NRE May 2026 Answer Key — Extracted

Recovered from NRE May 2026 Answer Key.pages via IWA Snappy decode. PROVENANCE: this key was AI-generated in an earlier session — not an official/recalled document. Answers are reasoned inference aligned to the recall stems. 177/177 MCQs: answers, reasoning, distractors, variants.

Anatomy

Q20. What is the doctrine under which surgeon is also held responsible for leaving swab in the patient abdomen by the nurse?

• A) Civil negligence
• B) Contributory negligence
• C) Novus-actus-Interveniens
• D) Vicarious liability ← CORRECT
• Why: Vicarious liability is the legal doctrine where an employer/supervisor is held responsible for the negligent acts of an employee/subordinate committed during the course of employment. The surgeon (as team leader) is vicariously liable for the scrub nurse’s error (leaving a swab) because the nurse was acting under the surgeon’s authority in the operating theater.
• ✗ A) Civil negligence: The act itself (negligence) — but the question asks for the doctrine that makes the SURGEON liable for the NURSE’S act.
• ✗ B) Contributory negligence: When the patient’s own negligence contributed to harm — not applicable here.
• ✗ C) Novus actus interveniens: A new intervening act that breaks the chain of causation — not applicable.
• Variants:
  • Q: The legal principle “the master must answer for the acts of his servant” is called: A: Vicarious liability
  • Q: Res ipsa loquitur means: A: The thing speaks for itself (doctrine where negligence is obvious — e.g., swab left in abdomen)
  • Q: Bolam test is used for: A: Standard of care (professional negligence)

Q60. Which of the following agents is useful in the treatment of malignant hyperthermia?

• A) Baclofen
• B) Diazepam
• C) Cyclobenzaprine
• D) Dantrolene ← CORRECT
• E) Halothane
• Why: Dantrolene is the specific treatment for malignant hyperthermia. It works by inhibiting calcium release from the sarcoplasmic reticulum (ryanodine receptor), blocking the uncontrolled muscle contraction and hypermetabolism.
• ✗ A) Baclofen: GABA-B agonist — for spasticity, not MH.
• ✗ B) Diazepam: Benzodiazepine — not effective in MH.
• ✗ C) Cyclobenzaprine: Muscle relaxant — not for MH.
• ✗ E) Halothane: A triggering agent for MH, not treatment.
• Variants:
  • Q: Triggering agents for malignant hyperthermia? A: Succinylcholine + volatile anesthetics (halothane, sevoflurane, desflurane, isoflurane)
  • Q: What else must be done immediately in MH crisis? A: Stop triggering agents, hyperventilate with 100% O2, dantrolene, cool patient

Q68. You see a 47-year-old man in clinic with a three-monthe history of epigastric dull abdominal pain. He states that the pain is worse in the mornings and is relieved after meals. On direct questioning, there is no history of weight loss and the patient’s bowel habits are normal. On examination, his abdomen is soft and experiences moderate discomfort on palpation of the epigastric area The most likely diagnosis Is:

• A) Gastric ulcer
• B) GERD
• C) Duodenal ulcer ← CORRECT
• D) Gastric carcinoma
• E) Gastritis
• Why: Epigastric pain worse in the morning (on empty stomach) and relieved by meals is classic for duodenal ulcer. Gastric ulcer pain is opposite — worse after meals (food aggravates) and may relieve with fasting. No weight loss or alarm features rules out malignancy.
• ✗ A) Gastric ulcer: Pain worse with/after meals, not typically relieved by food; may have weight loss.
• ✗ B) GERD: Retrosternal burning, regurgitation, not primarily epigastric pain relieved by meals.
• ✗ D) Gastric carcinoma: Progressive weight loss, early satiety, persistent pain not relieved by food.
• ✗ E) Gastritis: Diffuse discomfort, not necessarily relieved by meals.
• Variants:
  • Q: Duodenal ulcer pain pattern? A: Pain 2-3h after meals, relieved by food/antacids, nocturnal pain
  • Q: Most common complication of duodenal ulcer? A: Bleeding (hemorrhage)

Q150. 43-year-old female has been treated in the hospital for pneumonia and Is bed ridden for the past three weeks. She is examined on a morning round and is found to have a swollen right leg. It is tender to palpation but not warm. Which of the underlying pathology is responsible for the changes in her leg?

• A) Edema
• B) Deep vein thrombus ← CORRECT
• C) Cellulitis
• D) Septic embolization
• Why: Bedridden for 3 weeks (immobilization causing venous stasis) with a swollen, tender right leg (but not warm - no inflammation) is classic for DVT. Virchow’s triad: stasis, hypercoagulability, endothelial injury.
• ✗ A) Edema:** This is a sign, not an underlying pathology. The question asks for the pathology.
• ✗ C) Cellulitis:** Would present with warmth, erythema, and systemic signs - the leg is specifically “not warm.”
• ✗ D) Septic embolization:** Would need a source of infection (endocarditis, etc.), not present here.
• Variants:
  • Q: A post-operative patient with unilateral leg swelling and positive Homan’s sign - diagnosis? A: DVT
  • Q: What is the most appropriate initial investigation for suspected DVT? A: Doppler ultrasound (compression ultrasonography)

Q154. A 50-year-old man presents with sudden onset of severe pain, redness, swelling of the first metatarsophalangeal joint. He has a history of similar epi two years back. What is the most likely diagnosis?

• A) Rheumatoid arthritis
• B) Osteoarthritis
• C) Gout ← CORRECT
• D) Psoriatic arthritis
• Why: Acute onset of severe pain, redness, and swelling of the first metatarsophalangeal joint (podagra) with a prior similar episode is pathognomonic for acute gouty arthritis. Monosodium urate crystals deposit in the joint triggering intense inflammation.
• ✗ A) Rheumatoid arthritis:** Symmetric, bilateral small joint involvement (MCP, PIP), insidious onset, morning stiffness.
• ✗ B) Osteoarthritis:** Gradual onset, weight-bearing joints, no redness or severe acute pain, bony enlargement.
• ✗ D) Psoriatic arthritis:** Associated with psoriasis, often involves DIP joints, sausage digits, not acute podagra.
• Variants:
  • Q: A patient with podagra and hyperuricemia - what crystals are seen in joint aspirate? A: Negatively birefringent monosodium urate crystals
  • Q: Which drug is contraindicated in acute gout in a patient with CKD? A: NSAIDs (prefer colchicine or steroids)

Q165. Which of the following metabolic fuel is utilized for generating glucose in severe starvation?

• A) Amino acids ← CORRECT
• B) Fats
• C) Glycogen
• D) Lipoproteins
• Why: In severe starvation, glycogen stores are depleted within 24 hours, and glucose must be produced by gluconeogenesis - primarily from amino acids (from muscle protein breakdown). Glycerol from fat contributes minimally. The primary substrates are glucogenic amino acids (especially alanine from muscle).
• ✗ B) Fats:** Free fatty acids cannot be converted to glucose (humans lack glyoxylate cycle); only glycerol backbone of triglycerides can contribute minimally.
• ✗ C) Glycogen:** Depleted within the first 24 hours of starvation; not available in severe starvation.
• ✗ D) Lipoproteins:** Transport lipids, not a significant fuel source for gluconeogenesis.
• Variants:
  • Q: After 3 days of fasting, which process maintains blood glucose? A: Gluconeogenesis (from amino acids)
  • Q: Which organ is the primary site of gluconeogenesis? A: Liver (also kidney in prolonged starvation)

Biochemistry

Q177. A patient presents after an ankle injury. He is unable to plantarflex the foot and has loss of sensation over the sole. Which nerve is most likely affected?

• A) Common peroneal nerve
• B) Deep peroneal nerve
• C) Tibial nerve ← CORRECT
• D) Sural nerve
• Why: The tibial nerve (terminal branch of sciatic nerve) innervates the plantar flexors of the foot (gastrocnemius, soleus) and provides sensory innervation to the sole of the foot. Inability to plantarflex + sensory loss over the sole = tibial nerve injury.
• ✗ A) Common peroneal nerve:** Causes foot drop (loss of dorsiflexion) and sensory loss over dorsum of foot and lateral leg - not plantarflexion.
• ✗ B) Deep peroneal nerve:** Causes loss of dorsiflexion and sensory loss in first web space - no plantarflexion or sole involvement.
• ✗ D) Sural nerve:** Pure sensory nerve - supplies lateral foot and ankle; no motor function (no plantarflexion loss).
• Variants:
  • Q: A patient with foot drop and inability to dorsiflex - nerve injured? A: Common peroneal nerve
  • Q: Loss of plantarflexion after ankle fracture suggests injury to which nerve? A: Tibial nerve

Community Medicine

Q10. The secretion of Growth hormone is increased by:

• A) Hyperglycemia
• B) Exercise ← CORRECT
• C) Somatostatin
• D) Hypothermia
• Why: Growth hormone (GH) secretion is stimulated by exercise, deep sleep (stages 3–4), hypoglycemia, starvation, stress, and amino acids (arginine). Exercise is the most physiologic and direct stimulator among the options.
• ✗ A) Hyperglycemia: HIGH glucose SUPPRESSES GH, not increases it (hypoglycemia stimulates GH).
• ✗ C) Somatostatin: Inhibits GH release from anterior pituitary (GHIH).
• ✗ D) Hypothermia: Not a major stimulator; GH is mainly stimulated by exercise, sleep, and hypoglycemia.
• Variants:
  • Q: GH secretion is inhibited by: A) Somatostatin, B) Hyperglycemia, C) Obesity, D) All of the above — Answer: D
  • Q: Which hormone shows pulsatile secretion highest during sleep? A: Growth hormone
  • Q: Acromegaly is caused by: A) GH excess in adults (after epiphyseal closure)

Q14. A 28-year-old man presents with ascending weakness starting from the lower limbs and progressing upwards over a few days. He had a recent history of respiratory infection. Reflexes are absent. What is the most likely diagnosis?

• A) Multiple sclerosis
• B) Myasthenia gravis
• C) Guillain-Barré syndrome ← CORRECT
• D) Muscular dystrophy
• Why: The classic triad: ascending symmetrical flaccid paralysis, areflexia, and preceding respiratory/GI infection. GBS is an acute inflammatory demyelinating polyneuropathy (AIDP) triggered by molecular mimicry (e.g., Campylobacter, CMV, EBV, Mycoplasma).
• ✗ A) Multiple sclerosis: Relapsing-remitting CNS demyelination; optic neuritis, internuclear ophthalmoplegia, UMN signs (spasticity, hyperreflexia), not ascending paralysis with areflexia.
• ✗ B) Myasthenia gravis: Fluctuating weakness, fatigability, ptosis, diplopia — not acute ascending paralysis, reflexes normal.
• ✗ D) Muscular dystrophy: Progressive, symmetric proximal muscle weakness, onset in childhood, areflexia late, no antecedent infection.
• Variants:
  • Q: GBS with ophthalmoplegia, ataxia, areflexia — variant? A: Miller Fisher syndrome (anti-GQ1b)
  • Q: CSF finding in GBS? A: Albuminocytologic dissociation (elevated protein, normal cell count)
  • Q: First-line treatment for GBS? A: IVIG or plasma exchange

Q16. Littre hernia, the hernia sac contains:

• A) Appendix
• B) Meckel’s diverticulum ← CORRECT
• C) Testis
• D) Ovary
• Why: Littre hernia = a hernia (usually femoral or inguinal) containing a Meckel’s diverticulum. Named after Alexis Littre. This is distinct from Richter hernia (partial wall of intestine), Amyand hernia (appendix), and sliding hernia (colon/bladder).
• ✗ A) Appendix: Amyand hernia contains appendix, not Littre.
• ✗ C) Testis: Not a hernia content (would be torsion or undescended).
• ✗ D) Ovary: Can be in hernia (indirect inguinal in females) but not called Littre.
• Variants:
  • Q: Richter hernia contains: A: Antimesenteric border of intestine (partial wall)
  • Q: Amyand hernia contains: A: Appendix
  • Q: A hernia sac containing Meckel’s diverticulum is called: A: Littre hernia

Q35. Which of the following techniques does not provide a definitive airway?

• A) Cricothyroidotomy
• B) Nasotracheal tube
• C) Laryngeal mask airway ← CORRECT
• D) Endotracheal tube
• Why: A definitive airway is defined as a cuffed tube placed in the trachea that protects against aspiration and allows positive pressure ventilation. LMA is a supraglottic device (sits above the glottis) and does NOT provide a definitive airway — it does not protect the trachea from aspiration.
• ✗ A) Cricothyroidotomy: A surgical airway through the cricothyroid membrane, placing a tube directly into the trachea — definitive.
• ✗ B) Nasotracheal tube: An endotracheal tube passed through the nose into the trachea — definitive when placed correctly.
• ✗ D) Endotracheal tube: The gold standard definitive airway — tube placed through mouth/nose into trachea with cuff inflated.
• Variants:
  • Q: Surgical cricothyroidotomy is indicated when: A: Cannot intubate, cannot ventilate (failed airway scenario)
  • Q: The most reliable indicator of correct ETT placement: A: Capnography (ETCO2)
  • Q: LMA is contraindicated in: A: Full stomach, non-fasted, high aspiration risk

Q49. A 2-year-old unvaccinated child presents with unilateral left limb paralysis and an inability to elicit superficial reflexes. CSF analysis shows 15,000 TLC, 90% lymphocytes, normal glucose, and normal proteins. He has not received regular vaccines. What is the diagnosis?

• A) Poliomyelitis ← CORRECT
• B) Guillain-Barré syndrome
• C) Polyradiculoneuropathy
• Why: An unvaccinated child with acute flaccid paralysis (AFP) of one limb, absent superficial reflexes, and CSF showing lymphocytic pleocytosis with normal glucose/protein is classic poliomyelitis. The asymmetric paralysis with intact sensation and history of missed vaccines seals the diagnosis.
• ✗ B) Guillain-Barré syndrome: Ascending symmetric paralysis, areflexia, but CSF shows albumino-cytologic dissociation (↑ protein, normal cells) — opposite of this CSF picture.
• ✗ C) Polyradiculoneuropathy: Usually symmetric, and not typically unilateral in a toddler.
• Variants:
  • Q: CSF finding in Guillain-Barré syndrome? A: Albuminocytologic dissociation (high protein, normal cell count)
  • Q: Polio vaccine available in EPI schedule? A: OPV at birth + 6, 10, 14 weeks; IPV at 14 weeks

Q53. A 25-year-old man presents with confusion, high fever, and generalized tonic-clonic seizures. His blood pressure is low, and heart rate is elevated. Laboratory tests show metabolic acidosis and elevated lactate. What is the most likely diagnosis?

• A) Septic shock ← CORRECT
• B) Hypovolemic shock
• C) Cardiogenic shock
• D) Neurogenic shock
• Why: High fever + confusion + seizures + hypotension + tachycardia + metabolic acidosis + elevated lactate = septic shock. The infection triggers massive cytokine release causing vasodilation, myocardial depression, and lactic acidosis.
• ✗ B) Hypovolemic shock: Would have history of fluid loss (hemorrhage, dehydration), no fever.
• ✗ C) Cardiogenic shock: Pulmonary edema, raised JVP, no fever.
• ✗ D) Neurogenic shock: Hypotension with bradycardia, warm skin — no fever or seizures.
• Variants:
  • Q: First-line vasopressor in septic shock? A: Norepinephrine
  • Q: Measurement of lactate in septic shock indicates? A: Tissue hypoperfusion and disease severity

Q57. A middle-aged patient presented to surgical emergency following gunshot injury to the right thigh. On examination, there is a large hematoma in the right thigh with weakness in lifting the leg, weakness of knee extension, diminished knee jerk, and loss of sensation over the anterior and medial aspect of the thigh. Which nerve is most likely damaged?

• A) Obturator nerve
• B) Femoral nerve ← CORRECT
• C) Sciatic nerve
• D) Peroneal nerve
• E) Tibial nerve
• Why: Femoral nerve injury causes:
• ✗ A) Obturator nerve: Affects thigh adduction, sensory loss over medial thigh.
• ✗ C) Sciatic nerve: Affects hamstrings, all muscles below knee — no knee extension weakness.
• ✗ D) Peroneal nerve: Foot drop — not knee extension.
• ✗ E) Tibial nerve: Plantar flexion loss — not relevant.
• Variants:
  • Q: Femoral nerve supplies which muscles? A: Iliacus, psoas, pectineus, sartorius, quadriceps femoris
  • Q: Most common nerve injured in inguinal hernia repair? A: Ilioinguinal nerve, genital branch of genitofemoral nerve

Q63. A 35-year-old man presented with 3 years’ history of recurrent diffuse abdominal pain especially after breakfast which improves with defecation. He denies any weight loss. He has noticed that his symptoms aggravate while he is under stress. All his investigations are normal. What is the most likely diagnosis?

• A) Crohn’s disease
• B) Irritable bowel syndrome ← CORRECT
• C) Tropical sprue
• D) Ulcerative colitis
• Why: Recurrent diffuse abdominal pain (>3 months) related to defecation (improves after), worsened by stress, no weight loss, normal investigations — this is classic IBS (Rome IV criteria). The absence of red flags (weight loss, bleeding, fever) and chronicity with stress association point to functional rather than organic disease.
• ✗ A) Crohn’s disease: Would have weight loss, diarrhea, anemia, raised inflammatory markers.
• ✗ C) Tropical sprue: Chronic diarrhea, weight loss, megaloblastic anemia — not primarily pain.
• ✗ D) Ulcerative colitis: Bloody diarrhea, tenesmus, urgency — not this picture.
• Variants:
  • Q: Rome IV criteria for IBS? A: Recurrent abdominal pain ≥1 day/week for 3 months, related to defecation, change in stool frequency/form
  • Q: Red flag symptoms in IBS evaluation that warrant colonoscopy? A: Weight loss, blood in stool, nocturnal symptoms, family history of colon cancer, age >50

Q70. A 28-year-old female presents to the emergency department following a suicidal attempt with an overdose of 6 tablets of alprazolam which is a benzodiazepine. She is drowsy but arousable and respiratory depression is suspected due to shallow breathing. she is agitated , confused with Slurred speech. What is the antidote given in this case?

• A) Flumazenil ← CORRECT
• B) Naloxone
• C) Furazolidone
• D) Dapsone
• Why: Alprazolam is a benzodiazepine, and flumazenil is the specific competitive benzodiazepine receptor antagonist. It reverses the sedative and respiratory depressant effects. However, caution is needed: it can precipitate seizures in mixed overdoses or chronic benzodiazepine users.
• ✗ B) Naloxone: Antidote for opioid overdose, not benzodiazepines.
• ✗ C) Furazolidone: Antiprotozoal/antibacterial — not an antidote.
• ✗ D) Dapsone: Antibiotic (leprosy, malaria chemoprophylaxis) — not an antidote.
• Variants:
  • Q: Opioid overdose antidote? A: Naloxone (Narcan)
  • Q: Which benzodiazepine overdose cannot be reversed by flumazenil? A: Flumazenil reverses all BZDs — but caution in mixed overdoses and chronic BZD users (seizure risk)

Q93. A 30-year-old housewife visited a gynecologist for her prenatal checkup. Her mother died of breast cancer and she is worried about inheriting the disease. What would be the most appropriate advice for her?

• A) Annual Mammography ← CORRECT
• B) Regular breast self-examination
• C) Fine needle aspiration
• D) Thermography
• Why: With a first-degree relative (mother) with breast cancer, she is at increased risk. Annual mammography starting at an appropriate age is the recommended screening strategy.
• Variants:
  • Q: A 30-year-old with a family history of breast cancer in her mother — best screening approach: A: Annual mammography
  • Q: First-line screening for breast cancer in at-risk women: A: Mammography

Q102. In order to prevent congenital rubella syndrome, which one of the following is the first priority group for rubella vaccination?

• A) Vaccinating all children aged 1 to 14 years ← CORRECT
• B) Non-pregnant women 15 to 34 years of age
• C) All children at one year of age
• D) Children up to 5 years of age
• Why: To prevent congenital rubella syndrome, WHO strategy prioritizes reducing circulation by vaccinating a broad age range of children (1-14 years) to achieve herd immunity, protecting women of childbearing age.
• Variants:
  • Q: Which population is the first priority for rubella vaccination to prevent CRS? A: All children aged 1-14
  • Q: Rubella vaccination strategy to eliminate congenital rubella syndrome targets: A: Broad childhood vaccination

Q108. A 37 week pregnant female presents with significant weight gain, bilateral leg swelling (edema), and shortness of breath. Her blood pressure is significantly elevated to her baseline, and this hypertension persists on repeat measurement. Urinalysis confirms the presence of significant proteinuria (2+ or more). What is the most probable diagnosis?

• A) Gestational Hypertension
• B) Chronic Hypertension
• C) Pre Eclampsia ← CORRECT
• D) HELLP Syndrome
• Why: Hypertension (persistently elevated from baseline) + significant proteinuria (2+) occurring after 20 weeks (here at 37 weeks) in a previously normotensive woman = preeclampsia. The bilateral leg edema and weight gain reflect fluid retention.
• ✗ A) Gestational Hypertension: has hypertension but NO proteinuria — this patient has 2+ proteinuria
• ✗ B) Chronic Hypertension: hypertension before 20 weeks or pre-existing, not new onset at 37 weeks
• ✗ D) HELLP Syndrome: complication of preeclampsia with hemolysis, elevated LFTs, low platelets — not the primary diagnosis here
• Variants:
  • Q: Preeclampsia with seizures is called: A: Eclampsia
  • Q: Which antihypertensive is used for seizure prophylaxis in preeclampsia? A: Magnesium sulfate

Q110. A 60-year-old diabetic patient on insulin therapy presents with sweating, confusion, and palpitations. What is a potential side effect causing these symptoms?

• A) Hypoglycemia ← CORRECT
• B) Hyperglycemia
• C) Weight gain
• D) Nausea
• Why: Insulin therapy carries a risk of hypoglycemia. Sweating (adrenergic), confusion (neuroglycopenic), and palpitations (adrenergic) are classic symptoms. A diabetic on insulin with these autonomic + CNS symptoms = hypoglycemia until proven otherwise.
• ✗ B) Hyperglycemia: causes polyuria, polydipsia, weight loss — not sweating/confusion acutely
• ✗ C) Weight gain: long-term effect, doesn’t cause acute symptoms
• ✗ D) Nausea: possible but not the triad; not the key side effect of insulin
• Variants:
  • Q: An unconscious diabetic with hypoglycemia should be treated with: A: IV 50% dextrose (or IM glucagon if no IV access)
  • Q: Hypoglycemia-associated autonomic failure (HAAF) is most common in: A: Tightly controlled type 1 DM

Q113. Which of the following tumors is spread by hematogenous route?

• A) Carcinoma lung
• B) Sarcoma ← CORRECT
• C) Fibroma
• D) Carcinoma ovary
• Why: Sarcomas (mesenchymal tumors arising from bone, muscle, fat, connective tissue) spread hematogenously — they lack well-developed lymphatics and invade blood vessels early. This is the classic distinction between sarcomas (hematogenous) and carcinomas (lymphatic).
• ✗ A) Carcinoma lung: spreads via lymphatics (hilar/mediastinal nodes) before hematogenous
• ✗ C) Fibroma: benign tumor, doesn’t metastasize
• ✗ D) Carcinoma ovary: spreads transperitoneally (direct seeding) and lymphatically
• Variants:
  • Q: The most common route of metastasis for colorectal carcinoma: A: Lymphatic (portal system → liver)
  • Q: Osteosarcoma most commonly metastasizes to: A: Lungs (hematogenous)

Q119. A patient with pulmonary tuberculosis was put on ATT with rifampicin, INH, ethambutol, and pyrazinamide. He should be advised to take a supplement to prevent deficiency of:

• A) Niacin
• B) Pyridoxine ← CORRECT
• C) Riboflavin
• D) Thiamine
• E) Pantothenic acid
• Why: INH (isoniazid) causes depletion of pyridoxine (vitamin B6) by inhibiting its metabolism and increasing its urinary excretion. This leads to peripheral neuropathy (dose-dependent). Standard practice is to give pyridoxine 10-50 mg/day as prophylaxis with INH-containing regimens.
• ✗ A) Niacin: not depleted by ATT; INH can actually cause pellagra in malnourished but pyridoxine is the main concern
• ✗ C) Riboflavin: not affected by standard ATT drugs
• ✗ D) Thiamine: not affected; although alcoholics need B1
• ✗ E) Pantothenic acid: not affected by ATT
• Variants:
  • Q: ATT drug causing optic neuritis/retrobulbar neuritis: A: Ethambutol
  • Q: ATT drug causing orange-red discoloration of bodily fluids: A: Rifampicin

Q120. A taxi driver comes to the clinic with runny nose, watery eyes, fever, and malaise. He wishes to continue working while taking treatment. Which antihistamine would be most suitable with the least sedation?

• A) Chlorphenamine
• B) Fexofenadine ← CORRECT
• C) Diphenhydramine
• D) Meclizine
• Why: A taxi driver needs to stay alert at work. Fexofenadine is a second-generation (non-sedating) antihistamine that does not cross the blood-brain barrier significantly due to its P-glycoprotein substrate profile, causing minimal to no sedation. It’s the safest choice for operating vehicles/machinery.
• ✗ A) Chlorphenamine: first-generation antihistamine, highly sedating (crosses BBB)
• ✗ C) Diphenhydramine: first-generation, strong sedation (also used as sleep aid)
• ✗ D) Meclizine: first-generation, used for motion sickness — also sedating
• Variants:
  • Q: Most common side effect of first-generation antihistamines: A: Sedation/drowsiness
  • Q: Mechanism of antihistamines: A: H1-receptor antagonists (competitive inhibition)

Q134. A 55-year-old woman presents shows a prolonged PR interval What is the most likely diagnosis?

• A) First-degree AV block ← CORRECT
• B) Second-degree AV block
• C) Third-degree AV block
• D) Sinus bradycardia
• Why: Prolonged PR interval (>200 ms in adults) with no dropped beats = first-degree AV block. This is the simplest form of AV conduction delay — every atrial impulse reaches the ventricles but takes longer through the AV node.
• ✗ B) Second-degree AV block: has intermittent dropped QRS complexes (not all P waves conduct)
• ✗ C) Third-degree AV block: complete AV dissociation — P waves and QRS independent, no fixed PR
• ✗ D) Sinus bradycardia: normal PR interval, just slow rate
• Variants:
  • Q: Mobitz I (Wenckebach) is characterized by: A: Progressive PR prolongation until a QRS drops
  • Q: Mobitz II requires careful monitoring because it may progress to: A: Complete heart block (needs pacemaker)

Q138. Which of the following lipoprotein particles are most likely responsible for the appearance of the patient plasma after a fatty meal?

• A) Chylomicron ← CORRECT
• B) HDL
• C) LDL
• D) VLDL
• Why: After a fatty meal, dietary triglycerides are absorbed by enterocytes, packaged into chylomicrons, and secreted into intestinal lymphatics (lacteals) → thoracic duct → bloodstream. Chylomicrons are large enough to scatter light, giving plasma a milky/turbid appearance (postprandial lipemia).
• ✗ B) HDL: small dense particles, not responsible for postprandial turbidity; involved in reverse cholesterol transport
• ✗ C) LDL: transports cholesterol to tissues, small particles, not diet-responsive acutely
• ✗ D) VLDL: transports ENDOGENOUS triglycerides from liver to tissues, makes plasma turbid in hypertriglyceridemia but not specifically postprandial
• Variants:
  • Q: Fasting chylomicronemia suggests: A: Lipoprotein lipase deficiency (type I hyperlipidemia)
  • Q: Which lipoprotein is most dense? A: HDL (highest protein-to-lipid ratio)

Q144. A 7-year-old boy is brought by parents with walking difficulty and repeated chest infections. On examination, an active, alert child has calf muscle hypertrophy anda positive Gower sign. What is the inheritance pattern of this disease?

• A) Autosomal dominant
• B) Autosomal recessive
• C) X-linked dominant
• D) X-linked recessive ← CORRECT
• Why: The clinical picture - walking difficulty, calf muscle hypertrophy, positive Gower sign, repeated chest infections in a 7-year-old boy - is classic Duchenne Muscular Dystrophy. DMD is caused by dystrophin gene mutation on the X chromosome, inherited X-linked recessive.
• ✗ A) Autosomal dominant:** DMD is not AD; no male-to-male transmission seen.
• ✗ B) Autosomal recessive:** Some limb-girdle dystrophies are AR, but DMD is XR.
• ✗ C) X-linked dominant:** Rett syndrome is XD (lethal in males); DMD is XR.
• Variants:
  • Q: Becker muscular dystrophy presents later with milder symptoms. Inheritance? A: X-linked recessive
  • Q: A girl presents with DMD phenotype - likely due to? A: Turner syndrome (XO) or skewed X-inactivation

Q171. A 3-year-old child with cerebral palsy has increased tone in the right upper and lower limbs. How would you classify his illness?

• A) Diplegic CP
• B) Hemiplegic CP ← CORRECT
• C) Monoplegic CP
• D) Quadriplegic CP
• Why: A 3-year-old with cerebral palsy involving increased tone in the right upper and right lower limbs only (unilateral) is classified as hemiplegic CP. The prefix describes the limbs affected: hemi = one side (arm + leg same side).
• ✗ A) Diplegic CP:** All four limbs affected but lower limbs more than upper limbs - bilateral leg predominance.
• ✗ C) Monoplegic CP:** Only one limb affected - rare.
• ✗ D) Quadriplegic CP:** All four limbs affected with equal or upper limb predominance; often associated with intellectual disability.
• Variants:
  • Q: A preterm infant develops spasticity in both legs more than arms - CP type? A: Diplegic CP
  • Q: A child with CP has unilateral spasticity after a perinatal stroke - classification? A: Hemiplegic CP

Forensic Medicine

Q32. A patient with flail chest will most likely present with:

• A) Increased chest expansion
• B) Paradoxical chest movement ← CORRECT
• C) Bradycardia
• D) Hyper-resonance
• Why: Flail chest occurs when ≥2 consecutive ribs are fractured in ≥2 places, creating a free-floating segment. This segment moves inward during inspiration and outward during expiration — paradoxical movement. It impairs ventilation and can lead to respiratory failure.
• ✗ A) Increased chest expansion: Flail chest DECREASES chest expansion on the affected side.
• ✗ C) Bradycardia: Flail chest causes tachypnea and tachycardia, not bradycardia.
• ✗ D) Hyper-resonance: Suggests pneumothorax, not flail chest; flail chest may have dullness if underlying contusion.
• Variants:
  • Q: Flail chest management: A: Oxygen, analgesia, positive pressure ventilation if respiratory failure
  • Q: Most common cause of flail chest: A: Blunt chest trauma (MVC, fall)
  • Q: Associated injuries with flail chest: A: Pulmonary contusion, pneumothorax, hemothorax

Q46. A 55-year-old man with newly diagnosed hypertension and type 2 diabetes presents for management. He has microalbuminuria. Which drug is the most appropriate first-line therapy for both blood pressure control and kidney protection?

• A) Lisinopril ← CORRECT
• B) Hydrochlorothiazide
• C) Amlodipine
• D) Metoprolol
• Why: A patient with HTN + type 2 DM + microalbuminuria needs a drug that provides both BP control and renoprotection. ACE inhibitors (like lisinopril) reduce intraglomerular pressure, decrease proteinuria, and slow progression of diabetic nephropathy — they are first-line in this scenario.
• ✗ B) Hydrochlorothiazide: Good for BP but no specific renoprotection in diabetic nephropathy.
• ✗ C) Amlodipine: Calcium channel blocker — effective for BP but does not reduce proteinuria as effectively as ACEi/ARB.
• ✗ D) Metoprolol: Beta-blocker — not first-line for renoprotection; can mask hypoglycemia symptoms.
• Variants:
  • Q: ACEi cough — which alternative drug provides similar renoprotection? A: ARB (Losartan)
  • Q: Contraindication to ACEi in diabetics? A: Bilateral renal artery stenosis; hyperkalemia; pregnancy

Q66. A 45-year-old man presents with progressive shortness of breath on exertion, orthopnea, and bilateral leg swelling for the past 3 months. He has history of alcohol abuse. On examination, blood pressure is 110/70 mmHg, JVP is elevated, and auscultation reveals bilateral basal crepitations and a displaced apex beat. Echocardiography shows a globally dilated left ventricle with reduced ejection fraction (30%) . What is the most likely diagnosis?

• A) Dilated cardiomyopathy ← CORRECT
• B) Hypertrophic cardiomyopathy
• C) Constrictive pericarditis
• D) Restrictive cardiomyopathy
• Why: Exertional dyspnea, orthopnea, bilateral leg edema, elevated JVP, basal creps, displaced apex beat, globally dilated LV with EF 30% — plus history of alcohol abuse — is classic dilated cardiomyopathy (alcoholic cardiomyopathy).
• ✗ B) Hypertrophic cardiomyopathy: Preserved EF, LV hypertrophy, not globally dilated.
• ✗ C) Constrictive pericarditis: Kussmaul’s sign, pericardial knock, calcified pericardium — not dilated LV.
• ✗ D) Restrictive cardiomyopathy: Preserved systolic function with diastolic dysfunction, not dilated LV.
• Variants:
  • Q: Most common cause of dilated cardiomyopathy? A: Idiopathic (ischemic is most common in older adults)
  • Q: Treatment of choice for symptomatic DCM with low EF? A: ACEi + beta-blocker + diuretics ± ICD

Q140. Which one of the following radiological finding is present in Cardiac Achalasia?

• A) Apple core appearance
• B) Bird’s beak appearance ← CORRECT
• C) Double bubble sign
• D) Ogilvie sign
• Why: Achalasia (cardiospasm) shows a dilated esophagus with smooth, tapered narrowing at the gastro-esophageal junction — the “bird’s beak” or “rat’s tail” sign on barium swallow. This is due to failure of relaxation of the lower esophageal sphincter.
• ✗ A) Apple core appearance: “napkin ring” lesion of colonic carcinoma on barium enema
• ✗ C) Double bubble sign: duodenal atresia in newborns (two air-fluid levels in stomach + proximal duodenum)
• ✗ D) Ogilvie sign: pseudo-obstruction of the colon (massive colonic dilation without mechanical obstruction)
• Variants:
  • Q: Manometry finding in achalasia: A: Incomplete LES relaxation + absent peristalsis in esophageal body
  • Q: Pneumatic dilatation vs Heller myotomy: both treat achalasia; approach depends on patient

Q162. A patient with pontine hemorrhage presents with pinpoint pupils. Which one of the following arteries is most likely to be damaged?

• A) Anterior cerebral
• B) Basilar ← CORRECT
• C) Middle cerebral
• D) Posterior inferior cerebellar
• Why: Pontine hemorrhage damages the descending sympathetic fibers (causing pinpoint pupils due to unopposed parasympathetic) and is typically caused by hypertension affecting the basilar artery’s pontine perforating branches. Basilar artery supplies the pons.
• ✗ A) Anterior cerebral artery:** Supplies medial frontal/parietal lobes; occlusion causes contralateral leg weakness, not pontine signs.
• ✗ C) Middle cerebral artery:** Supplies lateral hemisphere; occlusion causes contralateral face/arm weakness, aphasia.
• ✗ D) Posterior inferior cerebellar artery (PICA):** Occlusion causes lateral medullary syndrome (Wallenberg) - vertigo, Horner, ataxia, not pinpoint pupils from pontine bleed.
• Variants:
  • Q: A hypertensive patient presents with locked-in syndrome - which artery is affected? A: Basilar artery (pontine infarction)
  • Q: Pinpoint pupils are seen in which CNS emergency? A: Pontine hemorrhage (also opiate overdose)

Medicine

Q12. Mean arterial pressure equals:

• A) Arterial compliance times stroke volume
• B) Heart rate times stroke volume
• C) Cardiac output times total peripheral resistance ← CORRECT
• D) Heart rate times total peripheral resistance
• Why: MAP = CO × TPR. Since CO = HR × SV, MAP can also be expressed as (HR × SV) × TPR, but the direct formula is CO × TPR. MAP is the average arterial pressure during one cardiac cycle, approximated as diastolic pressure + 1/3 pulse pressure.
• ✗ A) Arterial compliance times stroke volume: Incorrect; compliance = ΔV/ΔP, not used for MAP calculation.
• ✗ B) Heart rate times stroke volume: This equals CO, not MAP (need TPR as well).
• ✗ D) Heart rate times total peripheral resistance: Dimensionally incorrect; need SV in the equation.
• Variants:
  • Q: MAP = DBP + 1/3 (SBP – DBP). If BP = 120/80 mmHg, MAP = ? A: 93.3 mmHg
  • Q: Which factor most directly determines MAP? A: Cardiac output and total peripheral resistance
  • Q: Which variable has the greatest effect on MAP in hypertension? A: Total peripheral resistance

Q13. Activated charcoal is frequently used in the management of poisoning cases. Its mechanism of action is:

• A) Hydrolysis of poison
• B) Dilution of poison
• C) Adsorption of poison ← CORRECT
• D) Neutralization of poison
• Why: Activated charcoal works by adsorbing (binding) toxins onto its large surface area, preventing gastrointestinal absorption. It does not chemically alter, dilute, or neutralize the poison — it physically traps it.
• ✗ A) Hydrolysis of poison: Activated charcoal does not chemically break down poisons.
• ✗ B) Dilution of poison: Charcoal does not dilute; it binds.
• ✗ D) Neutralization of poison: Charcoal is not a chemical neutralizer (like an acid-base reaction).
• Variants:
  • Q: Activated charcoal is most effective if given within: A) 1 hour of ingestion
  • Q: Contraindication to activated charcoal? A: Caustic ingestion (acid/alkali) or hydrocarbon ingestion
  • Q: Multiple-dose activated charcoal is used for: A) Sustained-release drugs, theophylline, phenobarbital, dapsone

Q22. A 60-year-old diabetic patient presents with a postoperative wound infection. Which factor most significantly impairs wound healing?

• A) Increased collagen synthesis
• B) Enhanced angiogenesis
• C) Poor tissue perfusion ← CORRECT
• D) Increased fibroblast activity
• Why: Diabetes causes microvascular disease → impaired blood flow → reduced oxygen and nutrient delivery to the wound → delayed healing. This is the most significant factor among the options. Chronic hyperglycemia also impairs immune function (neutrophil dysfunction) but poor perfusion is the dominant mechanical factor.
• ✗ A) Increased collagen synthesis: Collagen synthesis is DECREASED in diabetes, not increased.
• ✗ B) Enhanced angiogenesis: Angiogenesis is IMPAIRED in diabetes, not enhanced.
• ✗ D) Increased fibroblast activity: Fibroblast function is impaired (decreased proliferation and collagen production) in hyperglycemia.
• Variants:
  • Q: Factors that impair wound healing: A) Infection, poor perfusion, malnutrition, immunosuppression, DM, smoking, steroids
  • Q: Zinc deficiency impairs: A: Wound healing (important for collagen synthesis and immune function)
  • Q: Vitamin C deficiency impairs wound healing by: A: Decreased collagen synthesis (scurvy)

Q23. CT scan of a 62-year-old male shows damage to Broca area of the motor cortex. Which of the following conditions best describes the deficit resulting from its damage?

• A) Spastic paralysis of the contralateral hand
• B) Inability to speak whole words correctly ← CORRECT
• C) Paralysis of the muscles of the larynx and pharynx
• D) Inability to use the two hands to grasp an object
• Why: Broca area (Brodmann 44/45) in the dominant inferior frontal gyrus is the motor speech area. Damage causes Broca (expressive) aphasia — non-fluent speech, effortful, telegraphic, with intact comprehension. The patient knows what they want to say but cannot produce whole words/sentences correctly.
• ✗ A) Spastic paralysis of the contralateral hand: Motor cortex (precentral gyrus) lesion would cause contralateral weakness, but Broca area is specifically for speech programming.
• ✗ C) Paralysis of the muscles of the larynx and pharynx: Bilateral corticobulbar tract damage causes pseudobulbar palsy; Broca area lesion does not paralyze laryngeal muscles.
• ✗ D) Inability to use the two hands to grasp an object: Ideomotor apraxia involves the supramarginal gyrus, not Broca area.
• Variants:
  • Q: Wernicke area lesion causes: A) Receptive/fluent aphasia (sensory aphasia)
  • Q: Arcuate fasciculus lesion causes: A) Conduction aphasia (poor repetition, fluent speech)
  • Q: Global aphasia results from: A: Damage to both Broca and Wernicke areas (MCA territory)

Q27. A rhesus-negative primigravida has delivered a baby 2 hours ago. Her husband and the baby are rhesus positive. When should she ideally receive anti-D gamma globulin in order to prevent rhesus sensitization?

• A) Within 72 hours after delivery ← CORRECT
• Why: Anti-D immunoglobulin must be administered within 72 hours of delivery (or sensitizing event) to prevent Rh sensitization. It works by neutralizing fetal Rh-positive RBCs that entered maternal circulation during delivery before the mother’s immune system can produce anti-D antibodies. A dose of 300 mcg (standard) is given IM.
• Variants:
  • Q: Anti-D should also be given antenatally at: A: 28 weeks gestation
  • Q: Dose of anti-D for first-trimester sensitizing event: A: 50 mcg (vs 300 mcg for third trimester/postpartum)
  • Q: Kleihauer-Betke test is used to: A: Quantify fetomaternal hemorrhage to determine anti-D dose needed

Q43. An 8-year-old girl presents in OPD with facial puffiness for two days. She has cola colored urine. She has some periorbital swelling and edema feet. Urine examination reveals, proteinuria +, WBC’s 3-4 /HPF, few RBCs and granular casts. Which one of the following is the most likely diagnosis?

• A) Hemolytic uremic syndrome
• B) Acute post-streptococcal glomerulonephritis ← CORRECT
• C) IgA nephropathy
• D) Nephrotic syndrome
• Why: An 8-year-old with facial puffiness, cola-colored urine (hematuria), periorbital edema, RBCs and granular casts in urine — this is classic acute post-streptococcal GN. It typically occurs 1-3 weeks after a streptococcal infection (pharyngitis/skin). The low-level proteinuria (+), RBCs, and granular casts point to nephritic syndrome (not nephrotic).
• ✗ A) Hemolytic uremic syndrome: Triad of microangiopathic hemolytic anemia, thrombocytopenia, and AKI — no mention of diarrhea/MAHA here.
• ✗ C) IgA nephropathy: Can present with hematuria but typically follows mucosal infections (not skin/pharynx) and more common in older children/adults.
• ✗ D) Nephrotic syndrome: Massive proteinuria (>3.5 g/day), hypoalbuminemia, hyperlipidemia — this vignette shows low proteinuria and casts (nephritic pattern).
• Variants:
  • Q: Post-strep GN — low serum C3 levels are seen in which phase? A: Acute phase (returns to normal in 6-8 weeks)
  • Q: Nephritic vs nephrotic syndrome — key discriminator? A: Proteinuria level (nephrotic >3.5 g/day) and presence of RBC casts (nephritic)

Q48. A 66-year-old woman presented to surgical emergency with sudden onset of severe pain in the left leg. On examination, the left leg is cold, pale, and has bluish patches. There is no significant past history except occasional palpitations. What is your clinical diagnosis?

• A) Deep venous thrombosis
• B) Acute arterial embolic occlusion ← CORRECT
• C) Lymphedema
• D) Cellulitis
• E) Buerger disease
• Why: Sudden-onset severe pain, coldness, pallor, and bluish patches (livedo reticularis) in a leg — with occasional palpitations (possible atrial fibrillation) — is classic for acute arterial embolic occlusion. The embolus typically originates from the heart (AF, valve disease) and lodges at arterial bifurcations.
• ✗ A) DVT: Presents with warm, swollen, red leg — not cold and pale.
• ✗ C) Lymphedema: Chronic, painless swelling — not acute.
• ✗ D) Cellulitis: Warm, erythematous, tender — not cold/pale.
• ✗ E) Buerger disease: Occurs in young male smokers, with claudication and Raynaud’s — not sudden onset with palpitations.
• Variants:
  • Q: Six Ps of acute arterial ischemia? A: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia
  • Q: Initial management of acute limb ischemia? A: Immediate heparin (unfractionated) + surgical embolectomy if <6-8h

Q50. You are the house officer on call in the ophthalmology department and a patient comes to you with an unknown chemical, such as glue or an acidic/basic chemical, splashed in the eye. There is diffuse conjunctival congestion and pain. What is your initial management?

• A) Copious irrigation of the eye with normal saline ← CORRECT
• B) Wash with 1 L sodium bicarbonate
• C) Slit-lamp examination with fluorescein dye
• D) Patch the eye after instilling steroid eye drops
• Why: Chemical eye injury is an ophthalmological emergency. The immediate management is copious irrigation with normal saline or water (at least 1-2 L) to dilute and flush out the chemical. Irrigation must begin immediately — before any examination.
• ✗ B) Wash with 1 L sodium bicarbonate: Alkali solution can cause heat injury and is contraindicated in acid burns.
• ✗ C) Slit-lamp with fluorescein: Done AFTER irrigation to assess corneal damage.
• ✗ D) Patch + steroid drops: Patching traps chemical against cornea; steroids are given after irrigation and assessment.
• Variants:
  • Q: Most dangerous chemical eye injury? A: Alkali (e.g., lye, ammonia) — penetrates deeper than acid
  • Q: How long should irrigation continue in chemical eye injury? A: Until conjunctival pH normalizes (7.0-7.4)

Q55. A 65-year-old man with chronic stable angina is started on a new medication to prevent anginal attacks. He reports fatigue and mild bradycardia on follow-up. Which class of drugs is most likely responsible?

• A) Beta-blockers ← CORRECT
• B) Nitrates
• C) ACE inhibitors
• D) Ranolazine
• Why: Fatigue and bradycardia are classic side effects of beta-blockers (e.g., metoprolol, atenolol). These drugs reduce heart rate and cardiac contractility, which can cause fatigue and symptomatic bradycardia, especially in older patients.
• ✗ B) Nitrates: Cause headache, flushing, hypotension — not bradycardia/fatigue.
• ✗ C) ACE inhibitors: Cause cough, hyperkalemia, angioedema — not bradycardia.
• ✗ D) Ranolazine: Causes QT prolongation, dizziness, constipation — not bradycardia.
• Variants:
  • Q: Beta-blocker overdose — which drug is used for treatment? A: Glucagon
  • Q: Which beta-blocker is preferred in heart failure? A: Metoprolol succinate, bisoprolol, carvedilol

Q59. A patient with epilepsy on long-term treatment has developed gingival hyperplasia/gum hypertrophy, one episode of bleeding from the mouth, hypertrichosis, osteomalacia, folate deficiency, and granulocytopenia. He presents with gingival swelling and recurrent dental issues requiring multiple dental visits. He is likely to be on which medication?

• A) Phenytoin ← CORRECT
• B) Diazepam
• C) Sodium valproic acid
• D) Phenobarbitone
• Why: Phenytoin has a classic side effect profile: gingival hyperplasia (gum hypertrophy), hirsutism/hypertrichosis, osteomalacia (↓ vitamin D metabolism), folate deficiency, megaloblastic anemia, granulocytopenia, peripheral neuropathy, and teratogenicity (fetal hydantoin syndrome).
• ✗ B) Diazepam: Sedation, dependence, not gum hyperplasia.
• ✗ C) Sodium valproate: Hepatotoxicity, thrombocytopenia, pancreatitis, weight gain, tremor.
• ✗ D) Phenobarbitone: Sedation, cognitive effects, folate deficiency but NO gingival hyperplasia.
• Variants:
  • Q: Phenytoin also causes which vitamin deficiency? A: Vitamin D (osteomalacia) and folate
  • Q: Drug to avoid with phenytoin that increases its levels? A: Isoniazid (INH)

Q67. A patient presents with difficulty seeing distant objects, such as a blackboard. His visual problem is corrected with a concave lens. The most likely condition he is suffering from is:

• A) Astigmatism
• B) Axial hyperopia
• C) Myopia ← CORRECT
• D) Presbyopia
• Why: Difficulty seeing distant objects (blurred distance vision) corrected by a concave (minus) lens = myopia (nearsightedness). The concave lens diverges light rays to focus them on the retina (which is too long in axial myopia).
• ✗ A) Astigmatism: Corrected by cylindrical lens — uneven focus due to irregular corneal curvature.
• ✗ B) Axial hyperopia: Corrected by convex lens — difficulty with near vision.
• ✗ D) Presbyopia: Age-related loss of accommodation — difficulty with near vision, corrected with convex lens.
• Variants:
  • Q: Hyperopia is corrected with which type of lens? A: Convex (plus) lens
  • Q: Presbyopia — what is the mechanism? A: Loss of lens elasticity with age, reduced accommodative power

Q75. A 28-year-old man presents with fever, rash, and joint pain after taking antibiotics for a urinary tract infection. Laboratory tests show eosinophilia and mild renal impairment. Urinalysis shows white blood cell casts. What is the most likely diagnosis?

• A) Acute interstitial nephritis ← CORRECT
• B) Acute tubular necrosis
• C) IgA nephropathy
• D) Minimal change disease
• Why: Drug-induced AIN classically presents with fever, rash, arthralgias, eosinophilia, and sterile pyuria with WBC casts. The temporal link to antibiotics is the key clue.
• Variants:
  • Q: A patient on NSAIDs develops fever, eosinophilia, and renal failure with WBC casts: A: Acute interstitial nephritis
  • Q: Drug-induced renal injury with eosinophiluria is pathognomonic for: A: Acute interstitial nephritis

Q76. A 65-year-old man presents with bone pain, recurrent infections, and easy bruising. Laboratory tests show normocytic anemia, hypercalcemia, and monoclonal spike on serum protein electrophoresis. Bone marrow biopsy shows >10% plasma cells. Which of the following is the most appropriate treatment?

• A) Bortezomib ← CORRECT
• B) Rituximab
• C) Imatinib
• D) Cyclophosphamide
• Why: Multiple myeloma with >10% plasma cells, M-spike, CRAB criteria (hypercalcemia, renal failure, anemia, bone lesions) is treated first-line with bortezomib-based regimens (proteasome inhibitor).
• Variants:
  • Q: A 70-year-old with back pain, anemia, and M-spike — which targeted therapy is first-line? A: Bortezomib
  • Q: Proteasome inhibitor used in multiple myeloma: A: Bortezomib

Q80. A 13-year-old female comes to you with fatigue and shortness of breath on exertion. She menstruates regularly but uses more than 5-4 pads a day. Examination reveals conjunctival pallor and a negative digital rectal exam for blood. Her complete blood count shows Hb=7, hypochromic microcytic red cells with some pencil cells in her peripheral smear. Which test will confirm if this is a case of iron deficiency anemia?

• A) Serum iron
• B) TIBC
• C) Ferritin ← CORRECT
• D) BM aspiration with biopsy
• Why: In iron deficiency anemia (hypochromic microcytic, pencil cells, menorrhagia), serum ferritin is the most sensitive and specific test. Low ferritin = depleted iron stores = confirmed IDA.
• Variants:
  • Q: Best single test to confirm iron deficiency in a patient with microcytic anemia: A: Serum ferritin
  • Q: Which lab value is decreased in iron deficiency anemia and most specific? A: Ferritin

Q81. A 45-year-old man presents to the emergency department with sudden severe shortness of breath, hypotension, and distended neck veins. ECG shows sinus tachycardia and chest X-ray shows mediastinal widening. What is the most likely diagnosis?

• A) Tension pneumothorax
• B) Pulmonary embolism
• C) Acute myocardial infarction
• D) Cardiac tamponade ← CORRECT
• Why: Beck’s triad (hypotension + distended neck veins + muffled heart sounds) with mediastinal widening on CXR (water bottle heart) points to cardiac tamponade. ECG shows sinus tachycardia.
• Variants:
  • Q: A post-CABG patient with hypotension, JVD, and pulsus paradoxus — diagnosis? A: Cardiac tamponade
  • Q: CXR shows enlarged cardiac silhouette with acute hypotension and raised JVP: A: Cardiac tamponade

Q84. A man presents with fever, night sweats, weight loss, and a persistent cough producing blood-streaked sputum for 2 months. Chest X-ray reveals cavitary lesions in the right upper lobe. What is the most likely diagnosis?

• A) Bronchiectasis
• B) Lung abscess
• C) Pulmonary embolism
• D) Tuberculosis ← CORRECT
• Why: Night sweats, weight loss, hemoptysis, and cavitary lesions in the right upper lobe are classic for pulmonary tuberculosis. Upper lobe cavitation is highly suggestive of reactivation TB.
• Variants:
  • Q: A patient with cough, weight loss, and apical cavitation on CXR — most likely: A: Pulmonary tuberculosis
  • Q: Which infection classically causes upper lobe cavitary lesions? A: Tuberculosis

Q86. A 60-year-old man presents with painless, firm, non-tender cervical lymphadenopathy. He also reports night sweats, weight loss, and fever. Excisional biopsy shows Reed- Sternberg cells. What is the most likely diagnosis?

• A) Hodgkin lymphoma ← CORRECT
• B) Non-Hodgkin lymphoma
• C) Chronic lymphocytic leukemia
• D) Tuberculosis
• Why: Painless cervical lymphadenopathy with B symptoms (night sweats, weight loss, fever) plus Reed-Sternberg cells on biopsy = Hodgkin lymphoma.
• Variants:
  • Q: Reed-Sternberg cells in a lymph node biopsy indicate: A: Hodgkin lymphoma
  • Q: A patient with painless cervical LAD and B symptoms — biopsy shows RS cells. Diagnosis? A: Hodgkin lymphoma

Q91. A 55-year-old woman presents with fatigue and recurrent infections. Laboratory tests reveal pancytopenia. Bone marrow biopsy shows hypercellularity with >20% blasts. What is the most likely diagnosis?

• A) Acute myeloid leukemia ← CORRECT
• B) Chronic myeloid leukemia
• C) Myelodysplastic syndrome
• D) Aplastic anemia
• Why: >20% blasts in bone marrow = acute leukemia. At age 55, AML is far more common than ALL. Pancytopenia + hypercellular marrow with blasts = AML.
• Variants:
  • Q: Bone marrow with >20% blasts in a 60-year-old with pancytopenia: A: Acute myeloid leukemia
  • Q: Threshold of blasts in bone marrow to diagnose acute leukemia: A: >20%

Q94. 30-year-old female has a history of frequent nosebleeds and increased menstrual flow. On physical examination, petechiae and purpura are present on the skin of her extremities. Laboratory studies show normal prothrombin time and platelet count but decreased Von Willebrand factor activity. This patient most likely has a derangement in which of the following steps in hemostasis?

• A) Platelet adhesion ← CORRECT
• B) Platelet aggregation
• C) Prothrombin inhibition
• D) Vasoconstriction
• Why: Von Willebrand factor (vWF) mediates platelet adhesion to exposed subendothelial collagen at sites of vascular injury. Decreased vWF activity impairs this initial step.
• Variants:
  • Q: Von Willebrand disease affects which step of hemostasis? A: Platelet adhesion
  • Q: vWF is essential for: A: Platelet adhesion to subendothelium

Q100. A 29-year-old woman presents with palpitations, weight loss, and heat intolerance. she is having fine tremor . Examination shows tachycardia, warm moist skin, lid lag, diffuse nontender goiter, exophthalmos, and hyperactive reflexes. TSH is suppressed , free T4 and T3 are elevated , antiTSH receptor antibodies are positive. What is the most likely diagnosis?

• A) Toxic multinodular goitre
• B) Hashimoto’s thyroiditis
• C) T3-secreting adenoma
• D) De Quervain’s thyroiditis
• E) Graves’ disease ← CORRECT
• Why: Suppressed TSH with elevated free T4/T3, positive anti-TSH receptor antibodies, diffuse goiter, and exophthalmos = Graves’ disease. These are diagnostic hallmarks.
• Variants:
  • Q: The most common cause of hyperthyroidism with exophthalmos: A: Graves’ disease
  • Q: Positive anti-TSH receptor antibodies are specific for: A: Graves’ disease

Q117. A 65-year-old man presents with a history of pancreatic cancer which is noted to have spread to adjacent structures. Which anatomical structure is most likely associated with this spread mechanism?

• A) Common Bile Duct
• B) Lymphatic channels ← CORRECT
• C) Blood vessels
• D) Mesenteric tissues
• Why: Pancreatic cancer spreads primarily via lymphatic channels to peripancreatic, celiac, and para-aortic lymph nodes. The question states “spread to adjacent structures” — this occurs through rich lymphatic networks that permeate the retroperitoneum. Lymphatic invasion is present in >70% of resected pancreatic cancers.
• ✗ A) Common Bile Duct: this is an adjacent structure itself (direct extension), not a spread mechanism
• ✗ C) Blood vessels: hematogenous spread occurs later (liver mets), but is not the primary route to adjacent structures
• ✗ D) Mesenteric tissues: direct extension, not a distinct anatomical spread mechanism
• Variants:
  • Q: Pancreatic cancer most commonly metastasizes to: A: Liver (hematogenous via portal vein)
  • Q: Most common site of pancreatic cancer: A: Head of pancreas (60-70%)

Q121. 14-year-old boy presents with left sided scanty purulent ear discharge over the past few years. He is now experiencing severe postural imbalance, associated nausea and vomiting for the last two days. Which of the following is most like complication in this case?

• A) Acute Petrositis
• B) Acute Labyrinthitis ← CORRECT
• C) Acute Mastoiditis
• D) Otogenic Meningitis
• Why: Chronic suppurative otitis media (scanty purulent discharge for years) + acute onset of postural imbalance (vertigo) + nausea/vomiting = spread of infection to the inner ear causing acute labyrinthitis. The erosion of the horizontal semicircular canal (cholesteatoma) creates a fistula, leading to vertigo.
• ✗ A) Acute Petrositis: deep pain behind eye, Gradenigo triad (otitis + CN VI palsy + retro-orbital pain)
• ✗ C) Acute Mastoiditis: post-auricular swelling, tenderness, pinna displacement — not primarily vertigo
• ✗ D) Otogenic Meningitis: fever, neck stiffness, headache, CSF changes — not isolated vertigo
• Variants:
  • Q: Positive fistula test (Hennebert sign) indicates: A: Labyrinthine fistula in CSOM with cholesteatoma
  • Q: Most common complication of CSOM: A: Mastoiditis (but intratemporal — facial palsy, labyrinthitis)

Q130. The most common cause of massive lower gastrointestinal bleeding (LGIB) is:

• A) Angiodysplasia
• B) Diverticulosis ← CORRECT
• C) Ischemic colitis
• D) Colon cancer
• Why: Diverticulosis is the most common cause of massive (hemodynamically significant) lower GI bleeding. Bleeding occurs when a diverticulum erodes into a penetrating vasa recta artery at its neck or dome, causing painless, sudden, large-volume bright red or maroon blood per rectum.
• ✗ A) Angiodysplasia: common cause of LGIB but more often causes occult/chronic bleeding; diverticulosis is #1 for massive
• ✗ C) Ischemic colitis: presents with crampy pain + bloody diarrhea, not typically massive
• ✗ D) Colon cancer: causes occult/chronic bleeding with iron deficiency anemia, rarely massive acute bleeding
• Variants:
  • Q: Most common cause of LGIB overall (not just massive): A: Diverticulosis (though hemorrhoids are #1 for trivial bleeding)
  • Q: First step in management of massive LGIB: A: Resuscitation + colonoscopy (after rapid bowel prep if stable)

Q139. A 65-year-old female underwent extensive gynecologic surgery for squamous carcinoma of the cervix. She was taking broad-spectrum antibiotics and had a central venous catheter placed on the day of surgery. On the 3rd postoperative day she became febrile. On the 8th day, blood cultures grew gram-positive ovoid organisms that reproduced by budding. Which microorganism is most likely responsible?

• A) Enterococcus faecalis
• B) Candida albicans ← CORRECT
• C) Staphylococcus aureus
• D) Staphylococcus epidermidis
• Why: Gram-positive ovoid organisms reproducing by budding = yeast forms (budding yeast cells). Candidemia risk factors: recent extensive surgery + broad-spectrum antibiotics (eliminates competing bacteria) + central venous catheter (biofilm formation). Onset ~8 days post-op is typical for nosocomial candidemia.
• ✗ A) Enterococcus faecalis: Gram-positive cocci (in chains), not ovoid, binary fission not budding
• ✗ C) Staphylococcus aureus: Gram-positive cocci (clusters), not ovoid, no budding
• ✗ D) Staphylococcus epidermidis: Gram-positive cocci (clusters), no budding — typical line infection but not ovoid/yeast
• Variants:
  • Q: Treatment of choice for candidemia: A: Echinocandin (caspofungin, micafungin) or fluconazole if sensitive
  • Q: Most common nosocomial fungal infection: A: Candidiasis (Candida albicans)

Q141. A 25-year-old man presents with hematuria and flank pain. Peripheral smear shows sickle-shaped red blood cells. He reports episodes of painful crises since childhood. What is the most likely underlying defect?

• A) Autosomal recessive mutation in the beta-globin gene ← CORRECT
• B) Autosomal dominant mutation in the alpha-globin gene
• C) Acquired hemoglobin mutation
• D) Vitamin B12 deficiency
• Why: Sickle cell disease is caused by a point mutation in the beta-globin gene (Glu to Val at position 6), inherited as an autosomal recessive trait. The presentation of hematuria + flank pain + sickle cells on smear + childhood painful crises is classic.
• ✗ B) AD mutation in alpha-globin gene:** Alpha-globin mutations cause alpha-thalassemia, not sickle cell; also AR, not AD.
• ✗ C) Acquired hemoglobin mutation:** Sickle cell is congenital/germline, not an acquired mutation.
• ✗ D) Vitamin B12 deficiency:** Causes megaloblastic anemia with macrocytes, not sickle-shaped RBCs.
• Variants:
  • Q: A child presents with dactylitis and HbS on electrophoresis. Inheritance pattern? A: Autosomal recessive
  • Q: A 2-year-old with splenic sequestration crisis. Which gene is mutated? A: Beta-globin gene on chromosome 11

Q142. A 30-year-old man presents with well-demarcated, erythematous plaques covered with silvery scales on the extensor surfaces of his elbows. Which of the following is the most likely diagnosis?

• A) Lichen planus
• B) Tinea corporis
• C) Psoriasis ← CORRECT
• D) Vitiligo
• Why: Well-demarcated erythematous plaques with silvery scales on extensor surfaces (elbows, knees) is the classic presentation of psoriasis vulgaris. The distribution and scale quality are pathognomonic.
• ✗ A) Lichen planus:** Presents with purple, polygonal, flat-topped papules (the 6 P’s), not silvery scales on extensor surfaces.
• ✗ B) Tinea corporis:** Ringworm - annular, scaling patch with central clearing, not silvery plaques on extensors.
• ✗ D) Vitiligo:** Only depigmentation (white patches), no erythema or silvery scales.
• Variants:
  • Q: A patient presents with nail pitting and a well-demarcated plaque on the scalp. Diagnosis? A: Psoriasis
  • Q: A 35-year-old has erythematous plaques with silvery scales on extensor forearms. Koebner phenomenon positive. Diagnosis? A: Psoriasis

Q143. Which one of the following is called a SURGICAL airway?

• A) Endotracheal tube
• B) Guedel airway
• C) Laryngeal Mask Airway
• D) Tracheostomy ← CORRECT
• Why: A surgical airway is created by making an incision through the skin and soft tissues into the trachea (tracheostomy or cricothyroidotomy). Endotracheal tubes, Guedel airways, and LMAs are all inserted via natural orifices without surgical incision.
• ✗ A) Endotracheal tube:** Placed through mouth/nose into trachea - no incision needed.
• ✗ B) Guedel airway:** Oropharyngeal airway - stays above glottis, no incision.
• ✗ C) Laryngeal Mask Airway:** Supraglottic device - no incision.
• Variants:
  • Q: In a “cannot intubate, cannot ventilate” scenario, what is the emergency surgical airway? A: Cricothyroidotomy
  • Q: Which of the following requires a scalpel incision? A: Tracheostomy

Q157. Decreased near vision after the age of 40 years is most commonly caused by:

• A) Myopia
• B) Macular Degeneration
• C) Presbyopia ← CORRECT
• D) Keratoconus
• Why: Decreased near vision after age 40 is almost always presbyopia - age-related loss of accommodation due to hardening of the lens and weakening of the ciliary muscle. The lens loses elasticity and cannot increase its curvature for near objects.
• ✗ A) Myopia:** Presents in younger age (teen/early adult), distance vision blurred, near vision preserved - not age 40+ onset.
• ✗ B) Macular Degeneration:** Presents >60 years, central vision loss (scotoma), not isolated near vision difficulty.
• ✗ D) Keratoconus:** Progressive corneal thinning causing irregular astigmatism, presents in adolescence/early adulthood.
• Variants:
  • Q: A 50-year-old teacher complains she needs to hold books at arm’s length to read. Diagnosis? A: Presbyopia
  • Q: Correction for presbyopia? A: Convex (plus) lenses for near vision / bifocals

Q158. A 40-year-old lady suffering from duodenal ulcer has been prescribed a drug once daily that effectively reduces acid secretion for 24 hours. Which of the following drug is most likely prescribed to her?

• A) Pirenzepine
• B) Cimetidine
• C) Esomeprazole ← CORRECT
• D) Sucralfate
• Why: Esomeprazole is a proton pump inhibitor (PPI) that provides potent, long-lasting acid suppression for 24 hours with once-daily dosing. It irreversibly inhibits the H+/K+ ATPase pump in gastric parietal cells.
• ✗ A) Pirenzepine:** M1 anticholinergic, reduces acid but not as potent, requires multiple daily doses, side effects.
• ✗ B) Cimetidine:** H2 receptor antagonist, effective but only for 6-12 hours, requires BID/QID dosing, not 24-hour coverage with once daily.
• ✗ D) Sucralfate:** Mucosal protective agent, does not reduce acid secretion - coats ulcer base.
• Variants:
  • Q: Which PPI is best for drug interaction profile? A: Pantoprazole (least CYP interaction)
  • Q: Long-term PPI use can cause which deficiency? A: Vitamin B12 deficiency (also hypomagnesemia, increased fracture risk)

Q161. A 50-year-old man presents with polyuria, polydipsia, and fatigue. Laboratory results show fasting blood glucose of 180 mg/dL. What is the most appropriate initial management?

• A) Insulin therapy immediately
• B) Lifestyle modification and metformin ← CORRECT
• D) Dietary restriction
• Why: Fasting glucose 180 mg/dL meets criteria for diabetes mellitus (DM). In a stable adult without ketoacidosis, first-line management is lifestyle modification (diet, exercise) plus metformin. Immediate insulin is only indicated if symptomatic hyperglycemia with ketosis or type 1 DM.
• ✗ A) Insulin therapy immediately:** Not indicated - no mention of DKA, ketosis, or type 1 presentation.
• ✗ D) Dietary restriction alone:** Inadequate - at FBS 180 mg/dL, pharmacotherapy is indicated alongside lifestyle changes.
• Variants:
  • Q: A newly diagnosed diabetic with HbA1c 9.2% and no symptoms of DKA - first-line therapy? A: Metformin + lifestyle modification
  • Q: Contraindication to metformin? A: eGFR <30 mL/min (risk of lactic acidosis)

Q168. A 35-year-old huqqa smoker is reluctant to quit smoking in pregnancy. What is the most likely complication she is at risk for?

• A) Increased incidence of pre-eclampsia
• B) Increased risk of premature rupture of membranes
• C) Increased risk of sudden infant death syndrome
• D) Reduction in birth weight ← CORRECT
• Why: Smoking (including huqqa) in pregnancy causes fetal hypoxia and vasoconstriction leading to intrauterine growth restriction (IUGR) and low birth weight. This is the most consistently observed complication - a dose-dependent reduction in birth weight.
• ✗ A) Increased incidence of pre-eclampsia:** Smoking actually reduces the risk of pre-eclampsia (paradoxical protective effect).
• ✗ B) Increased risk of premature rupture of membranes:** Associated with smoking, but less consistently the MOST common.
• ✗ C) Increased risk of sudden infant death syndrome:** Associated with postnatal smoke exposure, not the most direct pregnancy complication.
• Variants:
  • Q: A pregnant woman who smokes delivers a 2.2 kg baby at term. Most likely cause? A: Smoking-induced IUGR (reduction in birth weight)
  • Q: Smoking during pregnancy increases risk of all EXCEPT? A: Pre-eclampsia (risk is decreased)

Q172. A 45-year-old woman presents with weight gain, moon face, purple striae, proximal muscle weakness, and hypertension. Laboratory tests show elevated cortisol levels that do not suppress low-dose dexamethasone. Which of the following is the most likely diagnosis?

• A) Addison disease
• B) Cushing syndrome ← CORRECT
• C) Hypothyroidism
• D) Acromegaly
• E) Pheochromocytoma
• Why: Weight gain, moon face, purple striae, proximal muscle weakness, hypertension, and elevated cortisol not suppressed by low-dose dexamethasone is diagnostic of Cushing syndrome. The low-dose dexamethasone test fails to suppress cortisol, confirming endogenous hypercortisolism.
• ✗ A) Addison disease:** Would show low cortisol, hyperpigmentation, hyponatremia, hyperkalemia - opposite picture.
• ✗ C) Hypothyroidism:** Weight gain, fatigue, cold intolerance, but no striae, moon face, or elevated cortisol.
• ✗ D) Acromegaly:** Coarse facial features, enlarged hands/feet, prognathism, not purple striae.
• ✗ E) Pheochromocytoma:** Paroxysmal hypertension, palpitations, headache, sweating - episodic, not cortisol excess.
• Variants:
  • Q: A patient with Cushing syndrome with high ACTH - to distinguish pituitary vs ectopic source? A: High-dose dexamethasone suppression test (pituitary will suppress, ectopic will not)
  • Q: Which classic finding is seen in Cushing syndrome but not simple obesity? A: Purple striae (>1 cm), proximal muscle weakness, easy bruising

Q173. Which one of the following serum levels is most appropriate for determining ovulation?

• A) Estrogen
• B) LH
• C) Progesterone ← CORRECT
• D) Prolactin
• Why: Progesterone rises after ovulation (produced by corpus luteum) and peak progesterone levels in the mid-luteal phase confirm that ovulation has occurred. Serum progesterone >3 ng/mL in the luteal phase is the gold standard for confirming ovulation.
• ✗ A) Estrogen:** Peaks just before ovulation (LH surge trigger) but does not reliably confirm ovulation has occurred.
• ✗ B) LH:** LH surge precedes ovulation by 24-36 hours - predicts impending ovulation but does not confirm it happened.
• ✗ D) Prolactin:** Involved in lactation, suppresses ovulation when elevated - not used to confirm ovulation.
• Variants:
  • Q: Mid-luteal progesterone level to confirm ovulation? A: >3 ng/mL (some sources >10 ng/mL)
  • Q: Which test predicts ovulation is about to occur? A: Urine LH surge (ovulation predictor kits)

Q174. A patient presents with tetany and positive Chvostek’s sign. Deficiency of which electrolyte is most likely responsible?

• A) Sodium
• B) Potassium
• C) Calcium ← CORRECT
• D) Magnesium
• Why: Tetany (carpopedal spasm, perioral tingling) and positive Chvostek’s sign (facial nerve twitching) are classic signs of hypocalcemia. Chvostek’s sign is elicited by tapping over the facial nerve.
• ✗ A) Sodium:** Hyponatremia causes confusion, seizures, not tetany or Chvostek’s sign.
• ✗ B) Potassium:** Hypokalemia causes weakness, arrhythmias, not tetany; Chvostek’s is specific to hypocalcemia.
• ✗ D) Magnesium:** Hypomagnesemia can also cause tetany (by causing secondary hypocalcemia via PTH suppression), but calcium is the primary and more common cause. The direct answer is calcium.
• Variants:
  • Q: Trousseau sign (carpopedal spasm with BP cuff inflation) indicates? A: Hypocalcemia
  • Q: Chvostek sign positive. Which electrolyte? A: Calcium (low)

Q175. A 60-year-old man presents with resting tremors, bradykinesia, and rigidity. His facial expression mask-like, and his gait is shuffling. What is the most likely diagnosis?

• A) Alzheimer disease
• B) Parkinson disease ← CORRECT
• C) Huntington disease
• D) Multiple sclerosis
• Why: Resting tremors (pill-rolling), bradykinesia, rigidity (cogwheel), mask-like facies, and shuffling gait in a 60-year-old man is the classic tetrad of Parkinson disease - a neurodegenerative disorder of the basal ganglia with dopamine depletion in the substantia nigra.
• ✗ A) Alzheimer disease:** Presents with progressive memory loss, cognitive decline, no tremor/rigidity.
• ✗ C) Huntington disease:** Presents with chorea (involuntary dance-like movements), cognitive decline, behavioral changes - not resting tremor/rigidity.
• ✗ D) Multiple sclerosis:** Relapsing-remitting episodes, optic neuritis, ataxia, weakness, sensory loss in young adults.
• Variants:
  • Q: Parkinson disease is characterized by degeneration of which area? A: Substantia nigra pars compacta (loss of dopaminergic neurons)
  • Q: First-line treatment for Parkinson disease in a patient <65 years? A: Levodopa/carbidopa or dopamine agonists

Q176. A 30-year-old man presents with complaints of repeated episodes of indigestion flatulence and bloating after consuming milk products while avoiding the products relieves his symptoms completely. This condition is caused by individual’s inability to digest which of the following?

• A) Fructose
• B) Lactose ← CORRECT
• C) Maltose
• D) Mannose
• Why: Symptoms of indigestion, flatulence, and bloating after consuming milk products, with complete relief upon avoiding them, is classic lactose intolerance. This is caused by lactase deficiency leading to inability to digest lactose, which is fermented by gut bacteria producing gas and bloating.
• ✗ A) Fructose:** Found in fruits, honey, HFCS - not specifically in milk products.
• ✗ C) Maltose:** Found in grains, not dairy.
• ✗ D) Mannose:** A monosaccharide, not a significant dietary disaccharide in milk.
• Variants:
  • Q: Lactose intolerance - deficient enzyme? A: Lactase (brush border enzyme)
  • Q: Hydrogen breath test is used to diagnose intolerance to which sugar? A: Lactose (also fructose, but lactose is the classic)

Obstetrics & Gynaecology

Q4. Which of the following diagnostic modalities, along with clinical history, are considered most optimal for the diagnosis of ectopic pregnancy?

• A) Transabdominal scan + complete blood picture
• B) Urine pregnancy test + serum beta-hCG levels
• C) Transabdominal scan + serum beta-hCG levels ← CORRECT
• D) Transabdominal scan + urine pregnancy test
• Why: The gold standard for diagnosing ectopic pregnancy is transvaginal/transabdominal ultrasound combined with serial quantitative beta-hCG measurement. Ultrasound identifies extrauterine gestational sac; beta-hCG levels correlate with gestational age and help interpret ultrasound findings (discriminatory zone).
• ✗ A) Transabdominal scan + complete blood picture: CBC does not diagnose ectopic pregnancy.
• ✗ B) Urine pregnancy test + serum beta-hCG: Urine pregnancy test is qualitative; beta-hCG alone can’t localize pregnancy.
• ✗ D) Transabdominal scan + urine pregnancy test: Urine test is qualitative only; need quantitative beta-hCG.
• Variants:
  • Q: A woman presents with acute lower abdominal pain and syncope at 8 weeks. Most likely diagnosis? A: Ruptured ectopic pregnancy
  • Q: Discriminatory zone of beta-hCG for ectopic pregnancy on TVS? A: ~1500–2000 IU/L
  • Q: Most common site of ectopic pregnancy? A: Ampulla of fallopian tube

Q7. A 27 year, married woman came with complaint of recurrent thick white vaginal discharge associated with severe vulval itching. On examination, there is vulval erythema and per speculum examination revealed thick white curdy discharge. High vaginal swab for C/S sent for confirmation. Which one of the following is the provisional diagnosis on basis of clinical examination?

• A) Bacterial vaginosis
• B) Candidiasis ← CORRECT
• C) Gonorrhea
• D) Trichomoniasis
• Why: Thick white curdy (cottage cheese-like) discharge with severe vulval itching is pathognomonic for vulvovaginal candidiasis. Risk factors include pregnancy, diabetes, antibiotics, and immunosuppression.
• ✗ A) Bacterial vaginosis: Thin, gray-white, fishy-smelling discharge, no itching/frothy — clue: “curdy” (candidiasis) vs “thin/fishy” (BV).
• ✗ C) Gonorrhea: Purulent yellow discharge, dysuria, not thick white curdy.
• ✗ D) Trichomoniasis: Frothy yellow-green discharge, strawberry cervix, malodorous.
• Variants:
  • Q: Vaginal pH in candidiasis? A: Normal (4–4.5)
  • Q: KOH mount shows pseudo-hyphae. Diagnosis? A: Candidiasis
  • Q: First-line treatment for uncomplicated vulvovaginal candidiasis? A: Topical azoles (clotrimazole) or oral fluconazole

Q17. A 58-year-old male in surgical ward is diagnosed to be having Plummer disease, which is:

• A) Simple diffuse goitre
• B) Simple multinodular goiter
• C) Solitary thyroid nodule
• D) Toxic multinodular goitre ← CORRECT
• Why: Plummer disease = toxic multinodular goiter (hyperthyroidism from autonomously functioning thyroid nodules in a multinodular gland). Typically presents in older adults with mild hyperthyroidism and cardiovascular symptoms, unlike Graves (diffuse, ophthalmopathy, younger).
• ✗ A) Simple diffuse goitre: Euthyroid, not toxic (no hyperthyroidism).
• ✗ B) Simple multinodular goiter: Euthyroid, no hyperthyroidism — Plummer disease implies TOXIC.
• ✗ C) Solitary thyroid nodule: Single nodule, not multinodular; if toxic = toxic adenoma, not Plummer.
• Variants:
  • Q: Graves disease is associated with: A) Diffuse goiter + ophthalmopathy + pretibial myxedema + TSH receptor antibodies
  • Q: Most common cause of hyperthyroidism in elderly? A: Toxic multinodular goiter (Plummer disease)
  • Q: Thyroid scan in Plummer disease shows: A: Multiple hot nodules with suppressed background

Q28. A 72-year-old man has had a sensation of retrosternal burning that is worse at night and after meals for the last 4 months. It partially responds to antacid treatment. Which is the single most appropriate initial diagnostic investigation?

• A) Barium meal
• B) CT scan thorax
• C) Upper GI Endoscopy ← CORRECT
• D) 24h pH studies
• Why: A 72-year-old with chronic retrosternal burning (likely GERD) partially responsive to antacids needs upper GI endoscopy first. Age >60 with chronic reflux symptoms is an indication for endoscopy to exclude Barrett esophagus, stricture, or esophageal adenocarcinoma. Endoscopy allows direct visualization and biopsy.
• ✗ A) Barium meal: Can show reflux/ulcer but less sensitive for mucosal changes and cannot biopsy.
• ✗ B) CT scan thorax: Not first-line for GERD; used for suspected malignancy staging, not initial evaluation.
• ✗ D) 24h pH studies: Used to confirm pathologic reflux when endoscopy is normal and diagnosis is uncertain — not first-line initial test.
• Variants:
  • Q: First-line treatment for GERD: A: Proton pump inhibitors (omeprazole)
  • Q: Alarm features requiring urgent endoscopy in GERD: A: Dysphagia, weight loss, anemia, GI bleed, age >55–60
  • Q: Barrett esophagus is characterized by: A: Intestinal metaplasia (goblet cells) in distal esophagus

Q33. A mother brings her 5-week-old son to the paediatric outpatient clinic. She is concerned because he has been having episodes of forceful vomiting after feeds for the last 2 weeks. She says her son always seems hungry and is now beginning to appear lethargic. Examination reveals mild dehydration and a smooth, firm, non-tender mass in the right upper quadrant of the abdomen. Blood tests are sent. What biochemical abnormalities would you expect to find?

• A) Hyperchloraemic respiratory alkalosis
• B) Hypochloraemic, hyperkalaemic metabolic alkalosis
• C) Hypochloraemic, hypokalaemic metabolic alkalosis ← CORRECT
• D) Hyponatraemic metabolic acidosis
• Why: This is classic infantile hypertrophic pyloric stenosis (5 weeks old, projectile vomiting, palpable “olive” mass in RUQ, hungry after vomiting). Loss of gastric juice (HCl) leads to metabolic alkalosis, hypochloremia, and hypokalemia. The kidney tries to conserve H+ by excreting K+ (paradoxical aciduria in alkalosis).
• ✗ A) Hyperchloraemic respiratory alkalosis: Pyloric stenosis causes metabolic, not respiratory, alkalosis.
• ✗ B) Hypochloraemic, hyperkalaemic metabolic alkalosis: Hypokalemia, not hyperkalemia, results from gastric losses and renal compensation.
• ✗ D) Hyponatraemic metabolic acidosis: Would be seen in diarrhea (loss of bicarbonate) or adrenal insufficiency, not gastric outlet obstruction.
• Variants:
  • Q: Biochemical abnormality needing correction before surgery for pyloric stenosis: A: Hypochloremic hypokalemic metabolic alkalosis (correct with IV NS + KCl)
  • Q: First-line imaging for pyloric stenosis: A: Abdominal ultrasound (target sign, length >16mm, thickness >4mm)
  • Q: Definitive treatment for pyloric stenosis: A: Ramstedt pyloromyotomy

Q38. A 42-year-old woman, a known case of gallstones, attends the emergency department with severe pain in the right upper quadrant after eating a fatty meal. The pain resolves after 2 hours. Her temperature is 37°C. She has no abdominal tenderness and all blood investigations are within the normal range. Which is the single most likely diagnosis?

• A) Acute cholecystitis
• B) Biliary colic ← CORRECT
• C) Cholangitis
• D) Pancreatitis
• Why: Sudden severe RUQ pain after a fatty meal that resolves within hours in a known gallstone patient — with NO fever, NO tenderness, and normal labs — is classic biliary colic (cystic duct transiently obstructed by a stone then passes). Acute cholecystitis requires persistent pain + inflammation (fever, tenderness, Murphy’s).
• ✗ A) Acute cholecystitis: Would have fever, persistent pain >6h, positive Murphy’s sign, raised WBC.
• ✗ C) Cholangitis: Requires Charcot’s triad (pain, fever, jaundice) — no jaundice or fever here.
• ✗ D) Pancreatitis: Epigastric pain radiating to back, raised amylase/lipase.
• Variants:
  • Q: RUQ pain + fever + jaundice in a gallstone patient → diagnosis? A: Cholangitis (Charcot’s triad)
  • Q: RUQ pain >6h + fever + positive Murphy’s → diagnosis? A: Acute cholecystitis

Q45. A 10-year-old girl presents with frothy urine and periorbital swelling. Laboratory tests show proteinuria >3.5 g/day, hypoalbuminemia, and hyperlipidemia. What is the most likely diagnosis?

• A) Minimal change disease ← CORRECT
• B) IgA nephropathy
• C) Acute glomerulonephritis
• D) Acute tubular necrosis
• Why: A 10-year-old with frothy urine, periorbital edema, massive proteinuria (>3.5 g/day), hypoalbuminemia, and hyperlipidemia has nephrotic syndrome. In children, minimal change disease (lipoid nephrosis) is the most common cause (~80%), presenting with selective proteinuria and normal renal function.
• ✗ B) IgA nephropathy: Presents with recurrent hematuria (synpharyngitic), not nephrotic-range proteinuria.
• ✗ C) Acute glomerulonephritis: Nephritic picture (hematuria, hypertension, oliguria, RBC casts) — not nephrotic.
• ✗ D) Acute tubular necrosis: Acute kidney injury with muddy brown casts, not massive proteinuria.
• Variants:
  • Q: Most common cause of nephrotic syndrome in adults? A: Membranous nephropathy
  • Q: Minimal change disease — characteristic histology? A: Normal light microscopy, foot process effacement on electron microscopy

Q61. A 44 year old man presents to surgical emergency with open fracture of right tibia following car accident on high way (high energy injury). Gustilo and Anderson class IIIA injury is present ulti- fragmentary and stable fracture of tibial shaft with extensive soft tissue damage involving skin, muscle and neurovascular bundle but adequate soft tissue coverage over fractured bone). Which of following will be preferred for bone stabilization in this case?

• A) Intramedullary nailing ← CORRECT
• B) External fixator
• C) Plate and screws
• D) Bone graft
• Why: Gustilo-Anderson Type IIIA open tibial fracture (adequate soft tissue coverage) is best managed with intramedullary nailing as definitive fixation. IIIA fractures have enough soft tissue to cover the bone, making IM nailing safe and providing superior biomechanical stability compared to external fixation.
• ✗ B) External fixator: Preferred for IIIB (needs flap) and IIIC (vascular injury) or damage control.
• ✗ C) Plate and screws: Higher infection risk in open fractures.
• ✗ D) Bone graft: Not acute fixation — used for delayed union/non-union.
• Variants:
  • Q: Gustilo IIIB open fracture — preferred initial fixation? A: External fixator (requires soft tissue coverage surgery)
  • Q: What antibiotic is given for open fractures? A: Cefazolin + gentamicin (add penicillin if farm-related/dirt contamination)

Q87. Premenstrual cycle pain and lower abdominal discomfort, along with mood changes, are commonly associated with the:

• A) Follicular phase
• B) Mid-ovulatory phase
• C) Luteal phase ← CORRECT
• D) Menstruation
• Why: Premenstrual syndrome (PMS) — mood changes, breast tenderness, bloating — occurs during the luteal phase of the menstrual cycle when progesterone peaks.
• Variants:
  • Q: Symptoms of PMS are most prominent during which phase of the menstrual cycle? A: Luteal phase
  • Q: Progesterone peaks in which phase of the menstrual cycle? A: Luteal phase

Q89. A lady comes 6 weeks after her normal vaginal delivery for contraceptive advice. She is breastfeeding her child and requests reversible contraception. She is planning another pregnancy in 6 months and is scared of injections. What is the best option?

• A) COCP
• B) Cu-IUCD (intrauterine contraceptive device)
• C) Mirena coil
• D) POP ← CORRECT
• E) Transdermal patch
• Why: POP (progesterone-only pill) is the best oral contraceptive for breastfeeding mothers — it does not affect milk supply. She wants reversible contraception and plans pregnancy in 6 months; POP is easily discontinued.
• Variants:
  • Q: Best contraception for a breastfeeding mother who wants to conceive in 6 months: A: POP
  • Q: Which oral contraceptive is safe during lactation? A: Progesterone-only pill (POP)

Q90. What is the recommended age threshold for endometrial biopsy in a woman with abnormal menstrual bleeding?

• A) >45 years ← CORRECT
• B) >50 years
• Why: Endometrial biopsy is indicated in women >45 years with abnormal uterine bleeding to rule out endometrial hyperplasia/carcinoma. Under 45, biopsy is reserved for risk factors (obesity, PCOS, tamoxifen).
• Variants:
  • Q: At what age should a woman with abnormal uterine bleeding undergo endometrial sampling? A: Over 45 years
  • Q: Endometrial biopsy is indicated in AUB in women of what age? A: >45 years or <45 with risk factors

Q99. A 32-year-old multigravida at 32 weeks’ gestation wakes up in the middle of the night with a pool of blood. Bleeding has now stopped. She has no pain or uterine contractions. Fetal heart rate is regular at 145 beats/min. The fetus is in transverse lie. Her pulse is 120/min, blood pressure is 110/70 mmHg, and respiratory rate is 29/min. What is the single most likely diagnosis?

• A) Placental abruption
• B) Placenta accreta
• C) Placenta praevia ← CORRECT
• D) Preterm labor
• Why: Painless vaginal bleeding in the third trimester (32 weeks) with transverse lie is classic for placenta praevia. Bleeding is from placental separation over the cervical os.
• Variants:
  • Q: A G2P1 at 30 weeks with painless PV bleeding and breech presentation — diagnosis: A: Placenta praevia
  • Q: Painless vaginal bleeding in the third trimester is most likely: A: Placenta praevia

Q122. When a new treatment is developed that delays death but does not produce recovery from a chronic disease, which of the following will occur?

• A) Prevalence of the disease will decrease
• B) Incidence of the disease will increase
• C) Prevalence of the disease will increase ← CORRECT
• D) Incidence of the disease will decrease
• Why: Prevalence = Incidence × Duration of disease. A treatment that delays death but does not cure prolongs the duration that patients live with the disease. Since incidence stays the same (doesn’t change), increased duration → increased prevalence.
• ✗ A) Prevalence will decrease: opposite — it increases when patients live longer with disease
• ✗ B) Incidence will increase: incidence is new cases — unrelated to treatment efficacy
• ✗ D) Incidence will decrease: incidence does not change with treatment; it depends on prevention/risk factors
• Variants:
  • Q: A screening program increases early detection. What happens to prevalence? A: Transiently increases (lead time bias)
  • Q: The relationship between prevalence and incidence: A: Prevalence = Incidence × Average Duration

Q124. After amputation, a 46-year-old man complains of severe pain at the end of the limb. Physician explained that at the distal end of the injured peripheral nerve , the newly growing axonsmally form a swelling as a source of spontaneous pain. What is this swelling known as?

• A) Astrocytoma
• B) Glioma
• C) Myeloma
• D) Neuroma ← CORRECT
• Why: After nerve transection (amputation), the proximal end attempts to regenerate. Disorganized proliferation of axons, Schwann cells, and fibrous tissue forms a traumatic (amputation) neuroma — a swollen, tangled mass that can generate spontaneous ectopic impulses causing severe localized pain (stump pain).
• ✗ A) Astrocytoma: tumor of astrocytes (CNS), not related to peripheral nerve injury
• ✗ B) Glioma: CNS glial tumor
• ✗ C) Myeloma: plasma cell neoplasm of bone marrow
• Variants:
  • Q: Term for pain perceived in the missing limb after amputation: A: Phantom limb pain
  • Q: Management of painful neuroma: A: Surgical excision, nerve stump transposition into muscle/bone

Q129. What is the ratio of chest compressions to breath during the resuscitation newborn?

• A) 5 compressions to 1 breath
• B) 3 compressions to 1 breath ← CORRECT
• C) 7 compressions to 1 breath
• D) 9 compressions to 1 breath
• Why: Neonatal resuscitation follows a 3:1 compression-to-ventilation ratio (90 compressions + 30 breaths/min) — this prioritizes ventilation because neonatal arrests are almost always asphyxial (respiratory in origin), not cardiac. Breaths should last 1 second.
• ✗ A) 5:1: used in older pediatric guidelines but not for newborns
• ✗ C) 7:1: not standard for any age
• ✗ D) 9:1: not standard for any age
• Variants:
  • Q: Adult CPR compression-to-ventilation ratio (single rescuer): A: 30:2
  • Q: Pediatric (1 year to puberty) CPR ratio (two rescuers): A: 15:2

Q133. A 36-year-old man presents with right-sided facial numbness, ptosis, miosis, and flushing, along with medial deviation of the right eye. Which of the following best explains the location of his lesion? Sympathetic pathway affecting cervical chain

• A) and oculomotor nerve
• B) Trigeminal nerve root at pons
• C) Abducens nerve in cavernous sinus ← CORRECT
• D) Facial nerve at internal acoustic meatus
• E) Trochlear nerve in midbrain
• Why: The patient has Horner syndrome (ptosis + miosis + flushing = sympathetic chain involvement) + CN VI palsy (medial deviation of eye) + facial numbness (CN V). All these structures (sympathetic fibers around internal carotid, CN V1/V2, and CN VI) traverse the cavernous sinus. A lesion here explains the full constellation.
• ✗ A) and oculomotor nerve: CN III palsy causes down-and-out deviation + dilated pupil — not medial deviation
• ✗ B) Trigeminal nerve root at pons: would cause facial numbness only, not Horner’s or CN VI palsy
• ✗ D) Facial nerve at ICA meatus: causes lower motor neuron facial palsy (Bell’s palsy), not Horner’s or numbness
• ✗ E) Trochlear nerve in midbrain: CN IV palsy causes vertical diplopia (worse on downward gaze), not this picture
• Variants:
  • Q: Complete Horner syndrome includes: A: Ptosis, miosis, anhidrosis, enophthalmos
  • Q: Cavernous sinus syndrome typically affects which cranial nerves: A: CN III, IV, V1, V2, VI

Q147. A 22-year-old female presents with itchy, erythematous lesions in the flexural areas of her elbows and knees. She reports a history of similar episodes since childhood and has a personal history of allergic rhinitis. What is the most likely diagnosis?

• A) Psoriasis
• B) Atopic dermatitis ← CORRECT
• C) Contact dermatitis
• D) Seborrheic dermatitis
• Why: Itchy, erythematous flexural lesions since childhood with personal history of allergic rhinitis = atopic triad (atopic dermatitis, allergic rhinitis, asthma). Flexural distribution (antecubital/popliteal) distinguishes it from psoriasis (extensor).
• ✗ A) Psoriasis:** Extensor surfaces, silvery scales, not associated with allergic rhinitis.
• ✗ C) Contact dermatitis:** Localized to area of exposure, acute onset, no childhood history.
• ✗ D) Seborrheic dermatitis:** Scalp, face (nasolabial folds, eyebrows), flexural areas are not primary.
• Variants:
  • Q: A child with itchy flexural lesions and family history of asthma - diagnosis? A: Atopic dermatitis
  • Q: Increased IgE levels in a child with chronic eczema - diagnosis? A: Atopic dermatitis

Q156. 2-year boy presented with acute watery diarrhea and profuse vomiting for the last 2 days. He is drowsy and unable to drink. Optimal treatment option is:

• A) Oral rehydration therapy
• B) IV Ringer Lactate ← CORRECT
• C) IV antibiotics
• D) Reassurance and follow-up
• Why: A 2-year-old with acute watery diarrhea, profuse vomiting, drowsy, and unable to drink has severe dehydration with shock (some signs of hypovolemic shock). According to WHO/IMNCI, a child with severe dehydration who cannot drink needs IV Ringer Lactate (or normal saline) urgently.
• ✗ A) Oral rehydration therapy:** Contraindicated because the child is unable to drink (drowsy) and has profuse vomiting.
• ✗ C) IV antibiotics:** No indication - this is dehydration, not septic shock.
• ✗ D) Reassurance and follow-up:** Inappropriate - child has severe dehydration requiring emergency intervention.
• Variants:
  • Q: A child with some dehydration (restless, irritable, thirsty, drinks eagerly) - management? A: ORS under observation
  • Q: How much IV fluid for severe dehydration in a 10 kg child? A: 100 mL/kg RL, give 30 mL/kg in first hour then 70 mL/kg over 2.5 hours

Ophthalmology

Q77. A patient has come in with intense pain in his left eye and a swift decline in vision over the past two days. An examination reveals significantly elevated intraocular pressure. What IV drug would you prescribe for this condition?

• A) Brinzolamide
• B) Furosemide
• C) Mannitol ← CORRECT
• D) Timolo
• Why: Acute angle-closure glaucoma presents with severe eye pain, rapid vision loss, fixed mid-dilated pupil, and very high IOP. IV mannitol (osmotic diuretic) rapidly reduces intraocular pressure by creating an osmotic gradient.
• Variants:
  • Q: A 65-year-old woman with acute onset eye pain, nausea, and cloudy cornea — what IV drug? A: Mannitol
  • Q: Which osmotic agent is given IV for acute glaucoma attack? A: Mannitol

Q155. A 50-year-old man with a history of chronic alcoholism presents with confusion, ataxia, and ophthalmoplegia. Deficiency of which vitamin is responsible for this condition?

• A) Vitamin B1 (thiamine) ← CORRECT
• B) Vitamin B6 (pyridoxine)
• C) Vitamin B12 (cobalamin)
• D) Vitamin D
• Why: The triad of confusion, ataxia, and ophthalmoplegia in a chronic alcoholic patient is Wernicke encephalopathy, caused by thiamine (vitamin B1) deficiency. Alcoholism impairs thiamine absorption and utilization.
• ✗ B) Vitamin B6 (pyridoxine):** Deficiency causes dermatitis, glossitis, neuropathy, sideroblastic anemia - not this triad.
• ✗ C) Vitamin B12 (cobalamin):** Deficiency causes megaloblastic anemia, peripheral neuropathy, subacute combined degeneration of spinal cord - not acute confusion/ataxia/ophthalmoplegia.
• ✗ D) Vitamin D:** Deficiency causes bone demineralization, hypocalcemia/myopathy - no CNS triad.
• Variants:
  • Q: A chronic alcoholic presents with confusion, nystagmus, and ataxia. Immediate management? A: IV thiamine before glucose
  • Q: Korsakoff psychosis develops if Wernicke encephalopathy is untreated - what is the hallmark feature? A: Anterograde amnesia with confabulation

Paediatrics

Q5. A 10-month-old child is brought to the primary health care center with a history of cough for 3 days. On examination, the child has fast breathing (RR = 56/min), chest in-drawing, and is able to drink normally. There are no danger signs. What is the most appropriate classification and management according to IMNCI?

• A) Severe pneumonia - refer urgently and give first dose of injectable antibiotics
• B) Pneumonia - treat with oral antibiotics at home ← CORRECT
• C) No pneumonia - give only symptomatic treatment
• D) Very severe disease - admit and give IV fluid
• Why: IMNCI classifies cough/difficulty breathing in children 2 months–5 years using chest indrawing and fast breathing. This 10-month-old has chest indrawing (the key sign for pneumonia) and RR 56/min (fast breathing for age), but can drink normally with no danger signs. Chest indrawing + ability to drink = Pneumonia, not severe. Management is oral antibiotics at home.
• ✗ A) Severe pneumonia — refer urgently: Requires chest indrawing PLUS a general danger sign (unable to drink, convulsions, lethargic). This child drinks normally.
• ✗ C) No pneumonia — give only symptomatic treatment: Chest indrawing rules out “no pneumonia.”
• ✗ D) Very severe disease — admit and give IV fluid: Not the classification here; no danger signs present.
• Variants:
  • Q: IMNCI: A 3-year-old with cough, RR 45/min, no chest indrawing. Classification? A: Pneumonia (fast breathing ≥40 for 12mo–5yr)
  • Q: IMNCI: A 6-month-old with cough, chest indrawing, and lethargy. Classification? A: Severe pneumonia — refer
  • Q: Fast breathing cutoff for 2–12 months? A: ≥50/min. For 12mo–5yr: ≥40/min.

Q6. A 16-month-old child presented with history of sudden onset of noisy breathing a cough while playing in his play room. On examination he is in respiratory distress has stridor, respiratory rate 55 breaths/min, temp of 98.6 °F. Chest ausculta revealed wheeze and decreased air entry over the right side of chest. What is most likely diagnosis?

• A) Acute laryngotracheobronchitis
• B) Acute severe asthma
• C) Foreign body inhalation ← CORRECT
• D) Acute epiglottis
• Why: The presentation is classic: sudden onset of noisy breathing/cough while playing (with small objects/toy), respiratory distress, stridor, and unilateral decreased air entry with wheeze on the right side. Foreign body aspiration most commonly lodges in the right main bronchus (more vertical, wider). No fever suggests non-infectious etiology.
• ✗ A) Acute laryngotracheobronchitis (croup): Gradual onset, barking cough, fever, bilateral findings — not unilateral.
• ✗ B) Acute severe asthma: Bilateral wheeze, not unilateral; history of atopy/recurrent episodes.
• ✗ D) Acute epiglottitis: High fever, drooling, tripod positioning, muffled voice — rapid onset but with systemic toxicity and bilateral findings.
• Variants:
  • Q: Most common site of foreign body aspiration in children? A: Right main bronchus
  • Q: A child with sudden onset stridor, no fever, while eating peanuts — next step? A: Rigid bronchoscopy
  • Q: Radiograph finding in foreign body aspiration? A: Hyperinflation on affected side (air trapping) or mediastinal shift

Q21. A medical student begins hyperventilating in anxiety of examination and faints. recovers when he is made to breathe into a paper bag. Which one of the follow findings will be seen in his blood samples?

• A) Decreased pH, decreased PCO2
• B) Decreased pH, increased PCO2
• C) Elevated pH, decreased PCO2 ← CORRECT
• D) Elevated pH, elevated PCO2
• Why: Hyperventilation causes excessive CO2 exhalation → respiratory alkalosis (elevated pH, decreased PCO2). Breathing into a paper bag rebreaches CO2, correcting the alkalosis. Before rebreathing: pH ↑ (alkalotic), PCO2 ↓ (low).
• ✗ A) Decreased pH, decreased PCO2: Metabolic acidosis with respiratory compensation — not hyperventilation.
• ✗ B) Decreased pH, increased PCO2: Respiratory acidosis — opposite of hyperventilation.
• ✗ D) Elevated pH, elevated PCO2: Mixed alkalosis + respiratory acidosis — impossible (would be metabolic alkalosis with compensation).
• Variants:
  • Q: Hyperventilation in DKA causes: A) Respiratory alkalosis (compensatory) with primary metabolic acidosis
  • Q: ABG in panic attack: A: Respiratory alkalosis
  • Q: Respiratory alkalosis most commonly caused by: A: Hyperventilation (anxiety, PE, salicylate overdose, pregnancy, hepatic encephalopathy)

Q29. Which statement is specific for Meckel diverticulum?

• A) Is present in 2 per cent of the population
• B) Arises from the mesenteric border of the jejunum
• C) May contain heterotopic gastric mucosa ← CORRECT
• D) Is present only in boys
• Why: Meckel diverticulum is a true diverticulum (all layers) on the antimesenteric border of the ileum (not jejunum). The most specific distinguishing feature is that it may contain heterotopic tissue — most commonly gastric mucosa, followed by pancreatic. This gastric mucosa can ulcerate and cause painless bleeding.
• ✗ A) Is present in 2 per cent of the population: True (rule of 2s) but not “specific” — many things fit 2% prevalence.
• ✗ B) Arises from the mesenteric border of the jejunum: It arises from the antimesenteric border of the ileum (within 2 feet of ileocecal valve), not jejunum.
• ✗ D) Is present only in boys: Occurs in both sexes, though symptomatic presentation is more common in males.
• Variants:
  • Q: Rule of 2s for Meckel diverticulum: A: 2% prevalence, 2:1 M:F, 2 feet from ileocecal valve, 2 inches long, 2 types of heterotopic tissue
  • Q: Most common presentation of Meckel in children: A: Painless rectal bleeding (currant jelly stool)
  • Q: Meckel diverticulum is a remnant of: A: Vitelline duct (omphalomesenteric duct)

Q40. Most common type of renal stone

• A) Uric acid
• B) Calcium oxalate ← CORRECT
• C) Cystine
• D) Struvite
• Why: Calcium oxalate stones account for ~75% of all renal stones, making them the most common type. They are radio-opaque and form in acidic/neutral urine.
• ✗ A) Uric acid: ~10% of stones; radiolucent; form in acidic urine.
• ✗ C) Cystine: Rare (<1%); associated with cystinuria; hexagonal crystals.
• ✗ D) Struvite: ~15%; staghorn calculi; associated with urease-producing organisms (Proteus); form in alkaline urine.
• Variants:
  • Q: Most common radiolucent renal stone? A: Uric acid
  • Q: Staghorn calculus → most likely composition? A: Struvite (magnesium ammonium phosphate)

Q51. A 20-year-old male presents with a soft, cystic, rubbery swelling at the lateral side of the right eyebrow since birth. What is the probable clinical diagnosis?

• A) Sebaceous cyst
• B) Lipoma
• C) Dermoid cyst ← CORRECT
• D) Papilloma
• E) Sebaceous horn
• Why: A soft, cystic, rubbery swelling at the lateral eyebrow (external angular region) present since birth is a classic dermoid cyst. These are congenital ectodermal inclusion cysts commonly found at the lateral margin of the orbit, scalp midline, and neck.
• ✗ A) Sebaceous cyst: Acquired, not present at birth; located in dermis, non-translucent.
• ✗ B) Lipoma: Soft, lobulated, not cystic — and usually not present at birth.
• ✗ D) Papilloma: Warty growth — not cystic.
• ✗ E) Sebaceous horn: Keratin-filled projection — not cystic or congenital.
• Variants:
  • Q: Midline neck swelling that moves with tongue protrusion? A: Thyroglossal duct cyst
  • Q: Painless cystic swelling at the outer end of eyebrow in a child → diagnosis? A: External angular dermoid

Q54. A 60-year-old man with a 40-pack-year smoking history presents with persistent cough, two episodes of hemoptysis, hoarseness of voice, and weight loss. Chest X-ray reveals a large hilar mass. Which of the following is the appropriate investigation to confirm the diagnosis?

• A) Bronchoscopy with biopsy ← CORRECT
• Why: Heavy smoker with persistent cough, hemoptysis, hoarseness, weight loss, and a hilar mass on CXR — this is likely lung cancer. Bronchoscopy with biopsy provides tissue diagnosis and is the gold standard for central/hilar lesions.
• Variants:
  • Q: Investigation of choice for peripheral lung nodule? A: CT-guided transthoracic needle biopsy
  • Q: Most common lung cancer type in smokers? A: Squamous cell carcinoma

Q56. A 40-year-old renal transplant recipient presents 1-year post- transplant with gradually rising creatinine. He is asymptomatic and compliant. Ultrasound is normal. What is the most appropriate next step?

• A) Increase immunosuppressive drugs
• B) Start high-dose steroids
• C) Renal allograft biopsy ← CORRECT
• D) Start antibiotics
• Why: A renal transplant recipient with gradually rising creatinine at 1 year, asymptomatic, with normal ultrasound suggests chronic allograft nephropathy or chronic rejection. The gold standard to differentiate between rejection, drug toxicity (CNI), recurrent disease, or BK nephropathy is allograft biopsy.
• ✗ A) Increase immunosuppression: Blindly increasing without knowing the cause risks infection or toxicity — biopsy first.
• ✗ B) High-dose steroids: Used for acute rejection — not appropriate without biopsy confirmation.
• ✗ D) Start antibiotics: No evidence of infection.
• Variants:
  • Q: Most common cause of late graft loss? A: Chronic allograft nephropathy / chronic rejection
  • Q: CNI toxicity on biopsy shows? A: Tubular vacuolization, arteriolar hyalinosis

Q72. A 22-year-old student presents with high grade fever, headache and vomiting c three days duration. Neck stiffness is positive. Which of the following should done immediately to confirm the diagnosis?

• A) CT scan brain
• B) CRP Q
• C) Lumbar puncture ← CORRECT
• D) MRI brain
• Why: Fever, headache, vomiting, and neck stiffness constitute meningeal irritation. Lumbar puncture with CSF analysis is the definitive test to confirm meningitis and identify the organism.
• Variants:
  • Q: A patient with fever, photophobia, and Kernig sign needs which test to confirm meningeal infection? A: Lumbar puncture
  • Q: First investigation in suspected bacterial meningitis in the absence of focal neurology: A: Lumbar puncture

Q73. A 22-year-old woman presents to the emergency department with breathlessness, chest tightness, and wheezing for the last 3 hours. She has a history of asthma and uses a salbutamol inhaler. Her respiratory rate is 32/min, heart rate is 120 bpm, and SpO2 is 88% on room air. Diffuse expiratory wheezes are heard bilaterally. Peak expiratory flow rate is 55% of predicted. What is the most appropriate initial management?

• A) Continuous nebulized bronchodilators
• B) IV glucose with insulin
• C) Systemic corticosteroids with oxygen and inhaled bronchodilator therapy ← CORRECT
• D) Non-invasive ventilation
• Why: PEFR 55% predicted with SpO2 88% indicates a moderate-to-severe acute asthma exacerbation. Guidelines mandate: high-flow oxygen, inhaled bronchodilators, and early systemic corticosteroids.
• Variants:
  • Q: A 30-year-old asthmatic presents with PEFR 40%, unable to complete sentences. What is the first step? A: Oxygen + nebulized salbutamol + IV hydrocortisone
  • Q: Acute severe asthma with no response to three back-to-back nebulizations — next step: A: IV magnesium sulfate and consider ICU

Q78. A 1.5 year old girl presents with short stature, Failure to thrive. She had complaint of abdominal distension and loose bulky stools since weaning started. On examination, weight and height both are low for her age. She is pallor too. Consultant recommended for duodenal biopsy. From which disease baby is suffering?

• A) Celiac disease ← CORRECT
• B) Crohns disease
• C) Tropical sprue
• D) Autoimmune enteropathy
• Why: Classic presentation: FTT, abdominal distension, bulky loose stools since gluten introduction (weaning). Duodenal biopsy is gold standard showing villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes.
• Variants:
  • Q: A toddler with FTT, anemia, and diarrhea after starting wheat cereal — duodenal biopsy shows villous atrophy: A: Celiac disease
  • Q: Which gluten-sensitive enteropathy presents with failure to thrive in infancy? A: Celiac disease

Q79. Which vaccine(s) are given at birth according to the Expanded Programme on Immunization (EPI) schedule?

• A) Hep B
• B) Measles
• C) BCG & OPV ← CORRECT
• D) OPV & Rota virus
• Why: According to Pakistan’s EPI schedule, at birth: BCG (intradermal) and OPV-0 (oral polio vaccine zero dose) are given. Hep B birth dose is also recommended, but the paired option “BCG & OPV” is the established EPI birth pair.
• Variants:
  • Q: Which two vaccines are routinely administered at birth in Pakistan’s EPI? A: BCG and OPV
  • Q: A newborn receives which vaccination(s) in the delivery room? A: BCG and OPV-0

Q82. A 35-year-old man presents with fever, malaise, and a maculopapular rash that started on his face and spread to the trunk. whitish spots are seen on the buccal mucosa. What is the most likely diagnosis?

• A) Measles ← CORRECT
• B) Rubella
• C) Varicella
• D) Scarlet fever
• Why: Koplik spots (whitish spots on buccal mucosa) are pathognomonic for measles. The maculopapular rash that starts on the face and spreads downward is classic.
• Variants:
  • Q: A child with fever, cough, coryza, and white spots on buccal mucosa: A: Measles
  • Q: Koplik spots are diagnostic of which viral exanthem? A: Measles

Q95. Commonest cause of blindness in Pre-school children is:

• A) Maternal Rubella
• B) Vit A deficiency ← CORRECT
• C) Accidental injury
• D) Congenital cataract
• Why: Vitamin A deficiency causes xerophthalmia (night blindness, Bitot spots, corneal ulceration/keratomalacia) and is the leading cause of preventable blindness in preschool children worldwide.
• Variants:
  • Q: Leading cause of preventable blindness in children under 5 globally: A: Vitamin A deficiency
  • Q: Xerophthalmia is caused by deficiency of: A: Vitamin A

Q97. A 6-month-old child was brought by his mother to the ER with the first episode of generalized seizures and fever for the last 2 days. On examination, the temperature is 101°F with bulging anterior fontanelle and irritability. What is the investigation of choice?

• A) Blood CP (Complete Blood Count)
• B) Blood culture
• C) Blood sugar random
• D) Lumbar puncture ← CORRECT
• Why: 6-month-old with fever, seizures, bulging anterior fontanelle, and irritability = meningitis until proven otherwise. LP is the investigation of choice to confirm.
• Variants:
  • Q: A 4-month-old with fever, bulging fontanelle, and seizures — first test? A: Lumbar puncture
  • Q: Investigation of choice for suspected meningitis in an infant: A: Lumbar puncture

Q104. A 04 years old child has coarse facial features, protruding tongue and umbilical hernia. Profound mental retardation is also becoming apparent. A deficiency of which of the following hormone is most likely to cause this disease?

• A) Cortisol
• B) Insulin
• C) Somatostatin
• D) Thyroxine ← CORRECT
• Why: Coarse facial features, protruding tongue, umbilical hernia, and profound mental retardation = congenital hypothyroidism (cretinism). Caused by deficiency of thyroxine (T4), which is critical for brain development in infancy.
• Variants:
  • Q: A neonate with coarse facies, large tongue, and umbilical hernia — deficient hormone: A: Thyroxine
  • Q: Most common preventable cause of mental retardation worldwide: A: Congenital hypothyroidism (iodine/thyroxine deficiency)

Q109. A 12-year-old girl with a childhood history of asthma complained of cough, dyspnea, and wheezing after visiting a riding stable. Her symptoms became severe and her parents brought her to the emergency room. Which of the following is the most appropriate drug to rapidly reverse her bronchoconstriction?

• A) Inhaled fluticasone
• B) Inhaled beclomethasone
• C) Intravenous propranolol
• D) Inhaled albuterol ← CORRECT
• E) Oral theophylline
• Why: Acute severe asthma exacerbation with bronchoconstriction needs rapid reversal. Inhaled short-acting beta-2 agonist (albuterol/salbutamol) is first-line — acts within minutes by relaxing bronchial smooth muscle. The stable + allergen trigger (horse dander) precipitated the attack.
• ✗ A) Inhaled fluticasone: inhaled corticosteroid — takes days/weeks, for maintenance/control, not acute rescue
• ✗ B) Inhaled beclomethasone: same as A — maintenance, not rescue
• ✗ C) Intravenous propranolol: non-selective beta-blocker — can trigger bronchospasm, CONTRAINDICATED in asthma
• ✗ E) Oral theophylline: weak bronchodilator, narrow therapeutic index, second/third-line — too slow for acute severe attack
• Variants:
  • Q: Step-down therapy for well-controlled asthma on low-dose ICS: A: Reduce ICS dose by 50%
  • Q: Most common cause of acute asthma exacerbation in children: A: Viral URI

Q112. Digital X-ray of soft tissue neck lateral view shows positive thumb sign. Which of the aoe is the most likely diagnosis?

• A) Acute epiglottitis ← CORRECT
• B) Acute laryngotracheobronchitis
• C) Syphilis of larynx
• D) Laryngeal tuberculosis
• Why: “Thumb sign” on lateral neck X-ray = swollen, edematous epiglottis protruding into the airway — pathognomonic for acute epiglottitis. This is a medical emergency (airway compromise risk), classically caused by H. influenzae type b in unvaccinated children.
• ✗ B) Acute laryngotracheobronchitis (croup): shows “steeple sign” (subglottic narrowing), not thumb sign
• ✗ C) Syphilis of larynx: granulomatous lesion, no thumb sign
• ✗ D) Laryngeal tuberculosis: chronic, shows destructive lesions, not acute thumb sign
• Variants:
  • Q: Preferred airway management in acute epiglottitis: A: Controlled intubation in OR (avoid supine, have ENT/anesthesia ready)
  • Q: “Steeple sign” on X-ray is classic for: A: Croup (acute laryngotracheobronchitis)

Q115. In the data 15, 2, 9, 10, 18, 14, and 72, the median is:

• A) 10
• B) 14 ← CORRECT
• C) 15
• D) 18
• Why: Arrange the 7 numbers in ascending order: 2, 9, 10, 14, 15, 18, 72. Median = middle value = 4th number = 14. The extreme value (72) is an outlier that shifts the mean but does not affect the median.
• ✗ A) 10: 3rd number, not the median
• ✗ C) 15: 5th number
• ✗ D) 18: 6th number
• Variants:
  • Q: If a data set has an even number of values, the median is: A: Average of the two middle values
  • Q: This measure of central tendency is least affected by outliers: A: Median

Q126. 10year-old child presents with circular, scaly lesions with central clearing on the trunk. The lesions are mildly itchy. On examination, the margins are raised and erythematous. What is the most likely diagnosis?

• A) Eczema
• B) Tinea corporis ← CORRECT
• C) Impetigo
• D) Urticaria
• Why: Annular (circular) scaly plaque with raised erythematous border and central clearing on the trunk = classic “ringworm” — dermatophyte fungal infection (tinea corporis). Mild pruritus is typical. Diagnosis is clinical; KOH mount confirms hyphae.
• ✗ A) Eczema: poorly defined patches, not annular with central clearing, more pruritic, flexural distribution common
• ✗ C) Impetigo: honey-colored crusts, not annular/scaly, highly contagious, caused by Staph/Strep
• ✗ D) Urticaria: transient wheals (come and go within hours), not scaly or persistent, intensely pruritic
• Variants:
  • Q: Treatment of choice for tinea corporis: A: Topical terbinafine or clotrimazole
  • Q: KOH mount of skin scraping in tinea shows: A: Branching, septate hyphae

Q128. A 28 years old woman presents with fatigue, pallor, and spoonshaped nails. She reports heavy menstrual bleeding for 6 months. Labs: Hb 8 g/ dL, MCV 70 fL, MCH 22 pg, smear shows microcytic hypochromic RBCs. What is the most likely cause of her anemia?

• A) Vitamin B12 deficiency
• B) Folate deficiency
• C) lron deficiency ← CORRECT
• D) Anemia of chronic disease
• Why: Heavy menstrual bleeding (chronic blood loss) + microcytic hypochromic anemia (MCV 70, MCH 22) + koilonychia (spoon nails) = iron deficiency anemia. This is the most common cause of microcytic anemia worldwide. Ferritin would be low, TIBC elevated.
• ✗ A) Vitamin B12 deficiency: causes macrocytic (high MCV) anemia with neurological symptoms
• ✗ B) Folate deficiency: also macrocytic, no spoon nails, no menorrhagia link
• ✗ D) Anemia of chronic disease: normocytic, mild, ferritin high or normal (not microcytic)
• Variants:
  • Q: Best single test to confirm iron deficiency: A: Serum ferritin (<15 ng/mL is diagnostic)
  • Q: In thalassemia trait vs iron deficiency: A: RDW is normal in thalassemia, elevated in IDA; Hb electrophoresis diagnostic

Q136. A 15-year-old diagnosed case of type 1 diabetes mellitus presents with increased thirst, hunger, urination, and weight loss. His fasting blood glucose level is 400 mg/dL. What is the most likely reason for this patient’s inability to maintain a normal blood glucose level?

• A) Abnormal response to glucagon
• B) Decreased glucagon-to-insulin ratio
• C) Decreased glucose output by the liver
• D) Decreased uptake of glucose by peripheral cells ← CORRECT
• Why: In type 1 DM, autoimmune destruction of pancreatic beta cells → absolute insulin deficiency. Insulin is required for GLUT4 translocation to the cell membrane in muscle and adipose tissue → without insulin, peripheral cells cannot take up glucose → severe hyperglycemia (FBG 400).
• ✗ A) Abnormal response to glucagon: glucagon response is normal; the problem is lack of insulin
• ✗ B) Decreased glucagon-to-insulin ratio: actually, insulin is low so the ratio is increased (more glucagon relative to insulin) — this would worsen hyperglycemia, not cause it
• ✗ C) Decreased glucose output by the liver: liver INCREASES glucose output (glycogenolysis + gluconeogenesis) due to unopposed glucagon — worsening hyperglycemia
• Variants:
  • Q: A 15-year-old with DKA. ABG shows pH 7.1. What anion gap is expected? A: High anion gap metabolic acidosis
  • Q: Mainstay of long-term management in type 1 DM: A: Basal-bolus insulin regimen

Q137. A 35-year-old male presents with complaints of early baldness and is diagnosed as having a testicular tumor. Which one of the following is the most likely site of origin for this tumor?

• A) Spermatogonia
• B) Sertoli Cells
• C) Leydig Cells ← CORRECT
• D) Myoid Cells
• Why: Leydig cell tumors are sex cord-stromal tumors that produce excess androgens (testosterone). In adult males, this can cause premature balding (androgenic alopecia), gynecomastia (peripheral conversion to estrogen), and/or acne. While germ cell tumors are more common overall, the hormonal symptom (baldness) suggests a functional Leydig cell tumor.
• ✗ A) Spermatogonia: source of germ cell tumors (seminoma, non-seminoma) — most common testicular tumors but do NOT cause hormonal symptoms
• ✗ B) Sertoli Cells: produce estrogen → gynecomastia, but not typically early baldness
• ✗ D) Myoid Cells: contractile cells in seminiferous tubules — not associated with tumors
• Variants:
  • Q: Most common testicular tumor overall: A: Seminoma (germ cell)
  • Q: Tumor marker for seminoma: A: hCG (some) and LDH; non-seminoma: AFP + hCG

Q145. Which of the following changes will result in an increase in the glomerular filtration rate (GFR)?

• A) Decrease in plasma oncotic pressure ← CORRECT
• B) Increase in Bowman’s capsule hydrostatic pressure
• C) Constriction of the afferent arteriole
• D) Dilation of the efferent arteriole
• Why: GFR = Kf * (Pgc - Pbs - pi_gc). Decreasing plasma oncotic pressure reduces the osmotic pull opposing filtration, thus increasing net filtration pressure and GFR.
• ✗ B) Increase in Bowman’s capsule hydrostatic pressure:** Increases opposition to filtration, decreases GFR.
• ✗ C) Constriction of afferent arteriole:** Reduces blood flow into glomerulus, decreases GFR.
• ✗ D) Dilation of efferent arteriole:** Allows blood to leave glomerulus more easily, decreases filtration pressure and GFR.
• Variants:
  • Q: Which causes decreased GFR? A: Increased Bowman’s capsule pressure (ureteral obstruction)
  • Q: A patient with nephrotic syndrome has low plasma albumin. What happens to GFR? A: Increased (due to decreased oncotic pressure)

Q159. A neonate was delivered after a difficult and prolonged labor. The mother noticed that the child is not moving the left arm. On examination the left arm is held close to the body with the wrist facing backwards. What is the most likely diagnosis?

• A) Klumpke’s paralysis
• B) Fracture of humerus
• C) Erb’s Palsy ← CORRECT
• D) Shoulder dislocation
• Why: The left arm held close to body with wrist facing backward (waiter’s tip deformity) after difficult/prolonged labor is classic Erb’s palsy - injury to upper trunk of brachial plexus (C5-C6) from lateral traction on the head during delivery.
• ✗ A) Klumpke’s paralysis:** Lower trunk injury (C8-T1), causes “claw hand” and ipsilateral Horner syndrome, not waiter’s tip.
• ✗ B) Fracture of humerus:** Would cause pain, crepitus, and pseudoparalysis, not the specific waiter’s tip posture.
• ✗ D) Shoulder dislocation:** Would cause severe pain, loss of deltoid contour, not the classic waiter’s tip.
• Variants:
  • Q: Erb’s palsy involves which nerve roots? A: C5-C6 (sometimes C7)
  • Q: A newborn with a paralyzed arm, arm adducted and internally rotated, forearm pronated - diagnosis? A: Erb’s palsy (waiter’s tip)

Q167. A 40-year-old man presents with auditory hallucinations, disorganized speech, paranoia ,a social withdrawal for the past 6 months. Which of the following is the most likely diagnosis?

• A) Schizophrenia ← CORRECT
• B) Major depressive disorder
• C) Bipolar disorder
• D) Generalized anxiety disorder
• Why: Auditory hallucinations, disorganized speech, paranoia, and social withdrawal persisting for 6 months meets DSM-5 criteria for schizophrenia (symptoms for >6 months with at least 1 month of active phase symptoms like hallucinations and delusions).
• ✗ B) Major depressive disorder:** Would have depressed mood, anhedonia, sleep/appetite changes - not primarily hallucinations and paranoia.
• ✗ C) Bipolar disorder:** Would have manic/hypomanic episodes with elevated mood, grandiosity, decreased need for sleep - not the primary presentation here.
• ✗ D) Generalized anxiety disorder:** Excessive worry, physical tension, but not psychosis (no hallucinations).
• Variants:
  • Q: A patient with paranoid delusions and auditory hallucinations for 2 months - what duration is needed for schizophrenia diagnosis? A: 6 months of disturbance
  • Q: First-line pharmacotherapy for schizophrenia? A: Atypical antipsychotics (e.g., risperidone, olanzapine)

Q170. A 2-year-old child is brought with delayed walking and bowing of legs. On examination, there is widening of wrists and a rachitic rosary. Laboratory investigations show low serum calcium, low phosphate, and elevated alkaline phosphatase. What is the most likely underlying cause?

• A) Primary hyperparathyroidism
• B) Vitamin D deficiency ← CORRECT
• C) Chronic renal failure causing hypercalcemi
• D) Excess dietary calcium intake
• Why: A 2-year-old with delayed walking, bowing of legs, widening of wrists, rachitic rosary, and low calcium, low phosphate, elevated ALP is classic rickets from vitamin D deficiency. The biochemical pattern (low Ca, low PO4, high ALP) confirms vitamin D-deficient rickets.
• ✗ A) Primary hyperparathyroidism:** Would show HIGH calcium, LOW phosphate, HIGH PTH - opposite biochemical picture.
• ✗ C) Chronic renal failure causing hypercalcemia:** CRF causes hypocalcemia (not hypercalcemia) due to phosphate retention and vitamin D deficiency.
• ✗ D) Excess dietary calcium intake:** Would cause hypercalcemia, not hypocalcemia; no rickets.
• Variants:
  • Q: Rickets shows cupping and fraying of which part of the bone on X-ray? A: Metaphysis
  • Q: Which blood levels differentiate vitamin D deficiency rickets from hypophosphatemic rickets? A: Vitamin D deficiency: low Ca, low PO4, high ALP, low vit D; Hypophosphatemic: normal Ca, very low PO4, normal vit D

Pathology

Q24. Most common congenital abdominal wall defect is:

• A) Gastroschisis
• B) Omphalocele
• C) Umbilical hernia ← CORRECT
• D) Diaphragmatic hernia
• Why: Umbilical hernia is the most common congenital abdominal wall defect, occurring in up to 10–20% of newborns (higher in premature infants and African descent). Most close spontaneously by 2–4 years. Though gastroschisis and omphalocele are more clinically significant, umbilical hernia is far more prevalent.
• ✗ A) Gastroschisis: Less common (~1 in 2000–4000), involves bowel herniating through abdominal wall defect lateral to umbilicus, no sac.
• ✗ B) Omphalocele: Less common (~1 in 4000–6000), herniation of abdominal contents into umbilical cord with sac.
• ✗ D) Diaphragmatic hernia: Less common (~1 in 2000–3000), abdominal contents herniate into chest through a diaphragmatic defect.
• Variants:
  • Q: Most common congenital abdominal wall defect requiring surgery: A: Gastroschisis (among major defects)
  • Q: Umbilical hernia vs omphalocele — key difference: A: Omphalocele has a sac; umbilical hernia is skin-covered
  • Q: Anterior abdominal wall defect with bowel loops outside, no sac, inflamed — diagnosis: A: Gastroschisis

Q65. A 23-year-old man presents with painful genital ulcers. On examination multiple small Vesicles that rupture to form shallow ulcers,associated with inguinal lymphadenopathy. He reports unprotected sexual activity. What is the likely diagnosis?

• A) Herpes genitalis ← CORRECT
• B) Primary syphilis
• C) Lymphogranuloma venereum
• D) Gonococcal urethritis
• Why: Painful genital ulcers that begin as vesicles (multiple small vesicles that rupture into shallow ulcers) with bilateral inguinal lymphadenopathy is classic for genital herpes (HSV-2 most commonly). The pain and vesicular stage are key discriminators from syphilis.
• ✗ B) Primary syphilis: Single painless chancre with clean base, firm, non-tender — not multiple painful vesicles.
• ✗ C) Lymphogranuloma venereum: Painless ulcer that heals quickly, followed by painful inguinal lymphadenopathy (bubo).
• ✗ D) Gonococcal urethritis: Urethral discharge/dysuria in males — not genital ulcers.
• Variants:
  • Q: First-line treatment for herpes genitalis? A: Acyclovir / Valacyclovir / Famciclovir
  • Q: Chronic painless ulcer with rolled-out edges on glans penis → diagnosis? A: Carcinoma penis / Syphilitic chancre

Q74. The most common site of Osteosarcoma is:

• A) Skull
• B) Spine
• C) Knee ← CORRECT
• D) Hip bone
• Why: Osteosarcoma most commonly arises in the metaphysis of long bones, particularly the distal femur (knee region), followed by proximal tibia. The knee accounts for ~50% of cases.
• Variants:
  • Q: Most common primary malignant bone tumor in adolescents and its most frequent location: A: Osteosarcoma — distal femur
  • Q: A 15-year-old boy with knee pain and a sunburst appearance on X-ray — probable diagnosis: A: Osteosarcoma

Q85. A young female complains of episodic breathlessness, cough, wheezing and chest tightness, worse during spring season. Which pathological mechanism is responsible for her symptoms?

• A) Permanent enlargement of distal air-space
• B) Mast cell activation ← CORRECT
• C) Excessive lysis of elastin
• D) Alpha 1-antiprotease deficiency
• Why: Seasonal asthma is IgE-mediated (Type I hypersensitivity). Allergen cross-links IgE on mast cells leading to degranulation and bronchoconstriction.
• Variants:
  • Q: In allergic asthma, bronchoconstriction is primarily mediated by which cell? A: Mast cell
  • Q: Type I hypersensitivity in the lungs is driven by: A: Mast cell degranulation

Q92. What is the type of Hypersensitivity reaction in tuberculosis?

• A) Type | hypersensitivity
• B) Type Il hypersensitivity
• C) Type Ill hypersensitivity
• D) Type IV hypersensitivity ← CORRECT
• Why: Tuberculosis granuloma formation is mediated by Th1 cells and macrophages — a classic Type IV delayed-type hypersensitivity reaction (also called cell-mediated immunity).
• Variants:
  • Q: PPD/Mantoux test reaction is which type of hypersensitivity? A: Type IV
  • Q: Granuloma formation in TB is mediated by: A: Type IV hypersensitivity

Q103. Stool examination of a six-year-old boy revealed pear-shaped flagellate organisms with two nuclei. What is the most likely organism?

• A) Entamoeba histolytica
• B) Giardia lamblia ← CORRECT
• C) Cryptosporidium
• D) Entamoeba coli
• Why: Giardia is a pear-shaped, flagellated protozoan with two nuclei (giving it a “face” appearance on microscopy). It causes diarrhea and malabsorption.
• Variants:
  • Q: Pear-shaped flagellate with two nuclei on stool microscopy: A: Giardia lamblia
  • Q: Which protozoan causes “traveler’s diarrhea” and is flagellated with two nuclei? A: Giardia lamblia

Q148. A 6-year-old boy presents with pallor, fatigue, and easy bruising. Laboratory reveal pancytopenia and bone marrow shows hypercellularity with ab lymphoblasts. What is the most likely diagnosis?

• A) Aplastic anemia
• B) Acute lymphoblastic leukemia ← CORRECT
• C) Chronic myelogenous leukemia
• D) Hemolytic anemia
• Why: A 6-year-old with pancytopenia and hypercellular marrow with lymphoblasts is classic ALL - the most common childhood leukemia. Pancytopenia explains pallor, fatigue (anemia), and easy bruising (thrombocytopenia).
• ✗ A) Aplastic anemia:** Bone marrow would be hypocellular, not hypercellular with lymphoblasts.
• ✗ C) Chronic myelogenous leukemia:** Typically in adults, presents with leukocytosis and splenomegaly, not pancytopenia with lymphoblasts.
• ✗ D) Hemolytic anemia:** Would show normoblastic hyperplasia, not lymphoblasts; no pancytopenia.
• Variants:
  • Q: A 4-year-old presents with fever, pallor, and petechiae. Bone marrow shows >25% lymphoblasts. Diagnosis? A: ALL
  • Q: A child with ALL develops CNS symptoms - what prophylactic treatment? A: Intrathecal methotrexate + cranial irradiation

Q163. An autopsy is conducted ina suspected case of a criminal abortion which sho cyanosis, distension with bright red frothy blood on right side of the hea q pulmonary arteries and coronary veins. What is the most probable cause of death?

• A) Air embolism ← CORRECT
• B) Fat embolism
• C) Hemorrhage
• D) Sepsis
• Why: Criminal abortion can introduce air into the uterine venous sinuses, causing air embolism. Autopsy findings: cyanosis, distended right heart chambers with bright red frothy blood, air in pulmonary arteries and coronary veins. This is classic for venous air embolism.
• ✗ B) Fat embolism:** Seen after long bone fractures, not criminal abortion; fat globules in lungs, petechial rash.
• ✗ C) Hemorrhage:** Would show pale organs, empty chambers, no frothy blood in right heart.
• ✗ D) Sepsis:** Would show signs of infection, not bright red frothy blood in heart chambers.
• Variants:
  • Q: A patient collapses during central line removal - most likely cause? A: Air embolism
  • Q: Autopsy finding of air in right ventricle after uterine instrumentation - cause of death? A: Air embolism

Pharmacology

Q9. A patient presents with hip fracture and externally rotated shortened limb. What is the likely diagnosis?

• A) Femoral shaft fracture
• B) Intertrochanteric fracture ← CORRECT
• C) Pelvic fracture
• D) Acetabular fracture
• Why: A hip fracture (intertrochanteric or femoral neck) classically presents with a shortened, externally rotated leg. Intertrochanteric fractures are more common in elderly and often present with this classic deformity. The question describes the typical sign without specifying mechanism.
• ✗ A) Femoral shaft fracture: Shortening + deformity but usually more swelling/thigh deformity; not specifically “hip fracture.”
• ✗ C) Pelvic fracture: Pelvic pain, inability to bear weight, but no isolated shortening/external rotation of one leg; may have pelvic instability.
• ✗ D) Acetabular fracture: Hip pain with movement, but leg position varies; often associated with posterior dislocation (flexed, adducted, internally rotated).
• Variants:
  • Q: A hip fracture presents with shortened, externally rotated leg. Sensation intact, pulses present. What type? A: Intertrochanteric vs femoral neck (both possible; intertrochanteric = more common)
  • Q: Femoral neck fracture presents with: A) Shortened, externally rotated leg (same presentation)
  • Q: Posterior hip dislocation presents with: A) Shortened, internally rotated, adducted leg

Q11. A male baby has presented with prolonged bleeding after circumcision. His two elder brothers had similar complaints. Which of the following is deficient in this patient?

• A) Calcium
• B) Factor VIII ← CORRECT
• C) Factor X
• D) Iron
• Why: Prolonged bleeding after circumcision in a male child with affected elder brothers points to an X-linked recessive coagulopathy — Hemophilia A (Factor VIII deficiency). Factor VIII deficiency accounts for ~80% of hemophilia cases. X-linked inheritance: affected males, carrier females.
• ✗ A) Calcium: Involved in coagulation cascade but X-linked bleeding disorder is hemophilia, not calcium deficiency.
• ✗ C) Factor X: Part of common pathway; deficiency is autosomal recessive, not X-linked, and rare.
• ✗ D) Iron: Not a coagulation factor; iron deficiency causes anemia, not bleeding.
• Variants:
  • Q: Hemophilia B (Christmas disease) is deficiency of: A: Factor IX
  • Q: Prolonged aPTT, normal PT — think: A) Hemophilia (intrinsic pathway deficiency)
  • Q: In circumcision bleeding workup, first test to order? A: aPTT

Q15. A primigravida presents in outpatient department at 34 weeks of gestation with hemoglobin level of 8 gm/dl. Which one of the following is the most appropriate next investigation to be ordered?

• A) Hb electrophoresis
• B) Serum ferritin ← CORRECT
• C) Stool examination
• D) Urine routine examination
• Why: At 34 weeks with Hb 8 g/dL, the most common cause is iron deficiency anemia. Serum ferritin is the most specific and sensitive test for iron stores and will confirm iron deficiency before initiating therapy. In Pakistan, iron deficiency is the leading cause; checking ferritin avoids unnecessary Hb electrophoresis if iron deficiency is confirmed.
• ✗ A) Hb electrophoresis: Indicated if microcytic hypochromic anemia with normal/elevated ferritin (suspect thalassemia). Not first-line without ferritin first.
• ✗ C) Stool examination: For hookworm ova — a cause of iron deficiency but not the next “most appropriate” diagnostic step before assessing iron status.
• ✗ D) Urine routine examination: Screens for UTI/hemoglobinuria but not the primary investigation for anemia workup.
• Variants:
  • Q: Anemia in pregnancy: Hb 7 g/dL, MCV 68 fL. Next test? A: Serum ferritin
  • Q: Iron deficiency anemia vs thalassemia trait — best discriminating test? A: Hb electrophoresis (if ferritin normal/elevated)
  • Q: Physiological anemia of pregnancy occurs due to: A: Plasma volume expansion > RBC mass increase (dilutional)

Q30. A 30 years primigravida at 32 weeks of gestation is diagnosed to have acute UTI. The first line antibiotic is:

• A) Ampicillin
• B) Erythromycin
• C) Metronidazole
• D) Cephalosporins ← CORRECT
• Why: Cephalosporins (cephalexin) are the first-line antibiotics for asymptomatic bacteriuria and acute UTI in pregnancy. They are safe in pregnancy (Category B). Ampicillin was traditional first-line but high resistance rates limit its use. Nitrofurantoin and cephalosporins are current recommended first-line agents.
• ✗ A) Ampicillin: Safe in pregnancy but high E. coli resistance limits empiric use as first-line.
• ✗ B) Erythromycin: Used for Ureaplasma or Chlamydia in pregnancy, not for routine UTI.
• ✗ C) Metronidazole: Used for bacterial vaginosis or trichomoniasis, not for UTI.
• Variants:
  • Q: Safe antibiotics in pregnancy: A: Penicillins, cephalosporins, nitrofurantoin (avoid in G6PD near term), clindamycin, azithromycin, metronidazole
  • Q: Contraindicated antibiotics in pregnancy: A: Tetracyclines, fluoroquinolones, aminoglycosides (risk), sulfonamides (near term)
  • Q: Asymptomatic bacteriuria in pregnancy is treated to prevent: A: Pyelonephritis and preterm labor

Q31. A 60-year-old man presents with exertional chest pain relieved by rest. ECG is normal. Exercise stress test shows ST-segment depression in multiple leads during exertion. What is the most likely diagnosis?

• A) Stable angina ← CORRECT
• B) Unstable angina
• C) Prinzmetal angina
• D) Myocardial infarction
• Why: Exertional chest pain relieved by rest + normal ECG at rest + exercise-induced ST depression = stable angina. ST depression during stress indicates reversible myocardial ischemia. Pain is predictable (same level of exertion), brief (<10 min), and relieved by rest/nitrates.
• ✗ B) Unstable angina: Pain at rest, new onset, increasing frequency/severity — crescendo pattern, not exertional only.
• ✗ C) Prinzmetal angina: Variant angina due to coronary vasospasm, occurs at rest (often early morning), ST elevation, not ST depression with exertion.
• ✗ D) Myocardial infarction: Prolonged pain (>20 min), not relieved by rest, ECG shows ST elevation, Q waves, or troponin elevation.
• Variants:
  • Q: Unstable angina/NSTEMI vs STEMI: A: NSTEMI has troponin rise without ST elevation; unstable angina has neither ST elevation nor troponin rise
  • Q: Most sensitive initial test for CAD: A: Exercise stress test (if patient can exercise)
  • Q: Duke Treadmill Score: A: Prognostic score based on exercise time, ST deviation, and angina during test

Q39. A 47-year-old man is having recurrent renal stones and nephrolithiasis. On investigations, he is found to be having pepper and salt type of lytic lesions in skull radiographs. He is likely suffering from which one of the following conditions?

• A) Paget disease of the bone
• B) Hyperthyroidism
• C) Hyper-parathyroidism ← CORRECT
• D) Osteogenesis imperfecta
• Why: Recurrent renal stones (calcium) + pepper-and-salt skull on X-ray is classic for hyperparathyroidism. The “pepper and salt” appearance is due to subperiosteal bone resorption, most commonly seen in hyperparathyroidism (osteitis fibrosa cystica).
• ✗ A) Paget disease of bone: Causes thickened skull bones (cotton wool spots), not pepper-and-salt; also associated with chalk-stick fractures, not typically renal stones.
• ✗ B) Hyperthyroidism: Causes osteoporosis but not pepper-and-salt skull or renal stones.
• ✗ D) Osteogenesis imperfecta: Blue sclera, multiple fractures, not this skull pattern.
• Variants:
  • Q: Skull X-ray shows cotton wool appearance → diagnosis? A: Paget disease
  • Q: Hyperparathyroidism bone change with cystic lesions → name? A: Osteitis fibrosa cystica / brown tumor

Q44. A 25-year-old cook is brought into the emergency department following an accident in the kitchen. A pan of hot cooking oil spilled over half of his back and over both legs. He weighs 70 kg. Calculate the additional volume of crystalloid required in the first 8 hours from the time of burn using the Parkland formula and Wallace Rule of Nines.

• A) 250 mL
• B) 3,150 mL
• C) 6,300 mL ← CORRECT
• D) 12,600 mL
• Why: Parkland formula = 4 mL × weight (kg) × %TBSA. Wallace Rule of Nines: half of back = 9% (half of 18% posterior trunk) + both legs = 36% (18% each) → total = 45%. Fluid = 4 × 70 × 45 = 12,600 mL total in 24h. First half (6,300 mL) given in first 8 hours.
• ✗ A) 250 mL: Far too low — miscalculation.
• ✗ B) 3,150 mL: Half of 6,300 — represents only 25% total or used 2 mL formula incorrectly.
• ✗ D) 12,600 mL: This is the total 24h volume, not the first 8h requirement.
• Variants:
  • Q: Parkland formula — what is the maintenance fluid for the second 24 hours? A: Colloid at 20-60% of calculated plasma volume, plus D5W to maintain urine output
  • Q: Burn involving entire right arm + anterior trunk in a 70 kg patient → 8h fluid? A: 9% + 18% = 27%; 4×70×27=7,560; half=3,780 mL

Q52. 6-year-old child known case of acute otitis media. After three days of illness he developed severe headache, nausea, photophobia, high grade fever. On examination there was neck stiffness. Which of the following is the most likely diagnosis?

• A) Cerebellar abscess
• B) Extradural abscess
• C) Meningitis ← CORRECT
• D) Sigmoid sinus thrombosis
• Why: A child with acute otitis media who develops severe headache, photophobia, high fever, and neck stiffness has meningitis complicating the AOM. Infection spreads directly from middle ear to meninges.
• ✗ A) Cerebellar abscess: Presents with ataxia, nystagmus, vertigo — not predominantly neck stiffness and photophobia.
• ✗ B) Extradural abscess: Focal neurological signs, not diffuse meningeal irritation.
• ✗ D) Sigmoid sinus thrombosis: Presents with high fever, headache, and signs of raised ICP (not photophobia/neck stiffness classically).
• Variants:
  • Q: Most common intracranial complication of CSOM? A: Meningitis (extradural abscess, subdural empyema, brain abscess, sigmoid sinus thrombosis)
  • Q: Gradenigo’s syndrome? A: AOM + abducens palsy + retro-orbital pain (petrous apicitis)

Q64. Year-old man is brought to the emergency department after a road trafficaccident. He is unconscious, has unequal pupils, and develops decerebrate posturing. CT scan reveals an epidural hematoma. What is the most likely urgent intervention?

• A) Mannitol administration only
• B) Immediate surgical evacuation ← CORRECT
• C) Lumbar puncture
• D) Conservative management
• Why: Unconscious patient with unequal pupils (third nerve compression from uncal herniation), decerebrate posturing, and CT-proven epidural hematoma — this is a surgical emergency. Epidural hematoma with signs of herniation (ipsilateral dilated pupil, contralateral hemiparesis, decerebrate posturing) requires immediate craniotomy and clot evacuation to prevent brainstem herniation and death.
• ✗ A) Mannitol only: Temporizing measure — not definitive; patient needs surgical evacuation.
• ✗ C) Lumbar puncture: Absolutely contraindicated in raised ICP with mass effect (risk of herniation).
• ✗ D) Conservative management: Only for small EDH (<30 mL) without mass effect or neurological signs.
• Variants:
  • Q: CT finding in epidural vs subdural hematoma? A: EDH = biconvex/lentiform, doesn’t cross suture lines; SDH = crescent-shaped, crosses sutures
  • Q: Most common source of bleeding in epidural hematoma? A: Middle meningeal artery (pterion area)

Q71. A 4-year-old girl accidentally ingests her mother’s iron supplements and is brought to the emergency department with symptoms of nausea, vomiting, abdominal pain, and lethargy. On examination, she appears pale and drowsy. What is the most appropriate antidote for iron toxicity?

• A) Activated charcoal
• B) N-acetylcysteine
• C) Desferrioxamine ← CORRECT
• D) Sodium bicarbonate
• Why: Iron toxicity is treated with desferrioxamine (deferoxamine), which chelates free iron in the serum and enhances urinary excretion. Activated charcoal does not effectively bind iron.
• Variants:
  • Q: A child ingests ferrous sulfate tablets and develops hematemesis and metabolic acidosis. Which agent should be given immediately? A: Desferrioxamine
  • Q: Which IV chelating agent turns urine orange-red and is specific for iron overload? A: Desferrioxamine

Q88. A 52 year old man is on antihypertensive medication. He comes to cardiovascular Out Patient Clinic and complains about dry cough. Lab report shows Na: 139mmol/L, K: 6.7mmol/L, Ca: 2.55mmol/L, Creatinine : 165y/I. Which is the most probable medication causing the dry cough?

• A) Ramipril ← CORRECT
• B) Losartan
• C) Bendroflumethiazide
• D) Atenolol
• E) Verapamil
• Why: ACE inhibitors (like ramipril) cause dry cough (bradykinin accumulation) and hyperkalemia (decreased aldosterone). K+ 6.7 confirms hyperkalemia.
• Variants:
  • Q: A hypertensive patient on an antihypertensive develops dry cough and K+ 6.5. Which drug class? A: ACE inhibitor
  • Q: Which antihypertensive causes cough due to bradykinin accumulation? A: ACE inhibitor (Ramipril)

Q116. An individual with chronic hepatitis C viral infection has a chemistry profile performed. Which test amongst the following is most likely to be decreased?

• A) Gamma globulin
• B) Alanine aminotransferase
• C) Albumin ← CORRECT
• D) Lactate dehydrogenase
• Why: Chronic hepatitis C → progressive liver damage → decreased hepatic synthetic function → reduced albumin. Albumin is synthesized exclusively by the liver with a half-life of ~20 days, making it a marker of chronic liver disease severity (Child-Pugh score includes albumin).
• ✗ A) Gamma globulin: INCREASED in chronic hepatitis C (polyclonal hypergammaglobulinemia from chronic B-cell stimulation)
• ✗ B) Alanine aminotransferase (ALT): may be normal, mildly elevated, or fluctuate in chronic HCV — not typically decreased
• ✗ D) Lactate dehydrogenase: non-specific, can be elevated or normal — not decreased in chronic liver disease
• Variants:
  • Q: Best marker of synthetic function of liver: A: Albumin + PT/INR
  • Q: Most sensitive test for hepatocellular injury in acute hepatitis: A: ALT

Q131. A 39-year-old man comes to your office with the complaint that he has notice mucus-like discharge on his underwear. He denies any pain associated with the process and reports that the problem has been going on for 2 to 3 weeks. When questioned regarding past history of anorectal complaints, the man indicates that several years ago, he had some severe pain in his anal area that spontaneously resolved after several days. Which of the following is the most likely diagnosis in this patient?

• A) Crohn’s disease
• B) Chronic perirectal abscess
• C) Anal fissure
• D) Fistula-in-Ano ← CORRECT
• Why: History of severe anal pain years ago (spontaneously resolved → likely perianal abscess drained itself) + now painless mucus discharge = fistula-in-ano. The fistula tract connects the anal canal to the perianal skin, allowing mucus/pus drainage. Goodsall’s rule predicts tract direction.
• ✗ A) Crohn’s disease: can cause fistulas but would have systemic symptoms, younger age, GI complaints
• ✗ B) Chronic perirectal abscess: would have ongoing pain, swelling, not just mucus discharge
• ✗ C) Anal fissure: severe pain with defecation (esp. tearing pain), bright red blood on paper, not mucus discharge
• Variants:
  • Q: Goodsall’s rule: Q: Anterior fistulas open radially; posterior fistulas open in a curved line to posterior midline
  • Q: Treatment of choice for fistula-in-ano: A: Fistulotomy (if tract crosses <1/3 of external sphincter) or seton placement

Q135. A 30-year-old man presents with diarrhea, dermatitis around the neck and mild cognitive disturbances. His diet mainly consists of maize. Deficiency of which nutrient is most likely responsible?

• A) Riboflavin
• B) Niacin ← CORRECT
• C) Thiamine
• D) Pyridoxine
• Why: Pellagra: diarrhea + dermatitis (Casal necklace — photosensitive rash around neck) + dementia (cognitive disturbances). Caused by niacin (B3) deficiency. Maize (corn) is low in bioavailable niacin AND low in tryptophan (which is the precursor for niacin synthesis). Common in maize-based diets.
• ✗ A) Riboflavin (B2): deficiency causes angular stomatitis, cheilitis, glossitis — not the classic triad
• ✗ C) Thiamine (B1): deficiency causes beriberi (wet: high-output failure; dry: peripheral neuropathy) or Wernicke-Korsakoff
• ✗ D) Pyridoxine (B6): deficiency causes dermatitis, glossitis, neuropathy, but not the full pellagra triad
• Variants:
  • Q: Casal necklace is characteristic of which deficiency? A: Niacin deficiency (pellagra)
  • Q: “4 Ds” of pellagra: A: Diarrhea, Dermatitis, Dementia, Death

Q152. A 17-year-old girl was brought to the emergency ingestion of kerosene oil. Which is the most important common complication of this poisoning?

• A) Acute hepatic failure
• B) Bronchopneumonia ← CORRECT
• C) Encephalopathy
• D) Acute Renal failure
• Why: Kerosene oil ingestion most commonly leads to aspiration pneumonitis/bronchopneumonia due to its low viscosity and high volatility, causing chemical pneumonitis. This is the most important and common complication of hydrocarbon poisoning.
• ✗ A) Acute hepatic failure:** Kerosene is not primarily hepatotoxic.
• ✗ C) Encephalopathy:** Can occur with severe toxicity but is less common than respiratory complications.
• ✗ D) Acute renal failure:** Not a typical direct complication of kerosene ingestion.
• Variants:
  • Q: A child ingests turpentine and develops coughing and tachypnea. Most important complication? A: Aspiration pneumonitis
  • Q: Management of hydrocarbon ingestion - what should be avoided? A: Gastric lavage/emesis (increases aspiration risk)

Q169. A patient on anti-tubercular therapy develops hyperuricemia and joint pain suggestive of gout. Which of the following drugs is most likely responsible for increasing uric acid levels?

• A) Isoniazid
• B) Rifampicin
• C) Ethambutol
• D) Pyrazinamide ← CORRECT
• E) Streptomycin
• Why: Pyrazinamide inhibits uric acid excretion in the kidneys, causing hyperuricemia and gout-like joint pain. This is a well-known side effect of PZA, resolved by using allopurinol or switching drugs.
• ✗ A) Isoniazid:** Causes peripheral neuropathy (B6 deficiency), hepatitis - not hyperuricemia.
• ✗ B) Rifampicin:** Causes hepatitis, orange-red secretions, flu-like syndrome - not hyperuricemia.
• ✗ C) Ethambutol:** Causes optic neuritis (color blindness, decreased visual acuity) - not hyperuricemia.
• ✗ E) Streptomycin:** Causes ototoxicity (vestibular > cochlear), nephrotoxicity - not hyperuricemia.
• Variants:
  • Q: A patient on ATT develops arthralgia and increased uric acid - which drug is responsible? A: Pyrazinamide
  • Q: Which of the following ATT drugs requires dose adjustment in renal failure? A: Ethambutol and streptomycin

Physiology

Q1. A 25-year-old man enters a dimly lit room after being in bright sunlight. Initially, he is unable to see clearly but his vision improves over 20 minutes. Which of the following best explains this adaptation?

• A) Increased breakdown of rhodopsin in rods
• B) Regeneration of rhodopsin in rods ← CORRECT
• C) Increased activity of cone photoreceptors
• D) Decreased retinal sensitivity to light
• Why: Dark adaptation is the recovery of sensitivity in dim light after bright light exposure. Bright light bleaches rhodopsin (the visual pigment in rods); entering a dark room allows regeneration of rhodopsin, restoring rod function over ~20–30 minutes. Rhodopsin breakdown (A) happens in light, not dark.
• ✗ A) Increased breakdown of rhodopsin in rods: Rhodopsin is broken down (bleached) by light, not in darkness.
• ✗ C) Increased activity of cone photoreceptors: Cones adapt faster (~5 min) but are not responsible for the prolonged 20-minute adaptation; rods dominate dark adaptation.
• ✗ D) Decreased retinal sensitivity to light: Dark adaptation INCREASES retinal sensitivity, not decreases.
• Variants:
  • Q: A patient comes from bright sunlight into a dark room and cannot see. After 25 minutes vision improves. What pigment is responsible? A: Rhodopsin
  • Q: Dark adaptation curve shows an initial fast phase and a slower second phase. The slow phase corresponds to which photoreceptor? A: Rods
  • Q: Vitamin A deficiency would most impair which aspect of vision? A: Dark adaptation (night blindness)

Q19. A 45-year-old woman presents with symmetrical pain and stiffness in the small joints of both hands, especially in the morning lasting more than 1 hour. There is no history of muco-cutaneous lesions. Which investigation would be most appropriate to confirm the diagnosis?

• A) X-Ray hands
• B) ESR
• C) Anti CCP. ← CORRECT
• D) ANA
• Why: Symmetrical small joint pain with morning stiffness >1 hour = classic rheumatoid arthritis. Anti-CCP (anti-cyclic citrullinated peptide) antibody is the most specific serologic test for RA (specificity ~95–98%), more specific than rheumatoid factor. No mucocutaneous lesions rule out SLE.
• ✗ A) X-Ray hands: Shows late erosions; not appropriate for confirming diagnosis early (normal early in disease).
• ✗ B) ESR: Non-specific inflammatory marker, elevated in many conditions, cannot confirm RA.
• ✗ D) ANA: Used for SLE screening; positive in RA but not specific — anti-CCP is the confirmatory test.
• Variants:
  • Q: Most sensitive test for RA? A: Rheumatoid factor (sensitivity ~70–80%, specificity lower)
  • Q: Rheumatoid arthritis diagnosis requires: A: Clinical + serology (anti-CCP or RF) + acute phase reactants + duration >6 weeks
  • Q: Extra-articular manifestation of RA: A: Rheumatoid nodules, vasculitis, pericarditis, Felty syndrome

Q34. A gentleman was going to market when he suddenly stepped on a sharp stone. Which of the following reflexes will be resultantly initiated?

• A) Crossed extensor reflex in affected limb and withdrawal reflex in opposite limb
• B) Withdrawal reflex in affected limb and crossed extensor reflex in opposite limb ← CORRECT
• C) Stretch reflex in affected limb and withdrawal reflex in opposite limb
• D) Stretch reflex in affected limb and crossed extensor reflex in opposite limb
• Why: Stepping on a sharp stone triggers a nociceptive (painful) stimulus → withdrawal (flexor) reflex in the affected limb to remove it from harm + crossed extensor reflex in the opposite limb to support body weight. This is a polysynaptic spinal reflex.
• ✗ A) Crossed extensor reflex in affected limb and withdrawal reflex in opposite limb: Backwards — the stimulated limb withdraws (flexes), the opposite extends.
• ✗ C) Stretch reflex in affected limb: Stretch reflex (monosynaptic) occurs from muscle stretch (e.g., patellar reflex), not from a painful stimulus.
• ✗ D) Stretch reflex in affected limb: Same error as C.
• Variants:
  • Q: Which reflex is responsible for withdrawing the hand from a hot stove? A: Withdrawal (flexor) reflex
  • Q: Crossed extensor reflex is an example of: A: Spinal reflex that maintains posture
  • Q: A patient with spinal cord transection has brisk withdrawal reflex — why? A: Loss of descending inhibition (UMN lesion)

Q42. Frey’s syndrome is a complication of:

• A) Mandibulectomy
• B) Parotidectomy ← CORRECT
• C) SMR
• D) Thyroidectomy
• Why: Frey’s syndrome (gustatory sweating — sweating on the cheek while eating) is a well-known complication of parotidectomy. It occurs due to aberrant regeneration of parasympathetic nerve fibers that now innervate sweat glands instead of parotid tissue.
• ✗ A) Mandibulectomy: Can cause cosmetic/functional deficits, not Frey’s.
• ✗ C) SMR (submucous resection): Nasal surgery — no connection.
• ✗ D) Thyroidectomy: Causes recurrent laryngeal nerve injury, hypoparathyroidism, not Frey’s.
• Variants:
  • Q: Treatment option for Frey’s syndrome? A: Botulinum toxin injection / topical glycopyrrolate
  • Q: Parotidectomy can also damage which nerve? A: Facial nerve (VII)

Q58. A 55-year-old man suffers from cirrhosis of the liver. Toxins such as ammonia are not properly metabolized by the liver and can damage the brain. Which compound is expected to be in highest concentration in the brain as a result of detoxification of ammonia?

• A) Alpha-ketoglutarate
• B) Glutamate
• C) Glutamine ← CORRECT
• D) Asparagine
• Why: In the brain, excess ammonia is detoxified by combining with glutamate (via glutamine synthetase) to form glutamine. This is the primary ammonia-detoxification pathway in the brain. In hepatic encephalopathy, glutamine levels rise in the brain and contribute to osmotic edema.
• ✗ A) Alpha-ketoglutarate: Substrate in TCA cycle, consumed in ammonia detox but not the final product.
• ✗ B) Glutamate: Combined with ammonia to form glutamine — glutamate levels are consumed, not accumulated.
• ✗ D) Asparagine: Involved in separate transamination pathway, not the primary ammonia detox product.
• Variants:
  • Q: First-line treatment for hepatic encephalopathy? A: Lactulose (reduces ammonia)
  • Q: Urea cycle — which enzyme converts ammonia to urea? A: Carbamoyl phosphate synthetase I (first step)

Q127. A 45-year-old man presents with sudden-onset severe chest pain radiating t back. Blood pressure is significantly different in both arms. What is the appropriate investigation for diagnosis?

• A) Troponins
• B) Echocardiography
• C) CT angiography ← CORRECT
• D) D-Dimer
• Why: Sudden-onset severe tearing chest pain radiating to back + significant BP differential between arms = aortic dissection until proven otherwise. CT angiography (CTA) of the chest/abdomen with contrast is the gold standard — it can visualize the intimal flap, extent of dissection, and branch vessel involvement rapidly.
• ✗ A) Troponins: elevated in MI, not diagnostic for dissection (but helpful to rule out MI)
• ✗ B) Echocardiography: TEE can diagnose dissection but is operator-dependent, less available in ER; CTA is faster and more definitive
• ✗ D) D-Dimer: elevated in dissection but non-specific (also elevated in PE, DIC, surgery); not diagnostic
• Variants:
  • Q: Most common predisposing factor for aortic dissection: A: Hypertension
  • Q: Stanford type A vs B classification: A: Type A involves ascending aorta (surgical); Type B is descending (medical)

Q151. A new born starts to bleed from the umbilical cord and nostrils two delivery. This condition is due to deficiency of which of the following?

• A) Vitamin A
• B) Vitamin C
• C) Vitamin D
• D) Vitamin K ← CORRECT
• Why: Newborn bleeding from umbilical cord and nostrils is classic Hemorrhagic Disease of the Newborn (VKDB - Vitamin K Deficiency Bleeding). Vitamin K-dependent factors (II, VII, IX, X) are deficient because of poor placental transfer, sterile gut, and low vitamin K in breast milk.
• ✗ A) Vitamin A:** Deficiency causes night blindness, xerophthalmia, not bleeding.
• ✗ B) Vitamin C:** Deficiency causes scurvy (impaired wound healing, gingival bleeding, petechiae) - not umbilical cord bleeding in newborns.
• ✗ C) Vitamin D:** Deficiency causes rickets (bone deformities, hypocalcemia), not bleeding.
• Variants:
  • Q: A newborn develops melena and umbilical bleeding on day 3. Which prophylactic measure could have prevented this? A: Intramuscular vitamin K at birth
  • Q: Which coagulation factors are deficient in hemorrhagic disease of newborn? A: Factors II, VII, IX, X

Q153. What exits from the stylomastoid foramen?

• A) Accessory Nerve
• B) Facial Nerve ← CORRECT
• C) Glossopharyngeal Nerve
• D) Hypoglossal Nerve
• Why: The stylomastoid foramen is the exit point of the facial nerve (CN VII) from the skull after it traverses the facial canal in the temporal bone.
• ✗ A) Accessory Nerve (CN XI):** Exits via jugular foramen.
• ✗ C) Glossopharyngeal Nerve (CN IX):** Exits via jugular foramen.
• ✗ D) Hypoglossal Nerve (CN XII):** Exits via hypoglossal canal.
• Variants:
  • Q: Bell’s palsy involves compression of which nerve at which foramen? A: Facial nerve at stylomastoid foramen
  • Q: A patient with facial nerve palsy after a basilar skull fracture - which foramen is likely involved? A: Stylomastoid foramen

Psychiatry

Q98. A 25-year-old woman has had several sudden-onset episodes of palpitations, sweating, and fear. Her hands shake when they occur. These episodes occur almost every day and sometimes wake her from sleep. She has no previous psychiatric disorder and is not on any medications. What is the single most likely diagnosis?

• A) Phaeochromocytoma
• B) Panic disorder ← CORRECT
• C) Generalized anxiety disorder
• D) Agoraphobia
• E) Acute stress disorder
• Why: Recurrent unexpected panic attacks (palpitations, sweating, fear, shaking) occurring frequently and waking her from sleep = panic disorder. No trigger needed; distinct from GAD (chronic worry).
• Variants:
  • Q: Recurrent panic attacks that wake the patient from sleep — diagnosis: A: Panic disorder
  • Q: Difference between panic disorder and GAD: A: Panic disorder has discrete attacks; GAD has continuous worry

Q160. A 5-year-old boy presents with intellectual disability, upward slanting eyes, and a single palmar crease. Which chromosomal abnormality is most likely responsible?

• A) Trisomy 13
• B) Trisomy 18
• C) Trisomy 21 ← CORRECT
• D) Monosomy X
• Why: Intellectual disability, upward slanting eyes (epicanthal folds), and single palmar crease (simian crease) are characteristic features of Down syndrome, caused by trisomy 21.
• ✗ A) Trisomy 13 (Patau syndrome):** Cleft lip/palate, polydactyly, severe brain malformations, rocker-bottom feet.
• ✗ B) Trisomy 18 (Edwards syndrome):** Low-set ears, micrognathia, overlapping fingers, rocker-bottom feet, severe IUGR.
• ✗ D) Monosomy X (Turner syndrome):** Webbed neck, shield chest, short stature, lymphedema, no intellectual disability.
• Variants:
  • Q: A newborn with hypotonia, flat facies, and Brushfield spots on iris - which chromosomal abnormality? A: Trisomy 21
  • Q: Which congenital heart defect is most associated with Down syndrome? A: AVSD (atrioventricular septal defect)

Surgery

Q2. A burn patient has erythema and blistering involving the epidermis and part of the dermis. Burn type?

• A) First-degree
• B) Superficial partial thickness ← CORRECT
• C) Full thickness
• D) Fourth-degree
• Why: Erythema (redness) and blistering with involvement of the epidermis AND part of the dermis defines partial-thickness (second-degree) burns. If only epidermis were involved without blistering, it would be first-degree/superficial.
• ✗ A) First-degree: Only epidermis — erythema only, no blistering.
• ✗ C) Full thickness: Involves entire dermis and deeper; appears charred/white, no sensation, no blistering.
• ✗ D) Fourth-degree: Extends beyond skin into muscle/bone.
• Variants:
  • Q: A burn presents with charring, no pain, and leathery skin. What degree? A: Full thickness (third-degree)
  • Q: A scald causes erythema only, no blisters. What degree? A: First-degree (superficial)

Q3. Most common benign breast tumor in young females:

• A) Fibroadenoma ← CORRECT
• B) Lipoma
• C) Carcinoma
• D) Cyst
• Why: Fibroadenoma is the most common benign breast tumor in young women (15–35 years). It presents as a firm, smooth, mobile, painless lump (“breast mouse”).
• ✗ B) Lipoma: A benign tumor of fat cells, can occur in breast but far less common than fibroadenoma.
• ✗ C) Carcinoma: Malignant, not benign — incidence rises after 40; rare in young females.
• ✗ D) Cyst: Fluid-filled, common in perimenopausal age (35–50), not the most common “tumor” in young females.
• Variants:
  • Q: Most common breast mass in women of reproductive age? A: Fibroadenoma
  • Q: Most common breast cancer in Pakistani women? A: Invasive ductal carcinoma (NOS)
  • Q: A 20-year-old female with a firm, mobile, painless breast lump — most likely? A: Fibroadenoma

Q8. A 16-year-old girl presents with a smooth, round, painless lump in the midline of the neck. On examination, it is firm, transilluminates, is painless, and moves up when the patient is asked to protrude her tongue. This is likely:

• A) Papillary carcinoma of the thyroid
• B) Thyroglossal cyst ← CORRECT
• C) Lingual thyroid
• D) Sebaceous cyst
• Why: A midline neck mass that moves with tongue protrusion is pathognomonic for thyroglossal duct cyst. It moves upward because it’s attached to the hyoid bone and foramen cecum at the base of the tongue. It transilluminates (cystic), is painless unless infected.
• ✗ A) Papillary carcinoma of the thyroid: Thyroid mass, moves with swallowing (not tongue protrusion), hard/irregular, does not transilluminate.
• ✗ C) Lingual thyroid: At base of tongue, not in midline neck, presents with dysphagia or globus sensation.
• ✗ D) Sebaceous cyst: In skin, not attached to deeper structures, does not move with tongue protrusion.
• Variants:
  • Q: Thyroglossal cyst moves with: A) Swallowing B) Tongue protrusion C) Both — Answer: B (moves with tongue, not swallowing; thyroid moves with swallowing)
  • Q: First branchial cleft cyst presentation? A: Lateral neck mass near angle of mandible
  • Q: Sistrunk procedure is for? A: Excision of thyroglossal duct cyst (includes hyoid bone removal)

Q18. A 38-year-old G2P1 at 16 weeks of pregnancy with previous history of birth of a child affected with Down’s syndrome presents in the antenatal clinic. Which one of the following is the investigation of choice to rule out Down’s syndrome at this gestation?

• A) Chorionic villus sampling
• B) Amniocentesis ← CORRECT
• C) Cordocentesis
• D) Quad test
• Why: At 16 weeks gestation, amniocentesis is the procedure of choice for fetal karyotyping to diagnose Down syndrome. Performed at 15–20 weeks, it has a lower risk of miscarriage than CVS. CVS is done at 10–13 weeks (first trimester). The patient is past the window for CVS.
• ✗ A) Chorionic villus sampling: Done at 10–13 weeks; too late at 16 weeks.
• ✗ C) Cordocentesis: Performed after 18 weeks for specific hematologic/infectious workup; not first-line for Down syndrome screening at 16 weeks.
• ✗ D) Quad test: A screening test (not diagnostic) for Down syndrome; the question asks for investigation of choice to RULE OUT (confirm/refute) Down syndrome, requiring diagnostic test (amniocentesis for karyotype).
• Variants:
  • Q: First-trimester screening for Down syndrome (11–13 weeks): A: Nuchal translucency + PAPP-A + free beta-hCG
  • Q: Quad test includes: A: AFP, hCG, uE3, Inhibin A
  • Q: Risk of miscarriage with amniocentesis: A: ~0.1–0.3%

Q25. A marathon runner experiences muscle fatigue toward the end of a race despite adequate oxygen supply. Which of the following is the most likely physiological cause?

• A) Depletion of ATP stores
• B) Glycogen depletion ← CORRECT
• C) Failure of neuromuscular transmission
• D) Increased calcium release from the sarcoplasmic reticulum
• Why: During prolonged endurance exercise, as intramuscular glycogen stores deplete, the muscle can no longer sustain ATP production at the required rate, leading to fatigue. Despite adequate oxygen availability (aerobic metabolism), the limiting factor becomes glycogen substrate for glycolysis.
• ✗ A) Depletion of ATP stores: ATP is constantly regenerated and rarely fully depleted; even in severe fatigue, ATP levels remain near normal.
• ✗ C) Failure of neuromuscular transmission: Occurs in myasthenia gravis or high-frequency stimulation, not in marathon running.
• ✗ D) Increased calcium release from the SR: Calcium release is necessary for contraction; increased release would not cause fatigue.
• Variants:
  • Q: Muscle fatigue in high-intensity short-duration exercise (sprinting): A: Lactic acidosis (anaerobic glycolysis)
  • Q: Central fatigue hypothesis involves: A: Serotonin (5-HT) accumulation in brain
  • Q: Second wind phenomenon in McArdle disease: A: Myophosphorylase deficiency — muscle uses fatty acids after initial fatigue

Q26. A 55-year-old man with a history of long-term smoking presents with c productive cough for 3 months each year for the last 2 years. He also dyspnea on exertion. What is the most likely diagnosis?

• A) Chronic bronchitis ← CORRECT
• B) Emphysema
• C) Asthma
• D) Tuberculosis
• Why: Chronic bronchitis is defined clinically as cough with sputum production for at least 3 months in at least 2 consecutive years. A long-term smoking history with these criteria plus dyspnea on exertion confirms the diagnosis. No wheeze or reversibility mentioned (which would suggest asthma).
• ✗ B) Emphysema: Presents with progressive dyspnea, barrel chest, hyperresonance, pursed-lip breathing — not defined by chronic cough/sputum criteria.
• ✗ C) Asthma: Episodic/reversible wheezing, diurnal variation, triggers — not continuous cough for 3 months/year.
• ✗ D) Tuberculosis: Cough with hemoptysis, fever, night sweats, weight loss — not primarily defined by smoking history and chronic sputum.
• Variants:
  • Q: Emphysema is pathologically defined by: A: Destruction of alveolar walls (abnormal permanent enlargement of air spaces)
  • Q: Pink puffer vs blue bloaters: A: Pink puffer = emphysema; Blue bloater = chronic bronchitis
  • Q: COPD diagnosis confirmed by: A: Spirometry (FEV1/FVC < 0.70)

Q36. A 30-year-old male patient suffered a gunshot injury to the abdomen. On examination, the abdomen is generalized tender, and fecal matter is coming out of the wound. How will you classify the wound?

• A) Clean
• B) Clean contaminated
• C) Contaminated
• D) Dirty ← CORRECT
• Why: Gunshot wound with fecal matter coming out indicates a perforated viscus with established contamination/infection. In surgical wound classification, this is Class IV (Dirty) — not just contaminated, because a viscus has been entered and gross spillage/infection is present.
• ✗ A) Clean: No — this is traumatic and grossly contaminated.
• ✗ B) Clean contaminated: Requires controlled entry into GI tract without spillage — not applicable here.
• ✗ C) Contaminated: Class III is for fresh accidental wounds or major spillage, but fecal matter with established soil makes it dirty (Class IV).
• Variants:
  • Q: A patient with perforated duodenal ulcer undergoes laparotomy 18 hours after perforation. Wound classification? A: Dirty (Class IV)
  • Q: Elective cholecystectomy with bile spillage — wound class? A: Clean-contaminated (Class II)

Q37. A 45-year-old woman teacher is diagnosed with a submandibular calculus, h presented with a tender lump below the jaw on eating. Which structure is likely be obstructed?

• A) Warthin’s duct ← CORRECT
• B) Stensen’s duct
• C) Lingual nerve
• D) Facial nerve
• Why: The submandibular gland drains via Wharton’s duct (the question uses “Warthin’s” as a common exam misspelling/trap). A submandibular calculus obstructs Wharton’s duct, causing post-prandial pain and swelling below the jaw.
• ✗ B) Stensen’s duct: Drains the parotid gland, not submandibular.
• ✗ C) Lingual nerve: Provides sensory innervation to tongue, not a duct.
• ✗ D) Facial nerve: Motor nerve to face, not involved in salivary duct obstruction.
• Variants:
  • Q: Parotid gland calculus would obstruct which duct? A: Stensen’s duct
  • Q: A patient develops pain below the jaw while eating. Which gland is involved? A: Submandibular gland

Q41. A 40-year-old man presents with a recurrent bulge in the left groin 2 years after open left inguinal hernia repair without mesh. He has discomfort in the area and is unable to work out at the gym as usual. Physical examination shows a moderately dilated external inguinal ring with a small bulge produced by Valsalva maneuver. Which of the following is the most appropriate treatment approach?

• A) Obtain a CT scan to rule out a femoral hernia, followed by elective repair.
• B) Schedule the patient for left groin exploration and hernia repair with mesh placement. ← CORRECT
• C) Advise the patient to limit physical activities and reevaluate in 6 months.
• D) Schedule the patient for bilateral inguinal exploration.
• Why: A symptomatic recurrent inguinal hernia after prior repair (without mesh) requires re-operation. The standard approach is open exploration with mesh placement to reduce recurrence risk. Mesh reduces recurrence rates significantly in both primary and recurrent repairs.
• ✗ A) CT scan: Not needed before elective repair of a clinically obvious recurrent inguinal hernia.
• ✗ C) Limit activities and re-evaluate: Symptomatic recurrent hernia will not resolve — delaying surgery risks complications (incarceration/strangulation).
• ✗ D) Bilateral exploration: No indication for contralateral exploration in this vignette.
• Variants:
  • Q: First-line management of an asymptomatic inguinal hernia in a healthy adult? A: Elective open repair (Lichtenstein mesh repair)
  • Q: Emergency management of an incarcerated inguinal hernia? A: Urgent surgical reduction and repair

Q47. A 16-year-old boy was hit by a cricket ball on his left ear. Bleeding started from the ear after injury. He was taken to the hospital emergency department. On examination, the pinna was slightly swollen and the external auditory canal was full of clotted blood. Rinne test was negative on the left side and positive on the right side. Weber test lateralized to the left. Apart from deafness in the left ear, the boy is otherwise stable. The most important management at this stage is:

• A) Clean the blood and advise water precautions and follow-up. ← CORRECT
• B) Clean the blood clot from the external auditory canal with suction.
• C) Do not clean the blood clot and prescribe antibiotic ear drops.
• D) Do not clean the blood clot and advise follow-up.
• Why: After ear trauma with bleeding, visible blood in the external auditory canal should be gently cleaned to assess for tympanic membrane perforation. Water precautions (keep ear dry) prevent infection. Follow-up is needed to monitor healing. Rinne negative with Weber lateralizing to left = conductive hearing loss (likely from blood/TM disruption).
• ✗ B) Clean with suction: Suction can cause further trauma, especially if there’s a TM perforation — not recommended initially.
• ✗ C) Do not clean + prescribe antibiotic drops: Drops are ototoxic if TM is perforated; leaving the clot obscures assessment.
• ✗ D) Do not clean + advise follow-up: Leaving the clot prevents proper examination and increases infection risk.
• Variants:
  • Q: Traumatic TM perforation — contraindicated management? A: Ear drops (ototoxic), syringing
  • Q: Tuning fork tests in conductive vs sensorineural loss — Weber lateralizes to? A: Conductive → affected ear; Sensorineural → normal ear

Q62. A 52-year-old man on regular hemodialysis presents with sudden loss of thrill over his AV fistula. The limb is not red or tender. What is the most appropriate management?

• A) Immediate surgical thrombectomy
• B) Doppler ultrasound evaluation ← CORRECT
• C) Switch to peritoneal dialysis
• D) Start anticoagulation
• Why: Sudden loss of thrill in an AV fistula (with no redness/tenderness = no infection) suggests thrombosis. The first step is Doppler ultrasound (duplex) to confirm and assess the extent of thrombosis before any intervention.
• ✗ A) Immediate surgical thrombectomy: Too invasive without confirming diagnosis first.
• ✗ C) Switch to peritoneal dialysis: Premature — the fistula may be salvageable.
• ✗ D) Start anticoagulation: Not first step — need imaging confirmation first.
• Variants:
  • Q: Most common cause of AV fistula failure? A: Thrombosis (usually at the anastomotic site)
  • Q: What is the preferred management of AV fistula thrombosis? A: Angioplasty/thrombectomy (percutaneous or surgical) — depends on timing and extent

Q69. A 30 year old lady presented with pain, photophobia, and blurred vision in her right eye. On examination, intraocular pressure was raised in the affected eye with a significant amount of cells and flare in the aqueous. Examination shows circumcorneal congestion.Angle was open on Gonioscopy. What is the most likely diagnosis in such a case?

• A) Angle-closure glaucoma
• B) Open-angle glaucoma
• C) Allergic conjunctivitis
• D) Uveitis ← CORRECT
• Why: Pain, photophobia, blurred vision with cells and flare in the anterior chamber (aqueous) + circumcorneal congestion + open angle on gonioscopy = anterior uveitis (iritis). The cells and flare are pathognomonic of intraocular inflammation. Open angle rules out angle-closure glaucoma.
• ✗ A) Angle-closure glaucoma: Closed angle on gonioscopy, fixed mid-dilated pupil, significantly elevated IOP, no cells/flare.
• ✗ B) Open-angle glaucoma: Painless, no photophobia, no cells/flare, chronic raised IOP.
• ✗ C) Allergic conjunctivitis: Conjunctival injection, itching, discharge — not cells and flare in anterior chamber.
• Variants:
  • Q: Treatment of anterior uveitis? A: Topical steroids + cycloplegics (atropine/homatropine)
  • Q: Ankylosing spondylitis is associated with which ocular condition? A: Acute anterior uveitis

Q83. A 20-year-old man was stabbed on the upper arm. He received emergency tre and his wound healed. He developed a raised hypertrophic scar with bou beyond the original wound, and it did not regress. Which of the followin best describes this condition?

• A) Cicatrix
• B) Keloid ← CORRECT
• C) Callus
• D) Granulation tissue
• Why: A keloid is a scar that grows beyond the original wound boundaries and does not regress spontaneously. Hypertrophic scars stay within the original borders.
• Variants:
  • Q: A scar that extends beyond the original wound margin and is more common in darker skin: A: Keloid
  • Q: Difference between keloid and hypertrophic scar — keloid does what? A: Grows beyond original wound boundaries

Q96. An old man presents with slowly progressive dysphagia, vomiting without blood, abdominal pain associated with heartburn on eating, and a normal abdominal examination. DRE reveals slightly changed stool with blood. What is the suspected diagnosis?

• A) Peptic ulcer disease
• B) Carcinoma esophagus ← CORRECT
• C) Carcinoma rectum
• Why: Slowly progressive dysphagia (first solids then liquids), weight loss, heartburn, and blood in stool (melena from tumor bleeding) in an elderly patient = esophageal carcinoma.
• Variants:
  • Q: An elderly man with progressive dysphagia and weight loss — most likely: A: Esophageal carcinoma
  • Q: Dysphagia starting with solids then progressing to liquids suggests: A: Esophageal carcinoma

Q101. Patient with Rt upper quadrant pain.fever.jaundice.hx of stone O/E generalised abdominal tenderness and sluggish bowel sounds, High TWECs, High amylase, US showed mildly dilated CBD 1.1 What is the appropriate diagnosis:

• A) Pancreatitis
• B) Cholangitis ← CORRECT
• C) Appendicitis
• D) Cholecystitis
• E) Hepatitis
• Why: RUQ pain + fever + jaundice = Charcot’s triad, classic for ascending cholangitis. Dilated CBD (1.1 cm) and history of stones point to biliary obstruction with infection.
• Variants:
  • Q: Charcot’s triad (RUQ pain, fever, jaundice) is most specific for: A: Cholangitis
  • Q: A patient with gallstones presents with pain, fever, and jaundice — diagnosis: A: Cholangitis

Q105. 6-year-old child presents with foul smelling nasal discharge and unilateral nasal obstruction for the last 3 months. Which of the following is most likely diagnosis?

• A) Foreign body nose ← CORRECT
• B) Antrochoanal polyp
• C) Mucous plug
• D) Nasal myiasis
• Why: Unilateral foul-smelling nasal discharge with nasal obstruction in a child is classic for a retained nasal foreign body. The discharge is often purulent and bloody.
• Variants:
  • Q: A 4-year-old with unilateral, foul-smelling nasal discharge for weeks: A: Foreign body nose
  • Q: Fetid unilateral nasal discharge in a child is most likely: A: Foreign body nose

Q106. A 40-year-old female presented to surgical emergency with sudden onset of severe epigastric pain. She is a known case of osteoarthritis and has been taking NSAIDs for 4 years. On examination, she appears anxious and is lying still. The abdomen is tense and tender. Respiration is thoracic with no abdominal movement. Bowel sounds are absent. Erect X-ray abdomen shows free air under the right hemidiaphragm. What is your diagnosis?

• A) Intestinal volvulus
• B) Acute intestinal obstruction
• C) Perforated peptic ulcer ← CORRECT
• D) Toxic megacolon
• Why: NSAID use for 4 years + sudden severe epigastric pain + board-like abdomen + absent bowel sounds + FREE AIR under diaphragm on erect X-ray = perforated viscus. Free air is pathognomonic for hollow viscus perforation, and the epigastric location with NSAID history points to a perforated peptic ulcer.
• ✗ A) Intestinal volvulus: causes closed-loop obstruction, not free air under diaphragm
• ✗ B) Acute intestinal obstruction: shows air-fluid levels on X-ray, not free air
• ✗ D) Toxic megacolon: dilated colon on X-ray, not free air; associated with IBD
• Variants:
  • Q: A patient with sudden epigastric pain and board-like rigidity. Erect CXR shows air under diaphragm. What’s the next step? A: Emergency laparotomy
  • Q: Most common cause of perforation peritonitis in Pakistan? A: Duodenal ulcer (NSAID use + H. pylori)

Q107. A transudate is edema fluid that is:

• A) Rich in proteins
• B) Rich in neutrophils
• C) Rich in albumin
• D) Low in proteins ← CORRECT
• E) Rich in fibrinogen
• Why: Transudate is edema fluid with low protein content (<3 g/dL, specific gravity <1.012), caused by increased hydrostatic pressure or decreased oncotic pressure (e.g., CHF, cirrhosis, nephrotic syndrome). Exudate is rich in proteins/cells from increased capillary permeability (inflammation).
• ✗ A) Rich in proteins: describes exudate, not transudate
• ✗ B) Rich in neutrophils: describes purulent exudate
• ✗ C) Rich in albumin: transudate has low albumin too
• ✗ E) Rich in fibrinogen: describes exudate
• Variants:
  • Q: Which condition causes a transudative pleural effusion? A: Congestive heart failure
  • Q: Light’s criteria help differentiate which type of fluid? A: Transudate vs exudate

Q111. This condition affects middle-aged women more than men and is characterized by low mood, early morning waking, loss of libido, tiredness, and suicidal intention lasting for at least 2 weeks. What is the most probable diagnosis?

• A) Bipolar affective disorder
• B) Dysthymia
• C) Major depressive disorder ← CORRECT
• D) Schizoaffective disorder
• E) Recurrent brief depression
• Why: Core symptoms (low mood, anhedonia, early morning waking/terminal insomnia, low libido, fatigue, suicidal ideation) lasting ≥2 weeks = MDD per DSM-5 criteria. Middle-aged female predominance is consistent. The ≥2-week duration is the key discriminator from dysthymia.
• ✗ A) Bipolar affective disorder: requires at least one manic or hypomanic episode — no mention here
• ✗ B) Dysthymia: chronic depressed mood for ≥2 years, less severe symptom profile
• ✗ D) Schizoaffective disorder: depressive episode + psychotic symptoms (delusions/hallucinations) in the absence of mood episodes
• ✗ E) Recurrent brief depression: episodes last <2 weeks (typically 2-4 days)
• Variants:
  • Q: First-line pharmacotherapy for MDD: A: SSRIs (e.g., fluoxetine, sertraline)
  • Q: How many symptoms required for MDD diagnosis? A: ≥5 symptoms (including depressed mood or anhedonia) for ≥2 weeks

Q114. A 70-year-old patient presented with easy fatigability, exertional dysp difficulty in walking. His CBC showed Hb 8g/dL, TLC 2.7 and platelets 10 probable diagnosis?

• A) B12 deficiency anemia ← CORRECT
• B) Sideroblastic anemia
• C) Hemolytic anemia
• D) Anemia of chronic disease
• Why: Pancytopenia (Hb 8, low TLC, low platelets) + difficulty walking (subacute combined degeneration of the cord — dorsal column + corticospinal tract) in an elderly patient = classic B12 deficiency. The neurological involvement discriminates it from other causes of pancytopenia. B12 is needed for both hematopoiesis and myelin synthesis.
• ✗ B) Sideroblastic anemia: microcytic or dimorphic, may have high ferritin, ring sideroblasts on bone marrow — no neurological symptoms
• ✗ C) Hemolytic anemia: elevated reticulocytes, unconjugated bilirubin, LDH — no pancytopenia typically
• ✗ D) Anemia of chronic disease: normocytic/normochromic, mild, no neurological symptoms, not pancytopenic
• Variants:
  • Q: Lab finding that confirms B12 deficiency: A: Low serum B12 level; elevated methylmalonic acid and homocysteine (more sensitive)
  • Q: Schilling test differentiates between which causes of B12 deficiency? A: Pernicious anemia (intrinsic factor deficiency) vs malabsorption vs dietary deficiency

Q118. 70 YO man, 2months history of vague lower abdominal pain, alternating diarrhea, constipation, 4kg weight loss, he passed a small amount of dark red blood per rectum. Blood test show iron deficiency. A stool guaiac test was positive. Alpha-fetoprotein normal and raised CEA. Diagnosis?

• A) A.crohn’s diseae
• B) B.ulcerative colitis.
• C) Colorectal cancer ← CORRECT
• D) D.Diverticular disease.
• Why: Elderly patient (70 yo) + vague abdominal pain + alternating bowel habits + weight loss + dark red blood per rectum + iron deficiency anemia + positive FOBT + raised CEA (with normal AFP) = colorectal carcinoma until proven otherwise. This is a textbook presentation of left-sided colonic cancer.
• ✗ A) Crohn’s disease: typically younger (20s-30s), CEA not raised, would have longer history with fistulas/strictures
• ✗ B) Ulcerative colitis: also younger, bloody diarrhea with mucus, CEA not raised, continuous colonic involvement from rectum proximally
• ✗ D) Diverticular disease: left-sided pain, not typically anemic, CEA not raised, bleeding is usually acute and massive, not chronic anemia
• Variants:
  • Q: Gold standard for diagnosis of colorectal cancer: A: Colonoscopy + biopsy
  • Q: Most common site of colorectal cancer: A: Rectosigmoid region

Q123. A man ts rushed to casualty after a road traffic accident with massive blood | needing emergency transfusion. There is no time for cross-match. Patient receive any of the four blood groups. What is the patient’s blood group?

• A) AB negative
• B) AB positive ← CORRECT
• C) O negative
• D) O positive
• Why: If a patient can receive ANY of the four blood groups (A, B, AB, O) in an emergency, they must be a universal recipient. AB+ has no anti-A, anti-B, or anti-Rh antibodies and can accept any ABO/Rh type blood without immediate hemolytic reaction. AB- cannot receive Rh+ blood.
• ✗ A) AB negative: can receive ABO-universal but NOT Rh-positive blood (would form anti-D antibodies)
• ✗ C) O negative: universal DONOR, not recipient
• ✗ D) O positive: universal donor for Rh+, not universal recipient
• Variants:
  • Q: Universal blood donor: A: O negative
  • Q: In massive transfusion protocol, blood is given as: A: Type-specific or O negative if cross-match not yet available

Q125. During exercise, which one of the following regional circulations will show a decrease in blood flow?

• A) Cerebral
• B) Coronary
• C) Hepatic ← CORRECT
• D) Pulmonary
• Why: During exercise, sympathetic vasoconstriction redirects blood from splanchnic (hepatic, mesenteric, renal) circulations to working skeletal muscles, heart, and skin (for thermoregulation). Hepatic blood flow decreases significantly via α-adrenergic vasoconstriction.
• ✗ A) Cerebral: autoregulation maintains constant blood flow during mild-to-moderate exercise
• ✗ B) Coronary: INCREASES significantly to meet increased myocardial O2 demand
• ✗ D) Pulmonary: INCREASES with increased cardiac output (passive distension + recruitment)
• Variants:
  • Q: Which organ has the greatest increase in blood flow during maximal exercise? A: Skeletal muscle (up to 20× baseline)
  • Q: Reflex responsible for splanchnic vasoconstriction during exercise: A: Sympathetic baroreflex

Q132. A child with Down syndrome was brought in OPD for a routine examination. He pink and active, however cardiac auscultation revealed a pansystolic murmur lower left sternal edge. What can be the underlying cardiac defect?

• A) Atrial septal defect
• B) Mitral regurgitation
• C) Ventricular septal defect ← CORRECT
• D) Patent ductus arteriosus
• Why: Down syndrome (trisomy 21) is strongly associated with congenital heart disease — most commonly VSD (30%) or AVSD (atrial-ventricular septal defect, 40%). A pansystolic murmur at the lower left sternal edge is classic for VSD (left-to-right shunt across the ventricular septum).
• ✗ A) Atrial septal defect: ejection systolic murmur at pulmonary area (left upper sternal border), fixed split S2
• ✗ B) Mitral regurgitation: pansystolic murmur at apex, radiating to axilla, not typical Down CHD
• ✗ D) Patent ductus arteriosus: continuous “machinery” murmur, upper left sternal border, not pansystolic
• Variants:
  • Q: Most common cyanotic congenital heart disease in Down syndrome: A: Tetralogy of Fallot (less common in Down; AVSD is more characteristic)
  • Q: AVSD (atrioventricular septal defect) murmur: A: Pansystolic at left lower sternal border, often confused with VSD

Q146. A 48-year-old man is due for an open abdominal incisional hernia repair. The anaesthetist tells you that a high-dependency unit bed has been booked because the patient falls under ASA 3. From the list below, choose the definition that describes ASA grade 3:

• A) A moribund patient who is not expected to survive without an operation
• B) A patient with mild systemic disease
• C) A patient with severe systemic disease that is a constant threat to life
• D) A patient with severe systemic disease ← CORRECT
• Why: ASA 3 is defined as a patient with severe systemic disease that is NOT a constant threat to life. ASA classification: 1 = normal healthy, 2 = mild systemic, 3 = severe systemic, 4 = severe systemic constant threat to life, 5 = moribund.
• ✗ A) Moribund patient not expected to survive without operation:** ASA 5.
• ✗ B) Patient with mild systemic disease:** ASA 2.
• ✗ C) Severe systemic disease constant threat to life:** ASA 4.
• Variants:
  • Q: A patient with controlled diabetes mellitus undergoing surgery - ASA grade? A: ASA 2
  • Q: A patient with ESRD on dialysis scheduled for elective surgery - ASA grade? A: ASA 3

Q149. Which one of the following imaging studies shows “apple core appearance” in a case of colonic carcinoma?

• A) Barium enema ← CORRECT
• B) Barium follow-through
• C) Barium meal
• D) Barium swallow
• Why: “Apple core” or “annular constricting” lesion of colonic carcinoma is best demonstrated on barium enema - contrast is introduced retrograde through the rectum to outline the colon. The tumor grows circumferentially, creating a narrowed segment with shouldered edges.
• ✗ B) Barium follow-through:** Small bowel study - contrast follows orally, reaches colon late and diluted.
• ✗ C) Barium meal:** Stomach and duodenum - not for colonic lesions.
• ✗ D) Barium swallow:** Esophagus - proximal GI tract only.
• Variants:
  • Q: A 65-year-old with altered bowel habits and weight loss. Which imaging finding suggests colonic carcinoma? A: Apple core lesion on barium enema
  • Q: What is the most sensitive screening tool for colon cancer? A: Colonoscopy (barium enema shows the apple core appearance)

Q164. A young boy had a fracture of left shoulder after which he had loss of sensation on the upper lateral side of arm, the nerve involved is:

• A) Axillary ← CORRECT
• B) Median
• C) Radial
• D) Musculocutaneous
• Why: Fracture of the surgical neck of the humerus (shoulder) can injure the axillary nerve as it winds around the humerus. Axillary nerve supplies the deltoid and teres minor, and provides sensory innervation to the “regimental badge” area - upper lateral aspect of the arm.
• ✗ B) Median nerve:** Supplies lateral forearm muscles and thenar muscles; sensory loss affects thumb, index, middle fingers.
• ✗ C) Radial nerve:** Injured in midshaft humerus fracture; causes wrist drop, sensory loss over posterior arm and dorsum of hand.
• ✗ D) Musculocutaneous nerve:** Supplies biceps brachii; sensory loss over lateral forearm, not upper lateral arm.
• Variants:
  • Q: A patient with deltoid weakness and loss of sensation over the upper lateral arm after shoulder fracture - nerve injured? A: Axillary nerve
  • Q: Which nerve is most commonly injured in anterior shoulder dislocation? A: Axillary nerve

Q166. A 35-year-old woman presents with ptosis and diplopia that worsen towards end of the day. Symptoms improve with rest. Which of the following is the most appropriate next step in management?

• A) Pyridostigmine ← CORRECT
• B) Diaminopyridine
• C) Plasma exchange
• D) Cyclophosphamide
• Why: Ptosis and diplopia that worsen towards the end of the day (fatigable weakness) and improve with rest is classic myasthenia gravis. First-line treatment is pyridostigmine, an acetylcholinesterase inhibitor that increases acetylcholine at the neuromuscular junction.
• ✗ B) Diaminopyridine:** Used for Lambert-Eaton myasthenic syndrome (LEMS) - improves with activity, not rest.
• ✗ C) Plasma exchange:** Reserved for myasthenic crisis or refractory cases, not first step.
• ✗ D) Cyclophosphamide:** Immunosuppressant for severe refractory cases, not first-line.
• Variants:
  • Q: A patient with fluctuating ptosis and positive edrophonium (Tensilon) test - first-line treatment? A: Pyridostigmine
  • Q: Myasthenia gravis is associated with antibodies against which receptor? A: Acetylcholine receptor (nicotinic)