy
d. laparotomy
e. wait & observe***JM 1068
for 3 days u have to observe review xray after 1 week ,if
present then laparotomy

122. Baby with 10 days diarrhea, no fever or blood, what

to do?
Lactose free milk***
B. Soy milk
C.clear liquids

123. 4)4 months, wheezes, retraction, seems like

bronchiolitis: tx? O2
DO NOT smoke in the home or around your baby. This is
especially important around babies with any respiratory
illness.
Medicines do not usually help babies with bronchiolitis.
Antibiotics are not given because bronchiolitis is caused
by a virus. Antibiotics do not cure viruses.

971
 Babies need to rest and to take small amounts of fluid
more often. This will keep them from becoming too
tired when feeding.
Give more frequent breastfeeds or smaller amounts of
formula or water more often. If children do not get
enough to drink they can become dehydrated.
If your baby is distressed and having trouble feeding,
they may need to be admitted to hospital. Staff may
need to:
observe your baby
give extra oxygen
give extra fluids through a drip into a vein
(intravenous/IV therapy) or via a nasogastric tube into
the stomach

124. An 18months old baby was brought by his mother

who had 3 ear infections non perforated and 2
respiratory infections requiring antibiotics and sinusitis
with serous nasal discharge..his growth is normal and
well.asking the cause
A.recurrent childhood infections***
B. cystic fibrosis — diarrhoea,greasy stools,poor growth
C.immunodeficiency-10 warning signs in 12 months-

125. Child had chicken pox.After some days he

developed ataxic gait and difficulty balancing.Mother is
concerned.Other findings are normal.What could be the
cause?
Encephalitis-localised signs
Post infectious cerebellitis****acute cerebellar ataxia-common aft varicella infections provided no localizing
signs+
GBS-absent reflexes, progressive, other paralysis signs+

http://www.rch.org.au/clinicalguide/guideline_index/Ataxia/

126. 20 years old boy comes with fever of 37.9 and sore throat and headache for one week,Examination is
unremarkable and long lab interpretation was given only showing raised TLC.During his childhood his mother
often had to visit GPs. Single episode of vomiting 1 day back and he is feeling as his right side of body is not
healthy,what is the cause of his condition?
a) GBS
b) Meningitis
c) abscess****-raised tlc(brain abscess, source: sore throat)
e) pneumonina
f) Brain tumor-unremarkable tlc just after radiation therapy it decreases

127. .4 year old child difficulty in swallowing for 2 days . not willing to eat solid food but only drink milk
repeatedly.no cough mentioned. His brother had asthma. On examination child is well and normal examination.
What to do now?
x ray neck chest and abdomen…foreign body
Salbutamol
barium swallow

972
128. mother hepaatitis B core antibody positivé , management of new born
Hepatitis b vaccine at birth
Hepatitis b ig and vaccine*** jm 660
Hepatits Ig only

129. child who got treated for psgn.now during dischage what advice – (contro)
a.immediately can join school
B.with diet and activity restriction
C.immediate join without diet and activity restriction ***
D.after 1 week
Limitation of fluid and salt intake is recommended in the child who has either oliguria or edema.
Limited activity is probably indicated during the early phase of the disease, particularly if hypertension is present

130. 6month old child came for check up. On questioning about vaccination, mother said she had only 2 (1 at
birth and 2nd on 2months old) child is having recurrent URTI. On exam, child is alert, T- 37.8 c, clear discharge
from nose. What is the next management in terms of her vaccination?
a. Investigate underlying cause of urti
b. Hbs vaccination now ****
c. Vaccine after fever subsides
d. Hbs vaccination now and register for catch up vaccination

973
131. 10 day old baby thriving well,healthy baby had yellowish
discharge on the right only,cause
1.nasolacrimal duct obstruction - 2 weeks, just wipe with saline
,massage.
2.gonorrhoea-24 to 48 hours aft birth,systemic symptoms
3.chlamydia **- 1-2 weeks aft birth,conjunctivitis+pneumonia
can happen,Rx is oral antibiotics erythromycin

Blocked nasolacrimal duct cos here only one eye is affected...

Usually chlamydia has other systemic symptoms as well ..but here
baby is well.. And nothing is mentioned about an inflMmation so
am with 1

132. 10 days old baby yellow discharge Ask about ttt:

A- Wash with saline****
B- ceftrixone
C- topical azthromycin

133. At what age a child can differentiate between bold

colours,recognizes own name and stranger anxiety(-7 to 9 mnth
)may begin?
a. 5 months***
b. 3 months
c. 6 months
d. 9 months
e. 12 months

974
134. A 7yr old is brought to your clinic, Her neck was tilted and fixed to one side. On examination, she had 2
palpable neck lymph nodes. Her chest xray had bilateral pulmonary infiltrates (image not given). Her head
circumference was small for age, fundoscopy showed hyper-pigmented retina. She had significant hepatomegaly
of about 5cm from costal margin. What is your diagnosis?
a. Congenital rubella ***-triad-eye cataract,hyperpigmentation+sensorineural hearing
loss+congenital heart disease-PDA
b. Congenital CMV- lymphadenopathy, hepatitis,retinitis (brushfire app) and pneumonitis,
microcephaly & all other symptoms mentioned up
c. Cerebrohepatorenal (Zellweger) syndrome-feats +from birth, don’t live more than 1 yr.
-due to mutation-c/f: typically appear during the newborn period and may include
poor muscle tone ( hypotonia ), poor feeding, seizures , hearing loss , vision loss,
distinctive facial features, and skeletal abnormalities
Rx: oli symptomatic ,no cure
d. Combined immunodeficiency
e. Hypergammaglobulinemia-due to weakened immune system-c/f:Respiratory tract infections
Skin infections
Sinusitis
Pneumonia infections
Ear infections
Eye infections
Bronchitis
Other common ailments for those with hyperglobulinemia can include:
Diarrhea
Fatigue
Anemia
Spleen, liver, lymph nodes, and tonsils enlargement
975
 Stiffness in joints, especially the hips and knee
Rx: immunoglobulins transplantation

135. mother come with 12 month old infant with increase head size from 25 percentile at birth to 75 percentile
now and on examination child hypotonic. what will you do next??
a.CT SCAN head
b..check CMV infection
c..TSH***cretinism( congenital hypothyroidism > hypotonia)big fontanelles
D.head ultrasound
e.rubella test( cataract , pigmented retina)

136. 8 weeks premature infant At 10 months brought in by parents because his development seems to be
delayed: can roll over but can't sit propped up. He was in hospital for 6 wks after birth and also his prematurity
was due to maternal PIH. His centiles on corrected scales are 3% height, 20% wt( cant remember that well).How
can this delay be explained.
1.normal due to 8 weeks prematurity****
2.CP
3.Duchenne muscular dystrophy
4.spinal muscular atrophy

137. A 4 year old boy presents with small face short stature asymmetric body growth low IQ and short 5th finger.
What is your likely Dx?
- Russell-Silver Syndrome***** (small triangular face, with prominent forehead,normal head
circumference but short ht, narrow chin small jaw downturn corner of mouth, clinodactyly, digestive
abnormality).
- Beckwith-Wiedemann Syndrome(hypertrophy one side of body)
- Proteus Syndrome
- Prader-Willi syndrome
- Hypothyroidism

976
138. A 7 year old child with short stature presented to you. You
examined that he has normal growth velocity but bone age is
equivalent to chronological age. What is your likely diagnosis?
Familial short stature***
Constitutional delay in growth & puberty
Caeliac disease
Hypothyroidism
Chronic kidney disease

139. 5 years old child has been given a new toy that she likes.
Mother reported she played with the toy for just a few minutes
and never touched it again. Mother also reported daughter to be
turning on the tv and then leaves it after a few minutes. Mother
tries to talk with daughter but noticed daughter to look at her for
a few seconds and just repeats the what her mother says.
Everytime she is called by her name she looks at her mother for a
few seconds and repeats her name. Diagnosis?
A. Autism***
B. ADHD
C. Mental Retardation
D. Child Abuse
E. Asperger's

140. 7-year-old boy with a history of atopic eczema is brought to the surgery. Overnight he has developed a
painful blistering rash affecting his face and neck. His temperature is 38.1deg.
Which one of the following is most likely to be responsible for this presentation?
a. Varicella zoster virus
b. Streptococcus pneumoniae
c. Pox virus
d. Staphylococcus aureus
e. Herpes simplex virus****( atopic eczema with rash eczema herpeticum)

977
 Dx: eczema herpeticum

Eczema herpeticum is a rare, painful skin rash usually caused by the herpes simplex virus (HSV). HSV1 is
the virus that causes cold sores, and it can spread through skin-to-skin contact. EH most commonly
affects infants and young children who have eczema or other inflammatory skin conditions

978
141. Mother came with meningitis. Child had history of fever
and generalized lymphadenopathy and rash last day.. On CSF
monocytes, glucose 3.5( 2-4.5 normal), no RBCS, protein>45 (or
0.45...i couldn't get the exact value).Most probable cause?
a) Meningococcus( glucose decreases severely)
b) Echovirus***(in viral glucose is normal, bacterial pathogens,
glucose levels are substantially decreased)
c) HSV (rbc)
d)pneumococcus
e)h-influenzae

142. child with fever, conjunctivitis, rash lymphadenopathy,

abdominal pain . Initial Investigation (Kawasaki disease).dd:
TSS,SJS, measles,Scarlet fever
a. Aso titre
b. ESR-initial to rule out other diseases then blood tests then
echo(if asked best)
c. Echo
D. Ana
E. Urinalysis.
http://www.mayoclinic.org/diseases-conditions/kawasaki-
disease/home/ovc-20259782

979
143. A 12 years old girl presents with a sudden history of loss of sensation on the lower limbs associated with
decreased reflexes and progressive ataxia . Which of the following is most likely the cause of her condition
A. B12 deficiency( old age )
B. Friedreich´s ataxia**** (young age 7-15)
C. Charcot marie tooth diseases- Patients usually do not complain of numbness. This may be because patients
with CMT disease never had normal sensation and, therefore, simply do not perceive their lack of sensation
D. Dermatomyositis -accompanied with rash(painful and itchy violet) with muscle weakness.

144. Young patient presented with pallor and lethargy laboratory findings show hypo chromic microcytic anemia,
low calcium and increase INR. What investigation will you do next?
A. Abdominal ct
B. Ultrasound
C. Stool c/s
D. Antigliadin Ab ****aka Tissue Transglutaminase Antibody-celiac disease test-CD causes osteopenia
and osteoporosis with low Ca and also high INR
E. Urinalysis

145. Baby well postpartum , sudden central cyanosis, no murmur, I chose Ventricular hypoplasia,
a. Fallon è cyanosis+ but murmur also +
b.VSD è no cyanosis,L to R shunt,
c.PDA è no cyanosis, L to R shunt rubella h/o mother, usually asymptomatic unless large defect
d.ASD è no cyanosis ,L to R shunt
No Transpose of GA in options.

146. . Floppy child recall , normal development than heavy breathing, not eating, diminished all limb reflexes
a) Prader Willi è all developmental delays ,genetic, obese, no cure symptomatic Rx

980
 b) Early palsy
c) Botulinum è due to honey intake in under
12 months of age, Symptoms of botulism in
babies include: constipation, poor sucking
and feeding, choking and gagging, weak
feeble cry, reduced movements of the limbs,
inability to control head movements,
increasing weakness and floppiness,
paralysis, breathing difficulties.
d) Myotrophic sclerosis**? è Babinski sign,
muscle spasms, and overactive reflexes
(hyperreflexia) muscle wasting (atrophy),
weakness, and muscle
twitches.[3]Facial spasticity, dysarthria, and a
spastic gait uncontrolled laughter or crying, bladder dysfunction, and/or sensory
disturbances.[1] Cognitive function is not affected.
d)SMA

147. Child ingests washing detergent. Now having pain and drooling saliva. Which of the following complications
is he likely to get?
a.Aspiration pneumonia(petrol)
b.Esophageal stricture***
c.Septicemia

Severe change in acid level of blood (pH balance), which leads to damage in all of the body organs
Burns and possible holes in the throat (esophagus),vomiting,bleeding

https://www.rch.org.au/clinicalguide/guideline_index/Alkalis_poisoning/

148. A child was brought in by her father. She has been soiling her underwear for some time now and is said to
have had intermittent abdominal pain for the past four months. What is the most likely underlying problem?
a. Inflammatory bowel disease
b. Sexual abuse
c. Chronic constipation***
dx: Encopresis
https://www.rch.org.au/kidsconnect/prereferral_guidelines/Continence_Encopresis_Soiling/

149. Another case of a child with hematuria. He had rashes about a week ago. Diagnosis asked
a. Post-streptococcal glomerulonephritis***
b. IgA nephropathy
c. Minimal change Nephrotic syndrome
d. Hemolytic uremic syndrome

150. A 4 yr old child presented with c/o urti followed by petechiae and bruises on body
A long list of labs all normal except platelets 50000 which is most likely diagnosis?
a. Haemophilia
b. Vwf deficiency
c. ITP
981
 d. Aplastic anemia

151. A 5yr old boy brought in emergency after rescue from drowning, jelly fish is attached to his legs. He is
screaming due to pain what is your next step before removing tentacles of jelly fish?
A) vaccination (don’t remember name some vaccine against jelly fish sting)
B) immerse legs in hot water for bluebottle nd other jellyfish, for box jellyfish and tropical if use vinegar
C) iv morphine
d) anesthesia

982
152. mother brings her 18 month baby and said her baby Many times wake up an crying and settled each time
after drinking a bottle juice. In exam baby looks well. What's you will advice?
a) add thickner
b) high sugar diet
c) give plenty of fluids at night

153. cenerio of broncholitis with oxygen saturation 96% in a 6 month old child next step in management?
a) admit and give oxygen
B) antibiotics
c) bronchodilators
d) inhaled corticosteroids
no medication required for broncholitis with O2 more than 92%-mild.
Do NOT give ICS or antibiotics,mainstay is o2 therapy but not in this case as its mild.so if option of no
medications and just observe available go for that
http://www.rch.org.au/clinicalguide/guideline_index/Bronchiolitis/

154. Child pale drink cows milk alot .otherwise normal blood HB 6.5 mcv decreased. Plt normal wts management?
Rbc trasfusion
I.V. iron
I.M Ferrous

155. Septic Child pale, drink cows milk a lot .otherwise

normal but blood Hb - 6.5 MCV decreased. What's
management?
a. Rbc transfusion
b. I.V. iron
c. I.M Ferrous

156. Baby 18months Hb 6, WBC moderately dec,. nothing

else given. What to give?
1) Oral Fe
2) IV iron
3) IM iron
4) Folic acid
5) Vit B12
6) Transfusion of RBC

157. 4 yo boy known case of hereditary spherocytosis

came with his parents, his mom says he seems getting
pale during 3 months after URTI. physical exam reveals
just splenomegaly. Lab data: normal plt, Normal WBC and
Hb:43(nl 100-120). what’s the most important
management?
A-steroid
B-ferrous gluconate
C-Packed cell
Not sure if splenectomy was there or not..

158. small child collapsed in bed 4th day after delivery

with cyanosis and dyspnea, no murmurs heard
a) hypo plastic left heart – present at birth, congenital, symptoms start within first week aft birth, after
closure of ductus begins, same symptoms,Rx-norwoods,fontans operation, transplant
983
 b) TOF
c) PE

159. a child with anemia and low platelet after facing with a parvo virus .the retic count is 6 % . What is the
possibility of this condition in her siblings?
1. 25% of boys
2. 50% of boys
3. 25% of all siblings
4. 50% of all siblings HS
5. No sibling gets this condition

160. Hereditary spherocytosis scenario of a lady with blood picture which shows Hb 8.9 and 0.05% retic count.
Rest of the cells are within normal range. Which is the most likely organism for her condition?
a. Adenovirus
b. Parvovirus

161. a 10 years old boy had seizure at home , after that he was brought to the ED via ambulance . blood glucose 2
mmol/L , what will you give ??
A. IM glucagon
B. IV glucose –if iv acess then this
C. iV glucagon
D. IV normal saline

162. 14yrs old boy,One of your long term patient since birth,presents to you at your surgery after Dog bite at
home,when he was playing with it , accidentally fell over the animal and provoked it. O/E There were Two deep
puncture wounds. No deep structural injury.His last immunization for tetanus was at 4 yrs of age according to his
File.You advise him to get the wounds cleaned and apply non-Adherent , absorbent plaster by the Office nurse
and give him prophylactic antibiotics for 5 days. As the bytes are deep puncture wounds you decided to give him
tetanus injections as well.
Which one is the BEST vaccination?.
1.DTPa(Diptheria,Tetanus,Pertussis acellular) written as dTpa
2.Tetanus Toxoid è Tetanus toxoid should be administered if 5 years since the last dose and the patient
has completed a full primary course of tetanus immunisation
3.Adult Tetanus and Diptheria Toxoid
4.Tetanus immunoglobulin + Tetanus toxoid-in unvaccinated
5.Diptheria toxoid +whole cell pertussis +Tetanus toxoid (DPT) booster.
https://www.racgp.org.au/download/Documents/AFP/2009/November/200911dendle.pdf

984
163. bronchiolitis scenario---asking investigation?
Ans.nasopharyngeal aspirate

164. 14 months old child, fever, irritability sudden onset of left

lower limb pain, refuses to stand asking diagnosis
a.osteomyelitis-not necessarily joint
b. septic arthritis-joint swollen

165. A boy aged 10 months has had recurrent infections from

age 4 months. These included a persistent mucopurulent
nasal discharge, recurrent otitis media with discharge and
cough associated with fever. The infections were responsive
to antibiotics but with incomplete resolution of symptoms and
recrudescence on withdrawal. On examination, he was non-
dysmorphic, had a perforated left eardrum and was failing to
thrive, falling from the 50th to 3rd centile for weight. The
family history included the mother’s older brother dying in
early infancy from infection. Cause of his condition….
a. Neutrophil deficiency
b. T cell deficiency
c. B cell deficienct-agammaglobulinemia
d. Compliment deficiency

985
166. 5 yr old boy repeated abscess infections scenario. what will u find in investigation?
a.neutrophil count
b antibody deficiency
c.complement level

167. 64. Boy 7 years old with recurrent abscesses. On examination. Pharyngitis, gingivitis and multiple
scabs of abscesses. Low weight and height. What investigation is helpful for the diagnosis?
A-lymphocyte count
B-neutrophil function
C-complement level
D-antibody level

986
987
988
Paeds CVS CNS

1. drugs causing most neurological deficits in child if used in last trimester

a. Antipsychotic ,
b. anticonvulsant, most defects in first trimester
c. benzodiazepine
d. opiate analgesic
The symptoms of EPS and withdrawal in newborns may include agitation, abnormally increased or
decreased muscle tone, tremor, sleepiness, severe difficulty breathing, and difficulty in feeding. In some
newborns, the symptoms subside within hours or days and do not require specific treatment; other
newborns may require longer hospital stays.

2. which drug in czs neural tube defect in baby?

A.TCA
989
B. Benzo
C.opiate
D.Anticonvulsant
E.Antiepileptics

990
991
 For first trimester: anticonvulsant
For third trimester: antipsychotic

3. lady brought her baby born normal now on 6 weeks having

hypotonia and areflexia off all limbs, poor sucking and
progressive difficulty in respiration.diagnosis
a) spinal muscular atrophy—— jm 162
b) pradder willi syndrome(central cause)
c) early cerebral palsy(non progressive)
reflexes are increased in central cause.and decreased or
absent in peripheral cause
http://www.aafp.org/afp/2015/0101/p38.html

992
4. lady brought her baby born normal now on 6 weeks having hypotonia and areflexia off all limbs,poor sucking and
progressive difficulty in respiration.diagnosis?

a) spinal muscular atrophy

b) prader willi syndrome
c) early cerebral palsy
#march

5. Floppy 4 month old baby, gaining weigh, feeding well, but

floppy limbs
a)Cerebral palsy—— page 1059
b)Prader Willi syndrome(poor sucking) page 167
6. . 3 month( 6 month??) boy normal until 6 week of age. Now,
hypotonia in all four limb, feeding difficult, can’t control
head. Sometimes he smile
A. Early cerebral palsy
B. Botulism paralysis
C. SMA (spinal muscular atrophy)
D. Prader willi
https://step2.medbullets.com/pediatrics/120607/infantile-
botulism
SMA..we can't diagnose PWS before 3years of age

7. A 5-year-old girl presents with recurrent seizures. The

seizures usually occur at night and are witnessed by her
parents. Clinical examination reveals an area of roughed
skin lumbar spine what is the most likely diagnosis?
A) Homocystinuria
B) Herpes simplex encephalitis
C) Acute promyelocytic leukemia
D) Tuberous sclerosis —— jm168
E) Neurofibromatosis
Kaplan page 231
Shagreen patch

8. Guellin barre syndrome. Dx:

a. LP(initial)
b. EMG

993
Ø History of some GI infection and diarrhea followed by proximal muscle weakness (difficulty in getting up and
walking). What is the most appropriate next step?
a. Nerve conduction tests…should be emg
b. Some muscle test or biopsy
c. CT spine
Don’t remember other options
DX:viral myositis

Ø Flu like Symptom. 2 weeks ago, now weakness in lower limb &
dyspnea & sensory loss, which Inv needed ?
o A. CT
o B. LP
o C. MRI spine
o D. Vit. B12

994
Ø Ans: d.

myasthenia page 326 jm

Guillain barre page 334
Kaplan peads neuro chap
Neurofibromatosis and Duchenne muscular dystrophy page 162 jm
FragileX syndrome 165 jm
William syndrome page 167

995
Shumyla's Questions..(CNS paeds World )

https://www.rch.org.au/clinicalguide/guideline_index/Afebrile_Seizures/

9. drugs causing most neurological deficits in child if used in last trimester

a. Antipsychotic (prolong neurological deficit)
b. anticonvulsant(neural tube defects..congenital)in 1st trimester
c. benzodiazepine(hypotonia, resp depression, withdrawal symptoms)

10. mother come with 10 month old infant 50 percentile weight and height on birth now on 10 month same 50
percentile weight and height but with increase head size from 25 percentile at birth to 75 percentile now and on
examination child hypotonic with open anterior fontanelle what will you do next??
a. .CT ScaN head (hydrocephalus)
b. check CMV infection
c. TSH
d. head ultrasound
e. rubella test

Ensure all children have their BSL checked and corrected. See hypoglycaemia guideline.
Consider checking electrolytes if this has not been done previously. In particular, consider
hypocalcaemia in dark-skinned children.

If history of one seizure: check electrolyte

If history of recurrent seizure: check blood sugar

996
11. .4 years old somalian child with seizure<1 min. After that the child is smiling, afebrile. Next investigation?
a) EEG
b) LP
c) Blood C/S
d) CT head Age of onset

12. 4 years old somalian child with seizure<1 min. After that the child is smiling, afebrile. Next investigation?
a) EEG
b) LP
c) Blood C/S

997
 d) CT head
e)measure ca & vit. D

13. 11 yr old child had seizure at home.after that he became unconscious and remain.he was brought to ed via
ambulance.blood glucose 2.wat will u give
a.im glucagon
b.iv dextrose
c.iv glucagon
d.iv normal saline

14. case scinario of 5 years old child with sudden attack of seizure and faint. His parents mentioned that he is still wet
his bed and try to take more attention from them and the parent were watching TV when he had the attack infront of
them during their watch . what is the most imp history u ask will help u to reach the diagnose:
a. -Is it the first attack
b. -about cynosis during the attack
c. -family history of seizure (centrotemporal spike) benign

Here it is sudden attack so not probably due to BHS so it is important to know if it is 1st epileptic attack or it is episodic

15. which is the most common form of epilepsy that occurs between 4-10years old
1.infantile spasm —— 1st 3yrs
2.myoclonic attacks
3.breath holding attacks
4.peittmal seizure—— 4 to puberty (ans) (absence )
5.ACTH dependent seizure

16. 8 yrs old recently started having movements of his arm and head turned towards one side. Eyes fixed, stays for
30 to 60 seconds. Many times a day for 2 weeks and then nothing in other week.Could it be?
a) Temporal lobe epilepsy
b)juvenile myoclonic epilepsy absence + partial seizures h
c) Absence seizures(no autisms+shorter duration+many times a day)

17. mother came with child complain of episode of staring suddenly with movement of hand. head twitching lip
smacking for 60-90 sec. then become confused for few min. dx?
a. Temporal lobe epilepsy( motor autisms+warning+post octal phase)
b. Juvenile myoclonic epilepsy
c. Abs seizure

18. .A 5-year-old girl presents with recurrent seizures. The seizures usually occur at night and are witnessed by her
parents. Clinical examination reveals an area of roughed skin lumbar spine what is the most likely diagnosis?
a. Homocystinuria
b. Herpes simplex encephalitis
c. Acute promyelocytic leukemia
d. Tuberous sclerosis (ans)
e. Neurofibromatosis

998
19. A previously well 3year old boy brought into ED by his father. Pt had seizure & fainting. Scenario sounded like
breath holding spells. What history/findings most helpful in diagnosis?
a. cyanosis (ans) pg 1085 jm
b. Seizure/ involuntary movements
c. no neurological deficit.
d. drowsiness post seizure
e. urinary incontinence/dribbling of saliva

20. .2 YEAR somalian WITH ONE EPISODE OF SEIZURE LASTING

LESS THEN 1 MINUTE...NO FEVER OR INFECTION
SIGN,,,INVESTIGATION ASKED : a) EEG ,b) electrolytes c)
vitamine D deficency

21. Famous question of absense seizure asked for treatment

a. Na Val
b. Phenytoin
c. Ethosximide

22. 2 year old child with 5 minutes seizure without previous

history of seizure, on examination he has runny nose,

999
erythematous throat and lymphadenopathy, fever 39.2, management
a. ceftriaxone,
b. paracetamol,
c. diazepam,
d. some other antibiotic,
e. steroid.

1000
https://www.rch.org.au/clinicalguide/guideline_index/Febrile_seizure/

1001
23. aboriginal child with single episodes of seizures afebrile which ix should be done
a. EEG
b. vit D levels

1002
24. Developmental delay in a 4 yr old child.
a. Cannot ride a 2 wheel cycle (6 to 12 yrs)
b. Cannot stand on one foot for few seconds (ans)
c. Cannot unbutton his shirt(age 3 yr)
d. Cannot draw a face (5 yr)

25. Mother came with 14 month old baby ,she says she is not developing like his sister.She rolled at 6 months , sit
with walk,but can say only ba ba.Can pick small things and shifts from hand to hand,plays peek a boo.Auditory
and visual examination are normal.what is the problem?
a. a-No developmental delay
b. b-Gross motor
c. c-Fine motor
d. d-Language delay

Ø Developmental delay in 12 month old

a. Can’t understand no
b. Can’t walk unsupported
c. Can’t say an understandable word
d. Can’t eat with a spoon

1003
26. A child was born normally weight 3.2 kg. Apgar score was 5 5 in 1 minutes and 8 in 5 mintues. he has delayed
development. WOF condition is associated with his developmental delay?
1. paternal uncle has intllectual deficit
2. father is alcoholic
3. mother has 2 cafe lait spots-pigmented birthmarks
4. sister has febrile sizures- neurological outcome is not poor
5. paternal grandmother has hypothyroidism

27. 12 month old boy, pee ka boo at 8 month prone to supine at 6,said no at 9
months,have just started sitting unsupported and haven’t started walking
unsupported yet, cant point to his body parts,turns his head to sound and
visual stimulus
a)no developmental delay
b)speech delay
c)gross motor delay #peads

28. Child's head circumference increasing without symptoms . Now 95th

percentile . INV?
a. Ct head
b. Tsh
c. Below 6 month: usg
d. Above 6 mon: ct
Ø 6months old baby H/O reapeted jerk mostly multiple in a day
,during jerks arms are flexed and limbs are drawn up.this is
decline in milesatones as well,most likely
1.petitmal epilepsy
2.infantile colic
3.infantile spasm
4.benign spasm

29. 8 months old baby whose father is normadic farmer present with rare
folic acid deficiency mother claims child is feeding well mother was

1004
 known well controlled epilepsy patient on anticonvulsant therapy which one of the following is possible cause of
condition
A)cow milk feeding
B)goat milk feeding
C)possible side effects of mum's medication
D)nutritional anemia
E)rare genetic mutation

30. peads...1...A 2 week old child with temp of 40'c came to hospital with hx of seizure + looking ill. Mother very
concerned as child not feeding well. What is the diagnosis?
a) febrile convulsion (6 mon to 6 yr)
b) septicemia…don’t forget it mashaba
c) encephalitis
d)epilepsy

31. 12 Young boy brought to clinic,parents complain, he is blinking of eyes,Smacking of mouth,Symptoms occurs when
watching tv or feed.DxA.
a. Habit spasm(tics)
b. B.Benign Focal Epilepsy( photosensitive epilepsy)

32. .child with epilepsy on some drug (cant remember it maybe valproate ), now started on lamotrigine, asking what side
effect makes you stop lamotrigine ?
a.allergy (ans )
gum hypertrophy A…phenytoin
sorry can’t remember the rest
lamotrigine causes skin rash

33. 2 yr old female child presented with febrile seizures, q was in counseling of parents regarding febrile illness which is
ture:
a. she will have another attack soon
b. if her cousin has epilepsy she has 10% chance to get febrile seizure again
c. she will never get epilepsy

1005
d. she will have febrile seizure after each URTi

34. A mother brings you her 11 month s old son as he can't sit
unsupported till now .. She tells you that he was delivered
premature and was under special care at hospital for 6 weeks
.. Mother tells you that this is the second son of her after the

1006
 first one who is aged 4 years now , What is the most important question you ask the mother
a. When first the baby smiled social smile
b. Did the baby start to roll ?(ans)
c. Did the baby had kernicterus during (stay at hospital ?
d. When did his elder brother sit supported first time?
e. Does she have any family history of epilepsy

35. 2 yrs old child suddenly enters his parents room at night , they found him confused so they rush to the ED … by exam
all is nomal … what to do next ?? very weird Qs
a. EEG bening childhood epilepsy with centrotemporal spikes JM 614
b. CT brain
c. Drug screen
d. Glucose tolerance test

36. parents brought 3 yrs old son with c/o room spinning around with no loss of consciousnesses and lasting for two
minutes every month for last 6 months and subside spontaneously.No h/o headache or vomiting.What will you do to
diagnose
a. A.EEG and CT scan head
b. B.Audiology and ENT referral
c. Other weirded options

37. 2 year old child not good developmental milestones, talk a lot of words, dress himself, all other normal milestone but
difficult to handle and cry when u examine him:
a.normal child
b.gross moto delay
c.others were irrelevant

38. Developmental milestone question: 39 month old, what should he be able to do?
a. kick a ball
b. ride a bicycle
c. speak full proper sentences
d. can draw a face

Ø #PAEDS milestone,,learn to cut with scissors,, which month ? 3 yrs

1007
1008
39. A sudani mother came to you with her 3 months old baby who is irritable and is not feeding well. His labs were as
follows:
a. --Hb 9 ( 9.5-13)
b. --Alkaline phosphatase 1216 (raised)
c. --Bilirubin 33
d. --Vitamine D 16
Rickets is an important problem even in countries with adequate sun exposure. The causes of
rickets/osteomalacia are varied and include nutritional deficiency, especially poor dietary intake of
vitamin D and calcium. Non-nutritional causes include hypophosphatemic rickets primarily due to renal
phosphate losses and rickets due to renal tubular acidosis. The manifestations of rickets are initially
seen at the distal forearm, knee, and costochondral junctions which are the sites of rapid bone
growth.The child may be asymptomatic or may present with pain, irritability, delay in motor milestones,
and poor growth.[41] Visceroptosis leads to pot belly. Children may have waddling gait (antalgic gait).
Presentation with hypocalcemic seizures is frequent in the first year of life.Alkaline phosphatase (ALP) is
an excellent marker of disease activity because it participSerum ALP concentrations are elevated in both
hypocalcemia and hypophosphatemic ricketsates in the mineralization of bone and growth plate
cartilage.Children may present with irritability or paresthesias. D

Ø His examination finding are completely normal. What is the cause of his irritability?
a. Hb
b. Alkaline phosphatase
c. Bilirubin
d. Vitamin D

40. 11 months boy, cant sit unsupported, 10th percentile for

corrected age..delivered at 32 wks for maternal

1009
 placental abruption..was in NICU for 5 wks..reason for
delayed dev?..
a. due to 8 wks prematurity
b. Duchenne muscular dystrophy
c. cerebral palsy

41. What is considered a serious dangerous delay in a

4year child .
a. Cant cloth himself
b. Can't draw a face
c. Cant ride a two wheels bicycle
d. Cant stabilized on one foot for five second

42. .Girl é epilepsy her medicines changes to Na valproate

and lamotrigine, she had H/o of UTI and amoxicillin
6wks , Now she developed maculopapular rash fever
38 what the cause?
a. Amoxicillin
b. Lamotrigine
c. Septicemia
d. Valproate

1010
1011
1012
 CVS

1. A neonate few hours after birth developed cyanosis which was not responding to oxygen. NO murmur is there.
Diagnosis? (*)

A. Transposition of great vessels

B. Tetralogy of fallot’s
C. VSD
D. ASD
Kaplan 120

TGA= AORTA arises from RV and PA arises from LV

CF= CYANOSED AT BIRTH
Survival depends on Patent DA & foramen ovale(mixing of desaturated blood with
oxygenated)
If no septal defect= severe CYANOSIS & tachypnea
Murmur absent or very soft Systolic ejection(left lower sternal border)
CXR= EGG ON STRING
E C G —— normal neonatal right-sided dominance
Treatment= PGE1 (keep PDA patent)
Balloon arterial septostomy to keep FO open(within 1st few days )
Arterial switch(1st or 2nd week)

2. A 4days old infant found in cot cyanosed but no murmur heard, O2 saturation decreased in spite of giving O2, asking
Dx?

a) Transposition of great vessels. Hypoplastic left heart syndrome (ANS)

b) TOF(murmur present)
c) VSD (112kaplan)
Kaplan 118

TOF HAS 4 COMPONENTS:

1. PUL stenosis(Rt vent outflow obstruction)
2. VSD(Rt to left shunt)
3. Rt VENT hypertrophy(strain due to high resistance at outflow)
4. OVERRIDING AORTA(will receive blood both from Rt & Lt
ventricles=mixing)

CF = may be symptom free first week of life(unless very severe pul stenosis)
Murmur is loud harsh sys ejec (upper sternal border)
Untreated may develop chronically= clubbing,cyanosis,dyspnea on exertion
Cyanosis improves on knee chest position
CXR= BOOT SHAPED HEART
“TET SPELL”= gasping on exertion,cyanosed= squatt improves Pul blood flow &
decreases R to L shunt so cyanosis improves
1013
 Treatment= PGE(cyanotic at birth)
Pul shunt or corrective surgery(6 month)

3. Forty per cent of children with trisomy 21 have congenital heart defects. Which of the following is not associated with
Down’s syndrome?

A.Tetralogy of Fallot
B. Atrioseptal defect (ASD)
C. VSD
D. Atrioventricular septal defect (AVSD)
E. Transposition of the great arteries (ANS)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5370349/

4. parents brought 4 days child collapsed in bed CYANOSED HAND AND FEET .hr110 rr40 (incomplete ques)
asd
vsd
ps
tof
neonates with SEVERE pul stenosis= CRITICAL PS = R ~ L
shunt via foramen ovale
Mild= normal
MOD to Severe= signs of RVF(heptomegaly,edema,exercise intolerance)
Short low- med pitched SEM pul area radiating to both lungs
CXR= post stenotic dilatation of pul artery

Ø 4days old infant found in cot cyanosed but no murmur heard, O2 saturation decreased in spite of giving O2,
asking Dx?
a) Transposition of great vessels
b) TOF

1014
 c) VSD

Ø A baby delivered by normal vaginal

delivery, is well after birth. On the
4th day, the baby is found collapsed
in the cot, breathless and floppy. On
examination there are no murmurs.
Possible cause could be--
a) TOF
b) PDA
c) TGA with VSD
d) Pulmonary stenosis
e) L. Ventricular Hypertrophy or
HCM syndrome?? ans is
hypolastic left heart kaplan 122

Syncope is more common in children and

young adults with small left ventricular
chamber size and evidence of ventricular
tachycardia on ambulatory monitoring.
Some patients have abnormalities in sinus
node function, leading to sick sinus
syndrome. Syncope identifies children with
HCM who are at significantly increased risk
of sudden death and warrants an urgent
evaluation and aggressive treatment.

5. A child is cyanotic, apex beat on left

axillary line, loud murmur on the left
sternal border. (apex beat in axilla indicate cardiomegaly)
a) ASD
b) VSD
c) TOF (ANS)
d) TGA

Ø 10 days boy becomes blue when he cries or on exertion. At birth all examinations were normal. APGAR score was
normal. Now systolic murmur found on cardiac exam
. a. TOF (ANS)
b. ASD
C. VSD
D. TGA

6. Eight years old child with late systolic murmur best heard
over the sternal border, high pitch, and crescendo decrescendo.
The diagnosis is:
a. Physiological murmur .
b. Innocent murmur .

1015
 c. Ejection systolic murmur .
d. Systolic regurgitation murmur (ANS)

Mitral valve prolapse with mitral regurgitation causing systolic

regurgitation murmur

Mitral valve prolapse=Abn cusps of Mitral

valve billows into Lt Atrium with systole
Girls>boys
Cf= Chest pain,arrythmias,palpitation
Common finding in Marfan & Ehlers-Danlos synd.
Apical late systolic crescendo murmur Preceded by mid-systolic
click( MC)
No therapy needed

7. A baby delivered by normal vaginal delivery, is well after birth. On the 4th day, the baby is found collapsed in the cot,
breathless and floppy. On examination there are no murmurs. Possible cause could be--
a) TOF(cyanosed)
b) PDA
c) TGA with VSD(will present with murmur)
d) Pulmonary stenosis
e) L. Ventricular Hyplopasia (ANS)

CF=Dyspnea at rest,periods of inconsolable irritability

Abrupt sudden limpiness
Apnea
Seizures

F.Hx = Prenatal steroids

MOTHER DM
Sudden unexplained death
Cardiomyopathy
Un explained fetal loss

TX =symptoms improvement with B blockers

Septal myotomy

8. 14 years old has clinically apparent Marfan syndrome. Which of the following cardiac murmurs would you expect to
hear on cardiac auscultation?
a) Decrescendo high pitched diastolic murmur at left sternal edge –(aortic regurg in Marfan synd)
b) Midsystolic ejection murmur at 2nd right intercostal space- HOCM and AS
1016
c) Low pitched rumbling diastolic murmur at the apex – aortic regurg (Austin flint) ???
d) Pansystolic murmur at left sternal edge with no radiation - VSD
e) Continuous machinery murmur at 2nd left intercostal space- PDA

https://aapos.org/terms/conditions/68
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2083669/#!po=12.9630
http://emedicine.medscape.com/article/2062452-overview

Ø 15 y/o presented with playing basketball at school. O/e hyperflexable joints. Next investigation for long term
management?

A. Echo ( will show aortic root dilation & MR) sudden death
from aortic dissection
B. ECG

1017
 C. Karyotyping
D. Joint xray
https://step2.medbullets.com/orthopedics/120522/marfan-syndrome?expandLeftMenu=true

9. 9 year old boy complains of having difficulties in playing sports at school. His height is at 97th percentile for his
age and weight is at 3rd percentile. What is your next step in management –
a) Karyotyping
b) bone scan
c) growth hormone test
d) CT Scan
e) Cardiac ultrasound
10.

Diag= inf Endicarditis

Ans= ECHO

If blood c/s present choose that one

1018
11. Which of the ffs is the warning sign for the development of endocarditis except?
a. Change of character of murmur
b. Murmur with cyanosis
c. Dev of new murmur
d. Unexplained fever with cardiac murmur
e. A febrile illness after instrumentation or minor and major surgical procedure.
a,c d,e are the warning signs of infective endocarditis ,ACC TO JM page 289.so ans is B.

1019
12. child with URTI treated…. infective endocarditis. blood
cultures taken. treated with penicillins but murmer
persists. was to do ?
a. give antibiotic for 4 weeks with blood culture weekly
b. echo

Criteria for Endocarditis

o Pathological Criteria:
• Positive histology or microbiology of
pathological material obtained at autopsy
or cardiac surgery
• Valve tissue, vegetation, embolic fragments
or intracardiac abscess content

o Major Criteria
• 2 positive Blood Cultures showing typical
organisms consistent with infective
endocarditis, such as Streptococcus viridans
and the HACEK group OR
• Persistent bacteraemia from 2 Blood
Cultures taken > 12 hours apart or 3 or
more positive Blood Cultures where the
pathogen is less specific, such as
Staphylococcus aureus and Staphylococcus
epidermidis OR
• Positive serology for Coxiella burnetti,
Bartonella species, or Chlamydia psittaci OR
• Positive molecular assays for specific gene
targets
• Positive echocardiogram showing oscillating structures, abscess formation, new valvular
regurgitation or dehiscence of prosthetic valves
o Minor Criteria
• Predisposing heart disease
• Fever > 38
• Immunological phenomena such as glomerulonephritis, Osler's nodes, Roth spots, or positive
Rheumatoid factor
• Microbiological evidence not fitting major criteria
• Elevated C reactive protein (CRP) or erythrocyte sedimentation rate (ESR)
• Vascular phenomena such as major emboli, splenomegaly, clubbing, splinter haemorrhages,
petechiae or purpura Definite Infective

1020
Endocarditis • Pathological criteria positive OR • TWO major criteria OR • ONE major and TWO minor
criteria OR • FIVE minor criteria

13. # 2015 Which one of the following features is not part of the modified Duke criteria used in the diagnosis
of infective endocarditis?
A. Fever > 38ºC
B. Positive molecular assays for specific gene targets
C. Indwelling central line
D. Elevated CRP
E. Janeway lesions

14. Aug 2018 recall:.A patient with spiking fever, SOB and was inserted prosthetic heart valves 3 months ago. And 3
blood cultures done dx as due to staph aureus IE, and given flucloxacillin for treatment. The fever subsides after
2 weeks of treatment, but SOB still persists, diastolic murmur at the left sternal edge? What will u do for
investigation?
a) CXR
b) troponin
c) blood culture for every week
d) trans thoracic ECHO
15. July ###. 50yr old male,diabetic,hypertensive,come with h.o chest pain after 30 min walk which relived after 15 min
rest.on xm bp150./90,pulse68,temp n.what will be next appro inv?Ecg was not definitive ,no change except RBBB and
inverted p in lead 3
a.holter
b.angiogram
c.tropI
dchest xray
e.echo
16. 28child with migratory arthralgia, fever, rash in back. what will be next initial inv?
a.cbc
b,esr
c.throat swab

17. .pt with infective endocarditis scenario,got iv antibiotic,but diastolic murmur persists scenario.what next?
a.serial blood culture
b.transthoracic echo
c.cbc

1021
18. #contro#paeds 27. A child with fever and hx of sore throat 10 days back . He developed pain in wrist later developed
arthralgia n swelling in ankle joint. skin rash present . what's the most initial step of management ?
a. ESR
b. Full blood examination
c. throat swab-
d. Usg
DIAGNOSIS= Rheumatic fever

19. Long scenario of Somalian patiet with dry cough.no fever or hemoptysis history. The ECG is showing prolonged PR
interval. And chest is clear
A) TB
B) Mycoplasma pneumonia
C) rheumatic fever
D) Ca Bronchus Ans is rheumatic fever by exclusion

20. child with migratory arthritis typical rheumatic fever senario ...investigation
1 esr
2 sore throat

21. 8 year old boy has pain in the right hip and knee for 4 days fever. All movements are present.
a. septic arthritis
b. juvenile arthritis
c. Rheumatic fever

More like transient synovitis. B n c cant b in 4 days, and not juvenile arthritis cz it needs to be present
for at least 6 wks.

https://www.racgp.org.au/afp/2015/april/septic-arthritis-in-children/

22. 15 yo with fleeting joint pain. Changes its site when one gets better. Rash in the back with c/o sore throat 1 week ago.
What will be your next inv?
a full blood count
b. throat swab
c. ESR
d. ECG
e. Chest xray

MURMUR

1022
23. baby delivered by normal vaginal delivery, is well after birth. On the 4th day, the baby is found collapsed in the
cot, breathless and floppy. On examination there are no murmurs. Possible cause could be--
a. TOF
b. PDA
c. TGA with VSD ************ Murmurs are not a prominent feature unless there is a small to moderate sized VSD
or
d. left ventricular outflow tract obstruction. uptodate
e. Pulmonary stenosis
f. L. Ventricular Hypertrophy (hypoplastic left heart syndrome)

24. 10 days boy becomes blue when he cries or on exertion. At birth all examinations were normal. APGAR score was
normal. Now systolic murmur found on cardiac exam.
E- TOF**********
F- ASD
5. VSD
6. TGA

Tof (The clinical features of tetralogy of Fallot are directly related to the severity of the anatomic defects. Infants often
display the following:

Difficulty with feeding

Failure to thrive
Episodes of bluish pale skin during crying or feeding

25. infant (within 12months of age) with WPW syndrome,vital stable..tx-valsalva manuever 1st..then IV adenosine
six month child found murmur? Reassure
Resolve
refer to pediatritian ***********

26. young man with dizziness and fainting attack during exercise in school but otherwise normal during the day , no
family history of such findings. What is the most relevant to see on examination?
a. A-Heart rate less than 50
b. B- BP 90/50
c. C-Continuous machinery murmur (Patent ductus arteriosus)
d. D-Systolic murmur on right upper sternum(dx-as)
e. E-Presence of S3 murmur
Family history (+) ,Dual apex beat, systolic thrill at lower left sternal edge, harsh ESM à HOCM

1023
27. 1 yr old child growing well , good feeding , stand with assistance , sits unsupported , say some some sound like
BABA , on exam. He had a systolic murmur , whats next ?
D- refer him to pediatric cardiologist
E- reassure her
F- send for urgent echo
G- tell her that he could have a cong. Heart disease,
jm 1021 pg

The 7 Ss of innocent murmurs:

1024
 1 S ensitive (changes with child’s position or with respiration)
2 S hort duration (not holosystolic)
3 S ingle (no associated clicks or gallops)
4 S mall (murmur limited to a small area and nonradiating)
5 S oft (low amplitude)
6 S weet (not harsh sounding)
7 S ystolic (occurs during and is limited to systole).

ECG given similar with ST elevation and T inversion. Very weird ECG. Scenario give chest pain for 2 hours and
back pain. Nausea. I choose Troponin. thallium scan

28. lady with faintness for twice a week, lethargic. On exam on right side diastolic murmur, on left systolic murmur.
Whats the cause?
Mixed vulvular heart disease***********
Asd..................................ASD might have two components: a systolic murmur at the pulmonary area
and a diastolic
rumble along the left sternal border. It has a widely split S2 that is fixed during respiration.
Vsd......................................................The Holo/Pan systollic murmur of VSD is usually intense and is
classically
heard best over the tricuspid area, although it can also be heard loudest in the pulmonary area.
Moreover, it does not radiate to a specific area and its intensity does not change with respiration.
viral cardiomyopathy pulmonary hypertension
pda..................................................PDA-PDA is a medium pitched high grade continuous murmur heard
best in the
pulmonary area, which has a harsh machinelike quality and often radiates to the left clavicle.

29. Patient with 2 audible murmurs on the left second intercostal space and lower parasternal, one was diastolic and
the other was systolic. Asking about the cause?

226. Mitral stenosis

227. Combined aortic

lesion**************

228. VSD

30. A pregnant lady presents with a

widely split S2, cardiomegaly,
systolic-murmur best heard at
pulmonary area, and a diastolic

1025
 murmur in tricuspid area. Which is the most likely diagnosis?
a- Atrial septal
defect************
b- PDA
c- VSD
d- Pulmonary stenosis e- Aortic
stenosis

31. ecg of 65years old man on

hypertensive treatment & history
of MI 3yrs ago ,now all
examination is normal except of
soft blowing precordial murmur on
the left border of sternum.rate
around 50/min.what to do ?
a. cease digoxin
b. cease metaprolol &
commence verapamil
c. add warfarin
************ Soft
blowing murmur post
MI,may be dt ventricular aneurysm( or pseudo aneurysm),in this case we need warfarin

32. .ecg---AF & scenario was about pt has already AF, HTN & DM & taking anti HTN,metformin,now present an irregular
pulse HR around 200 ,so whats next most
appropriate??

Ans. Warfarin (if beta blocer in option choose

that)

33. old age pt for a long history of alzheimer's,now

brought by wife with complaints of random
urination in everywhere.wife is really very
annoyed for this,last wk the man urinate in his
pants in the shopping mall,yesterday same thing
happened in the bus stop,even it's also occurring
at home very
oftenly.when u asked the pt about it he was lil bit
angry & denied that he didn’t do anything like this.what is the reason for this condition???

ans.worsening alzheimer's

34. young lady with systolic murmur over left sternal border apex beat not deviated ,no radiation ?
a.ASD
b.VSD*********HB says Mitral regurgitaion causes cardiopathy
c.PDA

ASD has ejection systolic murmur . Both r left sternal border. ASD in upper and VSD lower sternal border

B VSD has pansy stoic murmur and radiation

1026
35. elderly who is 65 years old comes to you after an episode of loss of vision for 30 mins in the last 24 hrs now his
visual acuity test shows left eye 6/60 the right eye 6/36 , physical exam shows systolic murmur in the sternal area
, no carotid bruits what will you do to reach diagnosis:

a. 1.CT brain
b. 2.MRI brain
c. 3.EEG
d. 4.Carotid Doppler
e. 5.Echo ************ not 4 as no carotid bruit

36. aboriginal old lady non smoker bt heavy alcoholic easily breathless...became breathless in getting on the exam
bed..apex beat not shifted...bt murmur present on mitral area...next ix?
a.holter monitoring

b.transthoracic echo*********

c.stress test

37. 21 years old lady has exertion dyspnea, wide split 2nd intercostal heart sound, murmur on 2nd left intercostal
area. Whats the diagnosis?
a. ASD

b. VSD.....left lower

c. MS...........at apex/5thintercostal space

d. Pulmonary stenosis ************

1027
 ** If it wide and fixed and flow murmur ASD, if only wide and ejection systolic murmur PS,

38. , Aborginal laday with many comorbidities presented SHE LIVES FAR AWAY AND RARELY SEE A DOCTOR brought
to u by her sister ..on examination she become breathless as she got on exam table there was
diastolic murmur on the apex without radiation with tapping abex beat ,,whats is your next step : WE ALWAYS SLOVE
IT AS ECHO but options were : 1- establish a sustained theraputic relation with the patient ( the correct one for me )
...... 2- ECG ...3- ECHO ......4-angio ot cts

39. A baby cries a lot ,10 days old,on examination he has systolic murmurotherwise well and growing well
a. reassure because it is normal
b. .admit hospital
c. immediate ecg
d. refer to paediatrician *********** Acc to murtagh if less than 1 yr age always thnk not innocent

40. lady with complains of tiredness with less effort , dyspnoea, orthopnoea. on examination diastolic murmur over
the left 5 th intercostal space. what is the diagnosis?
a left heart failure
b biventricular failure c cor pulmonale
d mitral stenosis **********

41. A 4 yo child has loud pansystolic

murmurs at left sternal border and all
over the precardium. Chest X-ray
showed pulmonary plethora and the

1028
 apex extended to axilla. The diagnosis is:
• VSD ************

• PDA

• ASD

• transposition of great vessels

42. Midsystolic murmur and Systolic click on the apex

a. Aortic stenosis...here also midsystolic ejection
murmur is there but systolic click??
b. Mitral stenosis
c. Mitral Prolapse
d. Pulmonary Hypertension

43. pt with opening snap and mid diastolic murmur in apical area..diagnosis?
a. ASD

1029
 b. MS**********

c. AR

44. Newborn with bad apgar scores, not improving on Oxygen, o/e cyanosis,hr 140 only systolic murmur, xray (not
given) normal heart size with only mild lung plethora, likely Dx !
A. TGV*************???because usually no murmurs there but if vsd present can be murmur
(medscape:nomurmur (despite the ventricular septal defect) or early short systolic ejection sounds are heard. )
B. PDA………

C. TOF...her lung fielf plethora normal or decreased

D. VSD………….

45. Newborn with bad apgar scores, not improving on Oxygen, o/e cyanosis,hr 140 only systolic murmur, xray (not
given) normal heart size with only mild lung plethora, likely Dx !
A. TGV???(with vsd)

46. cardiac murmur 3/6. murmur heard at uper right sternal border. And apex situated at 5th ic space on axillary
line cause asked in child
a. aortic stenosis
b. pulm stenosis
c heart failure.

47. Newborn with bad apgar scores, not improving on

Oxygen, o/e cyanosis,hr 140 only systolic murmur,
xray (not given) normal heart size with only mild
lung plethora, likely Dx !
A. TGV************shows maximum plethora in
lung fleid
B. PDA
C. TOF******
D. VSD………….not cyanotic

1030
48. an old lady presented to you with early diastolic murmur at apex, mid systolic murmur at right parasternal side
and diastolic murmur at left sternum. What is the lesion?
A)MR
B)AR*********** but right parasternal is aortic
stenosis why AR here?(AS murmur )also seen in HOCM
similar......
1)ejection systolic murmur at upper right sternal
border radiating into neck.. AS
2)blowing decrescendo diastolic murmur at left
3rd intercostal space.. AR
3)diastolic murmur: soft, rumbling low-pitched
austin-flint murmur at apex — AR

C)MS but early diastolic is key word thats in AR not late

Diaststolic so not MS D)TR

49. Pt with heart problem. In Exam you find systolic & diastolic
Murmurs with wide splitting of S2. What the most likely Dx?
a. AS
b. VSD
c. ASD********(both sytolic and disatolic since features of
pulmonary valve involvement
d. PS........systolic murmur is there
e. AR

1031
50. History of ST segment elevation (DX-STMI) with classic history of coronary pain 24 hours ago .. after giving
morphine .. what to give next:
a. TPA
b. IV heparin
c. SC heparin
d. IV nitroglycerine
e. Other irrelevant options

PSYCH
1. which of the following regarding antidepressant therapy is correct?
A) Patient with no improvement after 2 weeks should stop and
receive another drug jm 181
B) patients unresponsive after 6 wks, treatment should be altered -
if inadequate response aft 6 weeks
C) if no improvement after 6 weeks, depression is unlikely to be the
cause

2. Depersonalisation and derealisation occur in :

a. Depression PTSD ANS
b. Schizo
c. Ocd
d. mania
e. all of the above

3. Depersonalization occur in
a. Depression
b. Schizo
c. Some religious thingy
d. Ptsd
e. Or all above

1032
4. -WHO criteria , s/sx of schizo
a. Flat affect
b. Lack insight
c. Sucide idea
d. Visual hallucinations
e. Auditory hallucinations

5. Jealousy is the main component of

a. schizo –
b. Depression-normal jealousy
c. Mania
d. Ocd-there is but its not normal pathological/morbid/obsessional/delusional jealousy

6. a Malaysian student,uni student ,his gf went back to attend dad’s funeral now this guy become restless ,irritable
and cant sleep and complains that his gf talking behind his back. Dx?
a. Suspicious cannabis (amphetamines would be best)
b. Grief reaction
c. Panic psychosis
d. Reactive psychosis
e. Onset of schizo
Brief reactive psychosis (designated since the DSM IV-TR as "brief psychoticdisorder
with marked stressor(s)"), is the psychiatric term for psychosis which can be
1033
 triggered by an extremely stressful event in the life of an individual and eventually
yielding to a return to normal functioning.

7. X ray abdomen given with pin inside a 25 year old man from local correlation facility and the police brought him
as a request for checking him up . He complained of with abd pain n tenderness for a day. He has many tattoos on
his body ..( No other history provided) What is your dx?
a. Factitious disorder( best is malingering)
b. Schizophreniform
c. Developmental instability
d. Eating disorder
e. Schizophrenia

8. young women aggressive, diverse ,mood change, sleep well..

history
Self harm dsm 4 for bpd—-page 56
Gambling
lost job in 6 months

9. farmer present with depressive symptoms and angry due to drought. Spend money recklessly in women and
accusing government for the loss due to drought. He said he is just exhausted and not depressed. Which kind of
mechanism is he demonstrating? (exact option) I confused this one.
a) Denial— if ask about present mechanism
b) Reaction formation
c) Projection — if ask about overall mechanism
d) Displacement
e) Rationalization

10.Patient male depressed wife left him, drink alcohol, smoker, he has chronic lower back pain for which he is taking
paracetamol, morphine tab, others I forget today he ate all medication in his bathroom feel drowsy nausea
depressed respiration. EMT gave him naloxone. When arrived ER he still have same symptoms with depressed
respiration. asking options:
a. give him more naloxone jm 861
b. check his paracetamol level
c. give him NAC
d. I forget others

11.old man with multiple drugs overdose( paracetamol, barbiturates, antipsychotics and alcohol). He was admitted
and given naloxone in ambulance after call of his son who found him unconscious. After infusion he is answering
on questions, well oriented but then suddenly got sleepy again and his pupils still are constricted. oxygen was 120
Asking what to do next.

1034
 1- repeat naloxone
2- check paracetamol level
3- give normal saline
4- check gas blood
5) reduce oxygen

12.Pt presented with amenorrhea, taking resperidone for what ever, has whitish discharge from nipples,
investigation given show prolactin level 2500 highly increase, other lab work normal. Vitals given all within
normal limit; CT of the pituitary gland done and was normal.asking about the cause:
a. microadenoma that is very tiny
b. resperidone
c. forget
200ng/L=5000mIU/L=up-to this level it can be mechanical above this is mostly adenoma
500ng/L=100000 =macro adenoma

13.16 years old boy who his grades fall because he doesn't pay attention to lectures and he do some Sketch drawing
instead of studying , he had fight with one of his colleagues and when you interviewed him he couldn't make eye
contact with you and was unable to explain his condition , he denied taking Alcohol or non prescribed
medications
A Asperger -asperger teens likely to get bullied not fighting
B Dysthymia page 21
C bound alcohol and drug
D Conduct (kaplan pg 14)
E Schiz

14.old male with heart failure ,HTN,diabetes ,he is on clozapine for three weeks now complaining of shortness of
breath and palpitation ,HR,Bp all normal what next :
a.clozapine level b.echo(clozapine induced myocarditis…best is trop i)
c.FBC D.irrilevant

1035
15.Man previous normal i think
Excessive gambling.. Insomnia.. Spending money in pathological gambling bla bla bla
drink coffe and energy drink much amount during gambling
Options were
A.Psychosis
B.Mania

16.Lewy body dementia which rx is inappropriate

a. quetiapine…could be used
b. haloperidol - First-generation antipsychotic medications, such as haloperidol (Haldol), should not be used
to treat Lewy body dementia. They may cause severe confusion, severe Parkinsonism, sedation and
sometimes even death
c. levodopa
d. donepezil

1036
17.A schizophrenic patient admitted involuntary. He wanted to sue hospital against his admission. He believes that God
wants to swim across Pacific Ocean. And he says other ppl in his religion have same belief. What's most important
justifying his continuing involuntary admission?
a. Loss of his insight
b. His belief at risk***
c. Fixity of his belief
d. Presence of positive psychiatric behavior

18.Woman asking for sick certificate on Monday, third time in a month. Declares she consumes 12 alcohols over
weekend. What is this?
a. Depression
b. Job dissatisfaction
c. Alcohol abuse

1037
19.Patient recently diagnosed with Huntington’s Disease, he has
been drinking, and acting erratic. The police have brought him
to ED as he was caught drink driving. What is your best next
management?
a. To detoxicate ans
b. To refer him to Huntington support group
c. To send to drug and alcohol clinic
d. Some other options

20. man was prescribed Selegiline for Parkinson’s. He was on

Sertraline 100mg per day for depression and was well
controlled on it. He developed abdominal pain and diarrhea.
His BP was high. What is the next appropriate step?
a. Stop Selegeline
b. Stop sertraline
c. Decrease the dose of sertraline
d. Decrease the dose of Selegeline
e. Stop both sertraline and selegiline
21.Woman presents after death of her sister. Which is indicative
of Major depression?
- Effect in food and sleep
- Poor concentration
- Weight Loss ans
- Two other ones of MDD
**all are correct
Low mood and anhedonia are best options if present

22.Young accountant wanted to quit job, headache, wakes at night, does not feel that he can continue job. What will
be your most appropriate next step other than pharmacological management?
a. Sleep hygiene
b. Recreational emotivation
c. CBT
d. Problem solving
e. Pleasure activity

1038
23.Arab woman who doesn’t speak English with 18 weeks pregnancy, was referred by the mid-wife for which she
suspects her mental condition. The woman seems irritable, worried(or anxious) about the people around and
she’s uncomfortable when her husband is not around. She is also irritated with her 2 children. What condition in
her history will be present to lead you to diagnose this patient? (looks like prodromal symptoms)
1. Panic attacks
2. Paranoid personality disorder
3. Family member with schizophrenia
4.h/o trauma

24.X ray abdomen given with pin inside

A 25 year old man from local correlation facility and the police brought
him as a request for checking him up . He complained of with abd
pain n tenderness for a day. He has many tattoos on his body and
poor dentation(SURE)..( No other history provided) What is your dx?
a. Factitious disorder
b. Schizophreniform
c. Developemantal instability
d. Eating disorder
e. Schizophrenia

25.child come to your clinic. O/E he suddenly hug you at first sight. he play for a few min with each toy. sometime
throw & hug his toy. he sometime accidentally hurt himself so the caregiver are difficult to care him. what is dx??
A. ADHD
B. Autism
C. Asperger
D. Oppositional defient disorder

26.A girl walking naked in the st , like the scenario in Kaplan p-28(schizoaffective d) whats the rx wld b if she agrees
to take?
A.risperidon jm514-15
B. Quetiapine
c.Antidepressent

27.30 yr female, exercise 100 push ups everyday, spend 4hr everyday in gym, hourly check mirror, changes clothes
everyday 2-3times.
a. Ocd
b. Anorexia nervosa
c. BODY DISMORPHIC ——-page 528
d. Excessive exercise syndrome
e. Chronic fatigue syn
**check betterhealth.vic .gov.au

1039
28.An 18-yrs old girl is referred after having threatened suicide on Facebook. She has unstable relationships, keeps in
touch with friends close and ends them in a violent way after argument. She has past history of self-harm (wrist-
cutting) and has attempted times of overdose on paracetamol after argument with her parents. What in her
history will you need to find for your diagnosis? (exact options)
A. Prenatal exposure to alcohol
B. Past history of early sexual abuse
C. Bullying
D. Death of a family member
E. Parental separation

29.a girl with signs and symptoms of depression.what in history will lead you to dx
a.difficulty going to sleep…..anxiety
b.difficulty staying awake….narcolepsy
c.early morning wake up and cant go back to sleep

30.scenrio of a schizophrenic patient walking naked in streets.which of the following is LEAST effective for this
patient.
A.olanzapine
b. quietiapine
c.amisulpride
d.clozapine
e.another antipsychotic cant remember now

31.woman with forgetfulness, doesn’t concentrate to wrk ,burning her hands during cooking once went to a place
and realize she don’t know y she is here , what in MMSE u will find about the affect of mood?
A, Lability..bpd,mania
B, flatness…schizophrenia,depression
c.blunting…same as flatness
d.blandness-dissociative fugue

32.6 years old child he likes to watched favourite tv show, playing with only one toys, No friends at all, mother was
worried, and option was
a. Poor eye contact (could be autism)
b.repetative interruptions
C. Maternal any bad Obs history , I was just confused just because of age

33.overdosed on 25mg indapimide? Or something. Was admitted and not able to sleep despite benzodiazepam.
Nurse found her staring at ceiling and other times agitated. Cause:
a) dementia
b) depression
c) catatonia
d) delirium-bcoz of electrolyte disturbance due to meds

34.36 yr old man father died 6 months…shard whole adult life with father and mother died in his teenager.now see
ghost of his father and ghost is just standing there and dissolved when comes near.his cognitive examination is
normal.what to assess next?
A . any abnormal believe
B. explain about processes of normal grief
C .tell him it is a normal response for grief ….management
D.SSRI
E. his relation with father-if qs says assess

1040
35.A man living with his father alone at home . has a complain of seeing ghost of his father in his bedroom every
night, when he move his hand or do something then ghost disappears and does nothing with him. his father died
6 months ago. What is the imp reason to reach diagnosis?
a. delusion
b. He takes 760ml alcohol daily night
c. He had strong relation with his father

36.17 year old boy says he has to count till 20 other wise her mom will be killed, they has a minor accident 3 months
ago, boy is keeping himself into the room most of the time saying he is hearing the voices but couldn't recognize
it, whats the diagnosis,
A. OCD,
B. sever depression,
C. shezophreniform disorder

37. mother brings her 12 yr old girl because she has stop going school on asking girl says she doesn't want to go high
school, she was very outstanding in the class. girl told that her mother was diagnosed with ca 6 months ago on
further conversation she is cheerful and happy what could possibly be the cause,
A bullying in school,
B her mothers illness,
C depression

38.juvenile pyromania, asking for cause—

a.for attention,
b. curiosity about fire.
C. for revenge
39. A executive business assistant came for a medical certificate, as he observed to have lower down in his efficiency
for the past few months. On assessing you found to have that he is with low mood and sleep disturbances. He is
using marijuana and smoking but he denies any addiction. Addiction scale is above normal. Apart from the
medications what psychotherapy you will give?
A. Psyco dynamic theraphy
B. CBT
c. DBT
D. Supportive therapy

CBT (cognitive behavioural therapy) comes in handy in patients with addictions, phobias and generalized anxiety. -
DBT is mainly for borderline -bis usually for adjustment disorder and acute stress -psycho dynamic therapy for
cluster B personality disorder, principally, hysterical

1041
40.40 yr old woman with known social phobia , now comes with her brother for the assessment. Whenever she goes
out, She feels anxious, palpitations. she has a plan to attend her cousin wedding ceremony next week. She sleeps
well and at home she enjoys gardening n painting.
What is your appropriate tx for her?
Temazepam
Olanzapine
Propronol — — if asked immed next step for wedding
Venlafaxine — snri
Citalopram — ssri for treatment

Jm 929 page

41.Young lady lost her job, recently being with low mood and lack
of interest, sleep disturbances, not interested in working
married to a loving husband diagnosis
A. MDD
B. Adjustment dis
C, Dysthymia

42.A well earned business man recently got divorce from his wife
and who asked for a big compensation from him came with
ingest all in the bathroom cupboard. After basic medical management what will be the next
A. MMSE
B. Alcohol level
c. Urine drug assay
D. Some other irrelevant

43.An aboriginal boy presented by the police for the suspicious of attempting suicide and he is still in police custody
asking what to test next
A.urine Drug test
B. Psychiatric referral - -next
C. STD
D some irrelevant

44.A boy friend had a fight with his girl friend in a public place was arrested by police and produced to Er , shouting
that he will complain this to the priminister and not much cooperative. When assessing he told that he know
better psychiatry than you and all should accept his themes
A. Anti social behavior
B. Narcissistic
C Borderline
No grandiose personality given

45. 17 year boy is having fights in school he is agitated and doesn't want to talk for his problem goes out then comes
back into the clinic he is not making eye contact whats the cause DRUGS
46.17 year boy is having fights in school he is agitated and doesn't want to talk about his problem goes out then
comes back into the clinic he is not making eye contact whats the cause Asperger/autism/ADHD

47. 16 years old boy who his grades fall because he doesn't pay attention to lectures and he do some
Sketch drowning instead of studying, he had fight with one of his colleagues and when you interviewed
him he couldn't make eye contact with you and was unable to explain his condition, he denied taking
Alcohol or non prescribed medications. what is the most likely diagnosis here.?
A Asperger's syndrome

1042
 B Dysthymia
C bound alcohol and drug
D Conduct disorder
E Schizophrenia
48.Arab woman who doesn’t speak English with 18 weeks pregnancy, was referred by the mid-wife for which she
suspects her mental condition. The woman seems irritable, worried(or anxious) about the people around and
she’s uncomfortable when her husband is not around. She is also irritated with her 2 children. What condition in
her history will be present to lead you to diagnose this patient? (looks like prodromal symptoms)
a. Panic attacks
b. Paranoid personality disorder
c. Family member with schizophrenia
Another 3 answer from which I chose my answer that I forgot. (confusing question and confusing answers)
h/o trauma

49.Old woman diagnosis as Schiz & taking Venlafaxine. Now ,she become confused, day time sleeping & reduced
concentration.. What test will u do ?
Ur & Cr
Electrolytes..venlafaxin causing hyponatraemia
FBS
LFT
Urine C&S

** Patients >65 years of age should have their electrolytes measured 3-5 days after starting venlafaxine therapy.
If hyponatraemia develops, it can be managed with modest fluid restriction without discontinuing drug treatment,
subject to close continued clinical observation and biochemical monitoring.

50. 42yrs woman (it’s 42yrs old & not child!), brought to you by her friends who wasn’t go out much for 10yrs and
stay in home. But she find enjoying doing gardening, staying at home. What in H/O will help you to treat her?
A) School refusal
B) Night terror
C) Alcohol consume

51.U interviewed a person who says he is planing to kill his girlfriend..on examination there are no signs of
depression agitation what will you do
1) inform police-amedex
2 ignore the threat
3 explore more
4 send him for forensic evaluation

52.Patient well controled on olanzapine 10mg and clozapine c/o 15 kg weight gain
Stop cloazpine
Increase dose of olanzapin
Decrease dose of olanzapin
Start orlistat

53.Schizophrenic patient with bilateral tibial fracture, patient was very well controlled with drug and refused to go to
OT. What will you do?
a. Informed consent
b. Utiltarian
c. Patient autonomy ans

1043
54.women who has started cleaning her house repetedly is flirtatious with her husbands friends and is is showing
inpuslsive behaviour for one weak?
a)Hypomania*****
B)OCD
C)borderline
D)histrionic

55.Business man got bankrupt, many financial problems, complaining of late insomnia, lack of pleasure, loss 15 kg
from his weight through 3 months, and many other symptoms of depression, his family concern about him and
the patient refused to take any medication as he doesn’t believe he is sick, he admit he is tired and exhausted but
not depressed, what’s this called?
A Denial (ans)***
B Reaction formation
C Depersonalisation
D Rationalisation

56.man brought by police to ED ,coz he said to his girlfriend who recently broke up with him tht he will kill himself so
girlfriend called the police. Says to u tht I don need treatment , I ll call my embassy and inform officials there , and
said tht I knw psychology , call ur senior u r no good at it. What personality disorder?
Borderline
Narcissistic****

57.man said to his friend that recently he became hypervigilant and something funny is going around him he feels.
He comes to u and said that something very peculiar is going to happen with him ?
a. Prodromal schizophrenia
b. Schizotypal personality
c. delusion
D. Idea of reference

58.24year old man confined with a friend came mentioning " funny business is going around" same in inverted
comma) he had a feeling something is going to happen. Euphoric
state. (it was diff scenario,nothing about promotion was
mentioned) . What is the example of his comments?
a) prodormal schezo
b) passivity phenomenon
c) idea of reference
d) delusional disorder

59.pt admitted in hospital wz history of pschiatric illness, agitated ,

looking at the roof , she becomes calm when lying on bed , urDx ?
1- delirum****
2-catatonia

60.9 years old girl with school truancy ,weight loss,tearfulness ,she
leave school and go to play video games in shopping mall ?
A. ADHD
B. depression**
C. separation anxiety
D. Conduct
**ans could be truancy without wt loss

61.29 year old male aggressive behavior at work place. He has

previous h/o being arrested by police. Now asking for treatment

1044
 A. risperidone
B. olanzapine
c. SSRI**** antidepressant in personality disorder to manage anger
D Diazepam

62.Schizophrenia pt long time on medication.come to you for some reason.ultimately you find a larger ulcers on rt
arm;you said to pt that u need antibiotics but refused.what should you do?

1.just ignore it (exact words)
2.take a swab now***
3.go to mental tribunal for permission to start rx (if life threatening)
4.give him a course of amoxicillin

63.44 year old woman complains of itchiness in the scalp. Upon checking her record, patient has been seen by
dermatologist and noted normal findings. Patient now tells you there are worms in her head and it needs
frequent medicated shampoo to get rid of it. She asks for prescription. What is your diagnosis?

A. Schizotypal disorder

B. Schizophrenia

C. Delusional disorder****
D. OCD

E. Munchausen Disorder

64.Recall where grandmother cries bcz she thinks she lost her grandson because of her negligence
bcz she kept the door open. While telling she gets tearful and started crying and tells there are
voices which tell her that she would be jailed and police is after her
A. MDD with psychosis
B. Complicated grief****
C. PtSD

65.Family with a newborn baby moved to a small village in rural Australia, father called up GP to inform wife sad all
the time, low mood, crying but taking good care of baby, cannot get her to the hospital as he is busy with new
work, what next:
a. Make a home visit
b. Send a social worker to check on woman
c. Insist husband to get the woman & baby to clinic
d. Admit the woman, baby can be with dad

1045
e. Wait for the husband to call back again

66.Amphetamine overdose asking treatment.??

Table 3. Toxidromes, complications and treatment options in common illicit drug poisoning

Illicit drug(s) Associated toxidrome Complications Treatment options

• Seizures • Acute coronary syndrome:
Amphetamines Sympathomimetic toxidrome • Hypertension aspirin, nitrates, opiate
Cocaine • Acute coronary analgesia, benzodiazepines
MDMA • CNS excitation: euphoria, syndrome • Agitation: benzodiazepines,
hallucinations, agitation, • Rhabdomyolysis droperidol
psychosis, delirium, seizures • Shock/cardiovascular • Seizures, hypertension:
• Neuromuscular excitation: collapse benzodiazepines
• Arrhythmias • Arrhythmias: sodium
hyper-reflexia, tremor
• Autonomic effects: • Hyponatraemia bicarbonate, amiodarone
hyperthermia, diaphoresis, (MDMA) • Hypotension/shock:
flushing, mydriasis • Hyperthermia (>39°C) crystalloid infusion,
• Cardiovascular effects: • Serotonin toxicity inotropes
tachycardia, hypertension, • Hyperthermia: IV fluids, ice
myocardial depression, packs. May need intubation
arrhythmias and paralysis
• Gastrointestinal effects:
nausea, vomiting, diarrhoea
• MDMA can precipitate
serotonergic toxidrome

• Respiratory failure • Oxygen plus respiratory

Opiates Opiate toxidrome • Aspiration support for acute
(pneumonitis) management
• Non-cardiogenic • Naloxone IV boluses (100–
• CNS depression: drowsiness to
coma pulmonary oedema 400 µg), titrated to clinical
• Rhabdomyolysis effect
• Respiratory depression,
hypercapnia • Hypothermia • If long acting opiate, may
need naloxone
IV infusion
• Supportive care:
• IV rehydration
• re-warming in hypothermia
• maintenance of
euglycaemia

• Agitation • Reassurance
Cannabis Psychological disturbance • Psychosis • Anti-emetics
• Hyperemesis • Titrated oral or IV
• Depersonalisation, benzodiazepines
disorientation, decreased • Anti-psychotics
inhibition, altered mood,

1046
 memory impairment, lack of
attention

67.An ambulance brought you a young lady who lost consciousness with body temperature of 40° and BP was
155/90 when they found her collapsed at a friends birthday party. What is next in Mx? Amphetamine Overdose
JM-214
a. Naloxone
b. Benzodiazepines
c. IV Normal Saline.
d. Cold blanket and Cool N saline

68.nowadays in the world mental health is increased, and some is more than others. which type of mental health is
increasing in australian population
a) schizophrenia
b) GAD
c) Dementia***
d) depression

69.A man becomes arrogant, restless and breaks things. What psychotherapy to give.
a) Dialectal therapy-borderline disorder
b) Cognitive behavioral therapy
c) Psychodynamic psychotherapy***(antisocial)

70.16-year-old girl is brought to a GP by the school psychologist, who is concerned that the girl has been losing
weight despite 6 months of counselling focusing on her distorted body image. The girl’s parents are not aware
that she is having a medical consultation, and she refuses to tell her parents of her condition because she does
not want to worry them. They have been preoccupied with one of their sons who has developed a serious heroin
addiction and is stealing money from the family??
tell parents
a. Admit her
b. Don't tell parents
c. Involve social worker
d. Call child protection

71.A foster mom tensed about 2 year old child with his behavior child witnessed severe domestic violence of
biological mother with her different sex partner . At times child became withdrawal and silent. Don't play with
toys and diff to settle at night cause?
a. separation anxiety
b. acute in ch stress***
c. oppositional defiant behaviour
d. autistic spectrum dis.

72.Girl experiences anxiety when goes out in meetings with strange people . Has stress at work cuz of work load.
Next ?
A. Propranolol before going to meetings****(social phobia)
B. Relaxation therapy
C. Psychotherapy

73.Pt on venlafaxine started now strolls in garden n insomniac psychosis wat to check-
1.electrolytes****
 - if confused - hyponatremia

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2. Lfts
3.bp - at the start of tx and 3 monthly f/u
4.urine analysis

74.25 old woman got severe depression, she state either some one killed me or I kill myself to prevent the end of
world, rx
a-flouxitin+haloperidol***
b-resperidon+venalfexine-venla-snri is more preferred for severe depression
c-diazepan+sertraline
d-robaxitine+mertazepam

75.35 yrs old female presented to you after taking overdose of venlafaxine, 1 yr back she was referred for
psychotherapy for behaving badly at office and shouting. She does not take interest in anything.
a. borderline personality
b. bipolar 2 depressive phase.
c. major depression***
d.GAD
e.anti social

76.A 16-year-old girl is brought to your clinic by her mother. Mother is concerned about her daughter’s behaviour.
She does not listen to her. She talks rudely to her father. She does not attend the classes regularly. Because of her
poor attendance, school authorities are planning to expel her from the school. What is next step in her
management?
a. Cognitive behavioural therapy
b. Family therapy***
c. Interventional psychotherapy
d. Psychodynamic psychotherapy
e. Reassurance

77.A very agitated schizophrenic patient was there, and the doctors admit him involuntarily.. what’s the reason of
involuntary admission?
A) Non-maleficence
Harm reduction

78.a young man comes with sleeping for 2 hours, agitation n full of energy. Last year, he had similar symptoms and
he was taking amphetamine. But this time, he doesn't take amphetamine. Initial Rx?-
A citalopram
B quetiapine***-if stem looks like mania,see dsm 5 criteria jm517
C BZ-otherwise this
D Mirtazapine

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 Dx - acute mania
1st line - antipsychotic- atypical- olanzapine or resperidome
2nd line- lithium

79.pt admitted in psychiatric ward for 10 days.he is treated with some antipsychotic n diazepam good now bt for
the last 4 days he become agitated n go to other ward n mess all the things with some urinary incontinence.no
other urinary symptoms.what is the dx?
a.benzo toxicity
b.relapse of pyschosis
c.UTI*** dx is uraemia
d.antipsychotic overdose

80.Woman with 2-month h/o affected mood, in customer service role, missing work, can’t be bothered to go to
work, gets teary eyed often, recently hit her car to the pole, not paying attention, worries in the night about
losing her job, does not listen to her favorite music in the car, married 1 month ago to a caring person
a. Adjustment disorder
Dysthymia- Dysthymia is defined as a low mood occurring for at least two years, along with at least two other
symptoms of depression
b. Major depressive episode
c. Generalized anxiety disorder
d. Borderline Personality disorder

81.An 18 yo Aboriginal man came to you concerned about increasing anger. Just came out of ?detention/jail after 3
years. Worried he may get detained again dt anger
a) Anger management
b) Supportive management
C) Vocational rehabilitation

82.A Man came with early morning with fatigue and tiredness. always avoids others and prefer to live alone, works
at home computer.came His breath was havig stong alcoholic smell, whats dx is most important now for urgent
attention..(ques was like this)
1.Chronic fatigue syndrome
2.Avoidant personality disorder
3.History of alcohol abuse ( opted this)

83. 30 years old unemployed man always avoids others and prefer to live alone, works at home
computer.came early morning with fatigue and tiredness. His breath was having strong alcoholic
smell.which one is most important diagnosis to address now?
a.Avoidant personality disorder
b.History of alcohol abuse
c.Living alone
d.Age of the patient
e.unemployment
** this early morning insomnia/fatigue upon waking is attributable to the alchol consumption which seems to be the
culprit here. Alcohol puts one to sleep quickly and as soon as the effect of alcohol wears off, the person wakes up
without taking the proper sleep hence feeling restless and more fatigued

84.22 year old.boy with intellectual disability lives in disability care Center.Recently he is agitated,aggressive ,self
harming and talks to.himself.He refuses to leave home.What in history will you look for diagnosis?
a. Significant changing 1049ehavior
b. He talks to his teddy bear

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** he is depressed although he is suffering from learning disability but he’s suffering from major depressive illness
Depression appears atypically in individuals who are mentally challenged , He is distressed as is apparent by his
behaviour agitated aggressive self talk and self harm, socially restricted to home because when he goes outside
he must be either getting bullied or abused sexual/physical So the two answers let’ you pick btw depression or
psychosis He may talk to the bear as he’s mentally challenged but his mood changes will indicate his depression as
an axis - 1 diagnosis

85.Patient brought by wife.wife complains that she is tired of his habit of collecting rubbish.he denies any problem
by saying I have lots of property and bank balance and 3 residence..wife says bitterly that they r all filled with
rubbish.what is the most appropriate pharmacological approach?
a. Venlafaxine.
b. CBT
c. SSRI
**dx is hoarding syndrome…rx is cbt+ssri

86.A man present with unable to sit as he is pacing whenever sit down. Last night, he was injected with depot
Zuclopenthixol decanoate. What to give?
1. Physostigmine
2. Benztropine
3. Diazepam jm516
4. Methyl phenidate
** 3. Diazepam (The dose should be reviewed and reduced if side effects occur, though in the short term an
anticholinergic medication benztropine may be helpful for tremor and stiffness, while diazepam may be helpful for
akathisia...)

87.an old lady loosing track of time,keep forgetting where she kept her things,when examined she becomes
agitated.what in MENTAL STATE EXAMINATION will help you to reach diagnosis?
1-orientation….MMSE
2-impaired insight…MSE
3-memory
4-praxis

88.A 20 year old male, diagnosed ADHD, requests your prescription. He left the medicines on his own accord a few
years back. What will you assess before re prescription?
a. Suicidal tendency
b. Illicit drug abuse **
c. His level of hyperactivity
d. Family history of something, don’t remember what

89.Grand mother h/o Bipolar Diorder….asking risk of Bipolar Disorder in child

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a. 5%
b. First degree relative =15% one parents 50%_2 parents
,siblings _13%, monozygotic twin 70%, dizygotic twin
20%
c. Second degree =3-7%(grandmother)

90.Schizophrenia in dizygotic twins, What’s the percentage

of getting the diseased?
1) 10%***
2) 20%
3) 40%
4) 100%
#May
JM 163

91.Pt always talks about her sertraline dose and her symptoms and that’s it. This time she talks for 30 mins and tells
you all about her personal life. What could be the reason?
a. trust
b. overstepping boundaries
c. countertransference

92.A man c/o forgetfulness . He easily gives up task when asked to do as part of examnation.What to check in mental
state examination?
a) Orientation
b) Hopelessness
c) Hallucination
d) insight
ans should be cognition if given in options

93.lady took 25 tablets of imipramine, now confused.,Agitated.

Cause?
a. Delirium
b. TCA causing delirium

94. 48 yrs Man comes with complaint of being unable to remember

details of Bali trip taken last year and details of last christmas. 3
months ago was hospitalized for major depression, was given a
course of ECT, and released 2 months ago. Cause?
a) early onset dementia
b) depression
c) effect of ECT- myoclinic
d)benign senescent forgetfulness

95.A man was prescribed Selegeline for parkinsonism. He was on

Sertraline 100mg per day for depression and was well controlled
on it. He developed abdominal pain and diarrhea. His BP was
high. What is the next appropriate step?
a. Stop Selegeline
b. Stop sertraline
c. Decrease the dose of sertraline
d. Decrease the dose of Selegeline
e. Stop both sertraline and selegeline-ss causes high bp, sweating, diarrhea etc

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96.Post partam psychosis. Lady afraid that terrorists will kill her, accused her husband that hes also working with
terrorists. Has establsihed breast feeding. What in hx will lead to her management
A. Previous depression
B. Relationship with husband
C. Thought content

97. ***Young man with prodromal schiz symptoms. First line?

• Aripiprazole
• Clozapine
• Chlorpromazine
Queitapine

98.17 yr old aboriginal just got free from detention centre after being there
for 3yrs... He has now severe anger bouts, not always happy and always
thinks about his childhood neglect and maltreatment. Now doesn't want to
go back to detention for his behavior what treatment to give him?
A. CBT
B. Dialectal therapy
C.antidepressants
D. Pschyanalytic therapy making conscious their unconscious thoughts and motivations, thus gaining insight. The aim
of psychoanalysis therapy is to release repressed emotions and experiences
E. Anger management program

99.A female patient shaved all of her hair because she thinks she has infection on her hair.Before that,she went to
multiple doctors to consult about her hair infection but the doctors could not find any problem.She doesn’t agree
with the doctors and she shaved all of her hair.What is treatment for this patient?
A. Fluoxetine — Dx Hypochondriasis Rx CBT & SSRI… delusional para
B. Amityptylline

100. Q.A grandmother brought by her husband,complaining,she has insomnia 2 months,feels agitated.this
happened after their grandchild was under her supervision and he went out of home and had accident.grandma
thinks its her fault as she kept the door open.what could be cause of her symptoms?
a-Posttraumatic disorder-ssri and beta blockers, upto 1 month its acute stress disorder,later ptsd
b-Genral anxiety disorder
c-Depression

few new questions in psychiatry cant remember the full stem. One was capgrass syndrome(imposter syndrome)
Mostly ass with alzheimers,schizophrenia,brain lesions
validation therapy, coherence therapy, delusions are supported instead of rejected, Reality orientation
Medications like cholinesterase inhibitors, which boost neurotransmitters involved in memory and judgment, for
dementia and Alzheimer’s disease
Antipsychotics and therapy for people with schizophrenia
Surgery, if possible, for brain lesions or head trauma

101. A hyperactive child with obvious attention deficit. Treatment of choice

A. Risperidone
B. Methylphenidate***** (ADHD) or meth
C. Temazepam
D. Behavioural therapy
E. Another option not valid

102. 15 year old male occational usage of metamphatamine.. daily usage of marijuana and unexplained scars in
forarm. Treat with psychotherapy but failed.what to do next

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a. Diazepam
b. Respiridone-if meth toxication
c. Methylphenidate
d. Fluoxetine—for meth withdrawal symptoms like anxiety and depression and suicide risk give antidepressants
e. Naloxone — for opiods
** Methamphetamine withdrawal is associated with more severe and prolonged depression.

103. Old male patient with depression tried to quit smoking. What will you give?
A. Bupropion****- Bupropion is a medication primarily used as an antidepressant and smoking cessation aid.
B. Nicotine patch
C. Educational therapy
D. Cognitive behavioral therapy

104. An Alzheimer patient was brought to clinic from shelter which she moved 2 weeks ago because her family
member cannot tolerate her odd behaviors and accusing them of stealing sth like that. Cause?
1. worsening Alzheimer ( dementia is seen in later stages of Alzheimer’s)
2. depression
3. dementia
4. delirium

105. primary insomnia, no family problem, what to do

1. dog walk before retiring
2. tv install in room
3. don’t go to bed until you fall asleep…sleep hygiene

106. All the following are anorexia nervosa investigations except:

a. ECG
b. LFT
c. Gonadotropin.
d. Osteoporosis
e. Electrolytes

107. 33 year old lady comes to consult you about her problem, she need to count up to 13 before igniting fire to
start her car. She felt better after that. But also feel bad that it disturbs her daily activities. What kind of
psychotherapy will help you to relieve her sufferings.
1. psychodynamic psychotherapy
2. interpersonal therapy
3. exposure and response prevention
4. CBT (COGNITIVE behavioral THERAPY)

108. 7 years old girl with soiling in her underwear, she tell lies about accidents at school and hide her soiled
underpants and cry and quarrel with her brother when he called her smelly. Dx?
1. regression
2. conduct
3. ODD?????/
4. delayed milestones

109. . a neuropath patient comes to you with a list of investigation ordered by his psychiatrist. Those tests are not
clinically justified. What will you do?
1. do investigation
2. tell him they are not necessary
3. perform tests at patient expense
4. discuss with psychiatrist ??/

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110. drug not to be used in lewy body dementia
1. donepezil
2. levodopa
3. SSRI dementia.
Haloperidol is absolute contraindication in lewy body ,Rx is neostigmine,donepezil etc

** Cholinesterase inhibitors that may be effective in the treatment of DLB also include donepezil and galantamine.
In a small minority of patients, motor features are worsened with cholinesterase inhibitors. Levodopa/carbidopa
may improve motor function in some patients with DLB; however, in many patients this combination has no effect
and may exacerbate psychiatric symptoms or confusion. Depression is frequent in patients with DLB; it may occur
as a result of damage in the dorsal raphe and locus ceruleus and/or as a psychological response to impaired
function. Selective serotonin reuptake inhibitors (SSRIs) are the drugs of choice for treating depression in DLB.

111. 1 can of beer + woman in hospital oxazeapam presenting features of paranoia ( agitated)
What is the dx
a. Benzop withdrwal –panic attacks
b. alahocl withdrawal

** Recreational drug use: Cannabis and amphetamine abuse often causes paranoid thoughts and may
trigger an episode of psychosis. Other drugs such as alcohol, cocaine and ecstasy can also cause paranoia
during intoxication or withdrawals.
(sice she is in oxazepam-a benzodiazepine-which is given for both alcohol withdrawal symptoms as well as
benzodiazepine withdrawal symptoms. Here she is showing paranoia so it is symptoms of alc withdrawal)

112. Patient after surgery present with agitation, tremor, restless. Previous medication contain oxycodone and
others drugs. HT + and history of drinking one glass of wine everyday before. Current medication list mention and
didn’t contain oxycodone.
a. Benzodiazepam withdrawal
b. Alcohol withdrawal

113. A woman comes to your clinic. She was prescribed trifluoperazine for her condition. She was
taking it for 3 years with improvement of her condition. She says that she discontinued taking
her medication for the last 3 weeks because her doctor was not present for he was in trip, she
also said that trifluoperazine makes her hand or some muscle part stiffy, rigid, and restless.
Now she presents with voices in her head. What is the most appropriate initial ‫؟؟‬choice
management?
A-trifluoperazine
B-resperidone
C-quitapine
D-respa depot
E-stop trifluoperazine

114. 25 years old lady previously on sertraline controlled on medicines, she stopped 5 weeks gestation when
came to know that she is pregnant. Now came with mood problems on 20 weeks. She is asking if she needs to
start sertraline or if there is any other medicine available
A. recommence sertraline
B. Start olanzapine
C. Explain benefits and side effects of sertraline and olanzapine
D. No medicine
E. Refer for psychotherapy

115. 30 yr old lady with well controlled on sertraline 50 mg but complained of abdominal pain . what is the next
management option
A stop the drug immediately
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B change the drug immediately
C taper to 25 mg and then four day free…then start another onejm181..washout period required
D taper to 25 mg together with low dose of another drug and then stop sertraline in four days with continue of
another drugs…for antipsychoticand for sertraline
hb363,hb597

116. 30 years old man with Schizophrenia is well controlled with Olanzapine and Temazepam. He increases 15 kg
after three months treatment and he is concerned about it. What will you manage this patient?
A. Refer to dietician
B. Change Olanzapine to Aripiprazole
C. Stop Temazepam
D. Continue same treatmen

117. A case of gynaecomastia pt on risperidone. What other drug to counteract the side effects
A. Quetiapine
B. aripiprazole****
C. olanzapine
D. Clozapine
E. Mirtazapine

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118. Patient comes to you from Japan. She believes that her bowels have exploded after a volcanic explosion. She
was treated with Trifluoperazine before in the past. She responded well but later lost contact with her doctor.
Later she stopped taking the drug because she was having some motor problems and stiffness. What is the most
appropriate next treatment?
Haloperidol
Trifluoperazine
Quietapine
Clozapine

119. pt put 10 kg weight after olanzapine 10mg/day, well controlled symptoms,bmi 26 , what to do beside
lifestyle modification handbook ..
a. Continue
b. Change to ziprasidone
c. Dec olanzapine
d. Inc olanz
For example ziprasodone and risperidone, both potent 5HT blockers are less likely to cause weigh-gain than drugs
with lesser 5HT affinity, like olanzapine and clozapine

120. 22 year old male who is diagnosed as schizophrenic since 19 years of age, on clozapine ?mg and well
stablilized with drugs, but he spend 15 hours per day for sleep and he also worry of sedation, what will be your
initial management?
a. Add risperidone
b. Increase clozapine
c. Decrease clozapine
d. Add sodium valproate
e. Add methylphenidate
Always add the other drug first . hb 615
**C, reducing dose might reduce sedation, will not give risperidone since there must have been an indication of using
clozapine in this pt (second line drug) ? previous severe EPSE or treatment failure

121. 17 yrs old carpenter presents with mother, forget where he leaves is tools. His mother said that he was a
difficult to control child in his childhood. What in history will lead you to diagnosis.
a. Use of marijuana in 9 yrs of age
b. Administration of methylphenidate(aka Ritalin given for ADD nd ADHD) at 11 yrs of age
c. Night terrors for 2 wks at 7 yrs of age

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122. woman is planning to do the IVF..she is well controlled on lithium..she takes 1000mg of lithium per day.what
to do now?
a) reduce the dose
b)cease lithium (known for sure it is contraindicated in brst feeding)
c) check the blood lithium level
check levels 4 wekly to maintain therapeutic dose
Regularly monitoring the serum lithium levels during pregnancy is essential as the levels can change with changing
maternal fluid volume. It is essential to maintain a therapeutic level of 0.6–0.8 mmol/L.11 Reducing the dose of
lithium at around 38 weeks gestation will reduce the risk of the infant having high serum lithium levels; however,
a full therapeutic dose must be restored immediately following delivery.

123. 26 year old woman complains of mild increase in her menstrual flow for last 3 months.She also feels irritable
during menses.She believes that her decreased libido affecting her marriage. What is the appropriate
management for this patient?PMS
a. High dose OCP without pill free week
b. Sertraline 100mg (ssri-antidepressant-given in this case)
c. Evening primrose oil

124. a man presented with mmse 27/30 history of htn , parkinsonism on many medication complaints
of seeing green cat in his window.asking diagnosis
1.due to medication- change to A, due to medication because dopaminergic drugs can cause hallucination or
psychosis. to diagnose lewy body dementia we need fluctuating cognitive impairment which is not present here
as MMSE is 27/30.
2.parkinsonism
3.lewy body dementia
There are also three cardinal symptoms, two of which must be present in order to make the diagnosis:
Visual hallucinations
Parkinsonism (tremors and stiffness similar to that seen in Parkinson's disease)
Fluctuation in mental state so that the person may be lucid and clear at one time and confused, disoriented and
bewildered at other times. Typically this fluctuation occurs over a period of hours or even minutes and is not due
to any underlying acute physical illness.

125. 86 years old man who is brought to ER due to his recent aggression to his roommate, he is on diuretics and
Oral Hypoglycaemic Agent and some drugs, and he complaint of seeing soldier in his room. Which in the history
will help you for diagnosis?
a. His pre existing visual impairment
b. Drugs taking history
c. His pre existing cognitive impairement-like alzheimers

**Option first will not have aggressive behaviour all of sudden. Option two, with that age, he ll be a know drug
user They did not mentioned medications in options otherwise hypoglycaemic agents can cause delirium Yes it's
kind of worsening vascular or Alzheimer's Dementia
126. An old lady come to consult you for medical review, she is in pension for 8 years ago because of her
behavior, she has been practicing naturopathy and being a fortune teller, she used to spend time with a regular
client who has same interest as her. She also suffering from bodily pain. She now said she is persecuted by a staff
from government office and who told she must either see the medical review or if not, her pension affected.
Which in the history will be important for worse prognosis?
a. Her interpersonal relationship
b. Character and intensity of her beliefs (pds –shizoids or shizotypal)
c. Her somatic symptoms

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127. Young man who is an marijuana user was brought to ER. He said he has been attack by Underground gangs
and police are also following him. His friend said he has used the amphetamine now long ago. Which of following
most dangerous for him?
a. Cardiotoxicty from amphetamine use
b. Gangsters attack
c. Police
d. Two drugs abuse
Rx of amph toxicity-activated charcoal
Benzo
For cardiac-give benzo,dc cardioversion,anti arrythmics, iv phentol or gtn
**marijana causes delayed decision making in person taking both amphitamine and marijana and person can easily
over dose with amphi as its effects are masked by marijuana...so ill choose 4
128. .23 woman several times jail.h/0 drug abuse prostitution from 16.dont want to talk about family.no h/0
sexual abuse.dx-
a.borderline personality disorder***-all other feats similar in conduct except relationship problems-all or nothing
attitude in relationships in borderline.
b.conduct disorder
c.avoidant disorder
no mention of antisocial

129. . Overdose of amitryptylline ( not mentioned how long ago) now drowsy and hypotensive and Wide QRS in
ECG, what is yr next management?
1. oral activated charcoal-large ingested doses
3. hemodialysis
3. gastric lavage
4. Intubation and IV sodium bicarbonate
5. something like cardioversion
Intubation and hyperventilation (aim for pH 7.50-7.55) are mainstays of treatment for severe overdoses (where there
is a decline in GCS) in addition to sodium bicarbonate (discussed below)
Ventricular arrhythmias caused by amitriptyline toxicity are unlikely to respond to cardioversion or defibrillation
— First line treatment is sodium bicarbonate (100mmol or 2mmol/kg) should be given IV every 1-2 minutes until
rhythm and perfusion are restored
— Second line treatment is lignocaine (1.5mg/kg) IV once pH is greater than 7.5

130. Non-Australian patient admitted for #femur & ribs after car accident. He was driving a stolen car, which
turned over while being chased by police, someone is killed in the accident. He is aggressive, argumentative,
demanding to smoke. Later, threatens that he will assault staff, discharge himself &will go to his embassy &
complain about inappropriate behavior of hospital. What will you do according to his last action?
A. Discharge immediately to police custody
B. Refer to nearest medical ward with correctional facility bcoz cant discharge pt with #femur and rib.
C. insist rather he use nicotine patch
D. Tell the embassy about his expired temporary visa
E. allow him to smoke in smokers room safely away from other patients

131. .A 15year old girl having difficulty in concentrating. She CONSTANTLY fight with father,need support in
school because she cant maintain tasks,Use multiple drugs, like amphetamine,marijuana,telling its difficult for her
to sleep,denied any hallucination or suicidal thought,what will you do?
a. Liase with father- qbank
b. Talk with parents and her(safety plan)
c. Give ssri
d. CBT-next option
Tell school to support her more

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132. 25yr Husband beating up the wife and hostile. Asking for previous significant history to make the diagnosis:
Child sexual abuse
Cruelty to animals during late childhood-antisocial disorder where ppl behave impulsively and disorderly,show
cruelty towards others and does not feel guilty.
school grade fall

133. A woman brings her husband after prostatectomy saying that he has been getting extremely angry and
agitated on most trivial things after the operation. Which of the following questions will help you identify the
problem?
a. History of drug abuse
b. History of domestic violence
c. History of self harm
D. Worsening of symptoms at night-symtoms of post op delirium.

134. . Female husband died one year ago she is still having same symptoms of grief says she has been sleeping
badly for last two weeks during interview she cries nd tearful wht will to do immediately reliever her symptoms
Citalopram-ssri-antidepressant
Temazepam-benzodiazepine-for insomnia
Vanelafixine- ssri-antidepressant-HANDBOOK 127 –for MDD

135. an opera singer has excessive sweating and9 flushing during her show.her employer is irritated and asked
her to improve her symptoms otherwise will let her go.she is now worried and cant sleep at night.wat will ease
her condition-
a.ssri-for both social phobia and gen anxiety rx is first cbt then ssris -antidepressants
b.bb****( social phobia)-this is non generalized social anxiety-rx bb
jm 919

136. Young indigenous male presents to you with insomnia, fear of darkness and seeing “mamu” . He has been
having these symptoms after the death of his mother. Which of the following should be next step in his
treatment?
a. Give him benzodiazepine
b. Counselling with an indigenous counsellor
c. antipsychotic agents

137. Young man whose father died 6 months ago. He’s seeing the ghost of his father at home which appears and
disappears without talking to him. He presents to you asking for advice. Most appropriate management asked.
- give him leaflet about process of natural grief
- reassure him that this is normal process of grief-upto 6 months normal later abnormal
- diazepam-benzo-minor tranquiliser
- ssri-antidepressant

138. Scenario of woman with melody stuck in her mind she can't get rid of it and being distracted and distressed
What help you in dx
Level of insight-part of ocd and rx is cbt and med ssri and clomipramine
Mood
Suicide idea
**The DSM-V contains three specifiers for the level of insight in OCD. Good or fair insight is characterized by the
acknowledgment that obsessive-compulsive beliefs are or may not be true. Poor insight is characterized by the
belief that obsessive-complsive beliefs are probably true. Absence of insight make obsessive-compulsive beliefs
delusional thoughts, and occurs
in about 4% of people with OCD.

139. Young man whose father died 6 months ago. He is seeing the ghost of his father at home while h appears
and disappears without talking to him. He presents to you asking for advice. Most appropriate management
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 asked.
Educate him about the process of natural grief
Reassure him that this is a normal process of grief
Diazepam Some other drug(NOT SSRI)

140. Bmi 32 pt, fallen asleep in office... says al time tired cant take workload. Dx?
Sleep apnoea
Narcolepsy

141. Boy in girlfriend’s underwear recall

a. he is a girl trapped in a male body
b. Transvestism
c. Homosexual in deep in his mind
d. Normal behavior of this age
e. Normal for children who dont have male role model

142. Old man has little contact with family lives in hostel. Now wants no more intervention n rx and just die as he
is. Asking advice
a. Tell him to talk to family and decide
b. Tell him he cant discuss with doctor
c. Explore more about his expectation and wishes about it

143. mmse 27/30,lady has some ca, daughter says do sx, pt says no sx just needs relief from pain, what nxt
a. Do sx as daughter says
b. Give symptomatic rx as pt says
c. Family meeting

144. schizo pt with melanoma recall

Explain him about melanoma and sx

145. Schizophrenia patient taking controlled release Depot medication on followup. You found a melanoma on
his face and advice him for treatment. He denied it saying he could heal himself. What to do?
A. Tell him about the risk of melanoma and treatment benefits
B. Formal mental state examination
C. Refer for psychiatric opinion

146. father has alzheimers brought by son, says cant take care of him, what next
Arrange urgent nursing care for him
Involve social worker

147. what to give to a girl with some adjustment disorder I think, not borderline…
a. Interpersonal therapy-cbt first
b. Dialectal psychotherapy
c. Behavioural dynamic psychotherapy-contraindicated

148. Lady overdose of venalfaxine prescribed for her, she is irritable at work and insomniac, she has low mood,
what should you added after recovery from overdose
a. sodium valproate
b. olanzapine
c. risperidone
d. oestrogen patch

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149. patient has taken lots of tablets of venlafaxine. Was on depression treatment. One year bak she was given
psychotherapy for anxiety and insomnia. After stabilization of the patient what next to add
A. Lorazepam
B. Risperidone
C. Mirtazapine
D. Olanzapine
E. Haloperidol
150. Lady overdose of venlafaxine prescribed for her,she is irritable at work and insomniac,she has low
mood,what should you added after recovery from overdose
a. sodium valproate
b. olanzapine
c. risperidone
d. oestrogen patch

151. Lady overdosed of venlafaxine prescribed for her. She was irritable at work and insomniac. Her mood is
euphoric now. What should be given after recovery from overdose?
A. sodium valproate
B. mirtazapine
C. risperidone
D. oestrogen patch
insomnia with depression so mirtazapine is the choice in 1st question and in 2nd ques hypomania, low mood so
Olanzapine is the choice and last one euphoria no olanzapine in the option hence risperidone.

152. man with severe depression treated with venlafaxine now presented with agitation pressured speech
euphoria and mania ask what next appropriate thing to do
a.add sodium valproate.
B.add clozapine
c.add olanzipine
d. Withdraw venlafaxine (there is no opt. Of withdraw venlafaxine and add olanzipine ...it's explained in JM in
bipolar disorder check JM 518 management of bipolar depression.
JM518
1st line for acute mania
Olanz or risper
2nd line sod valp/halo/lithium

153. Old lady wants to make changes to her will. Her daughter says she has some memory loss and she can’t do
this. You checked her and she has short term memory decreased and MMSE around 20-25 something.
a. She can’t change
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b. She can change
c. Sent her to neurologinst

154. A lady after 5 days(as I remember the days) postpartum, not allow anyone to touch baby.. so concern about
everyone, even nurses. She thinks someone will take her baby. Ask Dx?
a. Postpartum psychosis
b. Depression
c. Schizophrenia

155. scenario of post partum psychosis.lady hypervigilant ,moving furnitutre,fearing swapping of baby
Treatment asked?
1-quietapine
2-clozapine
3. Admission to psychiatry unit

156. An old lady diagnosed as Schizoaffective disorder on Risperidone living in a nursing home
And want to go out, she tries to climb fence so all her belongings kept away so that she cant packup, how to treat
her ?
a. Ask her brother who has attorney
b. Increase Risperidone
c. Guardianship court
d. Cognitive assessment

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157. Depression and dementia how to diagnose
Hopelessness
Level of insight
Orientation
**maybe asking to differentiate true and pseudodementia

158. Oxycodone overdose in an elderly lady with pinpoint

pupil- poppy seeds-oxycodone-causes vomiting
constricted pupils,drowsiness,rx is naloxone.

159. 92-old patient found unconscious at home brought

by son to emergency department . the patient was taking
tablets methadone, oxycodone , others , patient has
constricted pupil on examination which of the followings
is the likely cause?
A-methadone***
B-oxycodone
C-may be cocaine don not remember other options

160. an old women who is widow who seems well in past but since she became a widow and she moves to the
house and start to stay alone one of neighbour noticed her strange behaviour.she starts to dig some ground in
front of the house and when neighbour reached near her and looked at her, she then aroused him and get
aggressive and after that she became calm down and agreed to be seen at the medical clinic.Which one of the
following in her mental state exam will help u for ur dx and mx?
A)thought form
B) mood
C)orientation

161. A women come for interview, U asked about appetite. She said one doesn't get cheese from moonand I
came by bus .what is Dx?
a.behavioral problem
b.Dissociation-1st choice derailment. …Psychosis Amedex Qbank
c.Depression
d. Delusion

162. Patient on sodium vaproate and quietapine..change of doctor..wat to chek before commencng treatmnt..
a. valproate blood level..
b. quietapine blood level.
c. .ecg
163. An old man who is intubated, unresposive and I’m guessing that it was the family memebers who ask you to
be a witness for the same signature of his will (They did not mention if it was a new will or they happen to have
lost the previous will), what to do in this An old man who is intubated, unresposive and I’m guessing that it was
the family memebers who ask you to be a witness for the same situation?
a. Refuse to wintness
b. Call your defence lawyer
c. Ask the kin if he is comfortable with you witnessing
d. Sign infront of a lawyer

164. A man who works in a office and is always with seated, he is on SSRI and now feels “isolated” and “low
mood”. What to do besides giving him medications?
a. Event planning
b. Interpersonal therapy ….from amedex
c. c) Problem solving

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**Major depressive disorder and generalized anxiety disorder are among the most commonly diagnosed mental
illnesses in Canada; both are associated with a high societal and economic burden. Treatment for major
depressive disorder and generalized anxiety disorder consists of pharmacological and psychological interventions.
Three commonly used psychological interventions are cognitive behavioural therapy (CBT), interpersonal therapy,
and supportive therapy

165. There was woman having social phobia in that she was reluctant to go places and comes with her friend. She
states she is fearful outside but happy at home doing painting and all other kinds of activities, what in her history will
help us reach diagnosis?
School refusal
Night terror

166. 24 years old aboriginal male with lack of interest in normal life and is having visual hallucination, he is saying
my mother died last month but it is not the case and mother died year ago, what is most likely diagnosis?

a) Normal grief-upto 6 months

b) Personality Disorder
c) Depression with psychosis
d) Schizophrenia
e) Depression
167. A 24 years old aboriginal male with lack of interest in normal life and is having visual hallucination, he is
saying my mother died last month but it is not the case and mother died year ago, also has sucidal thought what
is most likely diagnosis?
A. Personality Disorder
B. Depression with unresolved grief
C. Depression with psychosis
D. Schizophrenia
E. Depression

168. A woman who cuts herself and breaks up with her long time boyfriend, many other incidents were written in
the stem but I cant remember all of them just the main two that aided me to diagonose her as having borderline.
a. Dialectical behavior therapy- for borderline PD
b. acognitive therapy
c. Interpersonal psychotherapy

169. A wife brought his husband who was not eating and drinking anything for 3 days with severe melancholic
depression. What will you do next?

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ECT approval from mental health tribunal
ECT approval under duty of care
ECT approval with consent from wife
ECT approval with consent of two doctors

https://www2.health.vic.gov.au/mental-health/practice-and-service-quality/mental-health-act-2014-
handbook/safeguards/electroconvulsive-treatment

170. A wife brought his husband who was not eating and drinking anything with severe melancholic
depression.H/O self harm for 3times,likes wrist injury,Neck injury.Now Suggests for ECT,but patient rufusing for
ECT.His MMSE is good.What will you do next?
ECT approval from mental health tribunal-victoria guidelines
ECT approval under duty of care
ECT approval with consent from wife
ECT approval with consent of two doctors

171. A young lady present with insomnia, low mood, giving away her personal jewelry to her friends. asking what
would be risk for suicidal ideation
a. Giving away her personal things
b. Insomnia

172. 14 year old girl who is living with her parents, fights with them, suffers from depression, weight loss and waking
up early, thinking abt suicide, tried suicide in the past week, what is your next management?
a. Psych admission
b. Tell her we need to tell parents

173. 14 years old girl comes to see you because she is feeling depressed and having recurrent suicidal thoughts.
She does not want her parents to know about her
consultation. You should:
A) contact her parents
admit her to hospital
C) give fluoxetine and review in 3 weeks
D) contact a child protection agency
174. Patient is agressive have h/o self harm, difficult relationship, what is the diagnosis?
a) Borderlline personality disorder
b) Obsessive compulsive personality disorder
c) Narcisstic personality disorder
d) Antisocial personality disorder

175. A typical Builimia nervosa scenario, which one is the most likely to occur?
a. Tachycardia - Repeated vomiting causes hypotension and tachycardia
b. Ankle edema
c. Amenorrhea-anorexia

176. Scenario of post partam psychosis,wife thinking terrorists will kill her, recently accused husband of working
with terrorists , what in the history will lead to her management?
a)Thought content
b) Previous depression
c) Her relationship with husband
d) Shes breast feeding baby also-may be if she does then we need ect so that she can recover early and breast feed
the baby

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177. A woman brings her husband after prostatectomy saying that he has been getting extremely angry and agitated
on most trivial things after the operation. Which of the following questions will help you identify an immediate need to
hospitalize this patient?
a) History of self harm
b) History of drug abuse
c) History of domestic violence

178. Anorexia nervousa scenario What to look for?

a. Feeling of inferiority
b) Guilt
c) Apparent loss of appétit
Low self esteem is a central theme in the development of an eating disorder

179. Anorexia nervosa with low BMI then now increased BMI .
a. Ankle swelling
b. Tachycardia
c. Thick hair
d. increase temperature

180. Recall of the young lady whose child is 10 days and she comes with him with complain that he cries
excessively and is difficult to handle. She has established breastfeeding. On examination, child is well and on 90th
percentile for weight and height. Which of the following factors in the mother will you consider to establish a
diagnosis?
a. Her mood
b. Her relationship with her partner
c. Her sleep
d. Her premorbid personality

181. Recall of the young lady whose child is 10 days and she comes with him with complain that he cries
excessively and is difficult to handle. She has established breastfeeding. On examination, child is well and on 90th
percentile for weight and height. Which of the following factors in the mother will you consider to establish a
diagnosis?
a Her premorbid personality
b. Thoughts about harming the child
c. How she is managing her life with the child???

182. a brother presented to you because of some behavior problem and during the consultation he told you that
his sister who also is in your inpatient care and have schizophrenia told him that she will attempt suicide
tomorrow but the brother asked you to keep this secret and don't tell her. What is your most appropriate next
step?
A-inform police
B-discuss with the patient her plans
C-don't tell anything as the brother told you
D- Ask the brother to talk to his sister

183. 17 years old girl comes with her sister. She cut her wrist. She doesn’t want to let anyone know. Mentally fit.
Parents separated. Lives with her mother but wants to live with her father. Whom to inform initially?
a) mother
b) father
C) both parents
D) Patient herself
E) School Counsellor

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184. Old Q of Man( no age mentioned ) aggressive , abusive to mum , had several offence against others too (
many violent offences can’t remember ) .difficult behaviour.What will you ask in history to get Dx ?
a-family history
b-mother took amphetamine during pregnancy
c-history of burning 12 years ago due to pouring petrol in neighbour’s dog
d-previous violence history

185. Guy is not happy with his surrondings and think nothing does make SENSE and he think as he become wild
animal
a. Delusion
b. Depersonalisation
c. derealisation-

Symptoms of depersonalization include:

Feelings that you're an outside observer of your thoughts, feelings, your body or parts of your body — for example, as
if you were floating in air above yourself

Feeling like a robot or that you're not in control of your speech or movements

The sense that your body, legs or arms appear distorted, enlarged or shrunken, or that your head is wrapped in
cotton

Emotional or physical numbness of your senses or responses to the world around you

A sense that your memories lack emotion, and that they may or may not be your own memories

Derealization symptoms

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Symptoms of derealization include:

Feelings of being alienated from or unfamiliar with your surroundings — for example, like you're living in a movie or a
dream

Feeling emotionally disconnected from people you care about, as if you were separated by a glass wall

Surroundings that appear distorted, blurry, colorless, two-dimensional or artificial, or a heightened awareness and
clarity of your surroundings

Distortions in perception of time, such as recent events feeling like distant past

Distortions of distance and the size and shape of objects

186. A 35-year old man has history of schizophrenia. He has inappropriate behavior recently. Which of the
following is important to choose appropriate treatment?
a. Reference idea
b. Depressed mood
c. Persecutory delusion-seen in late onset schizo-older age and abusive auditory hallucination
d. Insertion idea
e. Poverty of thought –thought disorder seen in early onset schizo

187. **Here the pt has h/o schizo which was treated and now pt is having behaviour problem again which could
be relapse of schizo so whether it is relapse of schizo or not we need to look for typical feature of early onset
schizo That means poverty of thought...
**stages of schizophrenia:
1.pre prodorm scizo
2.prodorm scizo: occurs after 18 month of stage 1
3.scizo: occurs after 2 years of stage 2 or 4 yr of stage 1

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188. 17 years old person left home when she was 13 after sexual abuse. Since then she left school, take drugs,
went to jail few times. He was a good student with excellent result in school before sexual abuse. What is your
diagnosis?
a. Antisocial
b. Post Tramatic Stress Disorder
c. C.Conversion disorder
d. D. Borderline
e. E. Bipolar

189. 30 (Aprox) yr old lady recently divorced from second marriage. She had problems with first husband who left
her after 4 year of marriage. She occasionally go to gambling,(some other bad things). She feels better when she
is at home with her mother and currently she is living with her mother.
A.Antisocial Personality Disorder
B.Borderline Personality Disorder
C.Bipolar Personality Disorder
D.Dependent Personality Disorder

190. Immigrant man comes and tells you that in his country, secret police are after him and they want to kill him
as they are worried that I would leak the name of another person who was involved in killing of a person. What
will you check in his collateral history?
a) Immigration visa status
b) Child hood psychiatric disorder
c) School performance
d) the truth of his saying

191. A man comes from somewhere telling g you he was followed by spies as his country fellow man had been
killed by them.What to check in the collateral history?
Family history of mood disorder
Immigration visa status
Potential truth about his saying

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192. 40 years old female brought by his friend in emergency,H/O Social phobia for 10yrs..She is alone at home for
many years due to social phobia.When at home,her interest on Gardening,Reading,Some others,I cant
remember.. Now Which History describes her personality disorder to be diagnosed??
A.School Refusal
B.Family H/O
C.Self Harm
D.Personal H/O Alcoholism

193. Post operative patient became agitated after 24 hours.He tries to remove his Iv line.Cause?
Alcohol withdrawal- The most common cause of agitation for admitted pt is delirium which come postoperative
and alcohol withdrawal. So A is answer
Drug reaction
Psychosis
Dementia
194. A 15 year old boy with history of sudden outburst of anger who is currently in a special school is now at the
verge of expulsion. What would be the best management for this case?
Sodium Valproate
Risperidone –suspecting autism and risp used to control outbursts
14 yrs in low dose
C- Olanzapine>18 yrs
Haloperidol
Carbamazepine
195. A man with psychiatric problems, he was on risperidone, sertraline and??. Now he's well controlled, no more
command hallucinations, no more Suicidal ideas. What to do now?
A. CT Brian
B. MRI Brian
C. Measure sertraline
D. Measure risperidone
E ECG- prolonged QTsyndrome causing
psychosis

196. mum dead 1 year ago , pt seeing his

mum , think she dead 1 months ago
A. Major depression psychosis…
anniversary rxn
B . Delusion
C . Complicated grief ( my fri has this
option but I don't have this one )
D. Normal grief reaction

Psychological literature calls it

the anniversary reaction and
defines it as an individual's response to unresolved grief resulting from significant losses.
The anniversary reaction can involve several days or even weeks of anxiety, anger,
nightmares, flashbacks, depression, or fear.

197. Man with lack of interest in normal life, insomnia + and is having visual hallucination and voices in his head +,
he is saying my mother died last month but it is not the case and mother died year ago, what is most likely
diagnosis?
A. Personality Disorder
B. Depression with unresolved grief

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 C. Major depression with psychosis
D. Schizophrenia

198. . 15 years old boy clever at school before. But 3 weeks ago , he start to use multiple ectasy ,and other drugs
at party , become agitated ,unable to sleep , school grade falls , multiple scars on arms which he doesn’t wanna
discuss about scars when ask .Next appropriate mx
a. Need to discuss the matter with parents
b. admission
c. CBT
**B..self harm. .he needs involuntary admission. .talking to parents will only give history or some extra
information. .but next step to prevent more self harm or possible suicide should be admission

199. Active perfectionist lady come with poor concentration at work , almost loss her job , she also very easy to
cry , last week nearly miss hitting a pole , recently got married , her husband care her . What is Dx ?
a. Major depression
b. Adjustment disorder
c. Post traumatic disorder

200. )- schizoaffective disorder on risperidone, and lithium. Went to party n took alcohol, cocaine n ecstasy
Now presenting with hyperreflexia, tremors, irritability, drowsiness, agitation, temp 37.8, bp 150/?
Wat nxt investigation
a. Alcohol level,
b. drug screen,
c. lithium level,
d. ck level

**In NMS mostly there is muscle rigidity (lead pipe), and hyporeflexia due to extra pyra effect. But in quest there
is hyperreflexia and no muscle rigidity. Hyperreflexia occurs in Lithium toxicity or serotonin synd. 2) In question,
there is no change of dose or no addition of new antipsychotic to cause NMS, But pt took alcohol and alcohol can
increase lithium level. this is my simple equation in support of C.

201. A woman comes with the complaint of weakness,

she is taking duloxetine, amitriptyline, paracetamol &
tramadol. What combination is causing this?
a. duloxetine &
amitriptyline****(SSRI+MAOI,SSRI+TCA,SSRI+opiates)
b. amitriptyline & paracetamol.
C. amitriptyline & tramadol
d. duloxetine & paracetamol

** best ans is duloxetine +tramadol

http://www.emedicinehealth.com/understanding_antidepressant_medications/page9_em.htm#bupropion_wellbutr
in_wellbutrin_sr_wellbutrin_xl

202. Pt 15yr,was normal before but now school grade fall, bunk classes, had several offences against him.
Difficult behaviour.what in the history will lead to diagnosis
A. Family history

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 B. Mother took amphetamine during pregnancy
C. H/o pouring petrol in neighbor's dog*** conduct disorder
Patients view on making those offence

203. A scenario of Lithium toxicity, the patient came with disturbed level of conscious, the level was given
(Cannot recall) what’s the treatment?
A. Dialysis
B. Activated charcoal
C. NaHCO3
if the person comes with in one hour of ingestion so we can do gastric lavage otherwise fluid therapy
if lithium level is less than 3 than normal saline therapy
If lithium level is more than 3 hemodialysis and
if there are symptoms of convulsion or comma than again do the Dialysis .. if patient has liver kidney and congestive
cardiac failure than again do Dialysis

204. 23 year young women with H/O multiple jail stay, prostitution, drug intake. she left her home at the age of
13 and does not want to talk about this. whats your dx
a.conduct disorder -ODD leading to conduct
b.drug abuse…it could be the cause of all these presentation
c.schizophreniA
d.borderline personality disorder****some psychotic feats like paranoia MAY be present and rel trouble

205. 03)post op patient within 24 hours fever and X-ray showed Atelectasis
Post op delirium ..
D1 hypoxia
D2 metabolic disturbance
D3 infection
D4 drugs
Post op fever
D1 wind ( atelectasis)
D3 water (UTI)
D5 walk (DVT)
D7 wound ( infection )
D9 Drugs, IV lines,BT
D14. Deep abscess

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206. Bulimia nervosa , finding ?
Ankle edema
Hyperthermia
Tachycardia, bradycardia in anorexia
Vitiligo

207. 19 yrs old schoolgirl say`I feel like I m going to have the whole bottle of paracetamol,everythings seems
nonsense to me`…she say she has been feeling like this after her favourite physic teachers resign.also has history
of sex abuse by her elder brother.what to give
A risperidone(to treat schizophrenia,bipolar disorder,irratibility with autism)
B haloperidol(hallucination where ever it is)
C quetiapine(major depressive disorder, bipolar,schizophrenia, it should b given in young age ppl with low
dose,otherwise ddrg dependence)
D venlafaxine**(1st choice for MDD,anxiety ,panic disorder)
E clozapine(drg resistant/refractory schizop)

208. .A patient on Amisulpride(some antipsychotic) 800mg well controlled now after developing psychotic and
hypomanic feature 2 years ago. (some other thing just forgot). Which one of following suggests poor prognosis of
this patient?
A. Past self harm
B. High dose of Antipsycotics
C. lost job in 06 months…may be schizophrenic
D. Other option also relavant cant remember at this moment

209. Mother comes asking you about her 17 year old son because she saw him wearing his girlfriend's underwear.
She is divorced and her son lives with her. Your advice regarding her son's behavior:
A He is a woman trapped in a mans body
B Its a normal thing at his age
C its a consequence of lack of a male role model in his life
D (something like to counsel him)
First choice is transvestism.

210. ADHD kid .14 years .missed medications ..doesn't attend school regularly.. recently has symptoms again.
A give him medications so he can take them by himself
B appoint a nurse to give him regularly
C change to long acting***
D Talk to the child regarding adherence

211. A lady post stroke sitting in uncomfortable position she admits she had stroke ,now she is having low mood
,weakness of limbs, lack of sleep ,tearful, what is the Dx
A. Post stroke depression****Amedex Qbank
B. Post stroke denial
C. Dementia

212. 6 years old kid with slow language improvement. When the parents say something to him, he repeats 3
words from what the parents say. He doesn't watch the same tv program for more than five minutes. When the
doctor talks to him, he repeats only 3 words from what doctor said to him?
a. Autism***
b. Asperger
c. ADHD
**Echolalia is the repetition of the speech of others. It is a feature of autism spectrum disorder for many children.

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213. A mother came with her 7 year old girl because she never had friends and the children in the school mock
her always but she never gives any reaction , she is developing very normally and had no language delay but she
has very restrict system of life and play with her dolls only , wts the dx ?
a. Autism
b. Asperger****(in Autism there is language delay but in Asperger no language delay but they are not
responding to social activities
c. ADHD (hyperactivity,impatience,inattentive,poor performance at school, d/d- deafness,tx
methylphenidate,methamphetamine)
d. Depression
e. Oppositional defiant

214. lady with 2nd day with post partum blues what do u do ?
Ans - send her at home with her baby and husband and a midwife following up with them –self limiting, no Rx

215. what is the most aspect that you need to assess in major depression ?
a. Inability to concentrate
b. Insomnia
c. Feeling of worthlessness

216. . Patient feels that there are funny games going on around him and someone will harm him because he got a
promotion and he mentioned to the police that danger awaits him soon.Diagnosis?
A. Ideas of reference-accept their idea was wrong when given evidence or proof(from amedex)
B. Delusion***…we are thinking about it as well….do not accept evn aft evidence
C. Derailment
D. Schizotypal personality

Most people tend to believe other people think more about them than they actually do, and believing oneself to be
more important than reality indicates is common. Ideas of reference are variations on this behavior, and occur
when a person believes something is referring to them when it is not.
While a person experiencing an idea of reference will change his or her mind when evidence dictates he/she must, a
person experiencing a delusion will believe something refers back to him or her even in the face of strong evidence
to the contrary

217. 12 year old girl at foster care. she's having difficult time in school in reading n writing . she has a collection of
her own toys and plays with them with her imaginary friend. her foster parents/ carers are irritated because she's
picky at food. what immediate danger to her in future ?
a. OCD****
b. sexual abuse
c. drug abuse
d. Anorexia nervosa
e. schizophreniform psychosis
218. A lady presented with her baby 5 times in 2 weeks at 10 weeks following delivery. she also presented at 8
wks all normal established breastfeeding , baby growing well on 50 or 70th percentile. what relevant info you will
ask in her history ?
A. her past obstetric history
B. her premorbid personality
C. her thoughts about harming the baby
D. depression**
( if there is option of family conflict and both baby and mother are fine on examination than choose this option)
otherwise go for depression

219. )woman after death of her husband due to prostate cancer , lives alone , 6 weeks later loss of appetite ,
thinks he died because of her infidelity . she had similar episode after the death of her child. prompt treatment

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 asked ?
a- Risperidone
c. venlafaxine(mdd)-since no insomnia mentioned,
d. ECT
e. temazepam

220. an old lady no h/o alcoholism.went through surgery for incarcerated femoral hernia.after 4 hour she became
agitated.spo2 86%.she wants climb the bed.after giving o2 via mask what do u next approach-
a.antibiotic
b.iv fluid
c.droperidol****Droperidol is an antidopaminergic drug used as an antiemetic and as an antipsychotic. be very
careful with this option it is very dangerous as causes cvs deaths and im prep has stopped manufacturing now.oral
has caused deaths in Europe,if any other suitable option present go for that.
d.anticoagulant

221. n woman brought after MVA ,she is denying analgesia.wat will u do-
a.check her mmse***
b.iv infusion’
c.iv antibiotic
d.iv something else
all options are with iv related

222. Son brought his dad after he found him fall down in his house, dad said he drank a local beer or smtg and
took his medications, and son brought all his meds and they were methadone, oxycodone and others were
mentioned.one dose naloxen given. And on PEx he has pinpoint pupils still and other signs normal.wat to do
a.give naloxen again****
b.iv fluid
c.o2
d.observe

223. 78.a man 57 year brought by children.they say symptoms started 2 weeks before when their mother died in
a car accident.since then he is sad,depressed,eat little,,crying .talk to his dead wife and say sorry it was his fault as
he didn’t give the car for servicing.
a.normal grieve with psychosis***
b.ptsd
c borderline personality disorder

224. 18 yr sad depressed for 2 weeks.she feels she is not the same person as before .3 weeks ago she was
raped.dx-
a.ptsd
b.acute stress reaction** Acute stress disorder (ASD) is a mental disorder that can occur in the first month
following a trauma. The symptoms that define ASD overlap with those for PTSD. One difference, though, is that
a PTSD diagnosis cannot be given until symptoms have lasted for one month.
c.bpd
d.antisocial

225. Girl 14 years history of weight loss bmi 15 when asked about any interests said why should I? What should
that entire world mean
A. Fluctuating fatigue
B. Sleep disturbances
C. Moving around with friends
D. Feeling inferiority****
E. idea of guilt

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226. An 18 year old girl suddenly lost her weight about 10 kg. Reduction in school performance or grades. What
appropriate thing will you ask in the history to make a diagnosis
a. Apparent loss of appetite
b. Feelings of guilt
c. Feelings of inferiority
d. Premorbid personality
E. Suicidal ideation

227. the woman with premenstrual symptoms affecting her marriage and daily life.husband also annoyed.but she
can go out and enjoy with friends.whats the Rx?
A sertraline***( if decreased libido or insomnia or other feats mentioned)
B evening primrose oil
C interpersonal(if no symptoms mentioned)
D COC pill without pill free interval

228. the woman with premenstrual symptoms affecting her marriage and daily life. she was worried tht it will
affect her marriage cos of loss of libido. but she can go out and enjoy with friends.whats the best therapy option
available ?
a. Psychotherapy
b. Relationship therapy.
c. Distress management
d. Sexual therapy

229. An afebrile female Patient on sertraline, temazepam, and daily drinking of one unit alcohol, after
hospitalization developed agitation , irritability, tremor, restlessness and paranoia
All vitals were normal
A.. Alcohol withdrawa****
B.. Serotonin syndrome
C..Benzodiazepines withdrawal

230. 41 years old man has headache and is accusing neighbors as they use insecticide excessively. He mentioned
he had frequent trouble with them as they are very noisy.he changed his living place two times before as he was
unlucky with his neighbors Thinking that they hate him and want to harm him .other persecution thinking was
there.
A)delusion
B)depression
C)schizophrenia
D)Paranoid personality disorder***
E) Mistrust

231. According to recent study, obsessive compulsive disorder have 2-3% risk in the population. If the symptoms
persist after one or more than one year, what is the natural course of disease?
A Risk developing of schizophrenia
B High tendency of suicide
C Progressive downhill deterioration and institutionalization
D Remission and recurrence on and off

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232. Which of the following conditions is
the COMMONEST anxiety disorder
encountered in general practice?
a)Generalised anxiety disorder Amedex
Qbank
b)Phobic disorder
c)Obsessive compulsive disorder
d)Panic disorder
e)Post-traumatic stress disorder

233. A 25 year man with a psychotic

illness, was treated with haloperidol 30
mg/day. On the third day he developed
pacing, and inability to sit at one place.
The medication likely to be helpful is ?
a. Pheytoin
b. Propranolol****
c. Methylphenidate
d. Trihexyphenedyl-benzhexol-antiparkinsonion-antimuscarinic
this pt has developed Akathisia....reduce the dose first...if no response then short course of propranolol ,diazepam
or benztropine ll help

234. A patient came with panic attack.what's the tx at this moment?

citalopram
diazepam
carbamazepine
olanzapine

235. A 28 year old man with long history of schizophrenia. He said he is feeling well with treatment with
Clozapine. Only sometimes he has symptoms (idea of reference). He also complains of 15hours sleep per day.
What is the management? Agranulocytosis .. HB
A. Add Risperidone
B. Lower the dose of Clozapine****
C. Add sodium valproate
D. Add Methylphenidate

After reading the following explanation we still decided to go with B option only
Patient complains from hypersomnolence, Clozapine is a CNS depressant so adding Resperidone (although less
sedative) will excacerbate this side effect, increases total sleep time and would increase risk of respiratory or
cardiac arrest.

Sedation is common in early treatment with Clozapine, and tolerable after 12 weeks.
Management of sedative side effect of Clozapine if moderate or sever:
1st ==> decrease to the lowest acceptable dose
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 2nd==> Avoid other nervous system depressant (BDZ, antipsychotics)
3rd===> if feared that patient would stop clozapine due to S/E then give Methylphenidate ((But it will
excacerbate Psychosis if present))

so from up only valid is B and D ... BUT being still with delusion, then D is the best answer.. Also patient
recently started clozapine as he is complaining from hypersomnolence which is early S/E, and the question
clearly mentions he is well controlled now except some reference delusions, THIS is NOT a FAILURE of the
treatment to add or switch or even augment.

236. scenario of hoarding disorder asking treatment.

A.clomipramine-TCA
B.venlafaxine****-SSRI-preferred
C.risperidone
D.quetiapine
E.amytriptiline-TCA

237. Lady previous history of sudden fear attack anxiety palpitation and choking when in plaza / shopping center .
became more frequent that she even afraid to go outside to buy grocerries . what to ask her if she using of
Caffeine ***(triggering factors for panic attack caffeine, smoking,lactate and co2)
Cannabis
Tobacco
Alcohol

238. )Old lady admitted for fracture of femur , got delirium while in hospital . she is taking multiple drugs
described many…..alprazolam(a minor tranquilizer) candesartan donepezil dothiepin risperidone
Next step?
A Switch alprazolam to diazepam
B Stop donepezil –anti alzheimer
C Stop dothiepin***(it is a tricyclic antidepressant…anticholinergic.. jm 509)
D Stop risperidone

Cholinesterase inhibitors, such as donepezil and

rivastigmine, may offer temporary relief from the
symptoms of Alzheimer’s disease. Enzymes called
cholinesterases break down acetylcholine in the brain
and if their action is inhibited, more acetylcholine is
available for communication between brain cells.
Some people may find improvements in their ability to
think clearly, memory, function in daily activities and
behavioural and psychological symptoms.

Anticholinergic drugs, which block the transmission of

acetylcholine in the brain, have the opposite
pharmacological action to cholinesterase inhibitors.
Concurrently taking cholinesterase inhibitors and
anticholinergic medications may reduce or nullify the
effectiveness of both medications.

In order to achieve
maximum therapeutic effects, these drugs generally
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 should not be used in combination with each other.

239. bipolar patient on lithium and controlled, now has tremor of hand mild at rest, increasing with activity
A ..lithium level
B.. Change to valproic acid
C.. Add propranolol
D.. add benztropin

240. 8 years old boy who is hard to be controlled . Teachers says he doesnot concentrate in class has no friends
fights with everyone and doesn't even listen to parents. Next step
Refer to child school counselor
Ask for school performance record****-ODD-starts around 8 years-pre school years
Commence methylphenidate

241. Prediction of violence is difficult but there

some guilelines. What predictor used to
measure the violence ?
A. Male
B. Juvenile ..
C. Alcohol abuse
D. Depression
E. Something about violen

First is h/o past violence

242. Mother brought her daughter 15 years old

unwillingly. Saying that her daughter recently
been always depressed, locks herself in the
room, decline school performace and fights with the father . What do you do to obtain diagnosis?
A. Talk to the girl with presents of both parents
B. Speak to her alone****
C. Ask the girl to go out and speak to her mother and get more information
D. Make an appointment to meet the father
E. Suicidal thoughts
Wat to do means speak alone and wat will lead u to dx means suicidal thoughts

243. Case of 74 yo patient with cancer and surgeon and oncologist decided for surgery as best treatment. Patient
has mini mental of 20/30 (>24). Patient understands pros and cons of surgery and accepts surgery.One of the
daughters tells you that she doesn't want surgery because of the mental state of mom.What to do?
A- patient want surgery, do surgery******
B- daughter has power of attorney so don't do surgery

244. A man on sertraline 100 mg dly complains about erectile dysfunction. What do u do as a physician
A. change to sertraline 50mg

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B. change to another drug in the same group …all ssri cause erectile dysfunction so need to taper and then change
to another group
C. Start the patient on clomipramine
D. Explain and reassure the patient

245. . A boy with ADHD was initially treated with methylphenidate after 6 months how do you adjust the dose of
treatment
A. Assess the level of hyperactivity****
B. Side effects
C. Reduced symptoms
D. Improved lifestyle
E. Good grades in school

246. A man presented for a sick certificate but presented with ataxia with alcoholic fetor asking
most important thing to address
a. alcohol counselling programme.
b. reassurance
c. CAGE PROTOCOL*****

247. A lady presented with her baby 5 times in 2 weeks at 10 weeks following delivery. she also presented at 8
wks all normal established breastfeeding , baby growing well on 90th percentile. what relevant info you will ask in
her history ?
A. her past bad obstetric history
B. her premorbid personality*****
C. her thoughts about harming the baby
D. history of psychosis
E. current mood
248. . Man brought by police, who was shouting in street, and walking naked, what is the best medication to start
treatment for this patient?
A-clozapine
b-quietapine
c-amisulpride
d-resperidone
e- olanzapine

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249. A clinical scenario of a patient with history of Alzheimer’s (or similar mental illness) refusing some treatment.
What is the most appropriate next step?
• a. Admit and give treatment
• b. Full mental examination • c.
Cognitive status examination • d.
Let him go

250. A middle aged Aboriginal man came with the frequent outburst of anger and other symptoms (I forgot). On
examination he denied sadness but admitted of negligence. He was past history of negligence when he was
young. What is your management for him?
a) Anger management***
b) Supportive management

251. . You are called to see 80y/o woman who lives alone at her home. At arrival she is in poor hygiene, house is
dirty, she calls you by her daughters name and then yells at you to leave, attacks you. What is your immediate
response:
a) Call police
b) Sedate her
c) Leave***JM 41
d) Restrain her

252. Woman with insomnia, past history of breast Ca,o

a) Mitrazapine***-antidepressant for insomnia too.
b) Olanzapine-antipsychotic

253. A patient has taken lots of tablets of venlafaxine. Was on depression treatment. One year back she
was given psychotherapy as she had problem at work (shout at her coworkers). She cant relax at home
after work. After stabilization of the patient, what should be added? (no mention of insomnia…it
revealed pt is anxious) A. Lorazepam b.respiridone……… C. Mirtazapine... D.Haloperidol E. sodium
valporate
254. Woman with symptoms of hypomania asking for treatment
a) Lithium
b) Olanzapine***-first choice
c) Lamotrigine
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 d) Sodium Valp.

255. Patient comes in as a strong smoker. He also has a history of hypertension. How will help achieve cessation
of smoking in this patient?
a.Bupropion****( if depression than bupropion)
b.Nicotine patch-bcoz no depression.

256. . A woman who delivered 2 weeks ago believes the staff want to take her baby away from her. She wakes up
at night and sprinkle water around to protect her baby. Her husband wants to send the wife home saying he
thinks the hospital’s environment is affecting her. What should you do? Postpartum obsession Amedex Qbank
a Send nursing staff to attend to her at home
b.Allow the patient to go home as the husband requests
c. Admit to psychiatric ward***

257. A patient has taken lots of tablets of venlafaxine. Was on depression treatment. One year
back she was given psychotherapy for anxiety and insomnia. After stabilization of the
patient what next to add
A. Lorazepam-sedative,antianxiety,seizures
B. Risperidone
C. Mirtazapine-atypical antidepressant
D. Olanzapine
E. Haloperidol

258. Lady overdose of venlafaxine prescribed for her,she is irritable at work and insomnia, ,she has low mood,
what should you added after recovery from overdose
a. sodium valproate
b. olanzapine
c. risperidone
d. oestrogen patch
major depressive disorder +Low mood olanzapine
mAD+
Euphoric risperidone.
mAD + insomnia mitrazapine
MAD +hyperactive venlafaxine

259. Man with severe depression treated with venlafaxine now presented with agitation pressured speech
euphoria and mania ask what next appropriate thing to do
a. add sodium valproate.
B. add clozapine
c. add olanzapine
d. Withdraw venlafaxine depression be mania then add olanzapine
e. add risperidone

260. .A woman comes to psychiatrist who is referred by GP, telling that GP doctors ‘treat him like a nut’. ‘All
doctors stick together’. she has h/o charged to doctor at court. SPLITTING PHENOMENON ALL GOOD R BAD
SUSPICIOUS
A) Borderline
B) Antisocial
C) Narcissistic
D) Passive aggressive
E) paranoid

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** This question is really confusing!!! I think it is E.paranoid they r suspicious,Every one is plotting against them. It
can't be narcistic Bec these people don't take criticism & they r positive oriented people. It can be borderline also
Bec delusions r present but no self harm and unstable relatioship
261. A woman brought by police recovered from beach after a suicidal attempt, her clothes are soaked. She
attempt sucide what is important in history?
A) family h/o sucide
B) h/o depression
c)intoxication at the time of sucide
d) recent loss of job

262. 15year old boy having difficulty in concentration at school because he can’t maintain tasks, use multiple
drugs, like amphetamine, marijuana, telling it’s difficult for her to sleep, denied any hallucination or suicidal
thought, what will you do? ODD ,leads to~ conduct
a. inform parents
b.Give ssri
c.CBT
d.Tell school to support her more

263. . scenario of a girl used drugs at party and found collapsed in washroom, o/e has temp 40 bp 165/95
confused, agitated rest of examination is normal( nothing was mentioned about pupil)
Asking next step in management?
Cold saline and cooling blankets
Inform to police
Iv droperidol
Pulse oximeter

264. questions about anger management therapy ,

person after trying to kill parents coz he thinks they are imposters,, arrested , tried to suicide in jail , brot for psych
assessment .
Options - therapy , admit in secure prison , admit in pych ward

265. man who lost his wealth develop depression and lost of interest say government is bad and blaming them
wishing to die decrease activity when asked to treat he said he is fine and not complaining com anything..what
defense mx......denial

266. woman with 2 month hx of liability and affected mood she have problem concentrating and delay in
accomplishing the task worry a lot and marked irritability weakness and lethargy she is married living with
husband caring for her ..ask Dx..
A.mdd. B. Adjustment disorder. C. Generalized aniexity disorder

267. a girl with Ascension of unstable relationship frequent splitting with friends arguing with parent....(pic of
borderline)ask what in hx that is significant in development this condition....
A.drugs (don't remember). B.hx of sexual abuse c. Parental separation

268. Man brought to hospital after throwing brick at windows he said last thing he remembers is leaving work
from rural farm
Dissociative fugue
Factitious disorder
Malingering

269. women who has started cleaning ( increase level of energy) her house repeatedly is flirtatious with her
husbands friends and is is showing inpuslsive behaviour for one weak?
a)Hypomania

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 B)OCD
C)borderline
D)histrionic

270. A female young patient very fond of music , came to you because she can’t stop listening to her music and
she repeat it several times per day , and always she keep singing the songs , what will you ask her ,will lead you to
a dx ?
a. Her level of insigt
b. Her appearance/dressing
c. Her mood and orientation

271. Business man got bankrupt, many financial problems, complaining of late insomnia, lack of pleasure, loss 15
kg from his weight through 3 months, any many other symptoms of depression, his family concern about him and
the patient refused to take any medication as he doesn’t believe he is sick, he admit he is tired and exhausted but
not depressed, what’s this called?
A Denial (ans)
B Reaction formation
C Depersonalisation
D Rationalisation

272. A pt was on resperidone consta has amennorhea from one yr want to conceive labs were given lh was
normal fsh low tsh low normal range prolactin raised around 1465. what is the reason?
a) pituitary microadenoma???
b) hypo pituitary dysfunction
c) pri hypothyroidism
d) resperidone

273. Bulimia nervosa , family history what to find ? – obesity, Lean family h/o =anorexia

274. 30 years old lady with depression symptoms .8 weeks ago her marriage-was broken, 1 year ago she was
referred for psychotherapy from work (Shouting at colleagues) . After finishing her work she cant able to relax at
home. What is the diagnosis?
A) Bipolar-II with depression
B) Cyclothymic disorder
C) GAD
D) Major depression
E) Borderline personality disorder

275. 21 yr old boy comes with mom, mom says he is keeping himself isolated for 18 months, taking marijuana
since one year, now having something delusion i forgot. Dx
Drug induced psychosis
Schizophrenia
Schizophrniform disorder

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276. 15 yo male, occasional use of metamphetamine.
Daily usage of marijuana, and unexplained scars in
forearm. Tried to treat with psychotherapy but
unsuccessful. What to do next?
- Diazepam
2. Resperidone
3. Methylphenidate
4. Fluoxetine f depression
5. Naloxone

277. pregnant lady came with husband.during

examination you found bruises on thigh, genitalia
what next-
Explanation… their can be pregnant loss so admit in
other circumstances shelter
admit now
refer to shelter
tell her to come alone without husband
confront husband
tell husband to be careful during sex

278. 17 years old girl comes with her sister. She cut
her wrist. She doesn’t want to let anyone know.
Mentally fit. Parents separated. Lives with her mother
but wants to live with her father. Whom to inform
initially?
a) mother
b) father
C) both parents
D) Patient herself
E) School Counsellor

279. bmi 18, sign and symptoms of bulimia asking

diagniosis
A anorexia (I choosed this because of bmi)
B bulimiaIndividuals with bulimia nervosa typically are
within the normal weight or overweight range (body
mass index [BMI] ≥ 18.5 and < 30 in adults).

sertaline & ejaculation q,---I got the same q twice with

different options
280. A man on sertraline 100 mg daily bcoz his wife left him for another guy.now complains about erectile
dysfunction. What do u do as a physician ?
a. cease sertraline
b. change to another drug in the same group
c. tell him to bring his wife
d. talk to his wife
e.decrease sertraline

281. 7.A man on sertraline 100 mg daily bcoz his wife left him for another guy.now complains about erectile
dysfunction. What do u do as a physician ?
a. cease sertraline
b. reassure him it will resolve with time if sildenafil in option choose .. ref Amedex Qbank

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c. tell him to bring his wife
d. talk to his wife
e. decrease sertraline

282. Depression man on amitriptyline for some time, complains of erectile dysfunction. He smokes 20 packs/per
day and he drinks 5 standard drinks per day. Mx?
A. Stop medication immediately
B. change amitriptyline to sertraline
C. Give sildenafil and continue medication
D. cease smoking
E. reduce alcohol

283. . Female for post partum depression taking paroxetine since 2 years. Symptoms are well controlled.now
planning to conceive again. What next?
a. cease paroxetine( birthdeafects) now
b. cease when pregnancy will be confirmed
c. continue paroxetine and add citalopram
d. increase paroxetine
e. continue paroxetine & citalopram both in pregnancy

SSRI paroxetine (Paxil) is generally discouraged during pregnancy. Some research suggests that paroxetine might be
associated with a small increase in fetal heart defects.

In addition, monoamine oxidase inhibitors (MAOIs) — including phenelzine (Nardil) and tranylcypromine (Parnate) —
are generally discouraged during pregnancy. MAOIs might limit fetal growth

284. young uni student feel very shy about attending class,he is not comfortable in any gathering ,usually don’t
attend the classes & don’t want to attend any class party bcoz he thought that others will talk about him in
behind,but his semester result in very good & he is the topper in his class,,so now what will help u to find out the
exact cause of this condition?
a.his belief for others talking about him avoidant personality
b.family history of schizoaffective disorder
c.his class result
d.other 2 optios were irrelevant

285. 17 yrs old schizophrenic pt whose symptoms is well controlled in risperidal costa, now came to u bcoz last
few days he was feeling agitated,restless,cant sit quietly in a place & hyperactive in most of the times ,what will
help u to find out the cause??
a.dose of risperidal costa
b.childhood history of taking methyphenidate
sorry forgot other options bcoz scenario was too long & new

Methylphenidate is a stimulant drug which is used for the treatment of attention deficit hyperactivity disorder.
Here, we report a case of akathisia and dyskinesia on starting methylphenidate in patient who was on
risperidone. The symptoms disappeared on stopping methylphenidate, despite continuing risperidone and
reappeared on starting methylphenidate again. Hence, physicians should be aware of the possible effect of
dyskinesia when using a neuroleptic and a methylphenidate together in a patient

https://www.jcdr.net/article_fulltext.asp?id=1152

286. another postpartum psychosis q,long scenario about serious psychosis of wife,husband called u & asking
help over phone,,what will u do ??
a.tell him its normal
b.call child protection authority
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c.involve social worker
d.arrange a home visit
e.arrange involuntary admission of the wife

287. hoarding syndrome scenario,,asking tx??

a.olanzepine
b.risperidone
c.velnaflexine

the effectiveness of selective serotonin reuptake inhibitors (SSRIs), such as Paxil (paroxetine), in the treatment of
hoarding. Most investigations have found that only a third of patients who hoard show an adequate response to
these medications. Results have been similar for other drugs affecting serotonin, such as the tricyclic
antidepressant Anafranil (clomipramine

ans.c (REST of the 4 options were antipsychotics)

***no SSRI or CBT in options

288. A 75yr old man killed his 72yr old wife hitting over her head several times with the stone .they lived together
for 50yrs.he was brought to ed by police for physical fitness.while examining him he confessed to you the whole
incident.what could be the reason?(may 2017)
A.she is ca patiet with multiple Mets
B.they had a dispute life
C.she had extramarital affair
D.she is taking psychiatrc medicin

289. 72 old person killed his 70 years old wife what in history will help you know the cause?
A) she has independent wealth
B)he became preoccupied with wife whereabouts
C)history of multiple periods of separation between the couple***

290. an 80 years old man killes his wife she was 70 years old they married for almost 50 years, you found multiple
bruises in her body.what was the cause of her death? A) she has metastatic cancer b) the old man had over
valued idea c) she had extra marritial affair.

291. Case of chronic schizophrenia has melanoma refuse surgery next appropriate step explain to him melanoma
and need for treatment. Or do cognitive test or do operation

292. Female Patient on Sertraline for her depression and well controlled , she started taking ecstasy, wut will u
tell her?
Ecstasy is contraindicated with Srtraline
Ecstasy cause irreversible psychosis
Ecstasy with Sertraline has synergistic action
#may
293. A patient on sertraline and want to start ECSTASY .advice to her-
a.It ‘ll cause irreversible psychosis
b..stop sertraline
c.continue with sertraline
d.Refer to Surgery
e.there action synergistic
294. 30 A young lady is on sertraline for depression but she wants to use ecstasy as a recreational drug on
occasion.She asks your view and what is best?!

a. Ecstasy and sertraline are agonists !

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 b. Ecstasy is contraindicated when on sertralin!
c. Sertraline and ecstasy have to have at least 24 h between each other!
d. Ecstasy will antagonize sertraline effect shouldn't be taken together!
e. no harm taking ecstasy and sertraline together

RESPIRATORY ADULT & PAEDS

1. Xray of a pt with history of chronic cough for 4 weeks smoker now rusty sputum asking diagnosis
A. Bronchiectasis
B. Copd
C. Pul fibrosis
D. Lung ca
E. acute on chronic bronchitis > ans

2. 82 year old lady had a hx of smoking 24 pack a year, now 10 kg wt loss hx, on physical ex only anorexia present
and left sided supraclavicular LN found. On chest and abd CT done, nothing specific. what is the cause?
a)ca lung
b)ca stomach> ans
c)ca colon
d)ca breast

3. Left sided swelling anteriorly of left ear in 62 years old

man. Swelling is fixed with muscles. The man spitted blood
stained sputum and is a heavy smoker. He cannot close his
mouth properly on the affected side. Dx:
a.Parotid pleomorphic adenoma
b.Parotid carcinoma> ans
c.Metastatic lung cancer – LN IN ANT. TRIANGLE
d.Cancer in lateral of tongue — LN IN SUBMANDIBULAR AREA
e.Carcinoma larynx

4. An elderly man with history of unresected lung ca and new

onset decreased level of consciousness found to have
large cerebral metastasis with oedema and midline shift
on mri of brain.Which one is most consistent with
diagnosis.
a.headache+seizures. > ans
b.increased HR.
c.reduced BP.
d.undisturbed cognition. —

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5. Chest x ray with diffuse opacites and high hemidiaphragm on one side with chronic cough with 2 weeks history
of rusty sputum. What is the diagnosis?
A. Bronchiectasis
B. Copd
C. Pul fibrosis…if no lung ca in option
D. Lung ca
E. Bronchitis

6. What is the most likely primary source of metastasis to the

lungs
Thyroid ca
Breast ca
Stomach ca
Renal ca > ans. HB 3.152

7. Lump under the angle of mandible. Hx of smoking. Drooping

of mouthDx.
A lung ca
B. tonsillar ca
C mets lymph node > ans . Parotid Ca

8. 60 yrs. old male,10 yrs history of hypertension,feeling dizzy

and light headache from this morning when he was doing
exercise. smoke 20 cigarettes per day, drinks 2-3 glass of wine
most of the night.BP 138/80 sitting 120/75 on lying.Currently
on ibesertan - thiazide 150/12.5 Mg and ASA 100 mg. ECG was given (SVT) HR around 150/min. Cause of his
dizziness.
A) dehydration – > ans
😎 ischemic heart disease –
C) hypertension
D)alcoholic cardiomy
E) mi

9. Another smoker with 30 year smoking history, has frequent trips to asia. Presents with weight loss, loss of
appetite, cough and a pansystolic murmur heard on the apex. On auscultation he had bilateral basal crepts and
decreased breath sound on the left lower lobe. What is the most likely diagnosis ?
a. Carcinoma lung
b. Tuberculosis
c. Bronchitis
d. Rheumatic fever
e. bronchiectasis

10. Elderly smoker with bilateral Lymphadenopathy,night sweats,increasing cough with green sputum production
with blood streaks.
Labs reveal
Hemoglobin reduced
WBC increased
Platelets reduced
Blast cells more than 60%
Diagnosis?
a. CLL
b. Acute leukaemia>ans. Jm 255 may be AML
c. Bone marrow infiltration due to Ca lung

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11. A 65 year old farmer presents with 2 year history of progressive cough. Patient is known to be a 30 pack year
smoker but ceased 5 years ago. On examination patient had clear breath sounds, but you noticed clubbing of his
fingers. What’s the most likely diagnosis?
A. Sarcoidosis
B. Lung CA
C. COPD> ans
D. Pneumonia
E. CVS disorder

12. A case of suspecting acute coronary syndrome with bp 160/90. What will you give?
A. Clopidogrel
B. Enoxaparin
C. Aspirin > ans
D. Oxygen via nasal cannula
E. Metoprolol

13. 55 year old male with complain of 30 pack years of smoking, mine workers now complains of cough, Dyspnoea,
pleural tap is blood stained, what is the diagnosis?
A. Mesothelioma …will be pleural thickening
B. SCC > ans
C. Small Cell Ca of Lung

B. SCC. Smoking plus occupational exposure increase risk nearly fifty fold. https://www.asbestos.com/cancer/lung-
cancer/mesothelioma/

14. new question man living alone .daughter bring him. Had
developed progressive dyspnoea in the past two weeks bp
pr normal I think was smoker in the scenario has bilateral
crepitation X-ray given show bil infiltrate and there is like
cavity or bubble in the costophrenic angle below the
heart.asking Dx...
A.pul embolism...
B.pul fibrosis
C.lvf.
D.lung ca A

PULMONARY FIBROSIS 3 FIGURES

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 LVF

15. which one of the Followings malignancies have been

approved except

A.Promiscuity (exact word) and Ca Cervix

B.Betel chewing and oral cancer
C.Schistosomiasis and bladder cancer
D.Nickel and hepatocellular carcinoma > ans. nickel is with lung

16. 20yr old man present with dyspnea from 1 yr ,on auscultation chest is clear , the X ray was given and it was clear
,On labs increase Ca, inc. Cr, inc. urea. wats next investigation ?
A- ACE levels - Done in sarcoidosis
B- CT chest> ans
C- CT abdomen
D- mantox test

17. Lump infront of throat& lymph node enlargement in the anterior triangle, dysphagia& hoarseness of voice &
weight loss what diagnosis
a. Cancer esophagus
b. Cancer thyroid
c. Cancer lung

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18. 80 yr old man with long time hx of
chronic prouductive cough about 1cup of
yellow green sputum now develop lower lobe
pneumonia what rx to give
a. oral rothoxi
b. oral augmentin
c. .iv ampicillin
d. iv fluoxacillin
e. iv tazobactem +clavulanic acid Ans

19. Young girl with a cough with a

cough for two weeks, productive of yellow
sputum, physical exam normal, all other tests
including sputum, chest X-ray, Blood culture,
ct scan all normal, she still insist on further
investigations, what do you do
A. Tell her no need for further investigation
ans dx bronchitis
B. Prescribe antibiotics
C. Sputum for tuberculosis

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20. COPD pt, comes with profuse yellow sputum with blood, h/o smoking.dx
a. pneumonia
b. Ca lung.> ans
**correct ans should be bronchiectasis

21. Chronic bronchitis pt, H/O yellow sputum, expectoration for last 3yrs. Now developed fever, cough, and some
copious amount of yellow green sputum. What to give
A. Roxithromycin
B. Ticarcillin ans
C. Ampicillin

22. child 3 years old,cough and yellow sputum for 3 weeks,no response for antibiotic,x ray given,white patch upper
lobe of right lung,, dx ?
a.mesothelioma
b.lobar pneumonia
c.aspiration pneumonia
d.lung ca
e.empyema

** empyema can resemble a pleural

effusion and can mimic a peripheral
pulmonary abscess, although a number
of features usually enable distinction
between the two (see empyema vs.
lung abscess). Features that help
distinguish a pleural effusion from an
empyema include:

Shape and location

1093
Empyemas usually:

• form an obtuse angle with the chest wall

• unilateral or markedly asymmetric whereas pleural effusions are (if of any significant
size) usually bilateral and similar in size 4.
• lenticular in shape (biconvex), whereas pleural effusions are crescentic in shape
(i.e. concave towards the lung)

#RESP

23. A given chest x-ray of a 45 yrs old male who had a severe cold 2 weeks ago now presents to you with complaints
of cough during night and early morning which produces small amount of yellow sputum especially when he
wakes up in the morning. What is the most likely diagnosis?
a. Chronic bronchitis
b. Tuberculosis
c. Bronchiectasis ans. postural cough
d. Pulmonary fibrosis
e. Carcinoma of the bronchus

C- its worse on waking, coz its posture related sputum production.

Chronic bronchitis - productive cough for at least 3 successive months in 2 succesive years.
Ref- JM, cough chapter. 476

24. A 78 yrs old male presented with ho fever rusty color sputum and cough for last two days xrays lower lobe
consolidation best next rx
1. Amoxiclav if less age
2. Ampicillin
3. IV benzyl penicillin ans aged pt(>65yrs)…moderate pneumonia jm472
4. Erythromycin
5.ceftriaxone

25. Aboriginal female has mitral stenosis. she presented with dyspnoea. C xray given. it had bilateral
middle LOBE OPACITY. Whats is the diagnosis.
A. Pulmonary Hypertension
B. Pulmonary Fibrosis
C. LVF

26. 25 yr indigenous lady presented with sob and cough since 3 weeks..o/e temp 37.8,pr,rr,bp,saturation all are
within normal limits,mitral stenosis with bilateral basal crepts ..x ray given with features likeblateral symmetrical
mid lobe pulmonary infiltrate especially perihilar area..diagnosis?
a.pulmonary edema????
b.pulmonary hypertension > ans
c.rheumatic fever
d.peumocystis pneumonia

27. A scenario of an aboriginal woman presents with mitral stenosis, shortness of breath, low grade fever, malaise
for 6 weeks. Bilateral basal crackles
a) TB
b) LVH
c) Pulmonary HTN

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28. xray quite abnormal.. left sided pleural effusion but no heart borders not dilated.. 6 weeks of cough and dyspnea
aboriginal lady with bibasal crepts and also left sided decreased breath sounds systolic murmur over apex
a. Rheumatoid heart disease
b. Left heart failure
c. Pulmonary hypertension> ans
d. Pneumonia

CAUSES
• Pulmonary arterial hypertension (PAH)
• e.g. Idiopathic PAH, Heritable-genetic disease, Drugs and toxins induced: appetite suppressants
e.g. fenfluramine, Associated with systemic disease: Connective tissue diseases e.g.
scleroderma, HIV infection, Porto-pulmonary hypertension
• Pulmonary hypertension due to left heart disease
• e.g. Systolic dysfunction, Diastolic dysfunction, Valvular disease: Mitral stenosis, Mitral
Regurgitation, Congenital abnormalities

• Pulmonary hypertension due to lung diseases and/or hypoxia

• e.g. Chronic obstructive pulmonary disease, Interstitial lung disease, Sleep-disordered
breathing, Alveolar hypoventilation disorders, Chronic exposure to high altitude

• Chronic thromboembolic pulmonary hypertension

• PH with unclear and/or multifactorial mechanisms
• e.g. Hematological disorders: myeloproliferative disorders, Systemic disorders: sarcoidosis,
vasculitis, Metabolic disorders: glycogen storage disease, Others: tumour obstruction, fibrosing
mediastinitis, chronic renal failure on dialysis

29. Aboriginal lady has mitral stenosis and dyspnea. On chest auscultation bilateral basal crepts. No fever cough
sputum. Chest xray given with bilateral peri hilar opacities coin like lesions Asked diagnosis.

1095
A.pulmonary hypertension,> ans
B.TB
C.Lymphoma
D. Left ventricular failure
E. Sarcoidosis

30. A man with dyspnea and SOB , taking metformin

and rosiglitazone for diabetes, amiadarone for
recurrent ventricular tachyarrythmias, enalapril
and metoprolol. Which drug may have caused
these symptoms?
A. Amiadarone
B. Metformin
C. Rosiglitazone- Hepatic effects, fracture risks. (Jm)
D. Enalapril
E. Metoprolol

31. Which one of the following causes of lung fibrosis

predominately affect the upper zones?
A - Bleomycin
B - Rheumatoid arthritis
C - Cryptogenic fibrosis alveolitis
D - Methotrexate
E - Extrinsic allergic alveolitis > ans

32. June 2016 #ortho

25 yr old female complain of Raynaud's phenomenon
in cold,also having edema of bl feet,,bibasal
crepitation on lung bases ,heart on CXR silhute
appearance .ana+, ENA neg..cz
A-primary Raynaud's
B-cold agglitonin antibody
C-sle
D-limited sclerosis

Cold Agglutinin happens with Systemic Scleroderma or as with Mycoplasma Pneumonia

• Raynaulds could be 1ry or 2ry, here it is 2ry to a problem caused ==> CHF+ Reynaulds
• Prepheral edema + Bibasilar Crackles which appear suddenly or acutely .. as in Infections with Virus or
bacteria
• Mycoplasma Pneumonia is a well known cause of Cold agglutinin causing Reynauld's , -ve ENA and
CHF could develop as a complication, Sever hemolysis after mycolplasma causes CHF

it is likely limited sclerosis... Reasons: SLE should have ANA and ENA positive...
Systemic sclerosis should have other manifestations... In this case only other manifestation is lung
infection long back...
Now, if they say Anti Centromere positive: then for sure CREST
And if Anti topoisomerase positive: systemic sclerosis...

1096
33. Middle aged man with a history of chronic lung disease, they didn't specify which presents with an increasing
dyspnoea over the past 12 hours.Now he looks well,he can speak in phrases ,the dyspnoea has been tolerated
well for the past few years.Now he has an oxygen saturation of 85% on 8L oxygen.What's the initial investigation
you will request?
ABG > ans
BLOOD CULTURE
C XRAY
CT CHEST

34. A PA chest xray of a man demonstrating widely spread reticulonodular shadows. The patient has a history of
bilateral loin pain and hematuria. His serum Calcium is elevated. What's the next investigation you would
request?
A. ACE levels> ans. sarcoidosis
B. CT chest.
C. CT abdomen.
D. Renal biopsy.
E. Urinalysis
If pt. presents with hemoptysis ( alveolar hg) and hematuria>goodpasture> kidney\ lung biopsy
Bilateral stone> hypercalcemima> hilar shadows on CXr> sarcoidoisis.> do ace levels first then
HRCT

35. Xray of chest .. showing increased bronchvascular marking .. with thickened interstitium .. NO HILAR SHADOWS
.. patient is developing progressive chest symptoms and some ronchi and abnormal breathing sounds.. long ABG
and lab results (about 10-12 result) I don’t remember exactly .. asking what to do next (as I recall it was directed
towards lung fibrosis or interstitial lung disease .. not classic for anything common)
a. Ca level
b. CT chest b
c. ACE level
d. Other irrelevant options
#august

36. Coal miner with asthma, what in spirometry will tell you there is something more than asthma:

1097
A. decrease TLC > more specific in restrictive
B. decrease VC> dec in restrictive, but not very specific
C. decrease FEV1/FVC> decrease in obstruction
D. decrease residual volume> more restrictive

37. 25 yr indigenous lady presented with sob and cough

since 3 weeks..o/e temp 37.8,pr,rr,bp,saturation all are
within normal limits,mitral stenosis with bilateral basal
crepts .x ray given with features like blateral symmetrical
mid lobe pulmonary infiltrate especially perihilar. Area
..diagnosis?
a.pulmonary edema
b.pulmonary hypertension > ans
c.rheumatic fever
d.peumocystis pneumonia

38. prolonged yellowish ear discharge in child 6 months.. organism

causing it
a) streptocoque pneumonia
b)morexellacatarhis
c)pseudomonas aeruginosa > ans
** P aeruginosa is the most commonly recovered
organism from the chronically draining ear. Various
researchers over the past few decades have recovered
pseudomonads from 48-98% of patients with CSOM.
Medscape

39. chest x ray showing just hilar shadows bilaterally with scenario
of a child with abd pain , fever and cough , what is ur Dx ?
A. Pneumococcal pneumonia
B. Aspergilous infection (Aspergillosis) C. Viral pneumonia D.
Mycoplasma pneumonia> ans E. Sarcoidosis D

40. Case of community acquired pneumonia was treated and got

well on day three. On day five patient started having fever,
chills and rigors associated with a basal pneumonia
A. Empyema> ans
1098
B. Hospital acquired pneumonia
C. Recurrent community acquired pneumonia
D. Iv cannula bacteraemia
E. Pleural effusion

41. Pneumonia child 2 yr , RR 30 /min , HR 120/min , fever 39 degree , no respiratory distress , what initial treatment
?
A. Oral amoxicillin > ans
B. IV flucoxallin
C. IV benzyl penicillin
D. Oral roxithromycin

42. A patient has pneumonia. His hip muscles become weak. CT shows
a spinal stenosis. He is on statins and multiple other drugs. On
examination knee jerk is absent, lower limb power is 3/6, absent
dosalis pedis pulses and sensation over thigh is loss. Next
investigation?
A) Mri >
B) Xray.
C) Arterial duplex
D) CK
E) LP
C is better choice becoz mixed varierty
Neurogenic caudiè MRI
VASCULAR è Duplex
Mixed vè Duplex

43. yrs old Child with fever 39.8 chills , abdominal pain, on examination
looks unwell resp rate 30 heart rate 120, treatment?
a)oral amoxicillin
b)oral roxithromycin
c)iv penicillin> ans
d) iv flucloxacillin

1099
44. patient with pneumonia and atrial fibrillation,his inv shows TSH normal at upper level, T3 normal range,T4
slightly raised. What will you do next?
A. Thyroid scan
B. Repeat Thyroid function test after one month> ans
C. Do the thyroid function test now
D. Echo
E. CT scan head
B

45. Case of community acquired pneumonia was treated and got well on day three. On day five patient started
having fever, chills and rigors associated with a basal pneumonia
A. Empyema> ans
B. Hospital acquired pneumonia
C. Recurrent community acquired pneumonia
D. Iv cannula bacteraemia
E. Pleural effusion
A
Here it’s within 48 hours == we can hAP
Cannula site not mentioned properly

46. .xray quite abnormal.. left sided pleural effusion but no heart
borders not dilated.. 6 weeks of cough and dyspnea aboriginal
lady with bibasal crepts and also left sided decreased breath
sounds systolic murmur over apex
Rheumatoid heart disease
Left heart failure
Pulmonary hypertension> ans
Pneumonia

1100
47. Another smoker with 30 year smoking history,
has frequent trips to asia. Presents with weight
loss, loss of apetite, cough and a pansystolic
murmur heard on the apex. On auscultation he
had bilateral basal crepts and decreased breath
sound on the left lower lobe. What is the most
likely diagnosis ?
a. Carcinoma lung
b. Tuberculosis
c. Bronchitis
d. Rheumatic fever
e. Bronchiectasis

48. Case Of severe pneumonia in child, nxt inv?

A. FBC
B. Blood culture > diagnostic
C. Chest X-ray …next

49. Case of pneumonia in child wth X-ray showing pleural effusion, wht nxt?
A. Blood culture
B. Pleural aspirate
X-ray = = blood culture == pleural effusion

50. Chest X-ray showing bilateral hilar shadow,

scenario of a child wth abd pain, fever,
cough, Dx?
A. Pneumococcal pneumonia
B. Aspergillous inf
C. Viral pneumonia
D. Mycoplasma pneumonia > ans
E. Sarcoidosis —
Management??
a) Ct
b) Pleural fluid aspiration
c) Antibiotics
d) Blood cultures
e) Pneumococcal PCR

Features of meningitis 1st line

No rash == blood culture
With rash== Abx
Neuro….
Pneumonia leads to meningitis
Blood culture è antibiotic è
Extra note: IN meningococcal meningitis è
emergency è Antibiotics first then blood
culture
Other meningitis: blood culture è antibiotic
51. 9 month baby with fever, clear nasal
discharge, coughing with vomiting.. crackles
and wheezes.. Dx?

1101
a. Pertusis
b. Viral Bronchiolitis > ans
c. Pneumonia

#May 2017

52. A 30 yr old woman long story about dysponea. Jvp 2.5

cm increased, crackles in base of lungs. oedema
around malleolus. Cause?
a- mitral stenosis
b- corpolmunale> ans
c- cardiomyopathy
d- pneumonia
e- copd

53. chest xray of a child showing opacities;has fever;severe

pneumonia.what to give?
a.iv ceftriaxone> ans
b.iv penicilline
c.amoxiclav

54. A young patient with both sided lobar pneumonia presents

with breathlessness.her breathing was labored & O2
saturation was 85%.( no h/o COPD or any other lung disease
was given.just this much info).What u will give her
a. 100% O2 by nasal prongs 2L/min> ans
b. 28% O2 by venturi mask
c. intubation and 100% O2
d. continuous positive pressure ventilation

1102
55. Pic of mild pneumonia with no signs of respiratory distress, what is the tt?
A. Amoxicillin> ans JM 473
B. Vancomycin
C. Corprofloxacin
D. Azithromycin
E. Erythromycin

1103
56. An infant came with pneumonia , X ray showed consolidation of a lobe with round translucencies and a small
pleural effusion. What is the treatment of choice?
A. Crystalline penicillin
B. Flucloxicillin > ans
C. Amoxicillin / clavulanic acid
D. Tetracycline

(Round lesion+pleural effusion+ flu like symptom always consider as staphè Flucloxacillin. B
Lower lobe consolidation Strep è so Amox+Clav
MC/Legio/Chlaè Erytho/Doxy?Azyth
But Azyth is the best covers all
B. Fluclox. The described pneumatoceles are quasi-diagnostic of staphylococcal pneumonia.)
Jm 295 pg

57. A middle-aged man complains of cough and productive sputum. CXR showed patchy infiltrates. What is the
management?
A Azithromycin > ans . Atypical( interstial ) pnemonia. JM 472
B Flucloxacillin
C Ampicillin
D Tetracycline Pneumonia with
A micoplasma

58. 2 year old child. Respiratory rate 30. Heart rate 120. Fever 30.9. one day history of fever, vomiting, abdominal
pain. On examination mild abdominal tenderness but no rigidity. Chest xray is given ( looks like pneumonia).
Which of the following is the most appropriate initial antibiotic?
a. Amoxicillin
b. Roxithromycin
c. Augmentin oral
d. IV penicillin> ans
e. IV ceftriaxone

59. Post carotid endarterectomy pt went home after 7 days came back with audible stridor and severe dyspnoea ,
wut will u do after u raise his bed feet?.
A) immediate Intubation> ans
B)O2
C) Remove suture
D) Send to back to OR and surgery immediately

***if immediate complication remove the suture first and then intubate….if late than do intubation
first and then explore
** Airway obstruction due to an enlarging neck hematoma after CEA is rare but potentially fatal. In
the early postoperative period, patients complaining of unusual neck discomfort warrant special
attention. Wound hematomas after CEA are relatively common, but fortunately, the majority are
small and cause no problems. In NASCET, wound hematomas were documented in 5.5% of the
patients and thus were a more common complication than a major stroke or death. [1] For large
hematomas or those that continue to expand and result in airway loss or respiratory compromise,
emergency treatment is indicated. If there is no airway compromise, the patient should return to
the OR for emergency hematoma evacuation. However, if the airway is already obstructed by the
hematoma, opening of the wound at the bedside is warranted.

1104
60. 82 yr old man with hx of smoking 80 pack a day presented with progressive decrease in FVC and FEV he is not
improved by bronchodilator ask what to do next they gave X-ray of diffuse bilateral lung shadow.
A. bronchscopy with alveolar lavage..
B. CT
C.plu biopsy
D. Oral steroid > ans . COPD JM 940 as acute flare up
**for maintainance inhaled corticosteroid

61. One female with h/o adenoma of lung now has haemoptysis lung X-ray done , what to do next most app inv,
a. Bronchoscopy.
b. VQ scan
c. CT JM 474
d. ESR

62. SURGERY lung abscess scenario oxygen saturation 95 percent

..antibiotics given what to do now?
a.Trans pleural drainage >ans
b.bronchoscopy
c.Cpap
d.Lobectomy

Case of a pt present with foul smelling cough, high fever with

rigor. xray was given and it showed opacity in middle zone with
air fluid level,after giving flucloxacilin what next
a) transpleural aspirate
b) waterseal drainage
c) aspiration
d) CT chest

63. No travel history ' feature of TB without fever !!

A. Sputum for AFB > ans JM 278

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B. Sputum culture
C. Bronchoscopy

64. Child from Sudan, cough since 2 weeks, dry, sub

febrile , CXR given with right upper apical circular
density / cavitary lesion, next best step :—
sputum for AFB ,> ans
start HRZE for 6 months, HB 443
Bronchoscopy + Bx,
HRCT
Same

65. X-ray showing left apical white shadow. patient

has ptosis myosis and anhydrosis next step

Ct chest> ans pancoast tumor

Ct abdomen
CT brain
MRI brain
bronchoscopy

66. Engineer from china working in a coal mine

complaining nocturnal cough non productive that
a wakes him from sleep with plaques on pleura,
cxr hyperinflaated, smoker,fev1 70 %, fvc 50 % wt
to do

a)Ct, ans
b)bronchoscopy,
c)percutaneous pleural biopsy
(A Saba Ismail The diagnosis is pneumoconiosis. The
spirometry is suggestive of fibrosis (see JM p.520
figure 50.3). JM p.524: “CT scans may be required to
confirm the presence of calcified pleural plaque
Pleural plaques without effusion quite unlikely mesothelioma...as most of these presents with bloody pleural
effusion...)

67. Male patient working in the cotton field, presented with 3 weeks history of cough. CXR showed bilateral hilar
lymphadenopathy and biopsy (by bronchoscopy) showed non-caseating granuloma. What’s your diagnosis?
a) Sarcoidosis> ans
b) Amylidosis
c) Histiocustosis
d) Berylliosis

1106
68. A 50 yr old male presented with
dysphagia for 2 wks and hoarsness of
the voice before that. What is the
best way to establish a diagnosis?.
a. Laryngoscopy> ans
b. CT
c. Barrium meal
d. Bronchoscopy

69. Pacemaker syndrome with difficulty

in breathing with faint heart
sounds,spo2 96%, bp-
90/60mmhg,jvp-6 with no ECG
given. investigation of choice
needed.
A. Chest xray.
B. CTPA.
C. ECG.
D. ECHOCARDIOGRAM. > ans . Right
ventricule rupture
E. SERUM TROPONIN

70. Patient on post operative day 3 started becoming agitated, irritable and had Shortness of breath.
What is the next and best appropriate investigation?
a. CTPA
b. D-Dimer
c. Chest x-ray
D. Blood gases> ans
E. Blood sugar level
A best d next

71. a lady with18 weeks gestation and previous DVT, present with sudden dyspnea and shortness of breath. What's
the initial investigation in this pt?
A) D-dimer
B) V/Q scan > ans
C) ECG
D) CTPA
E) Doppler

72. Post op day3, old lady, confused, pulled out

IVA, SpO2 88%, Invx
A- CTPA
B- CXR
C- Blood glucose
D-d dimer

73. a young woman present with severe chest pain aggravated by inspiration, and relieved on recumbent position.
on exam she has a crunchy systolic sound in left sternal border, she has H/o pulmonary embolism before. what
inv to do to reach dx??
a) ana> lupus pericarditis
b) ctpa
c) V/q scan

1107
d) ANCA
e) CT scan of chest
A to rule out SLE
74. 25 y/o fimale developed fx of tibia and fibula due to car accident. 5 day after tarauma she developed cyanosis
and tachypnea with o2 saturation od 85%. what investigation?
a. ABG> ans
b. ventilation perfusion scan
c. CTPA
d. D dimer
e. dopplersono of lower ext
NEXT a , best b

75. .A man develops pulmonary embolism.he has a low eGFR what is the best way to diagnose pE in this man?
a-ctpa
b-v/q scan> ans ( pregnancy and CKD )
c-xray
A

76. Smoker with COPD has gout attack made him house bound last week, with SOB & pleuritic chest pain .. next?
A CXR
B CTPA
C CT chest

77. 50 y.o. patient after knee replacement. On the 4th POD the develops chest pain and dyspnea.
ABG: pO2 90 (N 95-100 mm) p CO2 31 (N 35-45) HCO3 21 (N 22-28) pH 7.32 (N 7.35-7.45) What is the next step in
management?
a. Oxygen by Hudson mask.
b. CTPA
c. ECG
d.CXR

78. 75 year old female admitted to coronary unit for elective procedure soon but became confused, keeps getting
out of bed and removing her intravenous drip. What is her highest risk over the next 24 hours?
A. Myocardial infarction
B. Stroke
C. Falls
D. Pulmonary embolism

1108
79. A patient with chronic lung disease develops cough and fever. (?Acute on chronic bronchitis) was admitted to
hospital. Ipratropium and salbutamol
given 8 hourly.Oral prednisolone , oral
roxithromycin and iv amoxycillin given.
ABG done showing: pH 7.35, PaO2 80mmHg,
PaCO2 50mmHg, HCO3- 35mmHg
What is your next management?
A. Give IV hydrocortisone
B. Increase bronchodilator to 4 hourly
C. CPAP
D. Admit to ICU
E. Change to iv cefotaxime
#SEP2017
D(Indications for CPAP.

Hypoxemia that is refractory to high

concentrations of oxygen by other means.
Obstructive Sleep Apnea to prevent the
upper airway from collapsing)

80. pt with history of travel since 7 days from thiland, now shortness of breath, left chest pain, temp 38c and pain
increases with cough and inspiration ?
a- peumonia
b- pulmonary embolism
c- acute pericarditis
d- myocardial infarction

81. A lady has been travelling in an aeroplane and after 2 days from united kingdom presented with dyspnoea,
temperature of 38.1, and chest pain on coughing and inspiration.on auscultation lung found crackles. What is
the possible diagnosis?
• Pulmonary embolism
• Pneumonia
• Acute pericarditis

82. Adult girl with bilateral pneumonia.Oxygen saturation is 85% and patient is alert.How to give oxygen?
a. Nasal 100% oxygen 2L
b. Ventouse
c. Cpap
d. Intubation

83. Old recall: post subtotal thyroidectomy, difficult breathing, swelling to op site
A- Intubation
B- Remove deep layer suture
C- Remove skin staples
D- CXR
A(post neck operation swelling no stridor or horsebess, remove all sutures including strap muscles in the
word, do not send this pt to ot. If stridor or horeseness presents then 1st endotracheal intubation.)

84. case of acute tonsillitis with swollen and red tonsil and uvula shifted to left.1 hr after giving penicillin inj the pt
develop severe stridor with hoarseness.next?
1.endotraceal intubation
2.im adrenalin

1109
 3.02 by mask
4.drianage of peritonsillar abcess

** here there is no feature of hypoxia... stridor due to laryngeal edema. this anaphylactic reaction can
easily b mnged by IM adrenaline

85. after motor vehicle accident patient came with severe chest pain for which he cant breath...oxygen saturation
95%..chest examination and ct revealed hemopneumothorax...there is tenderness on fractured rib in both side
of chest...what to do next?
a.intubation
b.morphine
c.chest drain

86. 60-year-old man, who smokes 60 pack per year, presented with shortness of breath, was given 28% oxygen by
mask. 30 minutes later, his ABG was PaO2 68, PaCO2 60. What would you do next?
a) Stop oxygen and check ABG after 30 minutes
b) Continue oxygen until normal PaO2 is reached
c) Immediate intubation & ventilation
d) Give immediate antibiotic cover against gram negative bacteria
e) Start aminophyllin iv infusion

**if there is option for CPAP choose that one

1110
1111
87. new born baby who is cyanosed n whose apgar score is 3..wht will u do
next??
a.bag and mask ventilation
b.nasal suction
c.intubation n ventilation

88. pt comes to emergency dept post MVA with # ant rib of rt side. he has
hoarseness of voice & mild shortness of breath. vital stable, bp normal.
chest xray was given showing widening of mediastinum, loss of aortic
nuckle. most appropriet next step....
a.2nd ICS needle aspiration
b.intercostal drainage
c.CT angiogram
d. USG chest
e.pericardiocentesis

89. child with croup scenario, 38 fever and coryza, harsh cough, respiratory stridor on rest using collateral muscles
A. Prednisolone oral
B. IV prednisolone
C. Humidified oxygen
D.nebulized adrenalin

90. #respiratory
Child with moderate croup scenario
being managed in ER.Which clinical
features will suggest croup requiring
urgent intervention?
Restlessness and not settling down
Increased harshness of stridor
Increased respiratory rate
Increased fever

91. #resp
9 month old boy with fever 39,
cough, tracheal tug, intercostal
recessions and lethargy came to ED.
You give IV fluids and oxygen.
A) pneumococcal pneumonia
B) croup
C) bronchiolotis
D) anemia

92. #asthma H/o asthma intake of

salbutamol no preventer now
presents with noisy breathing
fever hoarseness of voice what
is the cause
a)Acute asthma
b)Anaphylaxis
c)Upper respiratory obstruction ….may be croup

1112
93. 6mth child with wheezing, fever, tracheal tug, sub costal recession, nasal discharge. What will you do to make Dx
A- CXR
B- Sputum Cx
C- Blood Cx
D- Nasopharyngeal as pirates for PCR
Dx bronchiolitis

94. A 6 month old boy. Had runny nose for 3 days. Cough for one day and today is coming in with restless breathing.
He has been vomiting intermittently for 2 days and fed poorly today. His temp 37.4. Pulse 160. Respiratory rate
70. He has wheezy chest and retraction and inspiratory tug. NEXT
a. CXR— RSV immunofloruscence.
b. blood gas
c. BLD culture
d. Blood glucose
B or c

1113
95. 20 child had urti runny nose now dyspnea n wheeze all over chest. Has hx of asthma and atopy. Bilateral crackles
in auscultation. Ix
A blood culture
B cxr
C ABGs
D nasopharyngeal aspirate…bronchiolitis
E Spirometry during inspiration expiration

1114
96. 9 month baby with fever, clear nasal discharge, coughing with vomiting.. crackles and wheezes.. Dx?
a. Pertusis
b. Viral Bronchiolitis
c. Pneumonia
#May 2017
B

97. A 8 months old kid is brought by his mother with cyanosis, breathlessness and mild fever. The infection started
with mild URTI type signs and has been continuing since 10 days. Now there are LRTI type grunting and sub
coastal recession etc.. (typical signs and symptoms + history of Bronchiolitis). RR = 44. What is the most
appropriate next step in the management of this kiddo??
A. Nebulised adrenaline
B. IV fluids
C. Antibiotics
D. Oxygen supplementation
E. Observe
D

98. Child 4yr with 2 day prodromal then harsh cough fever 39 nasal flaring, tracheal tug,intercostal recession o2 sat
80% treatment.rx?
a)nebulized salbutamol
b)nebulized budesonide…moderate croup
c),im adrenaline croup
d), iv benzyl penicillin
e)iv flucoxaacillin

99. old man h/o smoking , alcoholism.presented with dyspnea.O/E plethoric face, engorged neck
veins.what is most appropriate investigation? (sorry don’t remember full scenario)
1- Xray chest
2-ECHO
3CT CHEST dx:pancoast tumour???

100. Child 4years with 2day prodromal then harsh cough,fever 39,nasal flaring,tracheal tug, intercostal
recession,o2 saturation 85%.rx

1.nebulized salbutamol
2.im adrenaline
3.iv benzylpenicillin
4.iv flucloxacillin
could be moderate croup ans should be steroid nebulize

101. A child presented with 3 days history of fever, cough. He was grunting, his temperature was 39C. Chest
examination revealed left basal dullness and trachea shifted to the right. What is the antibiotic of choice?
a. Amoxicillin
b. IV penicillin
c. Roxithroycin
d. IV flucloxacillin dx: severe pneumonia

102. Child 4yrs with 2 day prodromal then cough fever 39 nasal flaring, tracheal tug, intercostal

1115
recession o2 sat 80% treatment
Nebulized salbutamol,
Nebulized bedosinuoed
Im adrenaline
IV penicillin
IV flucloxacillin+ IV gentamicin

103. 4 yr old child restless, irritable for 3 days, fever for 1

day, wheeze, t 39.5, RR-30..xray shows rt lower lobe
consolidation..whats best?
a. oral amoxiclav
b. iv flucloxacillin
c. iv ceftriaxone
**correct option is missing.this is moderate pneumonia

104. 3 Year old with cough fever. O/E tracheal tug temp
39.5 Creps in chest .Which antibiotic?
A)Co amoxiclav
B) oral Fluoxacillon
C) oral penicllin
D) Oral roxithromycin
E) IV fluoxacillin???

105. Farmer with the injury falling of the tractor 5yrs ago,
broke his rib, now complains of breathlessness and chest
pain, xray given. What to do next?
a. Thoracotomy
b. drain
c. Surgery dx delayed uncomplicated diaphragmatic hernia
d. Thoracentesis —

106. New Sept recall -

MVA scenario,pt was sevely injured on left chest,breath sound
diminished on left side,dull on percussion,there is no
pneumothorax ( exactly they said this line that no
pneumothorax),what will u do next??
a.IPPV
b.aspirate
c.o2
d.morphine

107. A young man MVA fractured his ribs and has minimal
left pneumothorax, peritoneal lavage is positive for blood
and laparatomy is planed for interperoneal hemorrhage,
what’s de most important thing to do
A-Assesing of nasogastrics
B-Inserting of intercostal drainage tube
C-determine PaO2
D-inserting of central venous pressure line

1116
**during operation pt will get 02.if no chest drain 02 will be trapped and pneumothorax will get worse.
Unstable do surgery(thoractomy). If stable Ct scan to see clots Rx. Oxygen —> drainage
Secure the airways first, pt needs chest darin
Cluster….knife injury…how to remove the knife? OT… remove it inder GA… with chest drain support

108. Hyaline membrane disease with pneumothorax, pneumothorax 25 percent pt stable with no symptom just
reduced air entery.next?
a) Admit and observe
b) drain insertion…2ndary spontaneous pneumothorax
C) come with cxr next day

109. Which of the following most commonly causes pulmonary hypertension & corpulmonale?
a) Emphysema
b) Bronchiectasis
c) Pulmonary embolism
d) Pneumothorax
e) Foreign body

1117
110. after being diagnosed with ca of oesophagus oesophagectomy has been done . on 4th post op day pt
developed pain in the epigastrium and shortness of breath . on examination left breath sounds diminished ,
percussion note dull . x -ray of chest been done. what would be the findings on x-ray?
a) heamothorax
b . plural effusion
c . mediastinal lymph node enlargement
d. pneumothorax
A or b

111. a man with penetrating chest trauma on left has now developed SOB his breathing has become laboured no
xray… he has got tachypnoea n tachycardia…. And there is also subcutaneous emphysema in neck ,on physical
exam there is dull breath sounds plus mediastinum shift towards left side, what’s the diagnosis?
a- tension pneumothorax
b- hemopneumothorax
c- aortic dissection
d- cardiactemponade
e- aortic rupture
B

112. Flail chest, CT given - haemopneumothorax. Painful shallow breathing. O2 given by face mask, what's next?
1. Morphine
2. Intubate
3. Drain
No compromised breathing , shallow
breathing becoz of painful broken ribs, so
need to correct that first
Ref: Oxford HB surgery

113. 25 yrs old male after RTa with open flail chest. With severe dyspnea. Decreased breath sounds and trachea
deviated towards the opposite side, wat will u do at site of accident.
a. morphine
b. ett and ven
c. needle thoracostomy
d.cover the wound
e.chest strapping

114. Patient with chest trauma +flail chest what to do at accident scene.
A. Opioid
B.chest tube
C. Mouth to mouth resuscitation( if emergency scene)
D. Cover open chest wound with a dressing

115. A patient with trauma .. flail chest again x-ray neck was given with vertebral fracture..collar was fixed
...chest dull on percussion. ..spo2 85% what is most appropriate step in management
A intubation
B tracheostomy
#May

116. A patient riding a horse in the rural area fell off the horse and sustain fracture of the ribs (5-11), femoral and
humeral fracture. X-ray shows small pneumothorax. Vitals stable and saturation 96%. She is to be air lifted to a

1118
 tertiary hospital. Before lifting her to the hospital after stabilizing the femoral and humeral fractures, what
should you do?
a.Needle aspiration
b. chest tube insertion
c. oxygen therapy
d. Strap chest

117. Young patient while travelling by airplane had cheat pain with mild dyspnoea,no other symptoms,has history
of sickle cell trait.What to do next?
Oxygen by mask **sickle cell pt develops hypoxemia easily
Hydration
Blood transfusion
Intubation and oxygen
Splenectomy

118. 36.patient fell off of the horse fractured both forearms and femur and fractured ribs. There is small
pneumothorax. Patient has to be transferred to hospital via helicopter. After stablizing
fractures what is the most next step in mx
A intubation n ventilation
B analgesics
C needle thoracocentesis
D chest drain with waterseal

119. A 30-year-old male patient fell down from his motorbike. He got multiple rib fractures on his left side from 7
to 10 ribs. Her oxygen saturation is 96% at the room air. He is conscious and well. Chest X-ray showed 15% of
pneumothorax on her left side. He is to be transferred to the nearest hospital by air ambulance . What is your
next step in her management? CONTRO
a. Insert an intercostal catheter
b. Intubate and ventilate
C. No further action neededd.
D. Needle thoracocentesis.
E. Air travel not allowed for three months
IF U TRAVEL CHETS DRAIN MUST
HOSPITAL HAS TO BE t 30 min otherwise air ambulance.
1119
120. 40% pleural effusion both lungs. X ray given. Pt stable what should you do first?
A. Aspiration JM 556
B. Give Benpen

121. Somebody has surgery for femoral surgery and on de third day she developed dyspnea,he being a heavy
drunkard and a smoker
Whats next appropriate thing to do
A-ABG
B-chest xray - next
C-blood culture
D CT angiogram – appropriate n best
E ultrasound

122. A 2yr old patient has with fatty diarrhea was brought in by the patient, failure to strive , physical exams
reveals rash in the limbs. What is the diagnosis . A, cystic fibrosis, b. Dermatitis c. Coliaec disease d. Amoebiasis
**dermatitis herpitiformis is manifestation of coeliac disease

123. daughter brings father complaining of increased breathlessness and cough last few days or 2 weeks i forgot.
known case of HTN and heart failure, on multiple drugs. smoker. o/e bilat basal crackles. xray
given ( bilat patchy infiltrates, no cardiomegaly, and heart borders were very poorly defined) Dx asked?
a) acute lvf b) lung ca c) acute on chronic bronchitis d) pulm fibrosis

**breathlessness and cough due to pul edema lvf also b/l patchy shadows points of pulmonary edema

124. 4 mo old child, bronchiolitis scenario, O2 96%, not dehydrated. MX?

a. admit for oxygen therapy,
b. supportive care and review in 24hrs,
c. nebulized adrenaline,
d. steroids

125. Child (3-4 year) with fever 39C and history of cough unwell for 3 days. I think he has wheeze but minimal
lung signs on exam. There was a xray which I can`t recognize.Asked which investigation will help in dx
a. pneumococcal pcr
b. pleural aspirate
c. blood culture
After A then B

126. A man, DM type 2, hypertensive, h/c of COPD and a smoker for more than 20 years. Came with complain of
progressive dyspnea. His face was plethoric and neck veins was engorged till the jaw line. (to me it looked like a
scenario of superior vena caval obstruction). What to
do?
a) CT chest to see SVC obs
b) ECG
c) Echo
d) CXR

127. pt with B/l leg oedema and crackles on Left side with some smoking history and MI hitory
Congestive heart failure/
copd with cor pulmone/
Lt heart failure

1120
128. old pt with cough n orthopnea,40 pack yrs smoking,MI five yrs back, after which stopped smoking,ankle
edema
a)copd plus cor pulmonale
b)copd plus CHF
c)copd
d)chf
**as smoking history copd is must …then if only peripheral oedema its rt sided
hf(corpulmonale) and if sob +peripheral oedema its CHF
Ø 64 old male, lost 8 kg in 6 wks , lethargic. Llodema left side chest crackles. Fatigue .smoke 40 packs per
yearfor long time , but stopped 5 years ago after he gets MI, DX
1.COPD CORPULMONALE
2. CHF
3. INTERSTITIAL LUNG DISEASE WITH BRONCHISAL CARCINOMA

129. old pt with cough n orthopnea,40 pack yrs smoking,MI five yrs back,after which stopped smoking,ankle
edema
a)copd plus cor pulmonale
b)copd plus CHF
c)copd
d)chf

130. 30 yrs woman. Long story about dyspnea . Jvp 2.5 cm increased .Crackles in base of lungs. Edema around
malleolus . Cause ?
a- mitral stenosis
b- corpolmunel
c- cardiomyopathy

131. A man with h/o smoking, cough now having ankle swelling , dyspnea, bilateral basal crepts:
a.copd
b.copd with cor pulmonale
c.cor pulmonale
d.LVH

132. a 65 year old man with a history of smoking previously came now to your office with peripheral edema and
raised JVP and hepatojugular reflux .bp is 130/95, fine bibasilar crackle on auscultation . what is the most
appropriate diagnosis ?
a. systolic heart failure
b. copd exacerbation
c. pneumonia
d. corpulmonale

133. 58 year old man with 40 years history of smoking 40 packs had an MI last year and he stopped smoking then,
now coming with exertional dyspnea, orthopnia, basal lung crackles , a dull area over the middle lobe of the right
lung, ankle edema bilat. Wts the dx ?
a. congestive heart failure
b. COPD with congestive heart failure
c. COPD with cor palmonale

134. 65 year old man comes with weight loss of 8 kg in 6 weeks and productive cough for 2 weeks. He complains
of orthopnea and cough. He is afebrile. He had a history of myocardial infarction in last 5 years. He used to
1121
 smoke 40 packs/year and stopped smoking after myocardial infarction. On examination, there is dullness and
reduced breath sounds in right lung base and inspiration crackles in left lung. He also had bilateral ankle edema.
What is the diagnosis?
COPD with cor pulmonale
COPD with Congestive cardiac failure
Interstitial lung disease
Bronchogenic carcinoma Ans

135. All copd with corpulmonale

# Resp- COPD
Copd with irregular heartbeat and chest pain . Most appropriate next
1. X Ray
2. Ctpa 3. PfT

136. Best preventer in 4 year old boy, asthma relieved by salbutamol

A. FLuticasone
B. SCG
C. LABA
D. Oral Montelukast

137. .5 yr symptom of severe asthma, admitted to hospital, nebulized by salbutamol & took oral steroid, Now
want to discharge ? (what to give)
A. Fluticasone…if ask about preventer
B. Oral Steroid
C. LABA

1122
138. 3 years old boy with recurrent attacks of asthma asking about the best preventer by inhalation
a.budesonide
b.fluticasoe
c. sodium cromoglycate
d. salmeterol/fluticasone

139. 3 years old child comes with complain of cough and

mother had hay fever and father is smoker, what drug is
used for prevention of asthma case here:
a.SCG
b.Fluticasone
c.budesonide
d.salbutamol
**correct ans should be montelukust

140. 5 years old boy with cough from 12 months before,

was on Salbutamol and also taken oral Prednisolone. He
has an eczema history, both parents are smokers,( typical
asthma scenario) which one is the best medication for
prevention which is used in “INHALATION MODE”?
A.Monteleucast
B.Chromoglycate
C.salbutamol
D.fluticasone
e.salmeterol

141. child who has wheeze and cough at night and during
exercise …..given salbutamol fluticasone.Whats the best
preventer?
A) LABA
SABA
C)Fluticasone…if they ask about best preventer
D) SCG
E) Monoleukast….if they ask what to give to this child

142. child with asthma attack on the way to hospital he was given 6 puff of salbutamol with spacer but still in
distress and has wheeze
A.add salmetrol
B.IV amynophiline
C.12puff further Salbutamol
D.atrovent
E.oral prednisolone

143. A 10 year old male child is brought by his mother with complaints of ongoing exercise induced asthma
despite being on a maximum dose of inhaled corticosteroids. Which of the following is most appropriate next
step in management?
A. Refer to chest physician
B. Add leukotriene antagonists
C. Cease Inhaled corticosteroids and start Iv steriods
D. Add long acting B2 agonists
E. Add short acting B2 agonists

1123
1124
1125
1126
144. child with history of asthma and he was aknown case of nut allergy, both parents are smoker, develop
wheeze , hoarseness of voice and other chest symptoms relieved by salbutamol. What is the most likely
preventive measure for such subsequent episode? A-avoid all type of nuts in foods B-prevent exposure to
passive smoking from parents C-remove all carpets from house D-remove cats and dogs

145. Known asthmatic patient presented to ER with status asthmaticus, before arrival to hospital he took
salbutamol inhaler but didn’t improve his symptoms, what should be given next ?
A salbutamol iv
B oral corticosteroid
C intubate after sedation
D magnesium sulphate im
#May2018
Mainstay Rx For status asthmaticus is
Beta agonists,steroids frst inhaled type then systemic type.
Regarding its action-
As we al knw asthma pathophysiology is hyperresponsiveness and inflamation.
So steroids can decrease the inflamation vth its antiinflamatory property.and also the hyper
secreted mucus and all wilb removed providing better airway.

146. Respiratory An elderly man comes to the ED as result of status asthamaticus. He has been on albuterol and
salbutamol for years in which it has not alleviated the symptoms. What medication will you give?
A. Prophylline + ipratrodium (I got this wrong )
B. B-agonist + albuterol + sedation
C. corticosteroids + salbutamol + sedation
D. Higher dose of albuterol
E. Corticosteriods only
Ans-C? Sedation in resp distressed patient?

FOR management of non severe Asthma (1) SABA inhale è 2) for long control low-dose
ICS+SABA è 3) if not controlled medium-dose ICS and a long-acting beta agonist
(LABA)/Ipatropiumè 4) if not controlled medium-dose ICS plus a
LABA,+LTRA(Montilucast)/theophlline/Ipatropium è 5)if not controlled HIGH-dose ICS plus a
LABA,+LTRA(Montilucast)/theophlline/Ipatropium If still not controlled it is severe Asthma
& the management becomes completely different as follows:
I/V medications (e.g. magnesium magnesium sulphate),..... aerosolised medications to dilate the
airways (bronchodilation) (e.g., albuterol or ipratropium bromide/salbutamol), and positive-
pressure therapy, including mechanical ventilation. Multiple therapies may be used
simultaneously to rapidly reverse the effects of status asthmaticus and ✔✔✔ Intravenous
corticosteroids and methylxanthines are often given to reduce long term damage. If the person
with a severe asthma exacerbation is put on a mechanical ventilator, certain sedating
medications such as ketamine or propofol, have bronchodilating properties. According to a new
randomised control trial ketamine and aminophylline are also effective in children with acute
asthma who responds poorly to standard therapy..NO ANSWER FIT ABSOLUTELY BUT C IS
ACCEPTABLE..

147. a child with history of asthma presented with upper respiratory tract infection , urine examination showed
glucose and ketone + in urine, what is the most appropriate test to follow up this child?
A-HbA1C
B-serum creatinine and electrolyte
C-FBS
D-OGTT
1127
148. An 8-year old boy is brought to the emergency depart-ment because ofwheezing.According to the
parents,the child has had asthma and uses an albuterolinhaler at home when he has wheezing.This episodestarted 2
days ago but did not respond to several dosesofinhaled albuterol.He has been coughing frequently and vomited
twice in the previous day.Examinationshows that he has diffuse wheezing with decrease inbreath
sounds on both sides,and prefers to sit up in atripod-like position.Vital signs are:pulse 142/min,respirations
38/min,blood pressure 108/72 mm Hg,andtemperature 37.2 C (99.0 F).Pulse oximetry shows
thatthe oxygen saturation is 89%.Which ofthe following isthe most appropriate first step in
management?
(A)Albuterol by nebulizer
(B)Chest x-ray
(C)Intravenous fluids
(D)Methylprednisolone
(E)Oxygen by mask

149. 4 year old child difficulty in swallowing for 2 days . not willing to eat solid food but only drink milk
repeatedly.no cough mentioned. His brother had asthma. On examination child is well and normal examination.
What to do now?
x ray neck chest and abdomen
Salbutamol ***
barium swallow. —— incomplete ques

150. Scenerio on #waldernstorm macroglobenemia having past history of chicken pox and glandular
fever Now history of pneumonia and started ampicillin and azithromycin after next day he
developed rash over abdomin ( picture is given small pustules type rash all over present not
looking like rash)
Ask what next investigation ?
A) skin swab /skin biopsy
B) Skin culture
C) Bone marrow biopsy
D) Blood test for fungal

151. waldenstorm macroglobenemia patient

came with rigors and fever and right lower
lobar pneumonia or some infection like this
admitted and started ampicillin and after
minimal time generalised vesicular rash
appeared asking management
a. prednisolone

1128
 b. immunoglobulin
c. cease ampicillin
d. Ganicyclovir
C first then A
d...here pt present with shingles, which occur in
Waldenstorm, cz pt usually remain immuno deficient
here.....nd in shingle best rx is anti viral

152. A 57yr male with waldenstorm macroglobulinemia

and myelodysplastic syndrome developed pneumonia.
Penicillin given. After 2 days he developed
maculopapular rash with some pustular
lesion (no pic was there).What would lead to definitive
diagnosis:
A) Skin biopsy
B) Immunoflourescense of lesion
C) Blood culture
D. Marrow biopsy
Ans d. And A id marrow isnt in option

153. Child 3 years old,cough and yellow sputum for 3 weeks,no response for antibiotic,x ray
given,white patch upper lobe of right lung,, dx ?
A) mesothelioma
B) lobar pneumonia
C) aspiration pneumonia
D) lung ca....
e)empyema

154. #Resp A middle aged man who was previously diagnosed with wegeners granulomatosus and on
azathioprine comes complaining of cough for 2 days with blood streaked sputum. He also has some mild
exertional dyspnea . Physical exam is unremarkable
Azathioprine induced interstitial pneumonitis…dry cough
Bronchopneumonia
Reactivation of wegeners granulomatosus
Atypical pneumonia
Pneumocystis infection

155. # resp sarcoidosis scenerio.CXR given.Ca high.what next? ACE level CT chest

156. resp patient was brought to emergency room after a fight causing a stab with a knife in the chest. patient BP
is normal but his O2sat is mildly decreased he is calm, he only has mild dyspnea, on examination he has dullness
to percussion, decreased air entry on left side with trachea deviated to the side of the injury (not the opposite)
what should you do?

A) Give O2 next
B) Chest tube best
C) Thoracocentesis
D) IV fluids e- Just cover the wound and send him home

1129
157. resp A 24-year-old female is referred to a pulmonologist
for worsening symptoms of asthma. Her past medical history is
otherwise unremarkable except for a worsening of her asthma
symptoms during her menses. She describes her period as
lasting for several days with severe abdominal cramping that
sometimes requires her to stay home from work. If this finding
was truly related to her asthma, what would you also expect
to find on this patient's physical exam? a) Cafe-au-lait spots b)
Skin telangectasias c) Saddle nose deformity d) Nasal polyps e)
Increased jugular venous distention

**Samter's Triad is a condition in which an individual

has asthma, sinus inflammation with recurring nasal
polyps, and sensitivity to aspirin and some other
NSAIDs.

158. 4 year old with cough and nasal discharge. The child is febrile and unwell. There is noisy cough, intercostal
retractions. RR-increased, PR-increased. Lungs clear. ENT
examination is normal. What is the most likely diagnosis? A.
Asthma B. Acute tracheitis C. Acute laryngotracheobronchitis
D. Acute epiglottis E. Acute bacterial Pneumonia
159. resp A pt smoker plus occupational asbestos exposure as
well.. Has pleural plaques & hyperinflation or CXR. Now
dysopnea. What will u do? A.CT B.bronchoscopy C. Sputum
exam D. Per cutaneous biopsy

Paeds-resp system
Note this:
#paeds
-biliary vomitous day 1 of life..... Duodenal atresia
-cyanosis day 4 of life with NO murmur....
Hypoplastic lt heart failure
- cyanosis day 1 of life, no murmur..... TGA.
- cyanosis after 3rd month, pan-systolic murmur....
Falot's tetralogy
-croup....... Para-inflenza type I
-bronchiolitis..... RSV
-epiglotitis.... Hemophilis influenza type B..... Ttt.. Cephalosporins

160. 4 years old child and mother went to store. Child asked for something but mother refused later child hold his
breath then fell to ground then become cyanosed and later have fits. After that child get up and remained fine
A) Breath holding attack(ans) jm 1072 dramatic emergency
6 months-6 yrs,Children emits a long cry & then hold breath
B) Tonic clonic seizure
C) Absence seizure
D) Malingering

management:reassurance
advise parents to maintain discipline & resist spoiling of child
avoid incidents known to frustrate a child/precipitate a tantrum

1130
161. Boy when sleep on his back stridor, otherwise ok, stressed tachypnea and cyanosis?
A. Foreign body inhalation (choking & coughing episode+wheezing)JM 1072
B. Epiglotittis (toxic febrile illness,expiratory stidor)JM 1069
C. Broncholitis (2wk-9months,exp wheeze,insp crackles,hyperinflated chest) JM 1072
D. tracheomalacia (ans)

https://www.google.com.au/url?sa=t&source=web&rct=j&url=http://emedicine.medscape.com/article/426
003-
overview&ved=0ahUKEwjF0fbvjcjWAhWJE7wKHdlqCxEQFgglMAA&usg=AFQjCNF2pfVLl_TKVVuaUwkiE9k8M
0jExg

Tracheomalacia is a structural abnormality of the tracheal cartilage allowing collapse of its walls and
airway obstruction. A deficiency and/or malformation of the supporting cartilage exists, with a decrease in
the cartilage-to-muscle ratio.
Tracheomalacia most commonly affects the distal third of the trachea. By virtue of its intrinsic flexibility, or
compliance, the trachea changes caliber during the respiratory cycle. Tracheal dilatation and lengthening
occurs during inspiration; narrowing and shortening occurs during expiration. Accentuation of this cyclic
process may cause excessive narrowing of tracheal lumen, thus deforming the entire length or a localized
segment. However, it is rarely found in combination with laryngomalacia because of the separate
developmental pathways for the trachea and the larynx.
Sign & symptoms
There are many types of tracheomalacia, and each child is different, but some common signs include:

High-pitched breathing
Rattling or noisy breathing (stridor)
Frequent infections in the airway, such as bronchitis or pneumonia (because your child can’t cough or
otherwise clear his lungs)
Frequent noisy cough
Exercise intolerance
More severe signs may include:

Choking during feeding

A halt in breathing, particularly when crying or during
strenuous activity
Blue spells (child appears blue because his heart isn’t beating
quickly enough)
Medical Therapy
Tracheomalacia of the milder primary variety is best treated by
nonsurgical means.
Most infants who have mild-to-moderate symptoms should be
offered conservative therapy because these patients improve
by age 18-24 months. [4, 10] The majority respond to such
therapy, consisting of humidified air, chest physical therapy,
slow and careful feedings, and control of infection and
secretions with antibiotics.
The use of continuous positive airway pressure (CPAP) has been recommended in patients having
respiratory distress and may be successful in patients requiring a short-term intervention as the disorder
spontaneously resolves. [2]
Surgical therapy is required when conservative measures are not adequate or when reflex apnea is
present. Surgery includes correction of the underlying cause, such as vascular ring when present,
tracheostomy, and aortopexy.

Respiratory distress syndrome..

1131
https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/perinatal-reproductive/neonatal-
ehandbook/conditions/respiratory-distress-syndrome

162. Newborn with hyaline membrane disease condition, was on oxygen, now place in the chamber and needed
to provide more oxygen, and breathing is laboured with rate increasing. What is the most likely diagnosis?
a. Pneumothorax (ans)
b. Severe respitaory infection
c. Cyanotic congenital heart disease

Kaplan 7

Typically RDS progresses over the first 48 to 72

hours of life with increased respiratory distress and
begins to resolve after 72 hours The use of
exogenous surfactant and/or CPAP (continuous
positive airway pressure) dramatically improves
pulmonary function and shortens the clinical course
Pulmonary air leaks are common acute
complications of RDS due to the rupture of an
overdistended alveolus, and may occur
spontaneously or arise from CPAP and resulting in a
pneumomediastinum, or pneumothorax.

163. A woman delivered a preterm baby in

her 2 nd pregnancy with 3100gm weight.
Apgar at
1 st min is 6 and at 5 th min is 9. Over the next
few hours he develops grunting and tachypnea
and subcoastal recession. He was started on o2
at 4 hours of age. What is the most likely
cause?
A-Birth asphyxia(no h/o fetal distress n apgar is
good)
B-Meconium aspiration(same)
C-Tension pneumothorax(rapid
deterioration+may need ventilator support or
inc oxygen requirements)
D-Transient tachypnea of newborn(term
babies+c-section+caused by retained lung fluid
not eliminated during birthing process)
E-Hyaline membrane disease (ans)
Hb mcq 2.127

KAPLAN 7

164. hyaline membrane disease with

pneumothorax, 25 percent pt stable with no
sx just reduced air entry
diagnosis: Secondary pneumothorax
a) Admit and observe

1132
b) drain insertion (ans)
C) come with cxr next day ·

JM page 450
165. a baby born with wt of 2100, apgar score was 5 at birth and
10 at 10 mins no breathing problem. after 4 hrs of birth develop
shortness of breath diagnosis
A : transient tachypnea of new born
B: hyaline membrane disease

Ans
If premature then b
If term n cesarean then a

166. Couple come for infertility problem for the last 12 months.
On testing examination and tests of the female are
unremarkable. Male has azoospermia. And bilateral absence of
vas deferens. Which of the following is most appropriate before
the starting the treatment of infertility? a. No testing required
as they can not have a child
b. Testing of both male and female for cystic fibrosis**** (ans)
c. Refer for IVF
d. Serum FSH n LH for male
e. Serum Testosterone level

167. #Sep2017
Recall of 4y old baby what make u worry
Don’t ride bike

1133
168. 4 yr old boy with high fever,grunting resp,cough,tracheal tug.how to treat?
1.IV fluclox ANS
2.IV Penicillin

whooping cough (pertusis)

169. Aidan, a 3 month old boy, presents with paroxysms of

coughing associated with cyanosis, lethargy and poor feeding
for several days. On examination, between episodes of
coughing, he is afebrile and examination is normal. What is
the NEXT step in management?
a) Admission to hospital
b) Nasopharyngeal aspirate and review in 24 hours
c) Immunisation at this visit with DTP and review in 24 hours
d) Erythromycin syrup and review in 24 hours
e) Trial of salbutamol by mask
1050 jm

•Classic whooping cough: Cough and coryza for one

week, followed by a more pronounced cough in spells
or paroxysms
• Vomiting often follows a coughing spasm.
• Infants may develop apnoea and/or cyanosis with
coughing spasms.
•Often, there are no clinical signs. Children are usually well between coughing spasms.
• Fever is uncommon.

1134
consider transfer to tertiary centre for any child under 6 months n older child with complications
of pertussis (apnoea, cyanosis, pneumonia, encephalopathy)
http://www.rch.org.au/clinicalguide/guideline_index/Whooping_Cough_Pertussis/

170. Simon aged 4 months is diagnosed with pertussis. What is the MOST APPROPRIATE management of Simon's
parents?
a) Immediate booster immunisations for pertussis
b) A 10 day course of erythromycin 1135 bcz of close contact pg 1038 jm erythromycin>1 months-qid for 7 days
c) Commence a 3 dose pertussis revaccination schedule
d) Arrange nasopharyngeal swabs
e) Immediate immunisation with pertussis immunoglobulin

indications for Prophylaxis Antibiotics::

Close contact (exposure within 1 metre) with confirmed case of pertussis < 21 days of cough and
< 5 days antibiotics
Children Age <6 months OR <3 doses pertussis vaccine
Adults (regardless of immunisation status) :
last month of pregnancy
Health care worker in maternity hospital or newborn nursery
Childcare worker in close contact with infants <6 months
Household member aged <6 months

171. Indigenous Australian never travelled abroad, developed cough 3 weeks. He has a 3 month old infant, does
not want him to get affected. What should be done now?
Nasopharyngeal PCR
Pertussis serology(ans)
Throat culture
Mycoplasma serology
Tuberculin skin test

Serology becomes positive after 2 weeks and N.P PCR becomes negative after 21 days(reference-racgp)

1135
Consider antibiotics if:
Diagnosed in catarrhal or early paroxysmal phase (may reduce severity)
Cough for less than 14 days (may reduce spread; reduces school exclusion period)
Admitted to hospital
Complications (pneumonia, cyanosis, apnoea)
Antibiotic options:
1136
Neonates
Azithromycin
Children who cannot swallow tablets:
Clarithromycin liquid
Children who can swallow tablets:
Azithromycin
If macrolides are contraindicated:
Trimethoprim-sulphamethoxazole

Exclude from school and presence of others outside the home (especially infants and young
children) until received 5 days of therapy, or coughing for more than 21 days.

172. 3 y with harsh dry cough for 2 weeks what the next step
Nasopharyngeal aspirate
CXR
Seology

Laboratory confirmation is not necessary for diagnosis of pertussis, but

may be helpful for infection control.
A nasopharyngeal aspirate/swab for PCR is the investigation of choice.
The test is usually negative after 21 days, or 5-7 days after effective
antibiotic therapy has been commenced.
Pertussis serology (IgA) may be detectable 2 weeks after the onset of
the illness but rarely affects clinical management.

Croup
(Loud barking cough )

173. child with croup scenario, 38 fever and coryza, harsh cough,
respiratory stridor on rest using collateral muscles
diagnosis:severe croup
Prednisolone oral ( moderate croup (cool humidified air first then oral
predn,if unresponsive IV prednisolone,still not responsive,then give
adrenaline)RCH
IV prednisolone
Humidified oxygen
Nebulized adrenaline
Inhaled steroids

https://www.rch.org.au/clinicalguide/guideline_index/Croup_Laryngotracheobronchitis/

Jm 1070 Croup
viral inflammation of upper airway, larynx, trachea and bronchi(laryngotracheobronchitis)
• Characteristic barking cough with inspiratory stridor
• Children 9 months to 3 years
• worse at night (Usually 11 pm to 2 am)

Tx:
Mild to Moderate Croup
Oral Prednisolone or Dexamethasone
Observe for 30min post steroid administration. Discharge once stridor-free at rest.
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Severe croup (lethargy or Marked Accessory Muscle Use)
Nebulised adrenaline + dexamethasone IM/IV

Supplemental oxygen is not usually required in croup management!!!

MILD MODERATE SEVERE

Behaviour Normal Some/intermittent Increasing irritability and/or lethargy

irritability
Stridor Barking cough Some stridor at rest Stridor present at rest
Stridor only when active or
upset

Respiratory Rate Normal Increased Resp rate Marked increase or decrease

Tracheal Tug Tracheal Tug
Nasal Flaring Nasal Flaring

Accessory Muscle None or minimal Moderate chest wall Marked chest wall retraction
Use retraction
Oxygen No oxygen requirement No oxygen requirement Hypoxemia is a late sign of
significant upper airways
obstruction

174. A child had harsh cough,no fever,running nose stridor. what next inv u will do ?
A-cxr
B-pulse oximetry ANS

The diagnosis of croup is clinical, based on the presence of a barking cough and stridor
investigations (NPA, CXR, blood tests) are NOT usually indicated

Although viral culture of secretions from the nasopharynx or throat is not typically required in most cases of croup,
identification of a specific viral etiology may be necessary to make decisions regarding isolation for patients requiring
hospitalization, for initiation of antiviral therapy (particularly when influenza is a consideration), or for public
health/epidemiologic monitoring purposes.

175. A child came to the emergency with cyanosis and stridor, expiratory wheezy and dyspnoea, what to do next?
A. Intubate dx epiglottitis as there is no cough
B. Oxygen
C. IM adrenalin (severe croup)?
D. Nebulized salbutamol
E.neb adrenaline

176. another moderate croup scenario with 02 saturation 93% asking next appropriate?
1.supplemental 02
2.oral prednisole(ans)
3.iv methylprednisolone
#july

177. moderate croup scenario with 02 saturation 93% asking next appropriate?
1.supplemental 02

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2.oral prednisole
3.iv methylprednisolone

178. 9 month old boy with temp 39,tracheal tug,resp distress.O/E wheeze.whats your dx?
1.RSV bronchiolitis ……if there wasn’t Mycoplasma pneumoniae , Chlamydophila pneumoniae
2.Strep.pneumoniae

Wheezing is more common in pneumonia caused by atypical pneumonia (Mycoplasma

pneumoniae , Chlamydophila pneumoniae ) and viruses

Clues to viral pneumonia in children

Usually children <5 years
Gradual onset
Preceding upper airway symptoms
Non-toxic appearing
Diffuse, bilateral auscultatory findings
Wheezing
May have associated rash (eg, measles,
varicella)

Clues to bacterial pneumonia in

children(most commonly Streptococcus
pneumoniae )
Children of all ages
Abrupt onset
ill-appearance
Chills
Moderate to severe respiratory distress
Focal auscultatory findings
Localized chest pain
WBC count >15,000/microL

1139
179. An 18 months boy is presented with inspiratory stridor and subcostal recession and cyanosis, T:37,6 puffs
sulbutamol given, but didn’t get better, O2 sat is 95%. Which one of the following is the best way to manage his
current problem?
A)IV hydrocortisone
B)nebulised salbutamol
C)inh bromocriptin
D)nebulised adrenaline JM 1070 ANS
E)IV penicillin

In my opinion-
The answer for this question is - Nebulised adrenaline not Nebulised salbutamol.
This is Croup - Inspiratory stridor not Asthma ( Wheezing) and the management of croup is
stepwise
Mild - Observe
Moderate - Oral Dexamethasone - 2 doses usually , If worsen Nebulised adrenaline
Severe - Nebulised Adrenaline + 2 doses of oral Dexa + Oxygen

A nasopharyngeal aspirate/swab for PCR is the investigation of choice. The test is usually negative
after 21 days, or 5-7 days after effective antibiotic therapy has been commenced.
Pertussis serology (IgA) may be detectable 2 weeks

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180. In croup routine management include
a)observation (ans here... Best is steroids)
b)oxygen

1141
c)bronchodilators
d)tracheostomy
e)sedatives
https://www.rch.org.au/clinicalguide/guideline_index/Croup_Laryngotracheobronchitis/

181. A child with moderate croup scenario being managed in ER. What clinical features will suggest severe croup
requiring urgent intervention ?
A) restlessness and not settling down (ans)
B) increased harshness of stridor
C) increased respiratory rate
D) increased fever

182. Severe croup with cyanosis wt is next

100% o2
Adrenaline (ans)

Bronchiolitis
jm pg 1071
kaplan pg 77

183. Baby with 2 wk harsh cough , fever , runny nose with dyspnea, how to dx ?
nasopharyngeal aspiration
B) Serology

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C) CXR
D) pulmonary function test
D/D Petussis(paroxysmal cough) ,croup (stridor, chest retraction),bronchiolitis (wheezy
breath,coryza)

Chest radiographs are not necessary in the routine evaluation of bronchiolitis. However, in infants
and young children with moderate or severe respiratory distress (eg, nasal flaring, retractions,
grunting, respiratory rate >70 breaths per minute, dyspnea, or cyanosis), radiographs usually are
indicated, particularly if there are focal findings on examination, the infant has a cardiac murmur,
or it is necessary to exclude alternate diagnoses

184. .A 6 month old infant presents with lethargy, poor feeding, No fever, tachypnoea ( this is a long stem forgot
other infos). What is the next investigation?
a. ABG
b. electrolytes
c. chest xray

bronchiolitis the commonest cause of acute LRTI in children under 12 mo.

in bronchiolitis CXR is NOT routinely required unless diagnostic uncertainty eg localised signs on
auscultation, cardiac murmur with signs of congestive cardiac failure.

185. .A woman came with her 9 month old baby having dyspnia , can’t feed , his chest is hyperinflated and there
are inspiratory and expiratory wheezes, wts the next best step ?
a. Nebulised adrenaline — its not croup
b. IV steroid
c. Oral cefriaxone
d. 100% O2 via facemask
e. 100% O2 via nasal catheter — bronchiolitis JM 1071

The radiographic abnormalities of bronchiolitis:

1) Hyper-inflation of the lungs with flattening of the diaphragms
2) Bilateral peribronchial infiltrations with air bronchograms
3) Patchy atelectasis, in particular of the right middle lobe

186. A child that goes to day care presents with a dry cough. Investigation:
A. Nasopharyngeal aspirate 1143 persistant dry cough= r/o of pertussis JM 1037 ANS
B. Sputum culture
C. Chest xray

1143
187. which of the following characteristic chest x-ray appearing neonatal RDS?
1) air bronchograms ANS
2) fluid in fissure
3) patchy infiltrate
4) concentrated atelectasis
5) enlarge heart

Respiratory distress syndrome (RDS), or hyaline membrane disease, is a common problem in

preterm newborn infants -> deficiency of pulmonary surfactant in an immature lung
RDS presents within the first minutes or hours of birth with signs of respiratory distress, such as
tachypnea, nasal flaring, expiratory grunting, intercostal, subcostal and subxiphoid retractions,
and cyanosis. Additional findings may include decreased ausculatory breath sounds, pallor, and
diminished perfusion.
The diagnosis of RDS is based on clinical findings of a premature infant with onset of progressive
respiratory failure shortly after birth and a characteristic chest radiograph, which demonstrates
low lung volume and diffuse reticulogranular ground-glass appearance with air bronchograms

resp distress syndrome (page 9 kaplan)

hb q 2.127
page 558 hb 3.253

188. Newborn with hyaline membrane disease condition, was on oxygen, now place in the chamber
and needed to provide more oxygen, and breathing is laboured with rate increasing. What is the most likely
diagnosis?
a. Peumothorax
b. Severe respitaory infection
c. Cyanotic congenital heart disease

Typically RDS progresses over the first

48 to 72 hours of life with increased
respiratory distress and begins to
resolve after 72 hours
The use of exogenous surfactant and/or
CPAP (continuous positive airway
pressure) dramatically improves
pulmonary function and shortens the clinical course
Pulmonary air leaks are common acute complications of RDS due to the rupture of an
overdistended alveolus, and may occur spontaneously or arise from CPAP and resulting in a
pneumomediastinum, or pneumothorax

1144
189. you see a neonate with hyaline membrane disease. The baby experienced dspnea after birth. O2
requirement increased from 40% to 85% during the last few hours. Nothing was mentioned about cyanosis.
What would be the dx?
a. cynotic heart disease
b. pneumothorax (ans?)
c. hyperviscosity syndrome

190. Neonate with hyaline membrane disease. Dyspnoea after birth, O2 requirement increased from 40% to 85%
during last hours. Nothing said about cyanosis.
a.cyanotic heart disease
b.pneumothorax
c. hyperviscocity syndrome

191. hyaline membrane disease with pneumothorax, pneumothorax 25 percent pt stable with no sx just reduced
air entery
a) Admit and observe
b) drain insertion
c) come with cxr next day

a. Infants without a continuous air leak or respiratory distress and who have no underlying
lung disease or have no need for assisted ventilation ……….close observing without specific
treatment
b. symptomatic pneumothorax in infant without mechanical ventilation …….Thoracentesis
c. pneumothorax that develops in a mechanically ventilated infant…. Chest tube
d. Tension pneumothorax….. Chest tube

192. Child 4yr with 2 day prodromal then harsh cough fever 39 nasal flaring, tracheal tug, intercostal recession o2
sat 80% treatment
a)nebulized salbutamol,
b)nebulized bedosinuoed
c),im adrenaline croup
d), iv benzyl penicillin...
e)iv fluxaacillin

Dx moderate croup jm1070

193. Pertussis infection of child, have a sis of 24 mnth fully vaccinated and all the members of the family treated
with erythromycin, wats next best option?
Reassurance
194. 4 year old child presents with fever and 12hrs history of stridor and harsh cough. How will you treat him?
a) Nebulise adrenaline
b) IV antibiotic
c) Nebulise salbutamol
d) Nebulise corticosteroid moderate croup

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 e) Oxygen

195. . 7-month-old infant came because of poor weight gain despite large food intake. He has had two episodes
of pneumonia and has frequent bulky stools. He coughs frequently. Which of the following is the most likely
cause of this infant's disorder?
A. Autoimmune disorder
b. Inability to synthesize apolipoprotein
c. villous atropy of jejnum

1146
cystic fibrosis page 160 jm kaplan 81 (ans)

features:
failure to thrive + chronic cough +loose bowel actions =cystic fibrosis

imp definitive test for cystic fibrosis

serum electrolytes /measurement of sweat chloride

cause of infertility in males n females..

early diagnosis n multidisciplinary team care are imp
physiotherapy fir airways secretion drainage

Asthma
196. A 5 years old boy with cough from 12 months before, was on salbutamole n also tkn oral prednisolone.. he
has an eczema history, both parents are smokers,( typical asthma scenario) which one is the best medication for
prevention which is used in “INHALATION MODE”?
a. monteleucast
b. Chromoglycate
c. Salbutamol
d.Fluticasone
e. Salmetrol

indications for preventer in 1-2y:

Persistent asthma
Multiple-trigger wheeze
inhaled sodium cromoglycate (SCG)
if wheezing symptoms are disrupting child’s sleeping or play : inhaled corticosteroids

197. *********3 year old child came with asthma attack every month for last 12 mo, he takes inhaled
salbutamol. What to use for prevention
a. Inhaled salbutamol
b. Inhaled fluticasone
c. Inhaled salbutamol/fluticasone
d. SCG
e. best is montelukast

Indications for Preventer in 2-5y:

Frequent intermittent asthma
Mild persistent asthma
Episodic (viral) wheeze with frequent symptoms
Multiple-trigger wheeze

oral montelukast……If doesnt respond: low dose inhaled corticosteroid

198. A 2year old child presents with paroxysms of severe cough.o/e u find nasal flaring and intercostal depression
on inspiration and expanded chest.on auscultation u find bilateral wheezing.most likely diagnosis?
a)mycoplasma pneumonia
b)viral croup
c)bronchial asthma 1147 no fever no prodormal symptoms
the cough will last for next four weeks

1147
199. child with asthma attack on the way to hospital he was given 6 puff of salbutamol with spacer but still in
distress and has wheeze
a. Add salmetrol
b. IV amynophiline
c. 12 further Salbutamol >6yrs child
d. Atrovent- ipratropium nebuliztion
e. oral prednisolone
f. Hydrocortisone iv

200. child with history of eczema and asthma asking prevention

therapy. Both parent smoke cigarette and history of hay fever in
mother
a. cromolyn <2 yrs
b. budesonide
c. fluticasone

Resp topics
Pneumonia
Meconium aspiration syndrome
Laryngomalcia
Pharyngitis
Tonsillitis
Influenza virus

201. old man with long time hx of chronic prouductive cough about 1cup of yellow green sputum now develop
lower love pneumonia what rx to give
a.oral rothoxi
B.oral augmentin
C.iv ampicillin
D.iv fluoxacillin
E.iv ticarciline-tzaobactam

202. a child with fever and cough , how could you definitely diagnose influenza?
a. chest x-ray
b. FBE

1148
 c. nasopharyngeal sampling and throat swab
d. CT

203. An infant presents with a typical crowing noise on inspiration. The noise is more noticeable on crying. There
is no cough. WOF is the Dx
a) Croup
b) Laryngomalacia
c) Bronchiolitis

** Crowing, causes of
Congenital laryngeal stridor Crowing may be the first sign of congenital epiglottic and
superglottic deformity or flabbiness–laryngomalacia and tracheomalacia with collapse and
partial inspiratory airway obstruction, a condition more common in ; during the
paroxysms, the children are hoarse, aphonic, dyspneic, have inspiratory muscle retractions
and if prolonged, fail to thrive
Double aortic arch

204. infant pale, fever, grunting tachypnea, on auscultation clear chest! Dx?
a. Pneumonia
b. Epiglotitis
c. Croup
d. Bronchiolitis
pneumonia is highly probable in a child with fever, tachypnea, cough, and infiltrate(s) on chest radiograph

205. 9 moth child with grunting respiration, temperature 39.2''c. lung clear. organism?
a. RSV b. strep pneumonie

206. 9 month boy admitted to hospital with respiratory distress. his temperature is 39''c. after admission he was
given i/v fluid and o2. wt the organism responsible?
a. RSV b. streptococcus pneumonie

207. 9 month child with fever 39.4, auscutation normal. xray infiltrates, grunting child cause?
pneumococcal
respiratory syncytial dx viral pneumonia ??

children with bacterial pneumonia may be more ill-appearing (eg, higher fever)
The presence of infiltrates on chest radiograph confirms the diagnosis of pneumonia in children
with compatible clinical findings

Airspace consolidation with air bronchograms in the right lower zone, clearly shown in the right
middle lobe on the lateral projection.

1149
208. A 9 month old with fever, dry cough, breathlessness, grunting, wheezes. Admitted, oxygen and IV fluids
given. What is your next step?
a. steroids
b. nebulised adrenaline
c. antibiotics
d. observation dx bronchiolitis

It can be difficult to distinguish bacterial pneumonia from bronchiolitis in young children because the
symptoms and signs of both conditions are nonspecific and cannot be reliably differentiated:
children with bacterial pneumonia may be more ill-appearing (eg, higher fever)
Wheezing is more common in pneumonia caused by viruses and atypical pneumonia

Bronchiolitis is a viral lower respiratory tract infection, generally affecting children under 12m
Bronchiolitis is diagnosed clinically with a viral upper respiratory prodrome followed by increased
respiratory effort (eg, tachypnea, nasal flaring, chest retractions) and wheezing and/or rales in children
younger than two years of age

Management
Mild: at home
Moderate:
Admission (respiratory distress or poor feeding)
Observation: colour, pulse, respiration, pulse oximetry
Oxygen: by nasal prongs to maintain Po2 above 90%(preferably >93%)
Fluids preferably IV or by NG tube if
Severe: Consider transfer to tertiary centre with HDU/ICU capabilities, as child may need CPAP or
ventilation

Jm 915 In bronchiolitis:
CX-ray, Nasopharyngeal aspirate and ABG should not be used for diagnosis (Hyperinflation of lungs)
Antibiotics, nebulised adrenaline, bronchodilators or corticosteroids not indicated

209. Mom worries as there is meningitis outbreak in bulletins presents with child with low grade fever, reddened
throat and red tympan memberane no vomiting no neck stiffness what should be done?
confirm viral illness by rapid test with throat swab
perform LP
give amoxi
**, rapid tests are tests take 20-30 minutes to give results

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210. 4 y child with fever 39 nasal flaring ,tracheal tug ,scenario
telling dullness in the lung bases
Im adrenaline
Nebulized salbutamol
Iv pencillin moderate pneumonia
Iv flucolacillin

211. a grand mother came to you asking about vaccination as

her grand son has born?
A) dtpa
B)mmr

212. children with runny nose from 2 days and many children in
his class absent because of infection with influenza what will
you do?
a…confirm influenza infection
b..give oseltamivir
c..give influenza vaccine
d..exclusion from school for 7 days

213. Case of severe pneumonia in child asking next

investigation? A) FBC 😎 blood culture c) chest xray

214. Primigravida gave birth at term to 3200g baby,normal vaginal delivery without any complications and there
was slight meconium staining of liquor.Baby was normal at birth with normal heart rate.After 1 minute, suddenly
stopped breathing.HR decreased.Cyanosed.Noresponse on stimulation.What is the most appropriate next step?
A-Intubate
B-Bag and mask ventilation.(ans) mcq 3.254 hb page 322
C-Nasopharyngeal aspiration of meconium

215. PNEUMONIA abd pain,fever x ray given one

lobe opacity
Penicillin
Azithro
Doxycycline

216. case of pneumonia in child with xray showing

pleural effusion asking wat to do next
a) blood culture
b) pleural aspirate

217. Bronchiectasis scenario with superimposed

pneumonia. Treatment?
a. Oral Roxithromycin
b. Iv Ampicillin
c. Oral Augmentin
d. IV Ticercillin Clavulanate

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218. Scenario of child presented with GI symptoms, vomiting, abdominal pain, CXR Pneumonia Picture, asking
what next Ix
a. Pneumococcus PCR a
b. Blood culture (ans)

219. adult girl with bilateral pneumonia , O2 saturation 85% , alert .. how to give oxygen ?
A) nasal 100 % O2 2L
B) Ventuse
C) Cpap
D) intubation , ppv
MILD Moderate Severe
severe:

Behaviour Normal Some/intermittent Increasing irritability

irritability and/or lethargy
Fatigue

Respiratory Normal Increased Resp rate Marked increase or

Rate Tracheal Tug decrease
Nasal Flaring Tracheal Tug
Nasal Flaring

Accessory
220. the mostNone or minimal
common Moderate
long term chestof
complication wall Marked
streptococus chest wall
pneumonia meningitis
Muscle Use palsy
a) cerebral retraction retraction
b) deafness untreated otitis media can lead to meningitis and deafness
Feeding
c) epilepsy Normal May have difficulty with Reluctant or unable to
feeding or reduced feed
221. One year old boy has repeatedly
feedingrespiratory infections,he was brought to de GP cos of ear discharge,last
month he had swollen tonsils
*diagnosis?
Oxygen No oxygen Mild hypoxemia corrected Hypoxemia, may not be
A- sinositis requirement by oxygen (Sa02 90 - corrected by oxygen
B-tonsilitis
(Sa02 > 93%) 93%)
C-Pneumonia (Sa02 < 90%)
D immune deficiency
Apnoeic None May have brief apnoeas May have increasingly
Chronic
episodesgranulomatous disease: cgd frequent or prolonged
Lack of nadphè dec oxygen
sopecies. From fAbstep 1 apnoeas

222. A male maybe 50 years with H/O

renal transplant for 10 years. has fever,
headache, neck stiffness n rigidity. CXR
explained in q as round opacity on
middle lobe. Dx? (contro)
a. TB
b. aspergillosis
c. lymphoma
d. pneumocystis pneumonia
Jm 309
If short history then aspergillosis

1152
223. #RESP36. A 4 years old child with fever 39.5, grunting respiration and dyspnoea, vaccination up-to-date.
What’s the possible organism?
Streptococcal pneumonia
Meningococcal pneumonia
Mycoplasma pneumonia

224. Pt from Iraq. Dry cough.no fever or haemoptysis history. You notice pan-systolic murmur on apex. Chest x-
ray given
A) TB. —- if lungs involve
B)Mycoplasma pneumonia ??
C) rheumatic fever—- if cardiomegaly
D) Ca Bronchus

***depends on xray

225. Moderate pneumonia treatment asked :

a. iv pencillin
b. oral roxithromycin
c. oral amoxicillin-colvanic
d. iv flucoxacillin

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**need to see whole scenario… age and symptoms

226. Child 1 year with severe pneumonia 3 days irritability stop feeding cough . TTT
1 oral Amoxicillin
2 oral cephalexin
3 Iv penicillin g
4 iv ceftriaxone
5 Iv flucloxacilline

227. 45 years woman previous on carbamazepine ,thyroidectomy done and now presents with swelling and
soreness of pharynx,dx
a) viral pharyngitis **unnecessary history
B)thyrotoxisis
C)tonsillitis

228. Which is important in dd between

viral and microbial pharyngitis?
A.lymph node (ans)
B.erythem
C.exuda..

229. Child treated for tonsillitis still has

3cm lump under mandible angle.
Painless. No lymphendopathy, no fever,
otherwise well.
a) Aspirate biopsy
b) Ultrasound
c) EBV serology
d) CT head and neck
e) Review in 1 week dx reactive lymph node enlargement

230. 4 year old child presents with 3cm mass closer to angle of mandible (unilateral). Child was
treated of tonsillitis 1 month ago. What’s next best?
a) Give first dose of antibiotics (exact words) b) review in one week c) needle
aspiration

231. . i got the viral tonsillitis but a bit different asking what is associated with it
. laryngitis
.exudates
.low grade fever
c?
http://www.abc.net.au/health/library/stories/2012/03/19/3419559.htmDi

232. a case of acute tonsillitis with swollen and red tonsil and uvula shifted to left.1 hr after giving penicillin inj
the pt develop sevre stridor with hoarseness.next?
1.endotraceal intubation
2.im adrenalin
3.02 by mask
4.drianage of peritonsillar abcess

** here there is no feature of hypoxia... stridor due to laryngeal edema. this anaphylactic reaction
can easily b mnged by I'm adrenaline

233. a case of acute tonsillitis with swollen and red tonsil and uvula shifted to left.1 hr after giving penicillin inj
the pt develop sevre stridor with hoarseness.next?

1154
1.endotraceal intubation
2.im adrenalin
3.02 by mask
4.drianage of peritonsillar abcess
https://www.rch.org.au/clinicalguide/guideline_index/Anaphylaxis/

234. 3 yr indigenous child with profuse yellow colour ear discharge , nasal yellow greenish discharge , inflamed
tympanic membrane , enlarged inflamed tonsils what is the next step ?
A) Soframycin ear drops
B) oral amoxicillin
C) Ear toilet
D) oral steroid
E) Oral Amoxicillin-Clavulinic acid

** Tympanic membrane perforation AOM with TM perforation is common and results in otorrhoea
and frequently, relief of pain. TM perforation does not alter AOM management (see flowchart).

1155
#PAEDS

235. which of the following make viral tonsillitis more likely :

a. exudates on tonsils
b. low grade fever
3.lymphadenopathy
4.laryngitis

People with tonsillitis often have:

• a sore throat and neck
• pain when they swallow
• drooling in children
• fever (a body temperature which is over 37.5ºC for adults
and over 38ºC in children)
• a loss of appetite, and feel generally ‘unwell’
• red and swollen tonsils (with pus)
• swollen and tender lymph nodes (glands) at either side
of the neck
• a change in the sound of their voice (such as sounding
‘hoarse’ or muffled).
Children may complain of tummy pain without having a sore
throat, and they may vomit. Young children may just have a fever

236. 4 year old child presents with 3cm mass closer to angle of mandible (unilateral). Child was

1156
treated of tonsillitis 1 month ago. What’s next best?
a) Give first dose of antibiotics (exact words)
b) review in one week
c) needle
aspiration

237. Which one of condition should we avoid bag and mask ventilation in neonate?
A oesophageal atresia
B Diaphragmatic hernia
C neonatal intestinal obstruction
D congenital lobar emphysema

RHEUMATOLOGY
(adult+peads)
1. 50 years old man who suffers from rheumatoid arthritis and who
has been treated with prednisolone for 3 years developed
peripheral neuropathy of the lower extremities. This neuropathy
is most likely due to
A. arsenic poisoning
B. thiamine deficiency

1157
 C. development of necrotising arteritis
D. ruptured intervertebral disc
E. vitamin B12 deficiency

2. A child presents to ur surgery with c/o joint pains.u find out that he also suffers from iron
deficiency anemia.what could be the most appropriate diagnosis?
a)juvenile rheumatoid arthritis anaemia of chronic disease
b)HSP
c)haemophilia
d)thrombocytopenia

3. 18month old baby with limp . Anti Ana antibodies 1:160 titres something improved with NSAIDs
.
1.juvenile rheumatoid arthritis ,
2.osgood
3.ankylosing spondylitis
4.SLE
Immune dysfunction in JIA is evident with the presence of autoantibodies, such as antinuclear
antibodies (ANAs)—present in 40% of patients—and rheumatoid factor (RF)—present in 5% to
10% of patients.
The child who has mildly painful and insidious claudication at the beginning of the walking, at around two
years of age, may be manifesting the early symptoms of the periarticular form of JRA. This form, which is
also the most common, is most prevalent in girls, at a ratio of
4:1. The most frequently affected joints are the knees and
ankles, and it is accompanied by swelling, local warmth, and a
decreased range of joint movements.
Laboratory tests such as WBC count, ESR, rheumatoid
factor, and ANA (antinuclear antibody) may be normal
during the initial clinical evaluation in up to 50% of
cases, which should not rule out its diagnosis (16).
The clinical picture is usually intermittent, improving with
rest, analgesics, and restriction of activity.

4. A couple came to you for pre pregnancy advice. Man has rheumatoid arthritis and pain is now
controlled with methotrexate and hydroxychloquine. Asks you advice regarding dug
continuation.

1158
 a. Stop both
b. Continue hydroxy and stop methotrexate
c. Stop hydroxychl and continue methotrexate
d. Continue both
e. Stop both and change to infliximab
https://www.nps.org.au/australian-prescriber/articles/managing-the-drug-treatment-of-rheumatoid-
arthritis

5. Treatment of choice for rheumatoid arthritis?

A. Infliximab
B. sulfasalazine
C. methotrxate
D. hydroxyurea

6. Picture of necrosis on 3 fingers, patient with rheumatoid arthritis, non smoker, can't remember
the rest of the description, but asks for diagnosis
A ana…if ra diagnosed to exclude other autoimmune
disease
B ena
C anti ssa
D anti citrulline (Anti-CCP)…if ra not diagnoses

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2950222/

7. Aboroginal female bring her husband with small joint pain with signs and symptoms of
Rheumatoid Arthritis. What will be the treatment for him ?
a. Aspirin
b. Amoxycillin
c. Paracetamol
d. Hydrochloroquine
https://www.webmd.com/rheumatoid-arthritis/features/getting-a-grip-on-rheumatoid-arthritis-pain

The gold standard DMARD is methotrexate. If methotrexate doesn’t work, doctors may try another DMARD,
such as leflunomide (Arava), hydroxychloroquine (Plaquenil), or sulfasalazine (Azulfidine).

8. A patient with rheumatoid arthritis got a flare up and doctor wants to administer azathioprine.
which screening test should be done before starting
this drug?
a) Tb Gold test …for infliximab
b) Thiopurine methyltransferase
C. Anti Acetylcholine inhibitors
D. Complements assay.
E. Anti gliadin IgA

9. Well controlled Rheumatoid arthritis with indomethacin presents with knee swelling
tenderness.After arthrocentesis what is the next
See for uric acid crystals in microscopy
Increase the dose of indomethacin

1159
 Blood culture
**this could be case of pseudogout or gout Diagnosis
• Synovial fluid aspirate → typical uric acid crystals using compensated polarised microscopy; this should be
tried first (if possible) as it is the only real diagnostic feature
• Elevated serum uric acid (up to 30% can be within normal limits with a true acute attack)19
• X-ray: punched out erosions at joint margins
jm treatment 379

10. A 32 year old woman presented with bilateral joint swellings of her proximal interphalangeal
joints associated with a 45 minutes period of early morning stiffness of joints. She has obvious
rheumatoid nodules and a high rheumatoid factor assay. Which of the following is the best
treatment of choice.
a. infliximab
b. sulfasalazine
c. methotrexate
d. prednisolone
e. Hydroxyurea

11. A 32 year old woman presented with bilateral joint swellings of her proximal interphalangeal
joints associated with a 45 minutes period of early morning stiffness of joints. She has obvious
rheumatoid nodules and a high rheumatoid factor assay.She got raynoud phenomenon treated
with nifedipine. Rhematoid positive, ds DNA positive but negative CCP. Which of the following
is the best long term management?
a. infliximab
b. sulfasalazine
c. methotrexate
d. prednisolone
e. Hydroxychloroquine
SLE, because CCP is specific for RA and it is negative. DsDNA is specific for SLE (Rx: 1st NSAID 2nd
hydroxychloroquine and for severe steroids)

12. Anemia in chronic rheumatoid arthritis patient

a. iron
b. erythropoitin

13. Lady with rheumatoid arthritis and something else. Labs: Normal ferritin, low total iron
binding capacity, low transferrin, low hemoglobin
A- Iron Infusion
B- Low dose prednisolone
C- Erythropoietin

14. Young boy developed pain in the right knee .. mild progressive marked swelling .. no other
systemic symptoms as I recall Blood results given .. anemia .. low platelets .. normal
WBCs What is your diagnosis
Juvenile rheumatoid arthritis but need to be at least 6 wks(by exclusion)
Acute leukemia
Apalstic anemia
SLE

** Patients with acute lymphocytic leukemia can present with joint pain and arthritis. Expansion
of lymphoblasts in bone metaphases results in pain, which is typically severe and may awaken
the child from sleep. Thrombocytopenia is rare in children with JIA; its presence suggests the
possibility of leukemia. Lymphocytosis is also uncharacteristic of JIA and likewise raises the
possibility of leukemia, particularly when neutropenia is present.

1160
https://amp.cancer.org/cancer/leukemia-in-children/detection-diagnosis-staging/signs-and-
symptoms.html

15. Which of the following is not considered an extra-articulate manifestations of Rheumatoid

Arthritis?
a) osteoporosis
b) Peripheral neuropathy
c) Cutaneous nodules
d) Pericardial effusions
e) Hepatomegaly
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3152850/#!po=15.6250

16. Sle with rash DSDNa and ANA positive Which drug to give
Methotrexate
Cyclophosphamide but Hydroxychloroquine is 1st choice
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3053574/
https://www.racgp.org.au/afp/2013/october/systemic-lupus-erythmatosus

1161
https://www.racgp.org.au/afp/2013/october/systemic-lupus-erythmatosus//

The overall aim of therapy is to control disease activity. Mild activity can be managed with non-
steroidal anti-inflammatory drugs (NSAIDs) or low-dose steroids, but more severe
manifestations require prompt treatment with moderate-to-high doses of steroids to minimize
organ damage. Steroid-sparing immunosuppressive medications should be considered early to
prevent steroid-related morbidities.
Hydroxychloroquine is an effective treatment in SLE, especially for arthritis and rash. Furthermore,
it has a protective effect in reducing damage accrual in the long term and confers a survival
benefit in SLE patients. Hydroxychloroquine is well tolerated and, when dosed appropriately,
ocular toxicity is very rare.27
A range of immunosuppressive medications has been used as a steroid-sparing agent in SLE,
such as cyclophosphamide and mycophenolate for lupus nephritis, although azathioprine and
methotrexate are used commonly. Belimumab, which is a human monoclonal antibody that
inhibits the activation of B-cells by interfering with a protein necessary for B-cell activity, has
recently been approved by the Australian
Therapeutic Goods Administration for
treatment of moderately severe SLE.28 This
therapy is currently not easily accessed, as it
has not been listed on the Pharmaceutical
Benefits Scheme.

17. Sle scenario asked Tx-

anti platelet & immunosuppressive

1162
 (Anticardiolipin Ab)
anticoagulant & immunosuppressive (APTT prolonged)
https://www.racgp.org.au/download/Documents/AFP/2013/Oct/201310apostolopoulos.pdf

18. Which is not criteria for juvenile rheumatoid arthritis?

Arthritis
Iridocyclitis
Positive Rf
Unexplained fever for few days
Splenomegaly

Interpreting investigations of adolescents with musculoskeletal complaints can be confusing.

Normal findings on investigations, such as rheumatoid–factor negative results or a normal plain
X-ray, do not exclude potentially significant arthritis. Conversely, isolated positive results,
particularly positive antinuclear antibodies or HLA-B27, are not necessarily diagnostic.18
Selection and interpretation of appropriate
tests will depend on the clinical history and
examination; a general guide to investigations
in the primary care setting is outlined in Table
2. Imaging modalities, such as plain
radiography, ultrasonography, computed
tomography, nuclear medicine and magnetic
resonance imaging, can play an important part
in the diagnosis and management; however,
careful selection and interpretation are
required. Discussion with a rheumatologist
may assist in the appropriate selection of
imaging approaches

1163
19. A pt. with Ankylosing
.Sp0ndylosis,treatment after analgesic
s,Trt?
anti tnf for axial as

https://www.racgp.org.au/afp/2013/november/ankylosing-spondylitis/

20. bamboo spine. Pic pt on paracetamol+ physiotherapy for ….long time but not getting better
.what will next step Mx?
A.physio
B.mtx
C.sulfasalazine
D.steroids
E.infilixamb

1164
 https://www.hopkinsarthritis.org/arthritis-info/ankylosing-spondylitis/

21. 85 old male pain and tender joints with effusion and no fever cause asked?
RA
OA
Reactive arthritis-there should be respiratory infection

Ø Eye changes in rheumatoid arthritis? Uveitis or scleritis

**in RA its scleritis and JIA in uveitis

22. Pt with ankle swelling, afebrile, stiffness for an hour relieved by walk ,xray show
periarticular osteopenia and narrow space, other
foot joint is normal
A-osteomylitis
B-rheumatoid arthritis
C-sle
D-septic arthritis

23. Elderly lady with X ray of hand.Case of

rheumatoid arthritis.Most diagnostic test.
RF
Anti CCP
ANCA
ANA

24. A patient with rheumatoid arthritis got a flare

up and doctor wants to administer azathioprine.
which screening test should be done before
starting this drug?

1165
 a) Tb Gold test
b) Thiopurine methyltransferas

25. Pt 65 with acute knee n ankle swelling ,intense pain tenderness n joint fluid What is dx
A)Reactive arthritis
Pseudo-gout
Gout
Rheumatoid arthritis

Given the absence of systemic symptoms or signs, Sam is unlikely to have septic arthritis
(although it must still be excluded). The distribution of arthritis is similar for both gout and
pseudogout. Both can be precipitated by trauma, medical illness or surgery. However, gout
classically affects the first metatarsophalangeal joint and the joints of the feet and hands, while
pseudogout is more likely to affect the larger joints (knee, wrist or
shoulder).https://www.racgp.org.au/afpbackissues/2008/200812/200812burnet.pdf
The final diagnosis must be fluid inspection

26. An old lady with osteoarthritis,c/o painful red knee joint with knee effusion,Cause?
pseudogout
OA
Gout..i went for 1st
A?#rheuma

27. 57 years old woman, suffering from chronic rheumatoid arthritis, recently develop
hypertension came for the treatment? She describe past history of asthma and pyelonephritic
syndrome.
a.) Amilodipine
b.) Ramipril
c.) Lorsatan
d.) metoprolol

**1 Arthritis patients take NSAID. NSAID causes sodium retention, so NSAID reduces the
Antihypertensives action of ACE inhibitors. 2. ACE inhibitors causes renal efferent arteriolar
dilatation. so reduces GFR. Again, NSAID blocks prostaglandin synthesis. Prostaglandin
causes vasodilation of renal afferent arterioles. So, NSAID causes afferent arteriolar
vasoconstriction. So again decrease GFR. So NSAID+ACEi or ARB causes acute renal failure.
Amlodipine has no such inter action..

1166
28. management of SLE long term :
a) immunosuppressive plus anti coags
b) immunosuppressive plus anti platelets
c) immunosuppressive plus antibiotics
d) anti coags plus anti platelets
#rheuma

29. rash on face &hand.pain in both hands . RF =14 (normal less than 14 ) , ANA =1/574 (
normal less than 7, ) rest of labs were all normal what will you find in xray on hands ? contro
a. chondrocalcinosis
b. periarticular erosions
c.punched out markings
d. periarticular osteopenia
#ortho #rheuma

** The normal range of ANA blood test varies from laboratory to laboratory. However, a test
result ranging between 1:40 - 1:60 is considered to be negative and is not a cause of concern.
Usually doctors get highly concerned if the ANA test results are more than 1:80.

* Sle .>>>> non erosions

Ra.>>>>osteopenia
Gout>>>>punched out markings, periarticular erosion
Pseudogout >>>>>chondrocalcinosis
O.a.>>>>osteophytes and osteosclerosis

30. A boy with joint pains. ANA +ve (can’t remember the no) RF –ve. What’s the long term
complications?
• Cardiomyopathy
• Uveitis
• Small bowel ulceration #rheuma

31. A case of Rheumatoid arthritis with complain of sudden pain for last 2 days.The fingers
turned black.Which investigation will lead to diagnosis?
Anti cardiolipin antibody
Anti nuclear antibody
Anti dsDNA
Anti topoisomerase

** RA + RV(black fingers) = best ANCA or ANA

RA + Antiphospholipid Synd (clots) = Anticardiolipin.

ANA, ÀNTI CCP, ANCA

1167
32. #Educational a)Pregnancy with rheumatoid
arthritis ...How to treat the patient?
b) Also what if the patient with RA trying to
conceive ?
Answers are present in the following slide..

33. A 35 year old man acutely complained of

Right knee pain and swelling right after playing
golf. Arthrocentesis done revealing 25 mL of
brown pigmented fluid aspirated. What is the
diagnosis?
A. Rheumatoid arthritis
B. Gout
C. Osteoarthritis
D. Pigmented villonodular synovitis
E. Hemochromatosis Achondrosis

https://orthoinfo.aaos.org/en/diseases--conditions/pigmented-villonodular-synovitis

34. Which one of the following causes of lung fibrosis predominately affect the upper zones?
A - Bleomycin
B - Rheumatoid arthritis
C - Cryptogenic fibrosis alveolitis
D - Methotrexate
E - Extrinsic allergic alveolitis

https://radiopaedia.org/articles/upper-lobe-pulmonary-fibrosistrace

Causes of lung fibrosis

Upper lobe fibrosis "BREAST X"

1168
 B: bronchopulmonary aspergillosis
R: radiotherapy
E: extrinsic allergic alveolitis
A: ankylosing spondylitis
S: sarcoidosis
T: tuberculosis
X: histiocytosis X

Lower lobe fibrosis "CRABSS"

C: cryptogenic fibrosing alveolitis

R: rheumatoid arthritis
A: asbestosis
B: bleomycin
S: SLE
S: scleroderma

35. #april2016 .rheumatoid arthritis,sudden pain in elbow next inv.

Xray,
s urate
XRAY TO see erosion which comes late

36. #RHEUM #PHARMA first line treatment for newly diagnosed rheumatoid arthritis,
methotrexate plus paracetamol OR methotrexate plus short course of steroids?

"The choice depends on several factors, but is best left to the specialist coordinating care. In most
patients with recently diagnosed RA, methotrexate is the cornerstone of management and
should be commenced
as early as possible.
Initial dose: methotrexate 5-ro mg (o) weekly,increasing to maximum of 25 mg weekly (o) SC or IM
depending on clinical response and toxicity.
Add folic acid 5 mg twice weeldy.
Biological DMARDs (bDMARDs) are the newer agents which should be considered if remission is
not achieved with appropriate methotrexate monotherapy, 'triple therapy' or other combinations.
All bDMARDs are more effective when combined
with methotrexate." JM 5th ed 343

37. one was confirmation of rheumatoid arthritis...

a. rh factor
b. antinuclear factor
c. intra articular effusion

Anti-cyclic citrullinated peptide (Anti-CCP) – Diagnostic of RA with 97 specificity

Rheumatoid factor – positive in ~80% of RA patients
BEST is Anti-CCP but here A
Anti-CCP antibodies is a relatively new test that has a similar sensitivity but higher specificity for RA than
RhF.

38. Picture of hand given tip of all fingers were amputated

History of pain and color change present. Especially during winter. No history of smoking.
Asked
Cause..?
A. Rheumatoid arthritis
B. SLE

1169
 C. Scleroderma
D. Berguer’s disease

39. Young boy developed pain in the right knee .. mild progressive marked swelling .. no other
systemic symptoms as I recall
Blood results given .. anemia .. low platelets .. normal WBCs
What is your diagnosis
Juvenile rheumatoid arthritis
Acute leukemia
Apalstic anemia
SLE

40. A man with rheumatoid arthritis and htn is on thiazide,enalapril,chloroquine,and diclofenac

is feeling lethargic,short of breath since a few months ago.He looks pale and his pulse is 80
bpm.Lab values were given.Haemoglobin was low,MCV was marginally low, leukocytes low
,platelets low.Cause?
a) Chloroquine
b) Thiazide
c) Enalapril
d) Diclofenac from mina note

41. pt on multi drugs for htn and diabetes included a thiazide...present with sudden onset
knee/elbow pain...old case of OA or RA ....swelling and redness but fever normal, range of
movements tender but otherwise normal..
what inv to do
1.FBC with ESR
2. URATE cz thiazide causes hyperurecemia
3.X RAY
#rheuma

42. Scenario of rheumatoid arthritis with all investigation + anti ccp ask best long term treatment
1.azathioprine
2.methotrexate
3.hydroxchloroquine
Nov#

43. male patient with RA on methotrexate and hydroxychloroquine, planing to start a family, how to
manage:
a. stop methotrexate and continue hydroxychloroquine
b. stop hydroxychloroquine and continue methotrexate
c. stop both
d. shift to leflonamide

44. 57 years old woman, suffering from chronic rheumatoid arthritis, recently develop hypertension
came for the treatment? She describe past history of asthma and pylonephritic syndrome.
a.) Amilodipine
b.) Ramipril
c.) Lorsatan
d.) Metopropanol

1170
45. A patient who has rheumatoid arthritis had history of DVT. She has been a regular patient with clots
forming at many places in her body. Now he came with black fingers .
what is the investigation to find the underlying cause?
A- ANCA
B- Anticardiolipin
C- ANA
D- Anti ds DNA
https://www.mayoclinic.org/diseases-conditions/antiphospholipid-
syndrome/symptoms-causes/syc-20355831

46. A 65-year-old woman, who is otherwise well, has disabling

rheumatoid arthritis. You elect to treat her with the nonsteroidal anti-
inflammatory agent (NSAID) ibuprofen in an attempt to reduce the inflammatory response and pain she
suffers. Which one of the following side effects of NSAIDs is most likely to develop in this patient?
a. Thrombocytopenia.
b. Duodenal ulcer.
c. Congestive heart failure.
d. Gastritis.
e. Acute renal failure

47. 60 years old women in nursing home had a Hx of fall and Fx of neck of femur. Lab test is
given.whats the best to given ?
a) Vit D
b) Aldronate
c) Raloxifene
d) calcium & Vit D
If vit d Low then d , if osteoporosis + then alendronate. BUT BEFORE TREATING WITH
ALENDRODATE level of vitamin D should be above certain level.. Vit d > 25 Ng/ml is required
for alendronate to effectively increase bone mineral density
https://www.ncbi.nlm.nih.gov/m/pubmed/19795092/

1171
49. 25 y/o young man with inflammed knees. aspiration done revealing 25 ml of viscous brown fluid.
what is the dx?
a.) gout
b.) osteoarthritis
c.) hemochromatosis with chondricalcinosis
d.) pigmented pilonodular synovitis

50. Pic of SLE female with malar rash asked about

diagnostic inv
ANA
Anti-sm
ANCA
antiphospholipid antibody

51. Child recurrent hx of swelling from last four yrs ( left

knee right ankle ) it respond to nsaids. Ena negative RF
negetive Ana increase
A. Juvenile arthritis
Rheumatic fever
sLE
52. Pt with ankle swelling, afebrile, stiffness for an hour
relieved by walk ,xray show periarticular osteopenia and
narrow space, other foot joint is normal
A-osteomylitis
B-rheumatoid arthritis
C-sle
D-septic arthrutis

53. which drug causes SLE like syndrome

A- Hydralazine
B- Propranolol
C- Amoxicillin

** There are 38 known medications to cause DIL but

there are three that report the highest number of cases:
hydralazine, procainamide, and isoniazid ( wiki pedia)

54. SLE patient presents with a rash on his hand.Most

appropriate step?
ANA
ANCA
Anti ds DNA
Acute: A chronic :C

1172
Labs
antibodies
antinuclear antibody (ANA)
best initial test
high sensitivity but low specificity
anti-double-stranded DNA (dsDNA) antibody
often rises during flares
high specificity but low sensitivity
poor prognostic factor
often indicates renal disease

55. A patient presents with pain in knee joints and on

investigations, his ANA is strongly positive.
His Ds DNA value is 4 (1-5 normal), Anti Ro Antibodies
strongly positive and RF is also negative.
What is the cause?
a. SLE
b. Sjorgen syndrome
c. RA
d. OA

56. 1.SLE diagnosed(anti DtsDNA+ and ENA+)hving pain in

joints.wht long term treatment?
a.Naproxen
b.Methotrexate
c.Hydroxychloroquine
d.paracetamol

57. .SLE -Rash and Joint pain .Best Nxt?

a.predisolone
b.Hydroxychloroquine
c.Methotrexate

58. recall of SLE children most common association long

terms ?
a. IBS…
b. conjunctivitis
c. uveitis
d. cardiomyopathy

** Pericarditis is the most common cardiac abnormality in children with SLE, but other problems, such as
myocarditis, valvular disease (eg, endocarditis), and coronary artery disease (CAD), can occur. Cardiac
abnormalities in children with SLE are often silent.

59. Sle pt taking steroids which vaccine contraindicated?

Bcg cz live vaccine
Pneumococcal
Influenza

60. Sle pt joint finding

A) Periarticular erosion
B) Periarticular osteopenia
C) deformed joint
Ref radiopedia
** Plain radiographs demonstrate soft tissue swelling of the involved joints, periarticular
osteoporosis, and normal joint spaces. Carpal instability may be seen in 15% of patients
Sle .>>>> non erosions
Ra.>>>>osteopenia
Gout>>>>punched out markings, periarticular erosion

1173
 Pseudogout >>>>>chondrocalcinosis
O.a.>>>>osteophytes and osteosclerosis

61. Scenario of pt with SLE. Asked for treatment along with prednisolone ?
A) MTX
B) cyclophosphamide
C) chloroquine
D) cyclosporine

62. 25 yr old female complain of Raynaud's phenomenon in cold,also having edema of bl feet,,bibasal
crepitation on lung bases ,heart on CXR silhouette appearance .ana+, ENA neg..cz
A-primary Raynaud's
B-cold agglitonin antibody
C-sle
D-limited sclerosis

https://emedicine.medscape.com/article/135327-clinical

1174
• Cold Agglutinin happens with Systemic
Scleroderma or as with Mycoplasma
Pneumonia
• Reynolds could be 1ry or 2ry, here it is 2ry
to a problem caused ==> CHF+ Reynaulds
• Prepheral edema + Bibasilar Crackles which
appear suddenly or acutely .. as in
Infections with Virus or bacteria
• Mycoplasma Pneumonia is a well known
cause of Cold agglutinin causing Reynauld's
, -ve ENA and CHF could develop as a
complication, Sever hemolysis after
mycolplasma causes CHF
• ENA being -ve excludes most immune
cases

63. child presents with rash on eyelids and

muscles pain symmetrically
dermatomyositis
polymyositis
polymyalgia rheumatica
sle
64. SLE children most common association
long terms ?
a. IBS
b. conjunctivitis
c. uveitis
d. cardiomyopathy

65. A boy with joint pains. ANA +ve and RF –e.

What’s the long term complications?
Cardiomyopathy
Uveitis
Small bowel ulceration

Racgp JIA

66. young woman w history of photosensitivity, malar rash, and arthritis (SLE case not on Tx) comes
with pericardial effusion:
treatment >
aspiration,…if presents with sob
steroid

1175
 cyclophosphamide,
HCQ
MT

**The overall aim of therapy is to control disease activity. Mild activity can be managed with non-
steroidal anti-inflammatory drugs (NSAIDs) or low-dose steroids, but more severe manifestations require
prompt treatment with moderate-to-high doses of steroids to minimise organ damage. Steroid-sparing
immunosuppressive medications should be considered early to prevent steroid-related morbidities
http://www.acc.org/education-and-meetings/patient-case-quizzes/latest-treatment-approach-for-recurrent-
lupus-pericarditis
IF SYMPTOMATIC:
1st aspiration
If pericarditis persists after aspiration- ibuprofen, colchicine and low dose corticosteroids
Anasarka; intravenous immunoglobulin (IVIG), or azathioprine could be considered as subsequent
therapy options if symptoms persists despite optimal triple therapy. Pericardiectomy could also
be explored as an alternative but as a last possible resort after extensive discussion between
the patient and the treatment team.
67. Sle scenario patient comes for dryness of eyes( main complaint)... all tests for sjogren positive. Hx
of sle with all tests positive. Ask for the next tx
A Hydroxychloroquine
B steroid
C metho
D artificial tears
https://www.aafp.org/afp/2009/0315/p465.html

68. 5 y lady with SLE has rash n arthritis takes NAISDs wt to add:
a-hydroxychloroquine
b-cyclosporine
c-sulfasalazine
d-methotrexate

69. a sle pt, on paracetamol. Which drug ll u add now.

Methotrexate << for severe cases
Hydroxychloroquine << joint and skin
Prednisolone <<carditis
NSAID < for joint
Topical steroids<< mouth ulcers
The overall aim of therapy is to control disease activity. Mild activity can be managed with non-
steroidal anti-inflammatory drugs (NSAIDs) or low-dose steroids, but more severe
manifestations require prompt treatment with moderate-to-high doses of steroids to minimise
organ damage. Steroid-sparing immunosuppressive medications should be considered early to
prevent steroid-related morbidities.

70. 25 yr old female complain of Raynaud's phenomenon in cold,it's occurring for 3 yrs after a lung
infection ..ana+, ENA neg..cz
-primary Raynaud's
-scleroderma
-sle
-limited sclerosis cz only in 20-30% of case antitopoisomearse ab will be positive jm 307
Cold agglutinin

71. Picture of hand given tip of all fingers were amputated

History of pain and color change present. Especially during winter. No history of smoking. Asked
Cause..?

1176
 A. Rheumatoid arthritis
B. SLE
C. Scleroderma
D. Berguer’s disease

#note_this
ANA...screening of SLE
DsDNA...specific SLE
Anti CCP..... Specific RA
RF...........+RA & in sjogren syndrome
C- ANCA.......specific wegener's syndrome and ulcerative colitis
ASCA.......Specific crohn's syndrome
Anti-mitochontrial abs....specific 1ry biliary cirrhosis & autoimmune hepatitis
Anti gastric parietal cells......specific Pernicious anemia
Tranglutamenase abs.....specific cealiac
Topoisomirase abs..... Specific scleroderma(diffuse)
Anti.centromere abs.....specific scleroderma( limited)
Anti.thyroid abs......Hashimoto disease
Anti.smith abs.....specific SLE
Anti.Ro,Anti La,...... Sjogren's syndrome(anti Ro more specific)

72. Male patient has trouble climbing stairs and also shoulder movement problems.
Diagnosis?
A- polymyositis
B- SLE
C- myasthenia gravis
D- Muliple sclerosis

73. woman with sle hydroxychloroquin prednisolon. how to monitor toxicity?

a. LFT
b. RFT
74. SLE patient.Patient had joint pain.ANA 1/640.Anti ds DNA is positive.Treatment?
Sulfasalazine
Hydroxychloroquine
Steroids
75. A patient presented with macroscopic hematuria. 6 months back he diagnosed as c-ANCA
positive vasculitis causing hematuria and started on Prednisolone and Cysclophosphamide.
The RBCs on examination are 20% dysmorphic and 80% normal, what is the most appropriate
next step?
a. Repeat renal biopsy
b. Stop cyclophosphamide
c. CT abdomen
d. Renal USG
Cyclo S/E: myelosppression, haemorrhagic cystitis

76. Another with some vasculitis . Now having

red urine . What to do
A. Cystoscopy
B. Check for some immune factor
C. I think cytology
ans: ANCA here

78. patient has history of bluish discoloration of

fingers especially in winter but after taken
nifedipine ,pt is feeling better but still left pain, SLE
hand pic given,next treatment

1177
 a. steroid
b. azithroprine
c. hydroxychloquine
d. cyclosporine
e.cyclophosphamide
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3762519/

78. 18month old baby with limp . Anti Ana antibodies 1:160 titres something improved with
NSAIDs .
1.juvenile rheumatoid arthritis ,
2.osgood
3.ankylosing spondititis I
4.SLE

79. Picture of necrosis on 3 fingers, patient with rheumatoid arthritis, non smoker, can't
remember the rest of the description, but asks for diagnosis
A ana
B ena
C anti ssa
D anti citrulline to diagnose the ra
**if already diagnosed do ana or anca to diagnose vasculitis

80. A patient with rheumatoid arthritis got a flare up and doctor wants to administer
azathioprine. which screening test should be done before starting this drug?
a) Tb Gold test
b) Thiopurine methyltransferase
C. Anti Acetylcholine inhibitors
D. Complements assay.
E. Anti gliadin IgA

81. Aboroginal female bring her husband with small joint pain with signs and symptoms of
Rheumatoid Arthritis. What will be the treatment for him ?
a. Aspirin
b. Amoxycillin
c. Paracetamold.
d. Hydrochloroquine
MTX – gold std for rheumatoid

82. bisexual man has several mouth ulcers ,arthritis,sausage fingers.also has h/o
diarrhea.MOSt likely ??
A.BEHCET DISEASE
B.REITER DISEASE
C.RHEUMATOID ARTHRITIS
D.ANKOLYSING ARTHRITIS
E.PSORIATIC ARTHRITIS

83. Lady with rheumatoid arthritis and something else. Labs: Normal ferritin, low total iron
binding capacity, low transferrin, low haemoglobin
A- Iron Infusion
B- Low dose prednisolone
C- Erythropoietin

1178
84. Elderly lady with X ray of hand.Case of rheumatoid arthritis.Most diagnostic test.
RF
Anti CCP
ANCA
ANA
85. Juvenile rheumatoid arthritis scenario asking long term complication
A. Uveitis
B. cardiomyopathy
C. Osteomyelitis
86. Which is not criteria for juvenile rheumatoid arthritis?
Arthritis
Iridocyclitis
Positive Rf
Unexplained fever for few days
Splenomegaly
87. A middle aged man with Rheumatoid arthritis presented with knee, ankle swelling and pain.
Blood sent for full blood count and inflammatory mediators. Next step?
a. Intra-articular steroid
b. synovial fluid study for uric acid (take it if it says uric acid crystal)
c. blood culture and synovial fluid culture

** septic arthritis
Symptoms

The classic picture is a single swollen joint with pain on active or passive movement. The knee is
involved in about 50% of the cases, but wrists, ankles, and hips are also commonly affected.[6]
Septic arthritis may present as polyarticular arthritis in about 15% of patients.[7]
It is more common in patients with prior joint damage, as in gout, rheumatoid arthritis and systemic
connective tissue disorders.[8]
Fevers and rigors are present in the majority of cases, but their absence does not exclude the
diagnosis. Bacteraemia is a common finding and, when present, may cause prostration, vomiting
or hypotension.

An approach to rapid evaluation of an acutely inflamed joint is to screen the synovial fluid for
crystals via polarizing microscopy and for organisms via Gram stain (63-96% sensitive). If crystals

1179
are present and the Gram stain findings are negative, treatment for crystal-associated arthritis
should be initiated. However, an exception to this would be the presence of significant risk factors
for infection (eg, the focus of infection lies somewhere that could lead to bacteremia, such as
pneumonia or pyelonephritis). Therapeutic decisions cannot be delayed until results of the
synovial fluid culture are available.

If microscopy demonstrates no crystals, treat the patient for presumed infection even if the Gram
stain findings are negative. The Gram stain is less than 60% sensitive for detection of bacteria in
synovial fluid. Always send the fluid for culture, regardless of the result of the screening
evaluation. A joint damaged by gout or pseudo-gout is prone to be infected. Culture of synovial
tissue is indicated primarily to detect mycobacteria or fungi.

If the patient's condition does not improve significantly after 5 days, the joint must be reaspirated
and examined. Most septic joints have a white blood cell (WBC) count that exceeds 50,000/μL,
with more than 75% polymorphonuclear leukocytes. However, various sterile inflammatory
processes may exhibit the same cellular profile.
http://emedicine.medscape.com/article/236299-workup@name...

88. A 65-year-old woman, who is otherwise well, has disabling rheumatoid arthritis. You elect to
treat her with the nonsteroidal anti-inflammatory agent (NSAID) ibuprofen in an attempt to
reduce the inflammatory response and pain she suffers. Which one of the following side effects
of NSAIDs is most likely to develop in this patient?
Thrombocytopenia.
Duodenal ulcer.
Congestive heart failure.
Gastritis.
Acute renal failure.

89. A case of hemoptysis and lateral diplopia and bilateral joint pain (I think it is Wegener
granuloma) what is your management
a. ANCA
b. ANA
c. joint fluid aspiration

Wegners – cyclophosphamide jm 290

1180
 lung biopsy – diagnostic

90. Picture of red eye with dilated pupil for days, male
patient with genital and oral ulcers, asks treatment
A- prednisone
B- cant remember
A?
behcet's syndrome –
HIGH DOSE
STEROIDS JM 290

91. A woman has

been prescribed long
term steroids for
polymyalgia
rheumatica. What
additional drug should
be added to prevent
osteoporosis?
A. Calcium
B. Alendronate
C. Vit D
D. Calcium resonium
E. Calcitonin

The first choice for prevention of corticosteroid osteoporosis is a potent oral bisphosphonate—for example,
alendronate or risedronate. ... For patients receiving chronic low dose corticosteroids treatment with
calcium and vitamin D may prevent further bone loss. (Harrison)

#educational #Rheumatology
92. Q.75 year old female patient ,on a number of drugs including statin,presents with proximal
muscle weakness.On examination muscles of the shoulders are tender on palpation.
Laboratory examination shows raised ESR and CK is normal. What is your possble
Diagnosis?(august 2016)
a)Drug induced myositis
b)Dermatomyositis
C)Polymyositis
D)polymyalgia rheumatica

**polymyositis :esr and ck increased

**polymyalgia rheumatic: esr raised and ck normal

1181
 Ans is D . Polymyalgia
rheumatica
RAISED ESR and normal CSK in
polymyalgia rheumatica
• rheumatologic disorder affecting the
muscles of the cervical and pelvic girdles
(climbing stairs/combing)
• Characterized by anatomically-specific,
regional pain and stiffness
• Most commonly seen in elderly females
(>55 years of age)
• muscle tender to palpation(O/E)
• reduced muscle strength and weakness
may not be appreciated on physical
exam(o/E)
• CBC may show anemia
• markedly elevated ESR
• Serum creatinine kinase (CK) is normal
• oral prednisone firsr line therapy 5-20
mg/day
Myopathy is defined in various ways. The National Lipid Association (NLA) defines myopathy as
symptoms of myalgia in addition to an elevation in serum creatine kinase (CK) greater than 10
times the upper limit of normal (CK >10 × ULN).
The most common symptoms displayed with statin-associated myopathies include fatigue,
flulike symptoms, and nocturnal cramping.also CK is normal here which should be raised (A
incorrect)

93. .A 67-year-old female presents to her primary care physician complaining of headaches in
her left temple and scalp area, neck stiffness, occasional blurred vision, and pain in her jaw
when chewing. The appropriate medical therapy is initiated, and a subsequent biopsy of the
temporal artery reveals arteritis. Five months later, the patient returns to her physician with
a complaint of weakness, leading to difficulty climbing stairs, rising from a chair, and
combing her hair. The patient states that this weakness has worsened gradually over the
last 2 months. She reports that her headaches, jaw pain, and visual disturbances have
resolved. Physical examination is significant for 4/5 strength for both hip flexion/extension
as well as shoulder flexion/extension/abduction. Initial laboratory work-up reveals ESR and
creatine kinase levels within normal limits. Which of the following is the most likely
diagnosis in this patient's current presentation?
a) Mononeuritis multiplex
b) polymyalgia rheumatica
C)Drug induced myopathy steroid induced
D)polymyositis
e)Dermatomyositis

1182
DISCUSSION: C correct here .This patient initially received corticosteroid therapy for management
of giant cell (temporal) arteritis. Her subsequent presentation of worsening proximal muscle
weakness is consistent with corticosteroid-induced myopathy.
Steroid-induced myopathy is thought to occur more frequently with fluorinated steroids,
such as dexamethasone or triamcinolone, over nonfluorinated agents such as prednisone or
hydrocortisone. Reducing or discontinuing the dose of steroids will lead to spontaneous
recovery; however, this may take weeks to months. In patients suffering from polymylagia
rheumatica (PMR) being treated with steroids, it may be difficult to differentiate between
recurrence of the disease (and need for an increased dose of steroids) versus development of
steroid-induced myopathy (and need for a reduction in steroid dose). The critical difference is
that steroid-induced myopathy, unlike PMR or inflammatory myositis, is associated with high
ESR and CK respectively.
Incorrect Answers:
Answer a: Mononeuritis multiplex is commonly coincident with arteritis; it is a painful and
asymmetrical peripheral neuropathy leading to nerve damage in 2 separate areas of the body.

1183
 Focal neurologic deficits are often noted, such as foot drop and sensory disturbances.
Answer b: Polymyalgia rheumatica (PMR) presents with pain, stiffness, and weakness in the
neck, pelvic girdle, and shoulder girdle. Although PMR and temporal arteritis commonly occur
together, this patient's normal ESR and worsening symptoms on steroid therapy make PMR a
less likely diagnosis. Additionally, pain is a more predominant symptom in PMR, whereas
myopathy is more characterized by weakness.
Answers d,e: Inflammatory myositis, including polymyositis and dermatomyositis, would be
expected to present with an elevation in creatine kinase.
REFERENCES:
1. Unwin B, Williams CM, Gilliland W. Polymyalgia rheumatica and giant cell arteritis. Am Fam
Physician. 2006 Nov 1;74(9):1547-54. PMID:17111894

94. What is the major cause of mortality in SLE patients?

A. Lupus nephritis according to books
B. Lupus cerebritis
C. Lupus hepatitis
D. Vasculitis
E. Atherosclerotic disease (take cardiovascular disease if it is in option..not atherosclerotic
disease)

95. A case of 30 years old male with tonsillitis and other symptoms. He has amoxicillin
he is complaining now of non blanching purpuric rash
(it was not clear when he took the amoxicillin and when the rash appeared)
what is the reason of rash

1184
 a. infectious mononucleosis
b.hypersensitivity vasculitis
c. allergy

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4577711/

96. Old man on poly pharmacy suffer from weakness and pain in upper and lower limb can`t
climb stairs all lab normal except CK 4000
Polymyalgia rheumatica
Statins Induced Myopathy
Anti-psychotic SE
https://neuro.psychiatryonline.org/doi/full/10.1176/jnp.23.3.jnpe49

97. The serum phosphate is MOST LIKELY to be low in which of the following disorders:
a) Osteoporosis increase or normal ca,decrease vit d and increase alp

1185
 b) Osteomalacia everything decrease
c) Multiple myeloma – pseudohyperphosphatemia, hyper calcemia
d) Polymyalgia rheumatica
e) Paget's disease – both ca n po4 normal, ALP increased

https://rarediseases.info.nih.gov › diseases › hypophosphatasia

Hypophosphatasia (HPP) is a genetic condition that causes abnormal development of the bones
and teeth. The severity of HPP can vary widely, from fetal death to fractures that don't begin
until adulthood. No uptake of calcium n phosphate inside bone

98. 40 year old female with tonsillitis,took Amoxicillin,after 3 weeks she developed purpuric
rash,not blanching .She had fever and painful joints.Diagnosis?
Hypersensitivity vasculitis
Henoch Schonlein Purpura
Infectious Mononucleosis
http://casereports.bmj.com/content/2015/bcr-2015-211622.full

99. An 8 yrs old child presented with multiple bruises and limbs. He also had fine Petechial rash
on his legs. O/E he is afebrile & otherwise well. What is the most likely cause?
a- Has to be reported to child health unit
b- He may develop arthralgia & macrohaematuria in the future
c- He has Henoch-Schonlein purpura
d- Do a whole body bone scan

100. Sjogren scenerio, dry eyes, dry mouth, mass in mandible fixed. Diagnostic test
A. Ana
B. Fnac
C. Ct

1186
BIOPSY WOULD BE the best for diagnostic
https://www.arthritis.org/about-arthritis/types/sjogrens-syndrome/articles/lymphoma-risk-and-
sjogrens-syndrome-230.php

101. Sjogren scenario.next treatment?

a.Naproxen
b.Hcq
c.MTX
d.Azathioprine
submandibular #parotid #sjogren #mass #ENT

Antimalarial medications and corticosteroids are

being re-evaluated in the treatment of Sjögren
syndrome.28 Hydroxychloroquine (Plaquenil)
may be useful for treating the arthralgia and fatigue associated with Sjögren syndrome.
Rituximab (Rituxan), an anti-CD20 monoclonal antibody that depletes B lymphocytes, holds
promise as a therapy for severe inflammatory manifestations of Sjögren syndrome. RACGP
102. A 30 yr old man with parotid gland swelling increasing while having food and dry mouth and dry
eyes. What investigation to be done?
A. salivary gland biopsy
B. CT
C. MRI
D. Sialography
Next: D best: A
103. Pic of submandibular swelling of man,H/O of joint pain and dry eye and dry mouth for 8yrs ago,Next
investigation?
A. anti nuclear antibody next
B. FNAC
C. CT head and neck
D. US
E. excisional biopsy best
104. A patient presented with swelling in parotid region from three months, which has sometimes dull
pain while eating. Patient had history of dry eyes. FNAC was done which showed non conclusive mixed
cellularity. What next step?
A- Biopsy
B- Sialography
C- CT scan
B coz biopsy is already done
105. A patient presented with swelling in parotid region from three months, which has sometimes dull
pain while eating. Patient had history of dry eyes (it was seeming he is have sjogren’s syndrome or
something) FNAC was done which showed non conclusive mixed cellularity. What next step?
A- Biopsy

1187
 B- Sialography
C- CT scan
106. Pic of an old man with immovable submandibular lump attached to the fascia. Old man with dry
eyes.
a. ANA
b. CT scan of head and neck
c. FNA
**Lymphoma due to Sjogren.this is sjogren syndrome which has a strong predilection for
lymphoma, based on this scenario with dry eyes we should go for FNA. ANA is for initial work
up but not diagnostic of sjogren syndrome where you have the complains of dry eyes and
mouth.
107. Pt has swelling in anterior side of mouth as well and asked for next to do beside antibiotics:
options were
a. usg to see teeth abscess
b. ct
c. mri
108. Scenario of sjogren syndrome. Ultrasound shows hypertrophied tissue of parotid gland.
FNAC shows type of cells ( sorry not remember but not cancer), what next?
CT
Sialography
biopsy-

109. Sjogren’s Syndrome scenario. Asked

imm appropriate Mx?
a. Sialography
b. Biopsy of Salivary Gland

110. A 45 year old coal mine worker

presents with cutaneous nodules, joint
pain and occasional cough with dyspnoea.
His chest radiograph shows multiple small
(1-4cm) nodules in bilateral lung fields
Some of the nodules show cavitation and
specks of calcification. Most likely these
features are diagnostic of
A)Sjogren syndrome
B)Caplan syndrome (ra+pneumoconiosis)
C)Silicosis
D)Wegener’s granulamatosis(lung+renal+eye+joint)

111. Male patient has trouble climbing stairs and also shoulder movement problems.
Diagnosis?
A- polymyositis by exclusion (dx;polymayalgia rheumatic)
B- SLE
C- myasthenia gravis
D- Muliple sclerosis

112. Polymyositis scenario. Important investigation.

n. CK
o. EMG
EMG findings are not specific and diagnostic>>>>go for CK from these options>>still biopsy is the gold
standard

113. A old man present with new onset of diarrhoea for 3 months and weight loss. Complains for
difficulty in getting up from chair and walking up the start.

1188
 ---campylobacter jejuni infection
---coeliac disease
---polymyositis
---thyrotoxicosis

114. A 50 year old man presents with a 2-year history of burning pains in his feet, and also has
pins and needles sensation in the fingers and toes. He has a weakness and unsteadiness of his
legs. On examination there is a distal wasting and weakness in all limbs and sensation lost in all
limbs. He has lost his reflexes. Which one of the following is the most likely diagnosis?
a) Polymyositis
b) Hereditary sensorimotor neuropathy (Charcot-
Marie-Tooth disease)
c) Diabetic peripheral neuropathy
d) Acute infections polyneuropathy
e) Diabetic amyotrophy

115. 50yr old diabetic patient presented with pain in

lumbosacral region involving hips region and thighs
including proximal muscle weakness.burning pains
in the feet,pins and needles in the fingers and toes
and weakness and unsteadiness of the legs with
glove and stocking sensory loss to all modalities
and absent knee jerk while ankle reflex was
preserved.he was statins 5mg for 8yr.which one of
the following is most likely diagnosis?
A. Diabetic peripheral neuropathy
B. Diabetic amyotrophy
C.lumbar radioculopathy
D. Statins induced myopathy
E.polymyositis

116. 75 year old patient ,on a number of drugs

including statin,presents with proximal muscle
weakness.Diagnosis?
Drug induced myositis
Dermatomyositis
Polymyositis

117. Apt comes to you with c/o weakness and wasting of

proximal muscles of shoulder and hips.he also has
atrophy of muscles of hand as well.he is on simvastatin
for 8 years.what is your diagnosis.
a.polymyositis
b.dermatomyositis
c.drug induced myopathy
J/M 32/316

118. patient presents with multiple sites pain and weakness. no reflexes problem, has been on statin for
8 years for cholesterol and well maintained
a myalgia
b drug induced myositis
c polymyalgia rheu matica
d myositis
# may

119. A 69 years old male with a two months history of difficultyin raising of his arms,ascending stairs and
dry mouth. He smokes 15 cigrates per day and admits huge consumption of alcohol. O/E he has

1189
 proximal weakness affecting his all four limbs with absent tendon reflexes. CXR shows right sided plural
effusion. What is diagnosis here?
a.Alcohol induced mypathy
b.Mysthania Gravis
c.Polymyalgia Rheumatica
d.Eaton-Lambert Syndrome
e.Polymyositis

Lambert-Eaton myasthenia syndrome (LEMS) is a rare presynaptic disorder of

neuromuscular transmission in which quantal release of acetylcholine (ACh) is impaired,
causing a unique set of clinical characteristics, which include proximal muscle weakness,
depressed tendon reflexes, posttetanic potentiation, and autonomic changes.
Associate with :SCC
Symptoms of Lambert-Eaton myasthenic syndrome (LEMS) usually begin
insidiously and progress slowly. Many patients have symptoms for months or years before
the diagnosis is made. Weakness is the major symptom. Weak muscles may ache and are
occasionally tender. Proximal muscles are more affected than distal muscles; lower extremity
muscles are affected predominantly. Patients typically have difficulty rising from a chair,
climbing stairs, and walking.The oropharyngeal and ocular muscles[2] are mildly affected in
about one quarter of cases of LEMS, with symptoms that may include ptosis, diplopia, and
dysarthria.Most patients have a dry mouth, which frequently precedes other symptoms of
LEMS. Many patients report an unpleasant metallic taste. Some patients have other
manifestations of autonomic dysfunction, including impotence in males and postural
hypotension(MEDSCAPE)
It hav incremental response( do activity feel better, mean weakness decrease) n myasthenia have
decremental (koi b function jaldi thak jate, weakness inc.)
Ix:
120. 5. A 64year old man who experiences numbness and tingling sensations in his fingers especially
during winter. He experience occasional fever and has significant hx of smoking. Recently he noticed
that the skin of his hand is changing colour. What is the most likely diagnosis(see image below)
a. Beurgers disease…
b. Scleroderma
c. Hansens disease( Leprosy)

1190
121. blue hand on cold exposure with pneumonia before 3 years ,,,, with +ANA and – ENA
asking dx
-limited scleroderma
-primary raynouds
-cryogloblinemia
-SLE

122. ..pt female with Raynaud's with lung infection

ana 1/80 and ena negative dx??
A)primary Raynaud's
b)scleroderma. C)sle (by exclusion)

**ANA is reported as a "titer". Low titers are in the range of 1:40 to 1:60. ... Although ANA are
most often identified with SLE, a positive ANA test can also be a sign of other autoimmune
diseases. Normal value ranges may vary slightly among different laboratories.
**ans should be limited sclerosis
If ENA not mentioned then we can be confused between B and C
SLE is the MC cause of secondary Raynaud's

Female patient
Prior lung infection
Ana +

Sle fits

123. old female complain of Raynaud's phenomenon in cold,it's occurring for 3 yrs after a lung
infection ..ana+,ENA neg..cz
a. -primary Raynaud's
b. -scleroderma
c. -sle
d. -limited sclerosis

1191
124. Smoker with hand deformity pic and winter symptoms:
a. burgers disease,
b. scleroderma

burgers disease Scleroderma

125. 21- Pic of elderly (80) pt face for 8 ys with minimal increase in size no other symptoms:
excisional biopsy with 2cm free margin, …should be 2mm
review in 12 month,
Imiquine cream,
5 fluqi..
some of topical cancer treatment
126. Patient has rheumatoid arthritis had history of DVT. Now he came in with black fingers. what is the
inv?
a) ANCA
b) Anticardiolipin
c) ANA
d) Anti ds DNA

127. Most consistent symptom of polyarteritis nodosa??

128. A patient presented with macroscopic hematuria. 6 months back he diagnosed as c-ANCA positive
vasculitis causing hematuria and started on Prednisolone and Cysclophosphamide. The RBCs on
examination are 20% dysmorphic and 80% normal, what is the most appropriate next step?
a) Stop cyclophosphamide
B)repeat renal biopsy
c) CT abdomen d) Renal USG e) Cystoscopy

1192
129. 13. Pics of erythematous rash in both legs, after taking amoxicillin, complaint of joint pain, rash is
non blanching, palpable
Henosch scholein
E. nodosum
Hypersensitivity vasculitis
2017 may

130. Woman sore throat, bronchitis, two weeks ago, took amoxicillin for it, now
presents with purpuric raised rash around ankle and dorsum of foot, rash does
not blanche and coalese together
1- Hypersensitivity vasculitis
2- Inf mononucleosis
3- HSP
#may2016
131. 46 year old woman come with arthralgia and rash on her legs. Last week, she took amoxicillin for
her sore throat. Blood test all normal. What is the diagnosis?
(A) HSP -Urinalysis
(B) Hypersensitivity vasculitis

132. Pic of foot with big toe amputated asking cause

A thromboangitis
B thromboembolic
C small vessel vasculitis

133. Which ONE of the following is the

most common cause of acute limb
ischemia?
a. Congestive cardiac failure
b. Smoking
c. Vasculitis
d. Embolism
e. Thrombosis
https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical-tools/vascular-
emergencies/acute-limb-ischaemia

**The correct answer is e. Thrombosis is the most common cause of acute limb ischemia.Both native
coronary vessels and bypass grafts can get blocked due to thrombosis. In the lower limbs, thrombotic
occlusion accounts for more than 80% of cases.

1193
134. Painless hematuria, on cyclophosphamide due to vasculitis-next-
cystoscopy,
CT abdomen

135. An IV drug user presents with a history of shortness of breath, fever and painful joints. A
few nodules were noted on his hands and toes. What is your next step in management?
a. Chest x-ray
b. Blood culture DX infective endocarditis
c. ECG

136. Patient with a history of chronic gout taking Allopurinol

regularly presents with a hot, painful swollen knee. He has
chronic renal failure too. Management:
A. Stop allopurinol and give colchicine
B. Stop allopurniol and give corticosteroid
C. Continue allopurinol and give corticosteroid
D. Continue allopurinol and give colchicine

137. #may2018-rheumatology(sjogrens) patient comes for

dryness of eyes (main complaint)... all tests for sjogren
positive. Hx of sle with all tests positive. Ask for the next tx
A Hydroxychloroquine
B steroid

1194
 C methotrexate
D artificial tears

138. Chronic gout pt who is already on allopurinol 100mg and intermittent colchicine. pt has
renal impairment. his urate level within normal limit.next appropriate mx?
A)Daily colchicine
B)Indomethacine
C)Paracetamol
D)increase dose of Allopurinol jm381
E)Naproxen

If uric acid levels in normal range and no acute attack .. they

the maintain dose for allopurinol is ok

so best option will be use regular low dose colchine.

1195
139. Juvenile Idiopathic Arthritis treatment:
A-Naproxen
B-Steroid
C-Penicillamine D
-Hydrocloroquin
E-Paracetamol

140. Old pt with known bilateral chronic osteoarthritis,

develop parasthesia and numbness in the lateral side of
leg below knee condition worse at night and improve after
walking for 10 min, wt is the important thing to examine in
this pt
A Straight legs raising test
B Any tenderness in lateral condyle
C Any loss of sensation in the lateral side of leg
**to check pts complaint
Dx: maralgia parasthetica

141. Old woman with steroid use taking risedronate 25 for 3 months has frequent #Thoracic
vertebrae, what next?
a. changes to alendronate
b.increase it
c. continue
d. change to IV zolendronic acid best is teriparatide. — have better compliance
**take b if it is in therapeutic dose

1196
142. A 40 year female had a history of breast ca which is treated at 24 year age . she has history
of osteoarthritis of hand, fingers and knees , now presented with back pain in L3-L4 region .on
exam there is tenderness too. Which one of following is your initial step of management?
a.ESR ans should be xray jm 408
b.Bone densitometry
c.Mri spine ..best

143. #ortho #rheumatology Old lady develop sudden back pain after closing window, she is
complaining of tenderness of lower back area, after investigation, it was noted that she is
having osteopenia. WOF is the cause of her presentation.
a.Osteomyelitis
b.Multiple myeloma.
c.Osteoporosis.
d.Stress fracture
144. 34 yr old female presents with purpuric rash on back of legs her only medication is
microgynon 30 she reports frequent nose bleeds and menorhagia cause
Drug induced thrombocytopenia
Hsp
TTP …life threatening
ITP
APLS(antiphospholipid antibody syndrome)

145. Long history about 55 years female ptn concerned about risk of osteoporosis she had done
an oesophageal operation and still complaing of some git problems her t score cervical 2.5
lumbar _2.5 ca and vit d normal no menopausal symptoms Appropriate management
Alendronate
Ca plus
vit d
Hrt
strontium

1197
146. 80 yr old woman fall from a low high chair and intramedullary nail is given for her femoral
fracture. how you will manage the patient
.alendronate ….discharge
2.bone scan
3.warfarin for 6 mnth
4.heparin….its already started after 12 hr of operation
147. A child presents to ur surgery with c/o joint pains.u find out that he also suffers from iron
deficiency anemia.what could be the most appropriate diagnosis?
a)juvenile rheumatoid arthritis
b)HSP
c)haemophilia
d)thrombocytopenia
148. #rheumatology -arthritis/drugs A 58 year old woman who has HTN and osteoarthritis
history, went for left knee joint total replacement surgery 3 months ago. She was on
Sulfasalazine, ACEI and warfarin. Now she is on just Sulfasalazine and ACEI. She got severe
urticaria 2 weeks ago. From the day she stopped sulfasalazine, she is fine. What medication
should she take instead of sulfasalazine.
1. Meselazine
2. Methotrexate
3. Infliximab
4. Corticosteroid
5. No need for any
149. Old lady develop sudden back pain after closing window, she is complaining of tenderness
of lower back area, after investigation, it was noted that she is having osteopenia. WOF is the
cause of her presentation
a.Osteomyelitis
b.Multiple myeloma.
c.Osteoporosis.
d.Stress fracture
150. woman has been prescribed long term steroids for polymyalgia rheumatic. What additional
drug should be added to prevent osteoporosis?
A. Calcium
B. B. Alendronate
C. Vit D
D. Calcium resonium
E. Calcitonin

151. The patient has 8 months history of joint pain in the wrist and the ankle and minimal pain in
other joints but now the patient comes with morning stiffness of both wrists for 1 to 2 hours. Her
lab results as follow. Hb à reduced MCV à slightly reduced (nearly below lower margin level)
ESR à 70 (sure for this level)
A. NSAIDs
B. Prednisolone
C. Hydroxychloroquine
D. Methotrexate
E. Etarnarcept

1198
152. Q. Old pt with known bilateral chronic osteoarthritis, develop parasthesia and numbness in
the lateral side of leg below knee condition
worse at night and improve after walking for
10 min, wt is the important thing to examine
in this pt A Straight legs raising test B Any
tenderness in lateral condyle C Any loss of
sensation in the lateral side of leg
153. man with fever n swollen knee join on
aspiration rhomboid crystals with GRAM
POSITIVE COCCI
a. IV ceftrioxne
b. Colchicine
c. Prednisolone
d. Arthroscopic washout/debridemet

154. A patient presented with macroscopic

hematuria. 6 months back he was
diagnosed as c-ANCA positive vasculitis
causing hematuria and started on
Prednisolone and Cysclophosphamide. The
RBCs on examination are 20% dysmorphic
and 80% normal (or maybe opposite not
sure). What is the most appropriate next
step?
a. Repeat renal biopsy
b. Stop cyclophosphamide
c. CT abdomen
d. Renal USG
e. Cystoscopy

155. A 60-year-old lady presents with nausea,dyspepsia and upper abdominal pain.She had
past history of going to many doctors and being treated for many disorders. She has been seen
by a rheumatologist for aches and pains in back and in the neck. A neurologist reviewed her for
possibility of epilepsy. A cardiologist just saw her for palpitations and gave her beta blockers
without significant improvement. She believes she has some serious illness. On examination
you find a tense anxious woman in spite of her daily dose of benzodiazepine.There is scar from
previous appendectomy and hysterectomy. What is the most likely diagnosis?
a. Conversion disorder
b. Hypochondriasis
c. Generalized anxiety disorder
d. Munchausen syndrome
e. Somatiform disorder

1199
156. osteoporosis scenario with T score -2.5 ,low normal ca ,and low vit D. What to give??
a) Alendronate
b) Calcium
c) Calcitrol
d) Ralixofen

Alendronate won’t work effectively to increase bone mineral density

157. female pt comes for elective hysterectomy with Hx of thyroidectomy .. all preoperative lab
was normal with normal thyroid &renal functions ..except hypocalcemia 1.8 was found .. what is
your intial treatment ??
a.oral calcium
b.iv calcium
c.calcitriol
d.calcitonin

158. Patient on medications for HTN. she feels dizzy when

get out of the bed.. happening for a while.. she also had
some falls. BP 160/100 Has AF. Next Ix A echo B xray C
holter monitoring D 24 hour BP monitoring
E check BP again in supine

159. 33 year of woman who had done TAH and BSO, t

score femur -2.5 and vertebra -1.5, what to give
A. oestrogen therapy
B. Oestrogen and progesterone
C. vit D and Ca
D. Alendronate
E. Strontium Ranoleate

160. A 49 year-old woman presented with a 2-year history

of intermittent episodes of arthralgia, rash and fevers. She complained of increasing fatigue,
breathlessness and swollen ankles over the previous 6 months. On examination, she had a
purpuric rash on the lower extremities and a right-sided pleural effusion. Urinalysis showed

1200
 protein 3+, blood 1+.
Investigations:
erythrocyte sedimentation rate 140 mm/1st h (<30) serum creatinine 140 μmol/L (60–110)
serum complement C4 <5 mg/dL (15–50)
antinuclear antibodies positive at 1:600 dilution (negative at 1:20 dilution)
rheumatoid factor 90 kIU/L (<30)
What is the most likely diagnosis?
A. Henoch–Schönlein purpura
B. microscopic polyangiitis
C mixed cryoglobulinaemia
D systemic lupus erythematosus
E Rheumatoid disease

161. 50 years old man who suffers from rheumatoid arthritis and who has been treated with prednisolone for 3
years developed peripheral neuropathy of the lower extremities. This neuropathy is most likely due to
A. arsenic poisoning
B. thiamine deficien
C.necrotising arteritis

#rheumatology

162. A old man present with new onset of diarrhoea for 3 months and weight loss. Complains for
difficulty in getting up from chair and walking up the start.
a)campylobacter jejuni infection
b)coeliac disease
c)polymyositis
d)thyroxicosis

163. A 50 year old man presents with a 2-year history of burning pains in his feet, and also has pins
and needles sensation in the fingers and toes. He has a weakness and unsteadiness of his legs. On
examination there is a distal wasting and weakness in all limbs and sensation lost in all limbs. He has
lost his reflexes. Which one of the following is the most likely diagnosis?
a) Polymyositis
b) Hereditary sensorimotor neuropathy (Charcot-Marie-Tooth disease)
c) Diabetic peripheral neuropathy
d) Acute infections polyneuropathy
e) Diabetic amyotrophy

EYE & ENT

1. Patient with red eye, decrease in vision, normal red reflex, what is the most likely diagnosis?
a. conjunctivitis
b. blepharitis
c. glaucoma…red and light reflex lost
d. keratitis…normal vision with grittiness
e. uveitis

1201
1202
2. chronic CSOM case asking sequelae in aboriginal child,
options were
a. cholesteatoma,
b. mastoiditis,
c. significant hearing loss

3. Neonatal conjunctivitis Tx after iv abs. .Sulphacetamide

drops.
4. Orbital cellulitis scenario, what invg to find causative organism?
a. eye swab
b. blood culture
c. CT brain

5. 8 mo old baby, parents concerned

not babbling yet. Appears to
respond well to sounds on
examination. MX? a) tell its normal
variant b) review in 6 mo c) arrange
speech pathologist referral d)ENT
consult

6. Another clinical scenario

mentioning painful red eye but not
much increase in lacrimation and
eye lids are not sticky (most likely
trying to rule out purulent cause).
Pic given showing marked
conjunctival vessel injection. Asked
for next appropriate step Almost
similar picture
a. Topical Steroids ANS
b. Topical Acyclovir
c. Topical Chloramphenicol
d. Other antibiotics I don’t
remember
#sept2016 EPISCLERITIS , ANT
UVEITIS

1203
7. Picture of red eye with complain of severe pain, no discharge. Treatment asked -- ( Looks like an
Episcleritis)
a) Topical hydrocortisone ANS
b) Topical methylprednisolone
c) Chloramphenicol

1204
8. A patient presents with very painful red eye with watery
discharge. Normal disc on fundoscopy Eye muscle movements
were all normal No picture given Investigation asked
A)Ct
B)Tonometry
C)Gonioscopy
D)slit lamp examination ANS

9. Patient was digging ground and suddenly develop left eye

pain. Can’t open eye due to photophobia. ask what you will
do to diagnose. (Short scenario) a. Apply topical atropine b.
Ct scan of head and eye c. Apply topical fluorescein d. Visual
acuity

Fluorescein

Fluorescein is used to detect any epithelial defect associated with the

foreign body. It can be instilled via a moistened strip or as drops, and
the ocular surface viewed with a cobalt blue filter from an
ophthalmoscope or a Wood’s lamp. Multiple vertically orientated
linear abrasions should raise suspicion of a tarsal plate foreign body.
The Seidel’s test using 2% fluorescein can detect an aqueous leak that will occur in non–self-sealing corneal
perforations.

10. Pic of red eye. H/o cataract surgery with painful loss of vision .
acute glaucoma. ANS

a. conjunctivitis.
b. Scleritis
ANS: UVEITIS
CUZ: hypopyon, dx: uveitis

11. Old age Pt. with cataract had improved vision after surgery , in post op. day 4 he wake at morning with
painful eye & blurred vision , what happened to this pt. ?
A) Conjunctivitis
b)Uveitis
C) suture infection & abscess
d) hypopyon
E) Acute glaucoma
Post-operative complication of cataract surgery >>>
1) cloudy vision
The main problem that can occur after cataract surgery is a condition called posterior capsule
opacification (PCO).
2) inflammation (swelling and redness) in the eye
3) swelling of the retina (cystoid macular oedema) – where fluid builds up between layers of the retina
at the back of the eye, sometimes affecting vision
4) swelling of the cornea – where fluid builds up in the cornea at the front of the eye; this usually clears
itself
5) Dislocated Intraocular Lenses
6) retinal detachment – a rare complication where the retina (layer of nerve cells inside the back of the
eye) becomes separated from the inner wall of the eye

1205
 7) infection in the eye, such as endophthalmitis (a rare bacterial infection)
Swelling of the cornea or retina.
9) Increased pressure in the eye (ocular hypertension).
10) Droopy eyelid (ptosis).

12. Pic of red eye... post op case of cataract... pt. woke up on day 3 with pain and lid swelling plus little
hypopyon plus red conjunctiva. pupil seemed to me small... also visual acuity decreased. most likely Dx?
a. Hypopyon
b. acute iritis
c. Glaucoma

SIMPLY,IN BRIEF, UVEITIS includes anterior uveitis(infl. of iris or and ciliary body, IRITIS OR
IRIDOCYCLITIS) and posterior uveitis( choroiditis or retinitis)and intermediate uveitis(vitritis),any of
those may be alone or in combination. ALMOST OF UVEITIS CONDITIONS R AUTOIMMUNE OR
ANTIGEN ANTIBODY REACTION HYPOPYON IS A TRANSUDATE in uveitis ,IT IS STERILE.

Here the patient has undergone a cataract extraction operation ,3 days later, he got
endophthalmitis _(bacterial infection of the uvea ) explained by pain and lid (EDEMA) swelling and
he got hypopyon which here is pus an exudate. A IS CORRECT,HYOPYOYON HERE MEANS PUS .staph
aureus and gram -ve is responsible within 3 days postoperatively while staph epidermidis is
responsible from 4th and 6th days posop.retained lens material may in the anterior chamber may
induce iritis but usually lid oedema ,pain and hypopyon are absent

13. Pic of red eye. Old man came 4th pod of cataract surgery. most likely dx?
a.acute iritis
hyphaemia
conjunctivitis
glaucoma
dx: depends on picture

14. red eye, decreased visual acuity, normal pupil response

a. Iritis(constricted and irregular pupil)
b. keratitis ANS
c. angle-closure glaucoma(non-reactive dilated pupil)
JM 591
discharge mainly present in keratitis....pupil normal in keratitis....pain and vision loss much in
keratitis....

....constricted pupil, poor response to light in iritis

1206
15. A patient with painful red eye and irregular pupil, best long-term management?
A. Acetazolamide
B. Steroids
C. Iridotomy

16. catact eye picture-

phacoemulsification (or "phaco") cataract surgery with foldable
intraocular lens (IOL) implantation***

first line drugs- acetazolamide

second line laser-iridotomy-for angle closure only surgery
trabeculectomy è For angle closure can do both laser
iridotomy and trabeculectomy
For open angle-laser trabeculoplasty and trabeculectomy,è
Open-angle glaucoma is also called primary or chronic glaucoma. It is the most common type of glaucoma

17. . Pic given with right red eye. Pt has seasonal hay fever and also complaining of lower back pain.
Diagnosis? AS
a. Conjunctivitis
b. Uveitis ANS
c. Iritis
d. Keratitis

Ø Neonatal conjunctivitis treatment after IV antibiotics???sulfacetamide

18. A 22-year-old man has had an acute, painful, red right eye with blurring of vision for one day. He had a
similar episode one year ago and has had episodic back pain and stiffness relieved by exercise and
diclofenac for four years. what is the most likely cause of his red eye?
A Chorioretinitis
B Conjunctivitis
C Episcleritis
D Iritis ANS
E Keratitis

19. Another clinical scenario mentioning painful red eye but not much increase in lacrimation and eye lids are
not sticky (most likely trying to rule out purulent cause). Pic given showing marked conjunctival vessel
injection. Asked for next appropriate step :
Almost similar picture
a. Topical Steroid dx-episcleritis
b. Topical Acyclovir
c. Topical Chloramphenicol
d. Other antibiotics I don’t remember

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20. Picture of cherry red spot on fundoscopy given. But
scenario said vision loss in right eye improved after
some time. Cause?
a. CRAO (DX)
b. Carotid Disease
c. Retinal detachment

21. Picture of very red eye with subconjunctival

haemorrhage (no scenario given)asking for next
step:
A- CT ANS if trauma history
B- Warm dressing…could be done acc to Medscape
C- Antibiotic
D- Local anaesthetic
#May Recall

22. Picture given of red eye, acute & painful, his brother
had ankylosing spondylitis. What the most
appropriate action to reach Dx?
A. X-ray spine
B. Bone scan
C. HLA haplotype ANS 377 jm hla B 27 association

23. a pic of eye with conjunctivval injection, very red eye.

. .headache with photophobia
A:uveitis
B:episcleritis
C:conjuctivitis
D:glaucoma ANS
#sept
. Patient came with painful red eye with blurred vision for last 2 hours, cornea was hazy, and
peri-corneal injection. Which of the following will give long term solution of the problem?
Laser therapy
Trabeculectomy
Iridotomoy ANS

25. your in a rural area and 4 cases of trachoma come to you then you find out extra 20 how can you treat
acute indexes ?
a-hand washing
b-azithromycin ANS
c-doxycyclin
d-don’t do anything
e-penicillin

1208
 Ø your in a rural area and 4 cases of trachoma come to you then you find out extra 20 how can
you treat acute indexes ? a-hand washing b-azithromycin c-doxycyclin d-don’t do anything e-
penicillin

Ø Rural indigenous community. 5 kids have trachoma. Contact tracing resulted to 20 people.
Community population is 250. What to do apart from treating index patient? a. Nothing more
b. Treat contact c. Treat community d. Prophylactic drops to contact e. Prophylactic drops to
community

26. Pic of uveitis with oral and genital ulcers.T/t asked

Oral prednisone ANS
Hydroxychloroquine
NSAIDs
Chloramphenicol

27. No purulent discharge, no itchiness. No impairment of vision. Which eyedrop will you give?
A. Hypomellose [eye drop]
B. Ketotifen
C. Sodium cromoglycate
D. Prednisolone
E. Chloramphenicol
Dx: Hay fever
What about redness of eye?
No itchiness rule out allergic cause
No discharge rule out conjuctivitis
No impaired vision rule out glucoma,uveitis,scleritis (painful loss of vision)
So A artifical tears by excluding all others

28. Old lady picture of jaundiced eyes – she looked scary , presented with left facial nerve plasy , dribbling
and some ear discharge CLEAr

1209
 Next –
ct
MRI
valcyclovie
prednisolone 327 jm

Unlike ordinary otitis externa, MOE requires oral or

intravenous antibiotics for cure

Treatment of necrotising external otitis includes correction of

immunosuppression (when possible), local treatment of the
auditory canal, long-term systemic antibiotic therapy and, in
selected patients, surgery. Strict control of diabetes mellitus is
mandatory, although it can be difficult to achieve during the
acute illness. Other immunosuppressive states and comorbid
conditions also must be aggressively managed.

#oct 2017

29. Patient presented with acute glaucoma what is the first thing you should give :
Oral acetazolamide ????
Topical timolol
Topical pilocarpine
topical acetazolamide
Topical atropine

#eye 2017 #oct

30. 40 year old woman of retro orbital pain and reduced visual acuity for 3 days. What is the most
appropriate ix?

1210
 1. Temporal artery biopsy
2. CT scan
3. VEP-on JM 886
4. Fundoscopy
5. Gonioscopy

31. Eye pic of an old main with sudden onset of pain, dilated pupil and red eye. T/m?
1-Atropine
2-Timolol
3- pilocarpine
4- trabeculoplasty-best-dx is acute angle closure glaucoma
5- steroid
32. Picture of red eye with complain of severe pain, no discharge. Treatment asked -- ( Looks like scleritis)
a) Topical hydrocortisone
b) Topical methylprednisolone****
JM 582 ( corticosteroids and NSAIDS)
c) Chloramphenicol
Scleritis associated with RA and herpes zoster, rarely sarcoidosis and tb
33. Young female complaining of eye pain, no watery eyes, no purulent
discharge, no ulcer on cornea on examination. Picture given of left eye,
woman looking down and medial, sclera filled with blood vessels. Asking
for topical treatment
a) Acyclovir
b) Prednisolon***(episcleritis)
c) Timolol
d) Antibiotic starting with B, pharmaceutical name(Bacitracin, Bactroban
or something, forgot)
ans.hypomellose eye drop

34. a man with painfull eye had cataract as well, his eye moment is not effected vision is good, asking what
to do in investigation A slit lamp examination or Gonioscopy-for glaucoma
35. Trachoma out break .....
a)Chloramphenicol to ptns
b)Chloramphenicol as a prophylaxis
c)Surgery for trachoma pts***
Prevention-pt. education
Antibiotics-azithromycin
Surgical correction(for trichiasis ,where relevant)

36. you are working in an area inhabited by aboriginals mostly,there is an epidemic of trachoma,advice to
community
1.face washing****
2.tetracycline to all
3.Chloramphenicol ointment for pt. only

1211
37. A man came because he can’t see the temporal side in his right eye and nasal side of his left eye field,
where is the lesion ?
a. Optic chiasma
b. Right optic nerve
c. Left optic tract
d. Right visual cortex
e. Right Optic radiation

38. Patient presented with acute

glaucoma what is the first
thing you should give :
(contro)Oral acetazolamide(
we give IV)
Topical timolol
Topical pilocarpine- JM 583
topical atropin

39. Patient clinical features:

Chemosis, blurring of vision,
painful, photophobia, pupils
semi dilated fixed and
irregular when compared to
the other side. He has been
having similar attacks in the past. What is the long management of his condition?(angle closure
glaucoma cus sudden onset)
A. Acetazolamide
B. Pilocarpine
C. Trabeculectomy
D Peripheral iridotomy****

40. Given right eye picture(the whole eye redden, no

discharge) patient come with severe pain in eye, injected
and loss of vision and pupil is not react to light
a. prednisolone
b.timolol
c.chloramphenicol
d.surgery

41. 70 year old man (kaung, bo recall) woman (nyi

recall) complains of sudden painless blurring of
vision in left eye. On examination, total loss of left
eye vision, relative afferent pupillary defect are
detected. BP and HR are normal.
a. MRI
b. Carotid Doppler
c. ESR-jm 886 practice tips-to rule it out as
otherwise other eye can also go blind
d. Forget two other options.

1212
 Sudden loss in elderly can be CRAO,ON,TA-check for
temporal arteritis by checkin esr as immediate
institution of cs to prevent blindness in other eye.

42. A little girl with sever pain in left eye and around it, with
discharge and fever. Hx of sinusitis. Dx
A. Blood culture
B. CT scan

orbital cellulitis

common signs and symptoms of orbital cellulitis include

pain with eye movement, sudden vision loss, chemosis,
bulging of the infected eye, and limited eye movement.
Along with these symptoms, patients typically have redness
and swelling of the eyelid, pain, discharge, inability to open
the eye, occasional fever and lethargy. It is usually caused
by a previous sinusitis. Other causes include infection of
nearby structures, trauma and previous surgery.

43. 25 y old pt came pain in the eye become red during pain time also painful urination for 2wks
Trachoma
Chlamydia- for baby common period of two weeks
Gonorrhoea- for baby 5 days
Herpes

1213
Eye Infection: Chlamydial Conjunctivitis. Conjunctivitis is redness and swelling of the clear membrane that lines the
inside of your eyelids and covers the white of your eye. This membrane is called the conjunctiva. Chlamydia is a type
of bacteria that can cause infections.

Most commonly children with active trachoma will not present with any symptoms as the low-grade irritation and
ocular discharge is just accepted as normal. However, further symptoms may include:

• Eye discharge
• Swollen eyelids
• Trichiasis (misdirected eyelashes)
• Swelling of lymph nodes in front of the ears
• Sensitivity to bright lights
• Increased heart rate
Further ear, nose and throat complications
The major complication or the most important one is corneal ulcer occurring due to rubbing by
concentrations, or trichiasis with superimposed bacterial infection.

44. got 4 fundoscopic pics with scenario with painless loss of vision or sth like that.
1. CRVO
2. Optic atrophy
3. Macular oedema
4. Retinal detachment
Almost the same pictures from google.
Central retinal vein occlusion — sunburst appearance

Ret

1214
 Macular oedema

45. 40 y/o conreal injection , hazy, edema, eye pressure raised what is the long term management
Irditomy
Acitazolmide
trabeculectomy

first line drugs-acetazolamide

second line laser-iridotomy-for angle closure only
surgery trabeculectomy.

For angle closure can do both laser iridotomy and trabeculectomy

For open angle-laser trabeculoplasty and trabeculectomy
Open-angle glaucoma is also called primary or chronic glaucoma. It is the most common type of
glaucoma, affecting about three million Americans.

46. Pic of hypopyon after eye surgery asking diagnosis

Acute iritis
Hypopyon
Hypopyon is a medical condition involving
inflammatory cells in the anterior chamber of the
eye. It is a leukocytic exudate, seen in the anterior
chamber, usually accompanied by redness of the
conjunctiva and the underlying episclera.

47. Pic of pupil asking mx if cataract

Laser phaco(method)
Lens change(mx)

1215
 Treatment is IOL ... if method asked then phacoemulsification

48. 78 yrs vision loss over 5 months, corrected by pinhole, cause

a. Age related macular degeneration
b. cataract
c. corrected by pinhole is only refractive error

49. old patient with decrease in vision from past few months .vision s 6/18 on right side and 6/12 on left
and on correction with pinhole is 6/9 on both sides .What is the cause fr this condition?
Retinal degeneration
Glaucoma
Cataract r
refractive error…amedex people
presbyopia…from amedex q bank

50. orbital cellulitis scenario,inv?-ct scan

periorbital cellulitis-first do cbc then blood culture for organism

Rch flowchart n Rx è

1216
51. young man HIT by a squash ball while playing, apart from headache which resolved by analgesic he
complained of decreased in vision. On examination, his
visual acuity was 6/12 in the left eye; right eye
was 6/6asking the most likely cause?
A-vitreous hemorrhage –acute, red tint, blurring vision..if
is same setting
B-retinal detachment
C-zygomatic fracture
D-orbital floor fracture-diplopia

52. young adult hit his eye with squash ball apart from
headache which resolved with paracetamol. in second
day developed slightly decreased in visual acuity in the
affected eye. anterior chamber is clear all other
examinaition are normal what is dx.
A. vitreous hemorrhange
B. B retinal detachemnt
C. retinal artey thrombosis
D. hyphema

1217
 E. cerebral hemhorrhage

53. RAPD aka markus gunn pupil scenario asking cause in 32 yr old women
A mnd
b ms

What are possible causes of Marcus Gunn Pupil?

• Optic Nerve Disorders: optic neuritis, optic nerve infections or inflammations, glaucoma, optic nerve tumor,
optic neuropathy, orbital disease
• Retinal Causes: ischemic retinal disease, retinal detachment, sever macular degeneration, intraocular tumor,
retinal infection
• Cerebral vascular disease
• Amblyopia

If I show the Marcus Gunn Sign, do I have of MS?

As mentioned above, there are a number of potential causes for a relative afferent pupillary
defect. Damage to the optic nerve is the most common cause and damage to the optic nerve is very
common in multiple sclerosis.

54. Melanoma eye picture. Mx?

Excision
Plastic surgeon reference

55. Blowout fracture of orbit what would you see-

A. Hyphaema
B.Horizontal diplopia –cant be as vertical diplo is seen
C. Enopthalmos
D. Depressed Zygomatic arch
E. Pain in mastication-mandible #

Signs & Symptoms

Some clinically observed signs and symptoms include:[10][11]

• Orbital pain
Eyes displaced posteriorly into sockets (enophthalmos)
• Limitation of eye movement
• Loss of sensation (hypoesthesia) along the trigeminal (V2) nerve distribution
• Seeing-double when looking up or down (vertical diplopia)
• Orbital and lid subcutaneous emphysema, especially when blowing the nose or sneezing
• Nausea and bradycardia due to oculocardiac reflex

Causes

Common medical causes of blowout fracture may include:

1. Direct orbital blunt injury

2. Sports injury (squash ball,[12] tennis ball etc.)

1218
 3. Motor vehicle accidents

56. Young man after a quarrel had a fracture of floor of eye what is the more consistent symptoms with
that
Conjunctival hg
loss of visual activity
anaesthesia around the cheek
Cant open the mouth completely
• Epistaxis
#eye
better vertical diplopia, if absent anesthesia cheek

Floor: vertical diplopia

Lat wall: horizontal diplopia

57. 30 year old lady comes to you complaining of blurring of vision for last 3 days. On examination of the
eyes you found left eye is 6/12 and right eye is 6/6. There is also pain behind the left eye on moving the
eye. Which of the following is the diagnosis?
a. Intracranial haemorrhage
b. Tumor of eyeball
c. optic neuritis

58. A man aged 68 develops gradual vision loss over

days bilaterally, what is the most likely diagnosis?
a) macular degeneration
b) CRAO
c) CRVO
d) HTN
e) diabetic retinopathy

1219
59. Scleritis Pic…Asking treatment..Same pic as
below..Options-
a) Topical steroid
b) Chloramphenicol
c) Topical Cipro
d) Topical Timolol
e) Acetazolamide
f) And: steroid or refer

60. middle age women come with swelling in the

submandibular ..pain and swelling more on
eating.How to Dx ? (submandibular calculi)
A Intra oral Xray-
B OPG
C . CT head and neck

61. Similar Q with swelling with eating but it say in

front of tragus , no fever ,What is the Dx ?
I chose salivary calculi …cause
Other options are
A . Parotid abscess
B .Parotitis..diagnosis

62. Baby with red eyes and swelling with yellow crust what is investigation- it is periorbital cellulitis JM586
A.Blood culture
B.LP

CT scan****( if it's orbital cellulitis than CT scan if it is periorbital than go for blood culture )

http://www.rch.org.au/clinicalguide/guideline_index/Periorbital_and_orbital_cellulitis/

Management - orbital cellulitis

This is a surgical emergency. After consultation with the ENT surgeons and ophthalmologists, an urgent CT
scan should be arranged to differentiate those patients with an associated abscess (usually subperiosteal)
from those without. This should be discussed with the radiologist who will ask for coronal views. Imaging
should pay particular attention to the orbital and frontal regions as the abscess may be small.Surgical
drainage of an abscess results in decompression of the orbit and obtains infected material for Gram stain
and culture.
Likely organisms include Strep pyogenes, Strep pneumoniae and Staph aureus. Over 5 years Staph aureus is
more common. Haemophilus influenzae type b is less common since HiB immunisation.

63. cellulitis, eyelid swelling, orbital redness, fever, he cant move eyeball, there is marked tenderness and
erythema around the eye, asking invesigation?
A. Ct scan-for orbital and FBE and C/S for peri
B. swab test

64. eyeball injury …two days later with decreased vision ..but no blood in anterior chamber ..cause?
A vitreous haemorrhage
B hyphema
C detached retina***
D artery damage
(no orbital floor # for sure)

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65. yrs female,visual problem from last 1 year,left eye 6/12 & right eye ??pale optic disc,no
cupping,afferent pupillary reflex absent,DX?
a.DM*** (optic atrophy)
b.glucoma
no optic neuritis/MS in options

66. Macular edema in fundoscopy in Htn and DM

Ans- diabetic retinopathy

67. .a boy presented with a punch in the face.he is asked to look upward and presented this-wats cause-
a.zygoma fracture
b.blowout fracture***

68. . Pic of a man’s face is given.

1221
69. No purulent discharge, no itching. No impairment of vision. Which eyedrop will you give?
A. Hypromellose****
B. Ketotifen
C. Sodium cromoglycate
D. Prednisolone
E. Chloramphenicol

70. Man with excessive tearing for two weeks, no vision impairment, no purulent discharge and not itchy.
What eye drops should give to him?Pic is given but there is no sign of bacterial conjunctivitis, I think.
Only reddening of lower eye lids.
Ketotifen
chloramphenicol-SUSPECTING BLEPH
artificial tears****
prednisolone
sodium cromoglycate
Dx: viral conjunctivitis?

71. Child with periorbital swelling and fever, when open eye lid showing yellow discharge
What to test
Eye swab — cellulitis jm 586
Blood culture
Lumbar puncture
Ct head — if restricted eye movements then ct

Management
Antibiotic guidelines may vary depending on local resistance patterns

• Check local guidelines; these may include advice regarding community acquired MRSA
• If inadequate Haemophilus influenzae type B (Hib) vaccination, treat as severe periorbital cellulitis

Orbital Cellulitis

• Admission
• Keep fasted until need for surgery clarified
• Seek ENT & Ophthalmology advice urgently
• Consider urgent contrast enhanced CT scan of orbits, sinuses +/- brain
• Investigations
• FBE and blood culture
• Lumbar Puncture (LP) is contraindicated due to risk of raised intracranial pressure (ICP) secondary to
possible intracranial extension
• Antibiotics (see below)
• Treat underlying sinus disease e.g. nasal decongestants, steroids (often guided by ENT)

Periorbital Cellulitis

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Severe
Inpatient investigations and management as per orbital cellulitis

Moderate
Inpatient management or consider Hospital in the home (HITH) admission if available locally

• Consider blood culture if febrile and unwell

• Antibiotics (see below)
• Once improving change to oral antibiotics
• If not improving or deteriorating within 24-48 hours, consider managing as Severe Periorbital Cellulitis

Mild

• Antibiotics (see below)

• Review

https://www.rch.org.au/clinicalguide/guideline_index/Periorbital_and_orbital_cellulitis/

72. women progressive loss of vision over 2 days and right sided rtetroorbital eye pain. On examination reduced
visual acuity
normal eye movement, no fundoscopy mention
next invx
MRI brain ***-can be optic neuritis or MS
Temporal artery biopsy
CRP

73. 40 year old woman of retro orbital pain and reduced visual acuity for 3 days. What is the most appropriate
investigation?
A- Temporal artery biopsy
B- CT scan

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 C- Visual evoked potential ****if MRI given then chose
that
D- fundoscopy
E- gonioscopy
Retro orbital pain-mostly optic neuritis and MS

74. Patient came with history of reduced vision she

asking of about MS as she searched in the web.
What is percentage of development of
neurological deficit from episode of optic neuritis
10%. 30 %. 50%. 70%***. 90%
60% JM

75. 10 day old baby thriving well,healthy baby had

yellowish discharge on the right only,cause
1.nasolacrimal duct obstruction - 2 weeks, just
wipe with saline ,massage.
2.gonorrhoea-24 to 48 hours aft birth,systemic
symptoms
3.chlamydia **- 1-2 weeks aft
birth,conjunctivitis+pneumonia can happen,Rx is
oral antibiotics erythromycin

76. 10 days old baby yellow discharge Ask about ttt:

A- Wash with saline****
B- ceftrixone
C- topical azthromycin

77. Eye pictures with yellow crust at lower eye lid margin .
I don’t see redness of conjunctiva. Patient present
with itchiness
Chloramphenicol eye drop
Frequently wash lower eyelid blepharitis jm 585

78. Patient presented with diplopia for 1 day. On

examination there was diplopia on the right eye when
looking towards the right side. his glucose is normal.
ECG has occasional verntricular ectopics. Whats the
most appropriate management.
A. Warfarin- suspecting TIA-giving anticoagulants etc
B. Peridropnil
c. Metformin
d. Observation-lateral rectus palsy-6th nerve palsy-
microvascular ischemia-only observe usually recover in 3-6
mnths

As glucose is normal ( so we exclude C) also its Vent ectopics

which are mostly benign therefore ( exclude A as we dont anticoagulate in Vent Ectopics) not B cuz BP isnt
mentioned to be elevated !

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79. a pt. presented with c/o dry eyes. He has history of seasonal allergic conjunctivitis c/o dry mouth as
well as positive anti Ro and La antibodies what is ur
next step in her management?
1. Hydroxychloroquine
2. Artificial tear drops — sjogrens jm306
3. Mehotrexate
4. Topica prednisolone

80. Another pic of red painful eye other examination

normal no history of any discharege no history of
itching and crusting c/o lower back pain asking dx
1.glaucoma
2 uvitis-since c/o back pain(AS)
3Episcleritis
4scleritis

81. builder 48 yr,weekness in left side of body for few

minutes.past same episode for 5 times.advice after giving
aspirin and discharge with follow up by local doctor
More antiplatelet
Can’t drive 6months.
Can’t go to work without local doctor’s permission
No strenous work

no role of more antiplatelet in prevention of recurrent TIAs

B -cant drive aft TIA for 2 weeks to 1 month
C sternous work related to stroke questionable
D by exclusion criteria is the answer

82. A 22 yr pt. came with numbness ,heaviness of the rt hand & leg together with left homoanyomous
hemianopia .Her hand & foot state resloved after 2 weeks but her visual field defect is still present 6 wk
later.wht would u do?
Cannot drive for 2wks
Cant drive for 2 months
Cant drive for 6 months
Cant drive forever
Ans .refer to occupational therapist

https://www.onlinepublications.austroads.com.au/items/AP-G56-17

83. 53 yo man who is on treatment for OA and DM, came diplopia when he kooks to lateral right side, GTT
and CT were mentioned normal. other things were normal. what’s ur most appropriate treatment?
A-observe
B-warfarin
C-metformin
D-perindopril

84. Picture of cherry red spot on fundoscopy given. But scenario said vision loss in right eye improved after
some time. Cause?
a. CRAO
b. Carotid Disease
c. Retinal detachment

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85. Patient will h/o DM and HTN hurt her wrist when she crashed into a parked car. On examination there
was significant peripheral vision loss which she was unaware of. Next appropriate step :
a. Check Intraocular pressure …next
b. CT head…best
Dx open angle or chronic glaucoma

86. .fundoscopy of MD with scenario of 72 yrs old man come with gradual vision loss over last 12 months
,but he has no other complains without it.which of the following is the most probable diagnosis??
a.MD inx:fluorescein angiograpgy,Rx-injection,laser,photo therapy
b.CRVO
C.CRAO
d.pappiloedema
e.optic atrophy
**** almost similar to this photo I had in my exam

1226
87. Eye Picture: Lady was taking hypertensive medicine for high BP and Metformin for Diabetes Mellitus. 2
weeks ago she started to fell gradual loss of her vision. No BP & lab values given.Fundoscopy was done
and the picture is as follows: What is the cause of her
problem?Almost the same picture.
1)CRVO
2)CRAO
3) Retinal detachment
4) Hypertensive retinopathy-av kinking
5) Diabetes Retinopathy

88. your in a rural area and 4 cases of trachoma

come to you then you find out extra 20 how can you
treat acute indexes ?
a-hand washing
b-azithromycin ANS
c-doxycyclin
d-don’t do anything
e-penicillin

89.It was something like this.. 5 kids in a community

found with Trachoma...20 household contacts were related to these kids.. it was a small community of
total 240 ppl. How to manage this outbreak?
1- treat kids
2- treat kids and household
3- treat whole community
4- prophylactic abx for household
5- prophylactic abx for community

90. #eye You see many trachoma cases in indigenous community. What to do to prevent trachoma cases?
A) Give eye drops to community
B) Give eye drops to contact
C) Give treatment to community
D) Give treatment to contact
*******(For case & contact-give tx;for community prevention -hand wash)
#July #2017
#note_this National governments in collaboration with numerous non-profit organizations implement
trachoma control programs using the WHO-recommended SAFE (mnemonic)strategy, which includes:
1.Surgery to correct advanced stages of the disease;
2.Antibiotics to treat active infection, using azithromycin
3.Facial cleanliness to reduce disease transmission;
4.Environmental change to increase access to clean water and improved sanitation.
a. Contacts of cases identified through community screening:

Active trachoma community prevalence in 5-9 year old Aboriginal and Torres Strait Islander children:
i. ≥20%: Treat all people >3kg living in households with children <15 years of age.
ii. ≥5 to < 20% and there is no obvious clustering of cases: Treat all people >3kg living in households with
children <15 years of age.

1227
iii. ≥5 to < 20% and cases are obviously clustered within several households and health staff can easily
identify all household contacts of cases: Single-dose azithromycin to all people >3kg living in households
with an active trachoma case.
iv. <5%: Treat all people >3kg living in households with an active trachoma case.

b. Contacts of cases identified outside of screening programs

Treat people >3kg who living in the same household (s) as the case

ENT RECALLS
91. Child with acute otitis media most common organism
Streptococcus pneumoniae (ans)
Staph aureus
H influenza

FIRST===SRETOCOCCUS PNEUMONIA
SECOND===H.INFLUENZA

Streptococcus pneumoniae
S pneumoniae is the most common etiologic agent responsible for AOM and for invasive bacterial
infections in children of all age groups. [9] It is a gram-positive diplococcus with 90 identified serotypes
(classified on the basis of the polysaccharide antigen), the frequency of which varies between age
groups and geography.

Haemophilus influenzae
In middle ear aspirates from patients with AOM, H influenzae is the second most frequently isolated
bacterium and is responsible for approximately 20% of episodes in preschool children. [10] The
frequency may be higher in otitis-prone children, older children, and adults who have received the
pneumococcal vaccine.(medscape)

Acute otitis media (AOM) is a common problem in early childhood; 2/3 of children have at least one
episode by age 3, and 90% have at least one episode by school entry. Peak age prevalence is 6-18
months.

Causes:
viral (25%)
Streptococcus pneumoniae (35%)
non-typable strains of Haemophilus influenzae (25%)
Moraxella catarrhalis (15%) (RCH)

https://www.rch.org.au/clinicalguide/guideline_index/Acute_otitis_media/

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92. Acute otitis media in a child with bulging tympanic membrane and temp. Fever...etc. Tx.
A amoxicillin oral (ans) 567 jm
B erythromycin oral
C iv penicillin etc

93. . A child with chronic ear discharge, a picture is given

(seems like a perforated ear drum with discharge) no
fever or deafness mention, what is the diagnosis?
a. chronic otitis media (ans)
b. acute otitis media
c. cholesteatoma
d. mastoiditis
https://emedicine.medscape.com/article/859501-
treatment#d9

asom

94. 7 years old child with history of chronic bilateral suppurative otitis media with history of bilateral gommet
operation presented with right ear pain, discharge and swelling behind his right ear
a. Culture
b. CT (ans)

1229
 c. Hearing examination
d. Ab treatment

95. Chronic suppurative otitis media scenario. After ear toilet what will you do?
a. Amoxicillin
b. Ciprofloxacin ear drops (ans)
d. Ceftriaxone

96. What is the most common complication of measles?

A)Subacute Sclerosing encephalitis (uncommon)
B)Acute Otitis media (ans)(most common)
C)Myocarditis
D)Pneumonia (common)
E)Keratoconjunctivitis (common)

Ear infection. One of the most common complications of measles is a bacterial ear infection.
Bronchitis, laryngitis or croup. Measles may lead to inflammation of your voice box (larynx) or
inflammation of the inner walls that line the main air passageways of your lungs (bronchial tubes).
Pneumonia. Pneumonia is a common complication of measles. People with compromised immune
systems can develop an especially dangerous variety of pneumonia that is sometimes fatal.
Encephalitis. About 1 in 1,000 people with measles develops encephalitis, an inflammation of the
brain that may cause vomiting, convulsions, and, rarely, coma or even death. Encephalitis can closely
follow measles, or it can occur months later.
Pregnancy problems. If you're pregnant, you need to take special care to avoid measles because the
disease can cause pregnancy loss, preterm labor or low birth weight.
Low platelet count (thrombocytopenia). Measles may lead to a decrease in platelets — the type of
blood cells that are essential for blood clotting
https://www.mayoclinic.org/diseases-conditions/measles/basics/complications/con-20019675

https://www.nhs.uk/Conditions/Measles/Pages/Complications.aspx

Common complications

More common complications of measles include:

diarrhoea and vomiting, which can lead to dehydration
middle ear infection (otitis media), which can cause earache
eye infection (conjunctivitis)
inflammation of the voice box (laryngitis)

1230
 pneumonia, bronchitis and croup – infections of the airways and lungs
fits caused by a fever (febrile seizures) .

97. 4yrs old girl with ear ache and discharge.organism responsible??
A. Staphylococcal pneumoniae
B. H. Influenza
C.streptococcas pneumonia (ans)(pseudomonas — if aboriginal boy)
D. Moraxella catarrhalis

98. 1 yr old boy crying and catching his left ear repeatedly. On PE both ear tympanic memb red , exudates present
on tonsils. No ear discharge or nasal discharge
a- Acute otitis media (ans)
b- Acute tonsillitis
c- Chronic otitis media

99. A 4yr has earache and fever. Has taken paracetamol several times. Now it’s noticed that he
increases the TV volume. His preschool hearing test shows symmetric loss of 40db. What is the
most likely dx?
a. OM with effusion (ans) (pain/dec hearing/fever/no external secretions)
b. Otitis externa
c. Cholesteatoma
d. CSOM (there will be discharge)
e. Tonsillitis

Serous otitis media(glue ear):

Otitis media (OM) with effusion (OME) often follows an episode of AOM. Consider OME in patients with
recent AOM in whom the history includes any of the following symptoms:

Hearing loss - Most young children cannot provide an accurate history; parents, caregivers, or teachers
may suspect a hearing loss or describe the child as inattentive

1231
 Tinnitus - This is possible, though it is an unusual complaint from a child

Vertigo - Although true vertigo (ie, room-spinning dizziness) is a rare complaint in uncomplicated AOM
or OME, parents may report some unsteadiness or clumsiness in a young child with AOM

Otalgia - Intermittent otalgia tends to worsen at night.

Every examination should include an evaluation and description of the following four TM characteristics:

Color – A normal TM is a translucent pale gray; an opaque yellow or blue TM is consistent with middle
ear effusion (MEE)

Position – In AOM, the TM is usually bulging; in OME, the TM is typically retracted or in the neutral
position

Mobility – Impaired mobility is the most consistent finding in patients with OME

Perforation – Single perforations are most common.

100. . An 8 year old boy , with previous hx of 2 ear surgeries comes with complaint of pain behind ear, profuse
offensive discharge . O/E the area behind ear is tender.Next inv?
A) Culture of discharge
B) CT (ans)(to rule out mastoiditis)
101. A child who is acting out in school, with hearing loss, comes to and there’s a picture like this. He has been
having multiple episodes of ear pain and discharge over the years. What is your diagnosis?
CSOM (ans)

1232
 Otitismedia with effusion
Otitis externa

102. Chronic suppurative otitis media (CSOM) is a perforated tympanic membrane with persistent drainage from
the middle ear (ie,jnd nasal congestion…incomplete stem)

a-sinusitis
b-mastoiditis
c-cholesteotoma (ans)

103. A boy is brought in by the father to see you because he has become very inattentive in school with falling
grades. He is said to have been having recurrent bilateral ear discharge for some
months now. On examination, he had bilateral hearing loss with findings of ear examination as
below:
What is the next step in management of this child?
a. Ciprofloxacin ear drop (ans)
b. Tympanic membrane grafting ?
c. Hearing aid
d. Amoxicillin-Clavulanic acid

A..Hand book:Topical antibiotics are an important part of therapy for otitis externa and for chronic
otitis media where there is a chronic perforation of the tympanic membrane. Whilst topical
ciprofloxacin drops are the most appropriate choice for this

104. A boy came to you with history of ear discharge 2 weeks ago, his tympanic membrane looks dull and
retracted and there is yellow discharge from his ear. Next step in management?
Oral Amoxicillin (ans
Ear toilet

More than 6 weeks: csom

1233
1234
105. 3yr indigenous child with profuse yellow colour discharge, nasal green discharge, inflammed TM, enlarged
inflammed tonsils. Next step?
Oral amoxil (ans)
Soframycin ear drops
Ear toilet
Oral steroid
Oral amoxil-clavulanic acid
https://www.rch.org.au/clinicalguide/guideline_index/Acute_otitis_media

106. 45 yrs pt. .. with Myopia..sudden onset of flashing of lights and particles floating in front of vision…
Dx…Retinal Detachment myopic pt. more prone to develop retinal detachment

There are various subtypes of OM. These include AOM, otitis media with effusion (OME), chronic suppurative otitis
media (CSOM), mastoiditis and cholesteatoma. They are generally described as discrete diseases but in reality there
is a great degree of overlap between the different types. OM can be seen as a continuum/spectrum of diseases:

AOM is acute inflammation of the middle ear and may be caused by bacteria or viruses. A subtype of AOM is acute
suppurative OM, characterised by the presence of pus in the middle ear. In around 5% the eardrum perforates.
OME is a chronic inflammatory condition without acute inflammation, which often follows a slowly resolving AOM.
There is an effusion of glue-like fluid behind an intact tympanic membrane in the absence of signs and symptoms of
acute inflammation.
CSOM is long-standing suppurative middle ear inflammation, usually with a persistently perforated tympanic
membrane.
Mastoiditis is acute inflammation of the mastoid periosteum and air cells occurring when AOM infection spreads out
from the middle ear.
Cholesteatoma occurs when keratinising squamous epithelium (skin) is present in the middle ear as a result of
tympanic membrane retraction.

OTITIS EXTERNA

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107. Facial paralysis and discharging ear…
A-bells palsy?
B-Malignant otitis externa? (ANS)
C-Ramsay Hunt?

Necrotising or malignant otitis externa

This is rare but is a life-threatening extension of otitis externa
into the mastoid and temporal bones. It is usually due to
Pseudomonas aeruginosa or S. aureus. It usually affects elderly
patients with diabetes or patients who are
immunocompromised. It produces pain and headache of greater
intensity than clinical signs would suggest. Facial nerve palsy is a
red flag sign but is not necessarily associated with a poorer
prognosis.[5] Obligatory criteria for diagnosis include:[6]

Pain
Oedema
Exudate
Granulation tissue (may be present at the junction of bone and
cartilage)
Microabscess (when operated upon)
A positive bone scan or failure of local treatment and possibly
Pseudomonas spp. in culture

*Facial paralysis + ear discharge = Malignant otitis externa.

*facial paralysis +vesicles around the ear= Ramsy hunt

108. Old woman had watery discharge from left ear. Two days later left facial paralysis. Most appropriate
investigation?
a) MRI head
b) CT head (ans)(to see malignant otitis externa)
c) ESR(initial)
d) CRP

109. Pt with otoache on exam ear full of wax and there is irregular swelling below mandible in rt
A-repeat otoscope after irrigation of the ear
B- ct head
C-exam the tongue(base of tongue)( Irregular swelling below the mandible seems like cancer , examine tongue)

110. a child with recurrent ear discharge,referred ear pain,with painless cervical lymph node enlargement, how
can you find cause?
a) do idl
b)clean discharge and view with otoscope..
c) gram stain and c/s of discharge (ANS)

1236
111.
Ans: apply cold pad
https://emedicine.medscape.com/article/82793-overview
we don’t do aspiration bcz of increase chances of recurrence.

1237
1238
112. ENT Echymosis of ear after trauma .What to do- 1. No specific Rx 2.Apply cold pad 3.Aspirate The collected
blood 4.antibiotic 5.Drainage

HEARING LOSS

113. 21month old child, hearing test,,,……….. Vra, abr, asr

#JM 483 more update ………

ABR= Auditory Brainstem Response test

Auditory brain stem response testing is used to evaluate children
(particularly young infants) for whom information on behavioural
hearing tests is either unobtainable or unreliable

Visual reinforcement audiometry= VRA

First 6 months=abr

1239
 6 to 24 months=vra
Upto 4 yrs=play audiometry
After 4 yrs=audiometry

114. 65 yesr of age pt. ringing both ear symptoms started 12 month ago; symptoms more on left then rt .there is no
hearing loss; wibber&rinne test all normal. what next?
1.audiometry- to asses hearing loss. (ans)
2.tonometry.
3.provocative audiometry
4. Us of carotid vessels
5. Mri brain

The results of both tests are noted and compared accordingly below to localize and characterize the
nature of any detected hearing losses.
Note: the Weber and Rinne are screening tests that are not replacements for formal audiometry hearing
tests
This Weber test is most useful in individuals with hearing that is different between the two ears.
It cannot confirm normal hearing because it does not measure sound sensitivity in a quantitative
manner.
Hearing defects affecting both ears equally, as in Presbycusis will produce an apparently normal test
result.

115. Pt hears a popping sound in ear before that mild vertigo the nystagmus and then fall down now have rt horner
syndrome and right ear total sensory neural hearing loss(SNHL). Probable cause?
a.Acoustic neuroma (unilateral hearing loos,tinititus,vertigo,nystagmus,headache)
b.Acute labyrinths
c.Meningioma
d.Basilar infarction
if they say basilar that means bilateral
if they would have said vertrobrobasilar then yes (aica)
otherwise acoustic neuroma
August_2018
https://emedicine.medscape.com/article/882876-overview#a9

normal tympanic membrane

normal TM

1240
 Chronic otitis media with a retraction pocket of the pars
ACUTE OTITIS MEDIA with purulent effusion behind a flaccid.
bulging tympanic membrane

cholesteatoma
Mastoiditis

1241
116. Blow out fracture of orbit while playing squash What would you see JM- 1458
A-hyphaema
B-horizontal diplopia- vertical diplopia
C-enophthalmos
D-depressed zygomatic arch

Orbital fracture or blow out fracture has 3 features:

-Diplopia on upward and outward gaze (due to loss of elevation of eye)
-loss of sensation of upper cheek and gum (due to damage to infra orbital nerve)
-enopthalamus
Reference Tjandra
117. 14yrs old boy,One of your long term patient since birth,presents to you at your surgery after Dog bite at
home,when he was playing with it , accidentally fell over the animal and provoked it. O/E There were Two
deep puncture wounds. No deep structural injury.His last immunisation for tetanus was at 4 yrs of age
according to his File.You advise him to get the wounds cleaned and apply non-Adherent , absorbent plaster
by the Office nurse and give him prophylactic antibiotics for 5 days. As the bytes are deep puncture wounds
you decided to give him tetanus injections as well. Which one is the BEST vaccination?.
1.DTPa(Diptheria,Tetanus,Pertussis acellular)***
2.Tetanus Toxiod
3.Adult Tetanus and Diptheria Toxoid
4.Tetanus immunoglobulin + Tetanus toxoid
5.Diptheria toxoid +whole cell pertussis +Tetanus toxoid (DPT) booster.

118. Child has chronic ear discharge and nasal congestion..risk—

a)Sinusitis
b) Mastoidities
c) Cholesteotoma

119. Most common long term complication of Streptococcus Pneumonia meningitis ?

A- Cerebral Palsy
B - Epilaspy
C- Deafness - Hearing issue
120. Sudden onset of vertigo, nystagmus, ataxia
and hearing loss in one ear. Dx?
1) Labyrinthitis
2) Meningioma
3) Acoustic Neuroma
4) Meinner's disease
5) lateral medullary syndrome
121. 25 year old man presents with a sudden acute history of vertigo on waking with loss of balance
affecting his left side and pain in his left ear. The sensation of environment rotating around him is
associated with giddiness, vomiting and ataxia unless he lies completely still. There is no associated
deafness and tinnitus. O/E he has a nystagmus with the rapid component to the left. Cranial nerve
examination is otherwise normal. Caloric test of vestibular function shows markedly reduced response
on left side. Diagnosis?
A cerebellopontine angle tumour
Meniere’s disease
Vestibular neuronitis
Vertebrobasilar ischemia
Paroxysmal positional vertigo

1242
122. A patient has had 4 episodes of vertigo with hearing loss in right ear lasting 10 hours each in last 12
months. Tinnitus is also present. Cranial nerve examination is normal except deafness in right ear..
Neurological examination in normal.
Labyrinthitis
Meniere's disease
Acoustic neuroma
BPPV
123. 65 year old woman presents with progressive worsening deafness over 6 months. She finds hearing
particularly difficult in noisy environment. She thinks right ear is more affected than left. Hearing tests
shows:
Hearing of whispered voice diminished on both sides
Rinne test shows AC>BC in both ears
Weber test – sound louder in left ear
Which is the most likely cause of deafness?
1. presbycusis
2. wax in external ear
3. acoustic neuroma
4. chronic petrositis
5. Otosclerosis
Hb mcq2.064
124. Woman with 3 kids, has otosclerosis with hearing aid. Which contraceptive method is best for her?
a. Low dose combined OCP b. High dose c. POP d. Condom e. IUCD

125. A child presented with right sided hearing loss. Tuning fork test was done and showed Air
conduction> Bone conduction. Weber test localised to left ear. What is the most appropriate
diagnosis?
A. Acute Otitis Media
B. Acute Otitis externa
C. Serous Otitis Media with effusion (glue ear)
D. Otosclerosis
E. Acoustic neuroma
126. 25 year old lady presents with progressive deafness over the past few months. She is currently
pregnant with her first child at 6 months of gestation and her antenatal progress has thus far been
normal. She has had associated tinnitus of mild degree. She has noticed that she can hear better in
noisy surroundings. Her mother also has a history of deafness. Which one of the following is most likely
cause of her deafness?
Acoustic neuroma
Vestibular neuronitis
Meniere’s disease
Otosclerosis
Cholesteatoma

127. A middle aged woman with deafness and loss of corneal reflex but with no tinnitus
A. vestibular neuronitis
B. Meniere’s disease
C. Acoustic neuroma
D. Multiple sclerosis
it presents e hearing loss (sensorineural)+ facial sensory impairment + headache + unsteady gait

1243
128. #2017 A patient presents with sudden onset of hearing loss associated with Vertigo, tinnitus and
loss of balance. There was also Horner syndrome. What is the diagnosis?
a. Acoustic neuroma????
b. Acute labyrinthitis
c. Basilar infarction

Lateral medullary syndrome, (or Wallenberg syndrome) is an acute ischemic infarct due
to occlusion of the vessels supplying the lateral medulla oblongata; most commonly occlusion of
intracranial portion of the vertebral artery followed by PICA and it's branches. This syndrome is
characterised by:
• vestibulocerebellar symptoms:
o vertigo, falling towards the side of lesion,
o diplopia, and
o multidirectional nystagmus (inferior cerebellar peduncle and vestibular nucleus)
• autonomic dysfunction:
o ipsilateral Horner's syndrome,
o hiccups
• sensory symptoms:
o initially abnormal stabbing pain over the ipsilateral face then loss of pain and temperature
sensation over the contralateral side of body (spinal trigeminal nucleus involvement)
• ipsilateral bulbar muscle weakness:
o hoarseness,
o dysphonia,
o dysphagia, and
o dysarthria,
o decreased gag reflex (nucleus ambiguus)....
o doesn't have hearing loss.

The infections that cause vestibular neuritis and labyrinthitis may resolve without treatment within a few
weeks. However, if the inner ear is permanently damaged by the infection and the brain does not
adequately compensate, symptoms can develop into chronic dizziness, fatigue, disorientation, as well as
tinnitus and hearing loss (if labyrinthitis is the cause).

1244
129. 72 yr female, sudden vertigo, nystagmus, tinnitus & deafness
in left ear.one sided body weekness. dx?
1.Wallenberg syndrome (Lateral medullary syndrome)
2.lateral pontine syndrome
3.acoustic neuroma???
4.Minneirs disease
5.Labyrinthitis
6.basilar infarction
It doesn’t have deafness
Signs of facial and loss of sensation are missing
It doesn’t cause weakness it causes loss of sensation of pain and temp

130. Sudden onset of vertigo, nystagmus, ataxia and hearing loss in one ear. Dx?
1) Labyrinthitis
2) Meningioma
3) Acoustic Neuroma
4) meniere’s disease
5) lateral medullary syndrome
131. Vertigo, vomiting, nystagmus, Horner syndrome, nerve deafness..
Cause, Options
middle ear defect,
acoustic neuroma,
meningitis
labyrinthitis.
132. #Nov2018
A 10yo girl has been referred for assessment of hearing as she is finding difficulty in hearing her teacher
in the class. Her hearing tests show: BC normal, symmetrical AC threshold reduced
bilaterally, weber test shows no lateralization. What is the single most likely dx?
a. Chronic perforation of tympanic membrane
b. Chronic secretory OM with effusion
c. Congenital sensorineural deficit
d. Otosclerosis
e. Presbycusis
?????????????

1245
133. a one-week old neonate developed severe jaundice and mother is quite concerned about the long-
term risk of sever hyperbilirubinemia
which of the following is not the possible consequence of kernicterus the baby
a. hearing deficit
b. athetoid cerebral palsy
c. paralysis upward gaze
d. hypothyroidism
e. dental dysplasia
#peads#2014
https://emedicine.medscape.com/article/975276-
clinical?fbclid=IwAR2OUHucka63E8wB4ahYDAhQVSVZy-a8dt3tMjQS2uDKMONnJNUzgdqneVU#b4

134. 28 years old girl student of business administration with vertigo for 3 months.she says that
irrelevant noises are ringing all the time but denies any hearing difficulty she is very fond of music and
keeps her earphones in ear all the time.one of her aunt on maternal side cannot hear normaly.which of
the following test will u perform to reach a diagnosis
A) Renies and weber test
B) Speech discrimination test
C) Pure tone audiometry
D) Electrocochleography
#ENT 2016
Dx: otosclerosis
Pure tone audiometry for definitive diagnosis n weber n rinne only for screening.
135. #2015 pt. complained of vertigo in left ear. with hall-pick manoeuvre he has vertigo and
nystagmus. other wise he is well and doesn’t have hearing loss what could be the cause?
a. acoustic neuroma
b. left labyrinthtis
c. right cerebella problem
d. left temporal problem
similar to Q 3.029 of HB

136. Elderly about 72 yr old with persistent ear pain. Heavy smoker, last wk PE everything normal
a) Chronic otitis media
b) CA tongue
c) Cholesteatoma
d) Acoustic neuroma
137. unilateral foul smelling ,bloodstained discharge from nose
A. foreign body
B. nasal polyps
C. Atopy
D. Rhinitis

138. nasal blockage especially at night & can't sleep well.he has periorbital darkness. allergy test
(+).what is ur initial step??
Normal saline wash
Oral cetrizine at night
Oral(another antihistamine) in the morning
Oral steriod at night
Nasal steriod spray at night

1246
139. A child present with sore throat, fever, rhinorrhea and cough for a few days. He is known asthmatic.
He used inhaled salbutamol two times in last year. Now he has no wheeze and respiratory distress.
Mgt?
A. Diphenhydramine cough mixture (exact words)
B. Oral cetirizine
C. Oral amoxicillin
D. IV ceftriaxone
E. Inhaled salbutamol
https://www.rch.org.au/clinicalguide/guideline_index/Sore_throat/?fbclid=IwAR2kS0dqibaGo8GQBNNp22jgKMuiHC
LwMM2jQ0INngjZrHegvnm5hNidmvY

140. 65-year-old male presents to your office complaining of worsening shortness of breath. He has
experienced shortness of breath on and off for several years, but is noticing that it is increasingly more
difficult. Upon examination, you note wheezing and cyanosis. You conduct pulmonary function tests,
and find that the patient's FEV1/FVC ratio is markedly decreased. What is the most likely additional
finding in this patient? Topic Review Topic
1. Decreased bicarbonate
2. Increased erythropoietin — dt prolonged hypoxia
3. Nasal polyps
4. Increased IgE
5. Pleural effusion

141. 29-Patient presents with redness and continuous pain for 24 hours in the maxillary area of the face. Diagnosis:
A. Trigeminal neuralgia- page 561
B. Acute maxillary sinusitis
C. Varicella
D. Herpes simplex (NOT zoster)

1247
142. 32- woman with sudden continuous pain in maxillary area with redess dx?
Herpes
Trigeminal n
Varicella

143. old man had allergic rhinitis and he taked intranasal stroid as he need
he plans to engage scuba diving wt he should do?
A/ use steroid before diving
b/ decongested (pseudo ephedrine ) before diving
144. 8 years old child affected with common cold most of the 12 months but more in winter season. On physical
examination, no LN enlargement. What investigation will u do?
A. Nasal swab
B. CT sinus
C. Skin prick test
D. Ig E
E. CT nasal bone

145. #resp A 24-year-old female is referred to a pulmonologist for worsening symptoms of asthma. Her past medical
history is otherwise unremarkable except for a worsening of her asthma symptoms during her menses. She describes
her period as lasting for several days with severe abdominal cramping that sometimes requires her to stay home from
work. If this finding was truly related to her asthma, what would you also expect to find on this patient's physical
exam?
a) Cafe-au-lait spots
b) Skin telangectasias
c) Saddle nose deformity
d) Nasal polyps
e) Increased jugular venous distention

Aspirin induced asthma( we assume here that shes taking aspirin for her menstrual problems)
Its a triad of asthma, acute rhinosinusitis with nasal polyp and bronchospasm
Treatment stop nsaids/aspirin
Aspirin induced Asthma -> polyps

https://www.ncbi.nlm.nih.gov/m/pubmed/20874438/?fbclid=IwAR1LQvAfkufZhvoD6TnzNKo7ae2lcoBXTMm2Kjp
WtXcbZQWv5HGSIoLGtMw

146. Young man comes to you complaining of brisk epistaxis. He says he has never had any nasal problems before.
What do you suspect?
A. Digital trauma
B. Foreign objects
C. Sinusitis
D. Allergic reaction
E. Picking nose
Picking nose is one of the subtype of digital trauma also encompasses mental trauma.Since E is commonest so may be
reasonable.

1248
147. An 18 year old girl presents with epistaxis, malaise and tiredness for months. no other symptoms .
Hb is 8.5, microcytic hypochromic picture. INR is 1.5. Calcium is 1.9. What is nex most appropriate to
reach diagnosis
a. Hb electrophoresis
b. serum electrolytes
c. Iron studies
d. anti glidian antibods
e. stool culture
148. Young woman presents with epistaxis and fatigue , she felt of tiredness for months and has had regular heavy
periods. She is pale, otherwise in no acute distress.
On investigations her Hb is 85g/l (low)
MCV (low)
Ca is 1.9 (low) and
INR is 1.5. (normal given with upper limit 1.1 so high INR)

1249
 Which of the following is the most appropriate next step?
A-blood transfusion
B-Iv calcium
C-hemolytic screen
D-fresh frozen plazma
E-vitamin K

149. this 21-year-old woman has a history of recurrent epistaxis: What is the most likely underlying diagnosis?
A- Idiopathic thrombocytopenic purpura
B- Peutz-Jeghers syndrome
C- Anorexia nervosa
D- Combined oral contraceptive pill use
E- Hereditary haemorrhagic telangiectasia

E.....""Hereditary haemorrhagic telangiectasia.......

Also known as Osler-Weber-Rendu syndrome, hereditary haemorrhagic telangiectasia (HHT) is

an autosomal dominant condition characterised by (as the name suggests) multiple
telangiectasia over the skin and mucous membranes. Twenty percent of cases occur
spontaneously without prior family history.

There are 4 main diagnostic criteria. If the patient has 2 then they are said to have a possible
diagnosis of HHT. If they meet 3 or more of the criteria they are said to have a definite diagnosis
of HHT:
epistaxis : spontaneous, recurrent nosebleeds
telangiectases: multiple at characteristic sites (lips, oral cavity, fingers, nose)
visceral lesions: for example gastrointestinal telangiectasia (with or without bleeding),
pulmonary arteriovenous malformations (AVM), hepatic AVM, cerebral AVM, spinal AVM
family history: a first-degree relative with HHT.......""

150. 33-patient with unilateral severe epistaxis young age ,what could be the cause ?
a.hypertention
b.cocaine abuse
c.foreign body
at this age group 2 possibilities 1 septal perforation b/c of cocaine abuse and 2 post.juvinile
nasopharyngeal angiofibroma.......so,B

1250
Neck lumps

1.The mother of a 2-year old becomes concerned after she notices

a lump in his neck. On examination, the child is well, there is a
swelling in the subcutaneous tissue of the posterior triangle
which transilluminates. The most likely diagnosis is:
Dermoid cyst
Branhial cyst
Thyroglossal cyst
Cystic hygroma
Ranula1251

2.QUESTION

2.A 61-year old lady presents with a neck lump. The mass is below
the sternocleimastoid muscle. Although the swelling is
painless, she is profoundly embarrassed by halitosis. The
most likely diagnosis is:
Goitre

1251
Reactive lymphadenopathy
Lymphoma
Pharyngeal pouch
Cervical rib1252

3.QUESTION 3
A 31- year old man presents with recurrent infection and
abscesses in the neck. On examination, you notice a midline
defect with an overlying scab. The swelling moves upwards
on tongue protrusion. The defect is most likely due to:

Dermoid cyst

Branhial cyst
Thyroglossal cyst
Cystic hygroma
Ranula1252

4.A 80-year old complains of neck swelling after a recent cold,

which has not resolved. On direct questioning, he has
experienced night sweats and has noticed some pain in the
lumps when he drinks wine with his meals. Examination
reveals multiple, painless swelling in the neck of a ‘rubbery’
consistency. His symptoms are most likely due to:
Goitre
Reactive lymphadenopathy
Lymphoma
Pharyngeal pouch

Cervical rib

1252Flare of pains in lymph nodes after alcohol intake is typical of Hodgkin lymphoma

Patients with Hodgkin's lymphoma may present with the following symptoms:

• Lymph nodes: the most common symptom of Hodgkin's is the painless enlargement of one or more lymph
nodes, or lymphadenopathy. The nodes may also feel rubbery and swollen when examined. The nodes of the
neck and shoulders (cervical and supraclavicular) are most frequently involved (80–90% of the time, on
average). The lymph nodes of the chest are often affected, and these may be noticed on a chest radiograph.

Lymphadenopathy or adenopathy is disease of the lymph nodes, in which they are abnormal in size, number, or
consistency.[1] Lymphadenopathy of an inflammatory type (the most common type) is lymphadenitis,[2] producing
1252
swollen or enlarged lymph nodes. In clinical practice, the distinction between lymphadenopathy and lymphadenitis is
rarely made and the words are usually treated as synonymous. Inflammation of the lymphatic vessels is known as
lymphangitis.[3] Infectious lymphadenitides affecting lymph nodes in the neck are often called scrofula

5.QUESTION

A fit 19-year old man notices a neck swelling whilst he is shaving.

On examination, there is a smooth, round and mobile lump
not tethered to underlying structures. Fluid aspirated from the
swelling contains cholesterol crystals. The most likely cause
of the swelling is:
Dermoid cyst
Branhial cyst
Thyroglossal cyst
Cystic hygroma
Ranula

Reactive
lymphadenopathy
Lymphoma

Dermoid cyst

: branchial cyst ( cholesterol crstals ) .ref tjendra

1253
6.Old aged man with tonsillar mass....most probable diagnosis: (incomplete)

A)Primary tonsillar carcinoma

B)Nasopharyngeal carcinoma

C)Parotid carcinoma.

7.old man 60 years old who is a heavy smoker for 40 years comes to you with a swelling in the tonsillar region,O/E
there is a mass in the tonsillar pouch,what is your diagnosis ?

a. Nasopharyngeal cancer

b. Lipoma

c. lymphoma

d. laryngeal cancer e. metastatic spread

8.year old boy with neck lump, after doing blood test and USG what investigation need to do?

a. FNAC(ans)

b. CT scan

c. MRI

1254
. 9 year old child with neck lump, USG done, some findings was explained but cant remember, asking for nest
inveatigation…

a. FNAC(ans)jm 980

b. MRI

c. X ray

#neck lump contro

10.Old aged man with tonsillar mass....most probable diagnosis:

A)Primary tonsillar carcinoma

B)Nasopharyngeal carcinoma

C)Parotid carcinoma.

11.old man 60 years old who is a heavy smoker for 40 years comes to you with a swelling in the tonsillar region,O/E
there is a mass in the tonsillar pouch,what is your diagnosis ?

a. Nasopharyngeal cancer

b. Lipoma

c. lymphoma

1255
d. laryngeal cancer

e. metastatic spread

12.Lump under the angle of mandible. Hx of smoking.This patient also had drooping of mouth Dx.

A. lung ca

B. tonsillar ca

C. met

Parotid CA with metastases to LN

Midline lumps:
Thyroid swelling
Thyroglossal cyst
Pharyngeal pouch
1256
Lateral lumps:
Cystic hygroma
Branchial cyst
Cervical rib
Carotid aneursym
SES1257

A COMMON COMPLIANT…
You will see a lot of neck lumps, whether you work in GP
pr hospital.

Affects all age groups.

Comes in all shape, sizes and consistencies.
Painful vs. painless.
Can occur in isolation, or accompany other systemic or
local symptoms.
A common presentation of head and neck malignancy,
beyond the scope of this presentation1257

1. REACTIVE LYMPHADENOPATy

By far the most common cause of neck swellings.

Affects all age groups.
Tender to touch.
History of local infection or generalised viral illness.
Should resolve spontaneously.

No specific treatment required1257

2. LYMPHOMA
Manifestation of a systemic malignancy.
Rubbery, painless lymphadenopathy.
Pain on drinking alcohol, uncommon symptom.
May be associated with night sweats, weight loss
and splenomegaly1257

3. DERMOID CYST
Can occur anywhere in the body.
Cystic teratoma.
Contains developmentally mature and well-differentiated
tissue: clumps of hair, pockets of sebum, bone, teeth, eyes,
cartilage and/or thyroid tissue.
Almost always benign.

1257
Management: Complete surgical removal without spillage
of contents.1258

4. THYROID SWELLING
Most likely due to hyperthyroidism or hypothyroidism.
Thyroid disease F > M.
Typically young female patients.

Midline swelling.
Moves upwards on swallowing.
Accompanied by thyroid symptoms: Heat intolerance,
palpitations, diarrhoea, fine tremor, proptosis etc.

FNA may be useful to rule-out more sinister pathology

Manage underlying thyroid disorder1258

5.5. THYROGLOSSAL CYST

Fibrous cyst due to persistence of the thyroglossal duct.

More common in patients <20 years age.

Location: Midline, usually between hyoid bone and thyroid

isthmus.

Movement: Upwards with tongue protusion.

12586. PHARYNGEAL POUCH

Posteromedial herniation between thyropharyngeus and

cricophayrgeus muscles.
Most common in older men.
Not usually seen, can be perforated during an OGD.
Can present as a large midline lump in neck.
Gurgles on palpation.
Trapped food debris causes halithosis.
Symptoms: Dysphagia, regurgitation, aspiration, halithosis,
chornic cough.1258

7. CYSTIC HYGROMA
Congential lymphatic lesion (lymphangioma).
Typically found in neck.
Classically on left side.
Most evident at birth.
90% present by age 2 years.

1258
Management: Surgery1259

8.BRANCHIAL CYST
Failure of obliteration of 2nd branchial cleft in
embryonic development.
Oval, mobile, cystic mass developing between SCM and
pharynx.
Usually presents in teenage years and early adulthood.
Management: Conservative (no treatment) or surgical
excision.
Management:1259

9.CERVICAL RIB
Extension of costo-cartilage on 7th cervical vertebra.
Prevalence: 1 in 500 (0.2% population).
More common in adult females.
10% develop thoracic outlet syndrome.
Also compression of brachial plexus and subclavian artery.
Abson’s sign: Loss of radial pulse on arm abduction and

external rotation.1259

10. CAROTID ANEURSYM

Pathological dilatation of carotid artery.

Secondary to atherosclerotic disease.

Puslatile lateral neck mass, doesn’t move on swallowing.
May hear a bruit.
Rare, incidence increases with age.
Other isk factors: Trauma, HTN, endocarditis.
Management dependent on size: Conservative vs. surgical

repair1259

INVESTIGATIONS

Blood tests
FBC
U&Es, CRP
Thyroid function tests

1259
Imaging:
USS
CT
MRI
Biopsy:
Fine needle aspiration (FNA)
Excision biopsy

Ans.. Ddccb

https://www.aafp.org/afp/2014/0601/p882.html

A 33-year-old male presented with a 3 cm swelling in front of the tragus of his left ear which is painful when he is
eating on examinations the swelling is round and smooth and is not attached to the underlying tissue nor the skin all
other examinations are normal. Which of the following is the likely diagnosis?
E. Ramsay Hunt Syndrome
F. Pleomorphic adenoma…painless ****
G. Cancer parotid
H. Warthin tumour
I. Parotid abscess

Pleomorphic adenoma is a common benign salivary gland neoplasm characterised by neoplastic proliferation of
parenchymatous glandular cells along with myoepithelial components, having a malignant potentiality. It is the most
common type of salivary gland tumor and the most common tumor of the parotid gland.the tumor is usually solitary
and presents as a slow growing, painless, firm single nodular mass

Warthin's tumor, also known as papillary cystadenoma lymphomatosum, is a benign cystic tumor of the salivary
glands Warthin's tumor primarily affects older individuals (age 60–70 years). There is a slight male predilection
according to recent studies. The tumor is slow growing, painless, and usually appears in the tail of the parotid gland
near the angle of the mandible. In 5–14% of

A patient presented with swelling in parotid region from three months, which has sometimes dull pain while eating.
Patient had history of dry eyes. FNAC was done which showed non conclusive mixed cellularity. What next step?
A- Biopsy
1260
B- Sialography
C- CT scan

Salivary gland biopsy — A labial salivary gland biopsy can serve as an important diagnostic tool in patients with
suspected SS. Indications for salivary gland biopsy in clinical practice include [77]: ●Confirmation of a suspected
diagnosis of SS, particularly in patients without other evidence of autoimmunity ●Exclusion of other conditions that
can cause salivary hypofunction and bilateral gland enlargement

1261
Swellinh while eating … ductal stones

Pic of an old female in nursing home with NG tubes and sick looking and has a left sided parotid swelling and redness
asking about cause
a. Parotid gland tumor
b. Parotid stone
c. Parotid infection (dx)
d. Poor oral hygiene (cause)

1262
Classic clinical picture of stone parotid stone
what is the next investigation
CT(non contrast ct)
MRI
US
FNAC
Core biopsy

Symptoms of sialothiasis may include:

• swelling of the affected saliva glands which normally occurs with meals
• difficulty opening the mouth
• difficulty swallowing
• a painful lump under the tongue
• gritty or strange tasting saliva
• dry mouth
• pain and swelling usually around the ear or under the jaw

1263
Salivary gland chronic parotid gland swelling at angle of mouth, skin over the mass is mobile, mass attached to
deeper structures painless and Asking Investigation along with FNAC??
Pet scan
MRI
USG
Plain of the mouth
Sialogram

.A 30 yr old man with parotid gland swelling increasing while having food and dry mouth and dry eyes. What
investigation to be done?
A. salivary gland biopsy(FNAc)
B. CT
C. MRI
D. Sialography
2. Pic of submandibular swelling of man,H/O of joint pain and dry eye and dry mouth for 8yrs ago,Next
investigation?
A. anti nuclear antibody
B. FNAC
C. CT head and neck
D. US
E. excisional biopsy

for sjoren: next: ana, best: biopsy

3. A patient presented with swelling in parotid region from three months, which has sometimes dull pain while
eating. Patient had history of dry eyes. FNAC was done which showed non conclusive mixed cellularity. What next
1264
step?
A- Biopsy******
B- Sialography
C- CT scan ************
4. Pic of an old man with immovable submandibular lump attached to the fascia. Old man with dry eyes.
a. ANA(dry eye with joint pain)
b. CT scan of head and neck (only dry eye or dry mouth)
c. FNA

5. Pt has swelling in anterior side of mouth as well and asked for next to do beside antibiotics:
options were
a. usg to see teeth abscess
b. ct
c. mri

Left sided swelling anteriorly of left ear in 45 years old man. Swelling is fixed with muscles. The man spitted blood
stained sputum and is a heavy smoker. He cannot close his mouth properly on the affected side. Dx:
Parotid pleomorphic adenoma
Parotid carcinoma (if blood stained saliva)_
Metastatic lung cancer ***(if blood stained sputum and cough)

1265
Cancer in lateral of tongue
Carcinoma larynx

pic of old lady with painful swelling infront of tragus with redness. Cause?
a) duct stenosis
b) duct stone
c) coxakie virus
d) poor oral hygiene
e) parotid duct Ca

Cause poor oral hygiene Diagnosis is duct stone and infection

18-swelling infront of tragus, pain on eating, Dx Pleomorphic adenoma Parotid abcess Chronic sialectasis Parotid
cancer

1266
1267