NRE-I FULL MOCK EXAM

Pakistan Medical & Dental Council — National Registration Examination I

200 MCQs | 3 Hours | No Negative Marking
Date: ___________ Start: ___________ End: ___________
Candidate: ___________ PMDC No.: ___________

INSTRUCTIONS

200 MCQs across Sections A–M. Select the single best answer.
No negative marking — attempt every question.
Recommended: 50–60 seconds per question.
No calculators, phones, books, or notes.

Exam Structure

Section	Subject	MCQs
A	Medicine & Allied	54
B	Surgery & Allied	50
C	Obstetrics & Gynaecology	14
D	Paediatrics	14
E	Ophthalmology	6
F	ENT	6
G	Applied Pathology	11
H	Applied Anatomy	11
I	Applied Physiology	10
J	Clinical Pharmacology	8
K	Applied Biochemistry	6
L	Community Medicine	6
M	Forensic Medicine & Toxicology	4
	TOTAL	200

SECTION A — MEDICINE & ALLIED (Questions 1–54)

1. A 62-year-old man with hypertension and diabetes presents with crushing substernal chest pain for 45 minutes. ECG shows ST elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?

A. Left anterior descending

B. Left circumflex

C. Right coronary artery

D. Left main

2. A 55-year-old woman with progressive fatigue, orthopnoea, and bilateral leg swelling for 3 weeks. Echo shows EF 35% with global hypokinesia. Which medication reduces mortality?

A. Furosemide

B. Digoxin

C. Carvedilol

D. Amlodipine

3. A 48-year-old man with sudden tearing chest pain radiating to the back. BP 180/100 right arm, 140/85 left arm. D-dimer elevated. Most definitive investigation?

A. Transthoracic echo

B. CT angiography of the aorta

C. Chest X-ray

D. MRI brain

4. A 28-year-old woman with type 1 diabetes: nausea, vomiting, abdominal pain, Kussmaul breathing. Glucose 380, pH 7.18, HCO3 9, urine ketones (+++). Initial fluid of choice?

A. 5% Dextrose

B. 0.9% Normal saline

C. 0.45% Half-normal saline

D. Ringer's lactate

5. A 35-year-old man: 2 months heat intolerance, weight loss, fine tremors. Diffuse goitre with bruit. TSH suppressed, free T4 elevated. RAIU shows diffuse increased uptake. First-line definitive treatment?

A. Propranolol alone

B. Carbimazole 12-18 months

C. Radioactive iodine

D. Total thyroidectomy

6. A 40-year-old woman: episodic severe headache, sweating, palpitations. During episode BP 210/130. Initial diagnostic test?

A. 24-hour urinary VMA

B. Serum cortisol

C. Aldosterone-to-renin ratio

D. Serum calcitonin

7. A 60-year-old man with alcohol use: haematemesis. Spider naevi, splenomegaly, ascites. Endoscopy shows oesophageal varices. Immediate pharmacotherapy?

A. IV PPI

B. IV octreotide

C. Oral propranolol

D. IV vitamin K

8. A 22-year-old woman: periorbital oedema, frothy urine, generalised oedema. Sore throat 2 weeks ago. Urine: 3+ protein, RBC casts. C3 low, ASO elevated. Diagnosis?

A. Minimal change disease

B. IgA nephropathy

C. Post-streptococcal GN

D. Membranous nephropathy

9. A 55-year-old man with CKD stage 4: confusion, BP 85/50, temp 39.5, lactate 4.8, WBC 18,000. Most critical step?

A. IV antibiotics within 1 hour

B. Wait for blood cultures

C. Oral antibiotics

D. CT abdomen

10. A 30-year-old man: high fever 12 days, relative bradycardia, rose spots on abdomen. Returned from rural Sindh. Gram-negative bacillus in blood culture. Drug of choice?

A. Oral ciprofloxacin

B. IV ceftriaxone

C. Oral azithromycin

D. IV meropenem

11. A 25-year-old man: sudden high fever, headache, retro-orbital pain, myalgia for 3 days. Day 4: petechial rash, bleeding gums. Platelets 45,000, NS1 positive. Management?

A. IV methylprednisolone

B. Platelet transfusion

C. Aggressive fluid resuscitation

D. Oral aspirin

12. A 45-year-old woman: progressive dysphagia to solids and liquids for 6 months. Regurgitation of undigested food. Bird's beak on barium swallow. Failed LES relaxation on manometry. Definitive treatment?

A. PPI therapy

B. Balloon dilation

C. Heller's cardiomyotomy

D. Botulinum toxin

13. A 38-year-old man: bloody diarrhoea, urgency, crampy lower abdominal pain for 3 weeks. Continuous inflammation from rectum, friability, no skip lesions. First-line for moderate disease?

A. Oral mesalazine

B. Oral prednisolone

C. IV infliximab

D. Oral metronidazole

14. A 65-year-old man with AF: sudden left-sided weakness and slurred speech lasting 20 min, fully resolved. CHA2DS2-VASc = 4. Long-term prevention?

A. Aspirin 75 mg

B. Clopidogrel 75 mg

C. Oral anticoagulation

D. No treatment

15. A 70-year-old woman: sudden worst headache of life, vomiting, neck stiffness. CT: hyperdensity in basal cisterns. LP: bloody CSF with xanthochromia. Most likely source?

A. Middle meningeal artery

B. Ruptured berry aneurysm

C. Hypertensive ICH

D. AV malformation

16. A 19-year-old boy: fever, sore throat, fatigue for 10 days. Posterior cervical lymphadenopathy, palatal petechiae, splenomegaly. Atypical lymphocytes >10%. Confirmatory test?

A. ASO titre

B. Monospot test

C. Blood culture

D. Bone marrow biopsy

17. A 50-year-old man with cirrhosis: confusion, disturbed sleep-wake cycle, asterixis. Ammonia elevated. Stool guaiac positive. Most likely precipitant?

A. GI bleeding

B. Hypokalaemia

C. Constipation

D. SBP

18. A 32-year-old woman: polyuria, polydipsia, 6-kg weight loss over 4 weeks. Glucose 320, urine ketones trace, pH 7.34, HCO3 18. Alert, well-perfused. Initial management?

A. SC insulin and oral fluids

B. IV normal saline and IV insulin

C. Oral hypoglycaemics

D. Observation

19. A 60-year-old man: progressive proximal muscle weakness, difficulty climbing stairs, violaceous rash on eyelids. CK elevated. Diagnosis?

A. SLE

B. Polymyositis

C. Dermatomyositis

D. Inclusion body myositis

20. A 28-year-old woman: malar rash, photosensitivity, oral ulcers, arthritis. ANA 1:640, anti-dsDNA positive, low complement. Urine 2+ protein. First-line for renal involvement?

A. Hydroxychloroquine alone

B. High-dose steroids + mycophenolate

C. NSAIDs

D. Methotrexate

21. A 55-year-old man: acutely painful swollen first MTP joint after red meat and alcohol. Uric acid 9.2. Treatment for acute attack?

A. Allopurinol

B. Probenecid

C. Colchicine

D. Intra-articular steroid

22. A 65-year-old man, 40-pack-year smoking: chronic productive cough 3 months x 2 years. FEV1/FVC 0.60, FEV1 55%, no reversibility. Initial maintenance therapy?

A. SABA as needed

B. LAMA

C. ICS alone

D. Oral prednisolone

23. A 45-year-old woman: fatigue, pallor, koilonychia for 4 months. Hb 8.5, MCV 68, ferritin 8, TIBC elevated. Stool occult blood negative. Next step after starting iron?

A. Bone marrow biopsy

B. Upper and lower GI endoscopy

C. Blood transfusion

D. IV iron infusion

24. A 4-year-old boy from Lahore: failure to thrive, pallor, abdominal distension since infancy. Frontal bossing, maxillary hypertrophy, hepatosplenomegaly. Hb 6, target cells, nucleated RBCs. HbF and HbA2 elevated. Definitive treatment?

A. Oral iron

B. Regular transfusion + iron chelation

C. Folic acid alone

D. Splenectomy

25. A 35-year-old woman: easy bruising, petechiae, menorrhagia for 2 months. Platelets 18,000. Bone marrow: increased megakaryocytes, normal erythroid/myeloid. First-line treatment?

A. Platelet transfusion

B. Oral prednisolone

C. Splenectomy

D. Rituximab

26. A 60-year-old man: fatigue, weight loss, early satiety for 3 months. Massive splenomegaly to umbilicus. WBC 85,000 with left shift, basophilia. Platelets 600,000. LAP score low. Diagnosis?

A. CML

B. CLL

C. Myelofibrosis

D. Leukemoid reaction

27. A 25-year-old man: fever, pallor, gum bleeding for 1 week. Sternal tenderness, petechiae. WBC 45,000 with 70% blasts. Platelets 20,000, Hb 7. Blasts MPO positive with Auer rods. Diagnosis?

A. ALL

B. AML

C. CML blast crisis

D. Aplastic anaemia

28. A 55-year-old man: progressive ascending numbness in feet for 2 months, then difficulty walking. Diarrhoea 3 weeks prior. Bilateral foot drop, areflexia, facial weakness. CSF protein 120, cells 2. Treatment?

A. High-dose IV steroids

B. IVIG

C. Oral pyridostigmine

D. Plasmapheresis contraindicated

29. A 30-year-old woman: recurrent severe unilateral throbbing headache with nausea, photophobia lasting 8-12 hours. Preceded by shimmering zigzag lines. 4 attacks/month. Prophylaxis?

A. Oral sumatriptan

B. Oral propranolol

C. Oral ergotamine

D. Oral naproxen

30. A 45-year-old man: involuntary flinging movements of right arm and leg, sudden onset 2 hours ago. History of rheumatic heart disease with mitral stenosis. Site of lesion?

A. Right internal capsule

B. Left subthalamic nucleus

C. Left putamen

D. Right cerebellum

31. A 70-year-old woman: progressive memory loss, disorientation over 2 years. MRI: bilateral hippocampal atrophy. MMSE 18/30. First-line pharmacological treatment?

A. IV mannitol

B. Oral donepezil

C. Oral risperidone

D. Oral fluoxetine

32. A 28-year-old woman: recurrent binge eating followed by self-induced vomiting for 2 years. BMI 21. Parotid enlargement, calluses on hand. Most common electrolyte abnormality?

A. Hypernatraemia

B. Hypokalaemic metabolic alkalosis

C. Hypercalcaemia

D. Hyponatraemia

33. A 50-year-old man: acute severe epigastric pain radiating to back, nausea, vomiting. Heavy alcohol. Lipase 1,200. CT: peripancreatic fluid. Initial management?

A. Emergency ERCP

B. Aggressive IV fluids and analgesia

C. Immediate surgical debridement

D. Oral pancreatic enzymes

34. A 60-year-old smoker: painless gross haematuria for 2 days. Dysmorphic RBCs. CT: 4-cm bladder mass. Next step?

A. IV antibiotics

B. Urine culture

C. Cystoscopy with biopsy

D. ESWL

35. A 45-year-old woman: progressive jaundice, pruritus, weight loss for 3 months. Clay-coloured stools. Dilated intrahepatic bile ducts, distended gallbladder. CA19-9 elevated. Diagnosis?

A. Hepatocellular carcinoma

B. Pancreatic head carcinoma

C. Acute viral hepatitis

D. Gallstone ileus

36. A 55-year-old man: exertional chest pain relieved by rest for 2 months. Stress test: 1.5 mm ST depression in V4-V6 at 7 METs. Definitive management?

A. Coronary angiography

B. Start aspirin and discharge

C. Thrombolytic therapy

D. Cardiac MRI

37. A 65-year-old man: palpitations and dizziness for 1 day. ECG: absent P waves, irregularly irregular narrow complex at 130 bpm. Stable. Immediate rate-control?

A. IV adenosine

B. IV amiodarone

C. IV diltiazem

D. DC cardioversion

38. A 30-year-old man: fever, night sweats, weight loss for 6 weeks. Cervical lymphadenopathy. CXR: bilateral hilar lymphadenopathy with infiltrates. ACE elevated. Diagnosis?

A. Pulmonary TB

B. Sarcoidosis

C. Hodgkin lymphoma

D. Histoplasmosis

39. A 40-year-old man: polyuria (8 L/day), polydipsia, nocturia for 3 months. Na 148, plasma osmolality 305, urine osmolality 100. Water deprivation fails. After desmopressin, urine osmolality rises to 450. Diagnosis?

A. Nephrogenic DI

B. Central DI

C. Psychogenic polydipsia

D. Uncontrolled DM

40. A 50-year-old woman: fatigue, weight gain, cold intolerance, dry skin for 6 months. TSH 25, free T4 low. Anti-TPO strongly positive. Cause?

A. Graves disease

B. Hashimoto's thyroiditis

C. Subacute thyroiditis

D. Pituitary adenoma

41. A 35-year-old man: severe right flank pain radiating to groin, microscopic haematuria. CT: 5-mm stone in right proximal ureter, no hydronephrosis. No fever. Management?

A. Emergency ureteroscopy

B. ESWL

C. Conservative with hydration and analgesia

D. PCNL

42. A 60-year-old man: painless progressive jaundice, 10-kg weight loss over 2 months. Gallbladder palpable, non-tender. Dilated CBD and pancreatic duct. Diagnosis?

A. Choledocholithiasis

B. Pancreatic head carcinoma

C. Primary sclerosing cholangitis

D. Chronic pancreatitis

43. A 25-year-old woman: fatigue, pallor. Hb 9, MCV 110, MCH 38. Macro-ovalocytes, hypersegmented neutrophils. B12 80 pg/mL. Underlying cause?

A. Dietary deficiency

B. Pernicious anaemia

C. Hookworm

D. Thalassaemia trait

44. A 55-year-old man with RA for 12 years: progressive dyspnoea and cough for 6 months. HRCT: honeycombing, traction bronchiectasis. Restrictive PFTs. Diagnosis?

A. Bronchial asthma

B. Usual interstitial pneumonia

C. Pulmonary embolism

D. Chronic bronchitis

45. A 45-year-old man: 2 days severe pain, swelling, erythema of left first MTP. Uric acid 9.8. Synovial fluid: needle-shaped negatively birefringent crystals. First-line treatment?

A. Oral allopurinol

B. Oral febuxostat

C. Oral indomethacin

D. IM testosterone

46. A 65-year-old man with HF (EF 30%): worsening dyspnoea and leg oedema. On enalapril and furosemide. K+ 2.8 mEq/L. Add which medication?

A. Oral KCl tablets

B. Spironolactone

C. Hydrochlorothiazide

D. IV normal saline

47. A 30-year-old woman: secondary amenorrhoea 8 months, galactorrhoea, headaches. Prolactin 180 ng/mL. MRI: 1.2-cm pituitary mass. First-line treatment?

A. Transsphenoidal surgery

B. Cabergoline

C. Oral contraceptive pills

D. Radiotherapy

48. A 55-year-old man: fever, productive cough with rusty sputum, right pleuritic chest pain for 3 days. CXR: right middle lobe consolidation. Sputum: lancet-shaped gram-positive diplococci. Outpatient antibiotic?

A. Oral amoxicillin

B. IV vancomycin

C. Oral ciprofloxacin

D. Oral doxycycline

49. A 60-year-old man with diabetes: non-healing plantar ulcer for 6 weeks. Painless, 3 cm deep, necrotic base. Pedal pulses absent. ABI 0.5. Most critical factor?

A. Oral antibiotics alone

B. Surgical debridement

C. Vascular revascularization

D. Tight glycaemic control only

50. A 45-year-old woman: progressive fatigue, pallor, dysphagia. Hb 7.5, MCV 70, ferritin 6. Barium swallow: proximal oesophageal web. Diagnosis?

A. Plummer-Vinson syndrome

B. Achalasia

C. Oesophageal carcinoma

D. Eosinophilic oesophagitis

51. A 50-year-old man with decompensated cirrhosis: increasing abdominal girth, fever, tenderness. Ascitic fluid PMN 350 cells/uL. Treatment?

A. Oral norfloxacin prophylaxis

B. IV ceftriaxone

C. Oral spironolactone

D. IV albumin alone

52. A 35-year-old woman: recurrent severe RUQ pain after fatty meals for 6 months. USG: multiple small gallstones, normal CBD. Definitive management?

A. Oral ursodeoxycholic acid

B. Laparoscopic cholecystectomy

C. ERCP with sphincterotomy

D. ESWL

53. A 70-year-old man with a 3-month history of progressive dyspnoea and orthopnoea presents with acute worsening over 2 days. He has a history of hypertension and type 2 diabetes. On examination: BP 180/110, JVP elevated, bilateral crackles up to mid-zones, pitting oedema. Chest X-ray shows pulmonary congestion and bilateral pleural effusions. Which medication provides the most rapid symptom relief?

A. Oral captopril

B. IV furosemide

C. Oral spironolactone

D. IV digoxin

54. A 55-year-old woman with type 2 diabetes mellitus for 10 years presents with a 2-day history of nausea, vomiting, and abdominal pain. Blood glucose is 450 mg/dL, pH 7.32, bicarbonate 16 mEq/L, urine ketones trace positive. She is alert and haemodynamically stable. What is the most appropriate initial management?

A. IV normal saline and IV insulin infusion

B. Subcutaneous insulin and oral fluids

C. Oral hypoglycaemic agents

D. IV sodium bicarbonate

SECTION B — SURGERY & ALLIED (Questions 55–102)

55. A 25-year-old man: periumbilical pain migrated to RIF over 18 hours, nausea, low-grade fever. Tenderness at McBurney's point. Alvarado score 8. Management?

A. Oral antibiotics and discharge

B. Laparoscopic appendicectomy

C. CT abdomen for confirmation

D. Observation 24 hours

56. A 60-year-old man: absolute constipation, abdominal distension, bilious vomiting for 2 days. Previous laparotomy. AXR: stepladder pattern. Most likely cause?

A. Paralytic ileus

B. Adhesive small bowel obstruction

C. Large bowel obstruction

D. Intussusception

57. A 45-year-old man: sudden severe epigastric pain radiating to back after heavy meal. Lipase 2,500. After 72 hours, temp 39, epigastric mass. CT: fluid collection in lesser sac. Complication?

A. Pancreatic pseudocyst

B. Pancreatic abscess

C. Splenic vein thrombosis

D. Acute peritonitis

58. A 55-year-old woman: 2 hours severe RUQ pain and fever. Murphy's sign positive. USG: thickened GB wall, pericholecystic fluid, stone in GB neck. WBC 15,000. Definitive treatment?

A. Oral amoxicillin-clavulanate

B. Elective cholecystectomy in 6 weeks

C. Early laparoscopic cholecystectomy (within 72 hours)

D. ERCP

59. A 20-year-old man after RTA: severe left upper quadrant pain, BP 80/50. FAST: free fluid in splenorenal recess. After fluids, BP transiently improves then drops. Next step?

A. CT abdomen

B. Angioembolization

C. Emergency laparotomy

D. Repeat FAST

60. A 30-year-old man after fall from height: unconscious, GCS 7. Left pupil dilated, non-reactive. Right limb decerebrate posturing. Most urgent intervention?

A. CT head

B. Mannitol and urgent neurosurgical evacuation

C. Endotracheal intubation only

D. Cervical spine X-ray

61. A 45-year-old man: 3 months progressive dysphagia, initially solids then liquids. Lost 8 kg. Endoscopy: ulcerated mass in distal oesophagus extending to GOJ. Biopsy: adenocarcinoma. Risk factor?

A. Achalasia

B. Barrett's oesophagus

C. Hiatus hernia

D. Oesophageal web

62. A 65-year-old man: sudden painful cold right leg for 2 hours. History of AF. Leg pale, pulseless, cold below knee. Immediate management?

A. Oral aspirin

B. IV heparin and urgent embolectomy

C. Warm compresses

D. CT angiography

63. A 35-year-old man: 6 hours tender, irreducible right inguinal lump. Nausea, no vomiting. Lump above and medial to pubic tubercle, no cough impulse. Management?

A. Elective herniorrhaphy in 2 weeks

B. Immediate surgical exploration

C. Manual reduction under sedation

D. Truss application

64. A 70-year-old man: acute urinary retention (bladder to umbilicus). Nocturia and poor stream for 2 years. PSA 3.5. Immediate management?

A. TURP

B. Urethral catheterization

C. Suprapubic cystostomy

D. Oral tamsulosin

65. A 15-year-old boy: sudden severe right testicular pain for 4 hours. Right testis high-riding, horizontal. Cremasteric reflex absent. Doppler: absent blood flow. Management?

A. IV antibiotics

B. Scrotal elevation and ice packs

C. Immediate surgical exploration and orchidopexy

D. Oral analgesia

66. A 50-year-old man: painless lump in right breast for 2 months. 2-cm firm, fixed mass in retroareolar area with nipple retraction. Axillary nodes palpable. Next step?

A. US-guided FNAC

B. Core needle biopsy

C. Mammography alone

D. Oral tamoxifen

67. A 45-year-old woman: 3-cm solitary thyroid nodule for 2 months. TSH normal. USG: solid hypoechoic nodule with microcalcifications. Next step?

A. RAIU scan

B. FNAC

C. Total thyroidectomy

D. Oral levothyroxine

68. A 60-year-old man: 4 months altered bowel habit, weight loss, intermittent rectal bleeding. DRE: hard, irregular mass 5 cm from anal verge. CEA elevated. Staging investigation?

A. Barium enema

B. CT chest, abdomen, and pelvis

C. Abdominal ultrasound

D. PET scan alone

69. A 30-year-old man: deep laceration on volar wrist after glass injury. Loss of sensation over palmar index and middle fingers, weakness of thumb opposition. Nerve injured?

A. Ulnar nerve

B. Radial nerve

C. Median nerve

D. Musculocutaneous nerve

70. A 55-year-old man: severe pain and swelling of left calf 7 days after total hip replacement. No fever. Doppler: thrombus in popliteal vein. Immediate treatment?

A. Aspirin

B. Compression stockings

C. Therapeutic anticoagulation with LMWH

D. IV antibiotics

71. A 40-year-old woman: 2 days severe pain, swelling, erythema of left breast with fever. Breastfeeding 3-month-old. Tender, indurated area in upper outer quadrant. Management?

A. Stop breastfeeding permanently

B. Oral flucloxacillin and continue breastfeeding

C. Incision and drainage

D. Mammography

72. A 25-year-old man after stab wound to left chest: tachycardic (130), hypotensive (85/60), distended neck veins. Heart sounds muffled. Trachea central. Immediate management?

A. Needle pericardiocentesis

B. Left intercostal drain

C. Emergency thoracotomy

D. IV fluids alone

73. A 60-year-old man: progressive difficulty swallowing solids for 4 months, regurgitation of undigested food. Bird's beak on barium swallow. Definitive diagnostic investigation?

A. Oesophageal manometry

B. Upper GI endoscopy

C. CT chest

D. 24-hour pH monitoring

74. A 50-year-old woman: 6 months slowly growing, painless mass in right popliteal fossa. Firm, non-tender, transilluminant. Diagnosis?

A. Popliteal artery aneurysm

B. Baker's cyst

C. Semimembranosus bursitis

D. Popliteal lymphadenopathy

75. A 55-year-old man: 3 months progressive dysphagia and weight loss. Endoscopy: mass in middle third of oesophagus. Biopsy: SCC. Risk factor?

A. GORD

B. Smoking and alcohol use

C. Barrett's oesophagus

D. Obesity

76. A 45-year-old man: 2 days severe pain, swelling, erythema of left leg. Skin tense, shiny, well-demarcated edges. Temp 38.8. Small blistering. Diagnosis?

A. Cellulitis

B. Erysipelas

C. Necrotizing fasciitis

D. DVT

77. A 30-year-old man: 1 week progressive weakness of both legs and urinary retention. URTI 2 weeks ago. Flaccid paralysis, areflexia, sensory level at T10. MRI: hyperintense thoracic cord lesion. Diagnosis?

A. Guillain-Barré syndrome

B. Transverse myelitis

C. Spinal cord compression

D. Anterior spinal artery syndrome

78. A 55-year-old woman: 4 months progressive jaundice, pruritus, weight loss. USG: 3-cm mass in head of pancreas with dilated CBD and pancreatic duct. CA19-9 elevated. Curative surgical option?

A. Distal pancreatectomy

B. Whipple's procedure

C. Total pancreatectomy

D. Palliative biliary bypass

79. A 40-year-old man: 3 days severe perianal pain and swelling. Tender, fluctuant mass at 3 o'clock, 2 cm from anal verge. Temp 38.5. Treatment?

A. Oral antibiotics alone

B. Incision and drainage under anaesthesia

C. Fistulotomy

D. Observation with sitz baths

80. A 60-year-old man: 6 months progressive difficulty walking, stiffness in both legs, numbness in hands. Spastic paraparesis, sensory level at T6. MRI: compressive lesion at T5. Management?

A. High-dose IV methylprednisolone

B. Surgical decompression

C. Radiotherapy alone

D. Plasmapheresis

81. A 25-year-old man: 2 days severe pain and swelling of right testis. Sexually active with multiple partners. Right testis tender, epididymis thickened. PCR positive for Chlamydia trachomatis. Treatment?

A. Oral ciprofloxacin

B. Oral doxycycline

C. IV ceftriaxone

D. Oral metronidazole

82. A 50-year-old man: 3 months progressive dyspnoea and orthopnoea. Wide pulse pressure, diastolic murmur at left sternal border, Quincke's sign. Echo: severe AR with LV dilation. Definitive treatment?

A. Oral nitrates

B. Aortic valve replacement

C. Balloon valvuloplasty

D. Oral digoxin

83. A 35-year-old woman: 1 month progressive dyspnoea and chest pain. Rheumatic fever in childhood. Loud S1, opening snap, mid-diastolic rumble at apex. Echo: mitral valve area 1.0 sq cm. Intervention?

A. Percutaneous balloon mitral valvuloplasty

B. Mitral valve replacement

C. Oral diuretics

D. Open commissurotomy

84. A 45-year-old man: 2 weeks progressive dysphagia and odynophagia. HIV-positive, CD4 80. Endoscopy: large, deep, linear ulcers in mid-oesophagus. Causative organism?

A. Candida albicans

B. CMV

C. Herpes simplex virus

D. Helicobacter pylori

85. A 60-year-old man: 3 months progressive dyspnoea and dry cough. Asbestos exposure. CXR: pleural plaques and unilateral pleural effusion. CT: nodular pleural thickening. Diagnosis?

A. Bronchogenic carcinoma

B. Mesothelioma

C. Tuberculous pleurisy

D. CCF

86. A 55-year-old man: 2 months progressive dyspnoea and orthopnoea. Elevated JVP increasing on inspiration (Kussmaul's sign), bilateral pitting oedema, ascites. Echo: thickened pericardium with RV diastolic collapse. Definitive treatment?

A. Pericardiocentesis

B. Pericardiectomy

C. Oral prednisolone

D. Oral colchicine

87. A 40-year-old man: 1 week severe epigastric pain radiating to back. Heavy alcohol. Lipase 1,800. CT: pancreatic necrosis 40%. Temp 39, WBC 18,000. Management?

A. Immediate surgical debridement

B. IV antibiotics and ICU monitoring

C. Oral pancreatic enzymes

D. ERCP with stenting

88. A 30-year-old woman: 3 months painless lump in left breast. 2-cm, firm, mobile, well-circumscribed mass in upper outer quadrant. USG: solid, homogeneous, smooth margins. Diagnosis?

A. Fibroadenoma

B. Breast carcinoma

C. Breast cyst

D. Phyllodes tumour

89. A 65-year-old man: 6 months progressive difficulty urinating, nocturia, incomplete bladder emptying. DRE: symmetrically enlarged, firm, smooth prostate. PSA 3.0. First-line pharmacological treatment?

A. Finasteride

B. Tamsulosin

C. Oxybutynin

D. Antibiotics

90. A 45-year-old man: 2 days severe pain and swelling of left leg. Recent hip surgery. Doppler: thrombus in left femoral vein. Immediate treatment?

A. Aspirin

B. Compression stockings

C. Therapeutic anticoagulation with LMWH

D. Thrombolytic therapy

91. A 50-year-old man: 3 months progressive dysphagia and weight loss. Endoscopy: mass in distal oesophagus extending to GOJ. Biopsy: adenocarcinoma. Risk factor?

A. Achalasia

B. Barrett's oesophagus

C. Hiatus hernia

D. Oesophageal web

92. A 35-year-old man: 1 day severe pain and swelling of right great toe. Similar episodes before. Uric acid 9.5. Negatively birefringent needle-shaped crystals. First-line treatment?

A. Oral allopurinol

B. Oral colchicine

C. Oral probenecid

D. IV corticosteroids

93. A 65-year-old man: 3 months progressive dysphagia and weight loss. Mass in middle third of oesophagus. Biopsy: SCC. Risk factor?

A. GORD

B. Smoking and alcohol use

C. Barrett's oesophagus

D. Obesity

94. A 45-year-old man: 2 days severe pain, swelling, erythema of left leg. Skin tense, shiny, well-demarcated edges. Temp 38.8. Blistering. Diagnosis?

A. Cellulitis

B. Erysipelas

C. Necrotizing fasciitis

D. DVT

95. A 45-year-old man: sudden severe headache, vomiting, and photophobia for 2 hours. Neck stiffness present. CT head shows hyperdensity in the Sylvian fissure. Most likely diagnosis?

A. Subarachnoid haemorrhage

B. Bacterial meningitis

C. Hypertensive ICH

D. Cerebral venous thrombosis

96. A 65-year-old man: 6 months progressive dysphagia, initially to solids, now to liquids. 10-kg weight loss. Endoscopy: mass in the middle third of the oesophagus. Biopsy: SCC. Most appropriate treatment for operable disease?

A. Radiotherapy alone

B. Surgical resection

C. Chemotherapy alone

D. Palliative stenting

97. A 55-year-old woman: 3 months of a slowly growing, painless lump in the left breast. 3-cm, firm, fixed mass with skin dimpling. Axillary lymph nodes palpable. Triple assessment includes all EXCEPT?

A. Clinical examination

B. Mammography and USG

C. FNAC or core biopsy

D. CT chest as first-line staging

98. A 40-year-old man: 2 days of severe pain, swelling, and erythema of the left leg. The skin is tense and shiny with well-demarcated raised edges. Temperature 39°C. Area of skin blistering and crepitus. Most likely diagnosis?

A. Cellulitis

B. Erysipelas

C. Necrotizing fasciitis

D. DVT

99. A 60-year-old man: acute urinary retention (bladder palpable to umbilicus). History of nocturia, poor stream, and terminal dribbling for 3 years. PSA 8.5 ng/mL. DRE: hard, irregular, nodular prostate. Most appropriate next step?

A. Urethral catheterization and PSA recheck

B. Transrectal ultrasound-guided prostate biopsy

C. Bone scan

D. Start alpha-blockers

100. A 35-year-old man: 1 day of severe pain, swelling, and erythema of the right great toe. History of similar episodes. Uric acid 9.5 mg/dL. Synovial fluid shows needle-shaped negatively birefringent crystals. First-line treatment for this acute attack?

A. Oral allopurinol

B. Oral colchicine

C. Oral probenecid

D. IV corticosteroids

101. A 55-year-old man: 6 months of progressive difficulty walking, stiffness in both legs, and numbness in the hands. Spastic paraparesis, loss of vibration sense in the legs, and a sensory level at T6. MRI shows an extradural compressive lesion at T5. Most appropriate management?

A. High-dose IV methylprednisolone

B. Surgical decompression

C. Radiotherapy alone

D. Plasmapheresis

102. A 30-year-old man: 1 week of progressive weakness of both legs and urinary retention. Upper respiratory infection 2 weeks ago. Examination shows flaccid paralysis of both legs with areflexia and a sensory level at T10. MRI spine shows a hyperintense lesion in the thoracic cord. Most likely diagnosis?

A. Guillain-Barré syndrome

B. Transverse myelitis

C. Spinal cord compression

D. Anterior spinal artery syndrome

103. A 45-year-old man presents with a 2-month history of progressive dysphagia, initially to solids and now to liquids. He has lost 10 kg. Endoscopy reveals an ulcerated mass in the distal oesophagus extending to the gastro-oesophageal junction. Biopsy shows adenocarcinoma. CT chest and abdomen shows no distant metastases. What is the most appropriate treatment?

A. Neoadjuvant chemotherapy followed by surgery

B. Palliative stenting

C. Radiotherapy alone

D. Definitive chemoradiotherapy

104. A 60-year-old man with a history of smoking presents with a 3-month history of progressive dyspnoea and a dry cough. Chest X-ray shows a unilateral pleural effusion. CT chest shows pleural plaques and a nodular pleural thickening. Pleural fluid analysis shows protein 4.2 g/dL, LDH 280 U/L, and mesothelial cells. What is the most likely diagnosis?

A. Tuberculous pleurisy

B. Malignant mesothelioma

C. Congestive cardiac failure

D. Parapneumonic effusion

SECTION C — OBSTETRICS & GYNAECOLOGY (Questions 101–114)

105. A 28-year-old G2P1 at 7 weeks: sudden severe RLQ pain and vaginal spotting. Dizzy on standing. BP 90/60, pulse 120. Urine pregnancy positive. TVUSG: empty uterus, 2-cm right adnexal mass with free fluid. Management?

A. Oral methotrexate

B. Laparoscopic salpingectomy

C. Expectant management

D. Dilation and curettage

106. A 32-year-old at 34 weeks: headache, visual disturbances, epigastric pain for 2 days. BP 165/110, urine protein 3+. Platelets 90,000, AST 180, ALT 200. Diagnosis?

A. Gestational hypertension

B. Chronic hypertension

C. HELLP syndrome

D. Acute fatty liver of pregnancy

107. A 25-year-old at 28 weeks: painless vaginal bleeding for 1 day. No abdominal tenderness. FHR normal. USG: placenta covering internal cervical os. Management?

A. Immediate caesarean section

B. Induction of labour

C. Expectant management with close monitoring

D. Manual removal of placenta

108. A 30-year-old G3P2 at 38 weeks delivers vaginally. Heavy vaginal bleeding (EBL 800 mL). Uterus boggy and soft. Immediate management?

A. Oxytocin infusion and uterine massage

B. Manual removal of placenta

C. Hysterectomy

D. Blood transfusion only

109. A 35-year-old woman: secondary infertility for 3 years. History of pulmonary TB. HSG: bilateral tubal blockage with beaded appearance. Cause?

A. Endometriosis

B. Genital tuberculosis

C. PCOS

D. Tubal factor from previous PID

110. A 55-year-old postmenopausal woman: vaginal bleeding for 2 weeks. BMI 35, diabetes. TVUSG: endometrial thickness 12 mm. Next step?

A. Oral progesterone

B. Endometrial biopsy

C. Hysterectomy

D. Observation and repeat USG

111. A 28-year-old at 30 weeks: severe abdominal pain and vaginal bleeding. Uterus tender and hard. FHR absent. Diagnosis?

A. Placenta previa

B. Abruptio placentae

C. Uterine rupture

D. Ectopic pregnancy

112. A 30-year-old at 36 weeks: generalized tonic-clonic seizure. History of preeclampsia. BP 170/115, urine protein 4+. First-line anticonvulsant?

A. IV diazepam

B. IV magnesium sulphate

C. Oral nifedipine

D. IV phenytoin

113. A 25-year-old woman: oligomenorrhoea, hirsutism, acne for 2 years. BMI 32. USG: bilateral enlarged ovaries with multiple peripheral cysts. First-line for fertility?

A. Oral clomiphene citrate

B. Metformin alone

C. Laparoscopic ovarian drilling

D. Oral contraceptive pills

114. A 45-year-old woman: 6 months heavy menstrual bleeding and intermenstrual bleeding. Uterus symmetrically enlarged to 12 weeks. USG: multiple well-defined hypoechoic masses in myometrium. Diagnosis?

A. Adenomyosis

B. Endometrial carcinoma

C. Uterine leiomyoma (fibroids)

D. Endometrial polyp

115. A 32-year-old at 32 weeks: severe pruritus, especially palms and soles, for 2 weeks. Serum bile acids elevated. No rash. Management?

A. Oral ursodeoxycholic acid and early delivery planning

B. Oral antihistamines

C. Topical corticosteroids

D. Immediate induction of labour

116. A 28-year-old G2P1 at 38 weeks: breech presentation. External cephalic version unsuccessful. Delivery plan?

A. Vaginal breech delivery

B. Elective caesarean section

C. Induction of labour

D. Expectant management until 42 weeks

117. A 35-year-old woman: 3 months postcoital bleeding. Speculum: friable, ulcerated growth on cervix. Next step?

A. Pap smear

B. Cervical biopsy

C. HPV DNA testing

D. Colposcopy alone

118. A 30-year-old at 20 weeks: blood glucose 210 mg/dL on 75-g OGTT. Fasting glucose 105 mg/dL. Initial management?

A. Medical nutrition therapy and exercise

B. Immediate insulin therapy

C. Oral metformin

D. Oral glyburide

SECTION D — PAEDIATRICS (Questions 115–128)

119. A 3-day-old term neonate: jaundice. Total bilirubin 18 mg/dL (indirect 17). Mother O Rh-negative, baby A Rh-positive. Direct Coombs positive. Diagnosis?

A. Physiological jaundice

B. ABO incompatibility

C. Rh incompatibility

D. Biliary atresia

120. A 2-year-old boy: 2 days barking cough, hoarseness, inspiratory stridor. Low-grade fever. Neck X-ray: steeple sign. Treatment?

A. Oral amoxicillin

B. Nebulized epinephrine and oral dexamethasone

C. Emergency tracheostomy

D. Oral prednisolone alone

121. A 4-year-old girl: high fever, drooling, difficulty breathing for 6 hours. Sitting upright with neck extended. Lateral neck X-ray: thumb sign. Immediate management?

A. Oral amoxicillin-clavulanate

B. Nebulized budesonide

C. Secure the airway (intubation in OT)

D. Throat examination with tongue depressor

122. A 6-month-old infant: tachypnoea, chest indrawing, cough for 3 days. RR 58/min. No chest indrawing. SpO2 95%. WHO IMCI classification?

A. Severe pneumonia

B. Pneumonia (non-severe)

C. No pneumonia—cough or cold

D. Very severe disease

123. A 5-year-old boy: generalised oedema, frothy urine, ascites for 1 week. Urine: 4+ proteinuria, no RBCs. Albumin 1.8 g/dL, cholesterol elevated. No haematuria, no HTN. Diagnosis?

A. PSGN

B. Minimal change disease

C. Membranous nephropathy

D. IgA nephropathy

124. A 3-year-old boy: 5 days high fever, bilateral conjunctival injection, cracked lips, strawberry tongue, cervical lymphadenopathy. Treatment to prevent complications?

A. Oral aspirin alone

B. IV immunoglobulin and aspirin

C. Oral prednisolone

D. Oral amoxicillin

125. A 2-month-old infant: machinery-like murmur at left infraclavicular area. Continuous throughout systole and diastole. Diagnosis?

A. VSD

B. ASD

C. PDA

D. Tetralogy of Fallot

126. A 6-year-old boy: squatting after exertion since early childhood. Central cyanosis and clubbing. CXR: boot-shaped heart. Diagnosis?

A. Transposition of the great arteries

B. Tetralogy of Fallot

C. Total anomalous pulmonary venous return

D. Ebstein anomaly

127. A 28-week preterm neonate: respiratory distress shortly after birth. Grunting, nasal flaring, chest retractions. CXR: ground-glass appearance with air bronchograms. Immediate management?

A. Surfactant therapy and CPAP

B. High-flow nasal cannula oxygen

C. IV antibiotics

D. Diuretic therapy

128. A 9-month-old infant: 3 days watery diarrhoea, vomiting, decreased urine output. Lethargic, sunken eyes, skin pinch >3 seconds. Degree of dehydration?

A. No dehydration

B. Some dehydration

C. Severe dehydration

D. Mild dehydration

129. A 3-year-old boy: fever, cough, generalized maculopapular rash for 3 days. Small white spots on buccal mucosa. Treatment?

A. Oral acyclovir

B. Vitamin A supplementation

C. Oral amoxicillin

D. Oral prednisolone

130. A 10-year-old boy: recurrent wheezing and cough for 2 years, triggered by cold air and exercise. No fever. Spirometry: FEV1/FVC 0.65, >12% improvement after bronchodilator. First-line maintenance?

A. Oral prednisolone

B. Inhaled corticosteroids

C. Oral montelukast

D. Oral theophylline

131. A 1-day-old term neonate: heart rate 70 bpm, no respiratory effort, flaccid and pale. Immediate step in resuscitation?

A. Positive pressure ventilation

B. Chest compressions

C. Endotracheal intubation

D. IV epinephrine

132. A 6-month-old exclusively breastfed infant: irritability, poor feeding, bulging anterior fontanelle. Mother had pulmonary TB, non-compliant. CSF: lymphocytes 200, protein 150, glucose 25. Diagnosis?

A. Bacterial meningitis

B. Tuberculous meningitis

C. Viral meningitis

D. Neonatal sepsis

SECTION E — OPHTHALMOLOGY (Questions 129–134)

133. A 55-year-old woman: sudden severe pain in right eye, headache, nausea, blurred vision for 4 hours. Right eye red, fixed mid-dilated pupil. IOP 55 mmHg. Immediate treatment?

A. Oral acetazolamide and topical pilocarpine

B. Topical antibiotics

C. Oral prednisolone

D. Topical atropine

134. A 65-year-old man: sudden painless loss of vision in right eye lasting 30 min, then partial recovery. History of AF. Fundoscopy: pale retina with cherry-red spot. Diagnosis?

A. CRVO

B. CRAO

C. Retinal detachment

D. Optic neuritis

135. A 50-year-old woman with diabetes for 15 years: blurred vision. Fundoscopy: dot-blot haemorrhages, hard exudates, cotton-wool spots. No neovascularization. Stage?

A. Mild NPDR

B. Moderate NPDR

C. Proliferative DR

D. Macular oedema

136. A 25-year-old woman: painful vision loss in right eye, difficulty distinguishing colours. Left leg numbness 6 months ago that resolved. Pupil reacts sluggishly. Swollen optic disc. Diagnosis?

A. Optic neuritis

B. Papilloedema

C. CRAO

D. Glaucoma

137. A 60-year-old man: gradual painless progressive vision loss in both eyes for 2 years. Reduced visual acuity, brownish opacity in lens. Definitive treatment?

A. Topical steroids

B. Phacoemulsification with IOL

C. Laser photocoagulation

D. Oral vitamin supplementation

138. A 45-year-old man: sudden painless vision loss in left eye. Fundoscopy: blood and thunder appearance with dilated, tortuous veins and widespread haemorrhages. Diagnosis?

A. CRAO

B. CRVO

C. Diabetic retinopathy

D. Hypertensive retinopathy

SECTION F — ENT (Questions 135–140)

139. A 4-year-old boy: sudden choking and coughing while eating peanuts. Stridor, decreased air entry on right. CXR: hyperinflation of right lung. Immediate management?

A. Heimlich manoeuvre

B. Rigid bronchoscopy under anaesthesia

C. Oral antibiotics

D. Nebulized salbutamol

140. A 50-year-old man: profuse bleeding from right nostril for 1 hour. History of hypertension. Bleeding point visible in anterior nasal septum. First-line treatment?

A. Posterior nasal packing

B. Chemical cautery (silver nitrate)

C. External carotid artery ligation

D. Oral tranexamic acid

141. A 3-year-old girl: severe ear pain, fever, irritability for 2 days. Tympanic membrane bulging, erythematous, loss of light reflex. Treatment?

A. Oral amoxicillin

B. Topical ear drops only

C. Myringotomy

D. Oral antihistamines

142. A 40-year-old woman: progressive hearing loss in right ear for 2 years. Recurrent ear discharge since childhood. Central perforation of tympanic membrane. PTA: 40-dB air-bone gap. Diagnosis?

A. Otosclerosis

B. CSOM (tubotympanic)

C. Otitis media with effusion

D. Acoustic neuroma

143. A 55-year-old man: unilateral progressive hearing loss, tinnitus, imbalance for 6 months. No ear discharge. Tuning fork tests: lateralization to contralateral ear. Investigation?

A. Pure tone audiometry

B. MRI with contrast

C. CT temporal bone

D. Caloric testing

144. A 30-year-old woman: recurrent episodes of severe vertigo lasting hours, with tinnitus and aural fullness. PTA: low-frequency sensorineural hearing loss. Diagnosis?

A. BPPV

B. Ménière's disease

C. Vestibular neuritis

D. Labyrinthitis

SECTION G — APPLIED PATHOLOGY (Questions 141–151)

145. A 60-year-old man: 3 months weight loss and abdominal discomfort. CT: mass in head of pancreas. Biopsy: poorly differentiated adenocarcinoma. Tumour marker most likely elevated?

A. CA19-9

B. Alpha-fetoprotein

C. CEA

D. CA-125

146. A tissue sample shows cells with increased mitotic figures, nuclear pleomorphism, and loss of polarity. This best describes:

A. Hyperplasia

B. Dysplasia

C. Metaplasia

D. Anaplasia

147. A 30-year-old man: fever, pallor, gum bleeding for 1 week. WBC 45,000 with 70% blasts. Blasts MPO positive with Auer rods. Diagnosis?

A. ALL

B. AML

C. CML blast crisis

D. Aplastic anaemia

148. A patient with chronic inflammation shows tissue swelling due to proliferation of fibroblasts and new blood vessels. This process is best described as:

A. Exudation

B. Transudation

C. Granulation tissue formation

D. Fibrosis

149. A 45-year-old woman: fatigue, pallor. Hb 8, MCV 110, MCH 38. Macro-ovalocytes, hypersegmented neutrophils. B12 80 pg/mL. Underlying cause?

A. Dietary deficiency

B. Pernicious anaemia

C. Hookworm

D. Thalassaemia trait

150. A biopsy of a lymphoid malignancy shows Reed-Sternberg cells. Diagnosis?

A. Non-Hodgkin lymphoma

B. Hodgkin lymphoma

C. Burkitt lymphoma

D. Multiple myeloma

151. A fluid analysis shows protein 1.8 g/dL, specific gravity 1.012, few cells. This fluid is best classified as:

A. Exudate

B. Transudate

C. Purulent exudate

D. Hemorrhagic exudate

152. A tumour arising from mesenchymal tissue is classified as:

A. Carcinoma

B. Sarcoma

C. Leukaemia

D. Lymphoma

153. A 55-year-old man with progressive dyspnoea and orthopnoea has a wide pulse pressure, diastolic murmur at the left sternal border, and Quincke's sign. Echocardiography shows severe aortic regurgitation with left ventricular dilation. Which pathological process is most likely responsible for the left ventricular dilation?

A. Myocardial fibrosis

B. Volume overload

C. Pressure overload

D. Myocarditis

154. A 40-year-old woman: 2 months fatigue and pallor. Hb 8, MCV 110, MCH 38. Macro-ovalocytes, hypersegmented neutrophils. B12 80 pg/mL. Which test confirms pernicious anaemia?

A. Serum folate level

B. Anti-intrinsic factor antibodies

C. Serum iron studies

D. Haemoglobin electrophoresis

155. A 60-year-old man: 3 months weight loss and abdominal discomfort. CT: mass in head of pancreas. Biopsy shows poorly differentiated adenocarcinoma. Which anatomical structure is most likely to be invaded by this tumour?

A. Superior mesenteric artery

B. Common bile duct

C. Duodenum

D. All of the above

SECTION H — APPLIED ANATOMY (Questions 152–162)

156. A 30-year-old man: fracture of surgical neck of humerus after fall. Weakness of shoulder abduction, loss of sensation over regimental badge area. Nerve injured?

A. Radial nerve

B. Axillary nerve

C. Musculocutaneous nerve

D. Suprascapular nerve

157. A 45-year-old woman: wrist drop after mid-shaft humeral fracture. Loss of sensation over dorsal first web space. Nerve injured?

A. Median nerve

B. Ulnar nerve

C. Radial nerve

D. Axillary nerve

158. A 25-year-old man: stabbed in cubital fossa. Inability to flex DIP joints of index and middle fingers, loss of sensation over palmar lateral 3.5 fingers. Nerve injured?

A. Ulnar nerve

B. Median nerve

C. Radial nerve

D. Musculocutaneous nerve

159. A 60-year-old man: claw hand deformity and loss of sensation over medial 1.5 fingers after medial epicondyle fracture. Nerve injured?

A. Median nerve

B. Radial nerve

C. Ulnar nerve

D. Musculocutaneous nerve

160. A 50-year-old woman: foot drop and loss of sensation over dorsum of foot after fracture of neck of fibula. Nerve injured?

A. Tibial nerve

B. Common peroneal nerve

C. Sural nerve

D. Saphenous nerve

161. A 55-year-old man: left-sided stroke affecting internal capsule. Vessel most likely occluded?

A. Anterior cerebral artery

B. Middle cerebral artery (lenticulostriate branches)

C. Posterior cerebral artery

D. Basilar artery

162. A 30-year-old woman: indirect inguinal hernia. Structure forming the deep (internal) ring?

A. External oblique aponeurosis

B. Internal oblique muscle

C. Transversalis fascia

D. Conjoint tendon

163. A 60-year-old man: portal hypertension. Most clinically significant site for life-threatening haemorrhage?

A. Umbilical region (caput medusae)

B. Lower oesophagus (oesophageal varices)

C. Rectal region (haemorrhoids)

D. Retroperitoneal veins

164. A 40-year-old woman: thyroid swelling. Nerve entering larynx posterior to cricothyroid joint?

A. External laryngeal nerve

B. Recurrent laryngeal nerve

C. Superior laryngeal nerve

D. Hypoglossal nerve

165. A 50-year-old man: diaphragmatic hernia through oesophageal hiatus. Vertebral level of oesophageal hiatus?

A. T8

B. T10

C. T12

D. L1

166. A 35-year-old woman: mass in femoral triangle. Lateral boundary of femoral triangle?

A. Adductor longus

B. Sartorius

C. Inguinal ligament

D. Pectineus

SECTION I — APPLIED PHYSIOLOGY (Questions 163–172)

167. A 50-year-old man with DKA: pH 7.18, HCO3 9 mEq/L, PaCO2 20 mmHg. Primary acid-base disturbance?

A. Metabolic acidosis with respiratory compensation

B. Respiratory acidosis

C. Metabolic alkalosis

D. Mixed metabolic and respiratory acidosis

168. A 60-year-old man with CKD: pH 7.30, HCO3 16 mEq/L, PaCO2 32 mmHg. Expected respiratory compensation (Winter's formula)?

A. Expected PaCO2 = 1.5 x HCO3 + 8 ± 2 = 30-34 mmHg

B. Expected PaCO2 = HCO3 + 15 = 31 mmHg

C. Expected PaCO2 = 0.7 x HCO3 + 20 = 31 mmHg

D. Expected PaCO2 = 40 - (24 - HCO3) = 32 mmHg

169. A 45-year-old woman with anxiety: hyperventilation. ABG: pH 7.52, PaCO2 25 mmHg, HCO3 22 mEq/L. Primary disturbance?

A. Metabolic alkalosis

B. Acute respiratory alkalosis

C. Chronic respiratory alkalosis

D. Mixed metabolic and respiratory alkalosis

170. A 55-year-old man with COPD: pH 7.34, PaCO2 58 mmHg, HCO3 32 mEq/L. Primary disturbance?

A. Acute respiratory acidosis

B. Chronic respiratory acidosis with metabolic compensation

C. Metabolic acidosis

D. Mixed respiratory and metabolic acidosis

171. A 60-year-old man with severe diarrhoea for 3 days: pH 7.28, HCO3 12 mEq/L, PaCO2 28 mmHg. Na 140, Cl 110. Anion gap?

A. 18 (normal anion gap metabolic acidosis)

B. 22 (high anion gap metabolic acidosis)

C. 10 (normal)

D. 26 (high anion gap)

172. A 50-year-old woman with primary hyperparathyroidism: calcium 12.5 mg/dL. Most characteristic ECG finding?

A. Prolonged QT interval

B. Short QT interval

C. ST segment elevation

D. U waves

173. A 45-year-old man with Addison's disease: weakness. K+ 6.2 mEq/L, Na 128 mEq/L. Hormonal deficiency explaining these findings?

A. Cortisol

B. Aldosterone

C. ACTH

D. ADH

174. A 30-year-old woman: secondary amenorrhoea and galactorrhoea. Prolactin elevated. Hypothalamic hormone that normally inhibits prolactin?

A. GnRH

B. Dopamine

C. Somatostatin

D. TRH

175. A 55-year-old man with heart failure: reduced cardiac output. According to Frank-Starling mechanism, which intervention increases stroke volume?

A. Increasing afterload

B. Increasing preload (up to a point)

C. Decreasing contractility

D. Increasing heart rate above 180 bpm

176. A 40-year-old man with pulmonary embolism: V/Q mismatch. Best description of physiology?

A. Perfusion without ventilation then shunt

B. Ventilation without perfusion then increased dead space

C. Both ventilation and perfusion reduced equally

D. Increased diffusion capacity

SECTION J — CLINICAL PHARMACOLOGY (Questions 173–180)

177. A 55-year-old woman with diabetes, eGFR 25 mL/min/1.73m sq, on metformin. Most appropriate action?

A. Continue metformin at same dose

B. Stop metformin immediately

C. Increase metformin dose

D. Add a sulfonylurea

178. A 30-year-old woman with epilepsy planning pregnancy, on valproic acid. Most appropriate advice?

A. Continue valproic acid—safe in pregnancy

B. Switch to lamotrigine and supplement folic acid

C. Stop all antiepileptics before conception

D. Double the dose of valproic acid

179. A 60-year-old man with asthma and hypertension started on beta-blocker. Develops wheezing within hours. Property causing this adverse effect?

A. Beta-1 selectivity

B. Beta-2 blockade causing bronchoconstriction

C. Alpha-1 blockade

D. ACE inhibition

180. A 50-year-old woman with hypertension and bilateral renal artery stenosis started on ACE inhibitor. Develops AKI. Mechanism?

A. Dilation of efferent arteriole reducing GFR

B. Constriction of afferent arteriole

C. Direct tubular toxicity

D. Renal artery thrombosis

181. A 45-year-old man on warfarin for AF: INR 7.5, minor gum bleeding. Immediate management?

A. Hold warfarin and administer IV vitamin K

B. Continue warfarin at reduced dose

C. Administer FFP only

D. Administer protamine sulfate

182. A 35-year-old woman on OCPs diagnosed with TB, started on rifampicin. Advice regarding contraception?

A. Continue OCPs—no interaction

B. Rifampicin induces CYP450, reducing OCP efficacy—use additional contraception

C. Stop OCPs permanently

D. Double the OCP dose

183. A 55-year-old man with AF started on amiodarone. Most concerning adverse effect with long-term use?

A. Pulmonary fibrosis

B. Hypoglycaemia

C. Renal failure

D. Hearing loss

184. A 60-year-old man with heart failure started on spironolactone. Most important electrolyte abnormality to monitor?

A. Hyponatraemia

B. Hyperkalaemia

C. Hypocalcaemia

D. Hypomagnesaemia

SECTION K — APPLIED BIOCHEMISTRY (Questions 181–186)

185. A 25-year-old man: fatigue and jaundice after starting primaquine. Peripheral film: Heinz bodies and bite cells. Enzyme deficiency?

A. Pyruvate kinase

B. G6PD

C. Hexokinase

D. Glucokinase

186. A newborn: vomiting, lethargy, musty odour after feeding. Guthrie test: elevated phenylalanine. Enzyme deficient?

A. Homogentisate oxidase

B. Phenylalanine hydroxylase

C. Galactose-1-phosphate uridyltransferase

D. Branched-chain alpha-ketoacid dehydrogenase

187. A 30-year-old man: fatigue, pallor. Hb 7, MCV 105, hypersegmented neutrophils, B12 low. Metabolic pathway impaired by B12 deficiency?

A. Conversion of methylmalonyl-CoA to succinyl-CoA

B. Glycolysis

C. Urea cycle

D. Beta-oxidation of fatty acids

188. A 45-year-old man with chronic alcoholism: confusion, ataxia, ophthalmoplegia. Thiamine administered urgently. Enzyme requiring thiamine as cofactor?

A. Pyruvate dehydrogenase

B. Lactate dehydrogenase

C. Alanine aminotransferase

D. Gamma-glutamyl transferase

189. A 60-year-old woman: bone pain, muscle weakness, fractures. Ca low, PO4 low, ALP elevated, 25-OH vitamin D low. Diagnosis?

A. Primary hyperparathyroidism

B. Osteomalacia

C. Paget's disease of bone

D. Multiple myeloma

190. A 35-year-old woman: photosensitivity, abdominal pain, neuropsychiatric symptoms. Urine: elevated PBG and delta-ALA. Enzyme deficient in acute intermittent porphyria?

A. Ferrochelatase

B. PBG deaminase

C. Uroporphyrinogen decarboxylase

D. Delta-ALA dehydratase

SECTION L — COMMUNITY MEDICINE (Questions 187–192)

191. A researcher wants to determine incidence of a new infectious disease. Most appropriate study design?

A. Cross-sectional study

B. Case-control study

C. Cohort study (prospective)

D. Ecological study

192. A new screening test for breast cancer evaluated in 1,000 women. Correctly identifies 90/100 true cases. False positive in 50/900 healthy women. Specificity?

A. 90%

B. 94.4%

C. 85%

D. 50%

193. A public health team wants to evaluate efficacy of a new vaccine. Strongest study design?

A. Case-control study

B. RCT (double-blind, placebo-controlled)

C. Cohort study

D. Cross-sectional survey

194. According to Pakistan EPI schedule, age for first dose of measles vaccine?

A. At birth

B. 6 weeks

C. 9 months

D. 15 months

195. A community health survey finds 50/500 people have diabetes. Measure of disease frequency?

A. Incidence

B. Point prevalence

C. Relative risk

D. Odds ratio

196. A TB control programme in Pakistan uses DOTS strategy. Most critical component?

A. Free medication

B. Directly observed therapy (supervised treatment)

C. Hospital admission

D. Surgery for resistant cases

SECTION M — FORENSIC MEDICINE & TOXICOLOGY (Questions 193–196)

197. A 25-year-old man found dead in closed room with coal fire. Post-mortem: cherry-red discoloration of skin and blood. Cause of death?

A. Carbon monoxide poisoning

B. Cyanide poisoning

C. Organophosphate poisoning

D. Hydrogen sulfide poisoning

198. A 30-year-old woman ingested unknown substance. Excessive salivation, lacrimation, miosis, muscle fasciculations, garlic-like odour. Poisoning?

A. Organophosphate poisoning

B. Barbiturate overdose

C. Iron poisoning

D. Lead poisoning

199. A body recovered from water. Washerwoman appearance of skin and fine foam at mouth and nostrils. Findings indicate?

A. Hanging

B. Drowning

C. Strangulation

D. Poisoning

200. A forensic pathologist examines a scalp wound. Edges irregular with tissue bridging and surrounding bruising. Wound type?

A. Incised wound

B. Laceration

C. Stab wound

D. Abrasion

ANSWER KEY WITH EXPLANATIONS

Section A — MEDICINE & ALLIED

Q	Ans	Brief Explanation
1	C	Inferior STEMI (II,III,aVF) = RCA occlusion.
2	C	Carvedilol (beta-blocker) reduces mortality in HFrEF.
3	B	CT angiography is gold standard for aortic dissection.
4	B	0.9% NS for rapid volume expansion in DKA.
5	B	Graves disease. Carbimazole 12-18 months is first-line.
6	A	Suspected pheochromocytoma. 24-hr urinary VMA is initial test.
7	B	IV octreotide reduces splanchnic blood flow in acute variceal bleeding.
8	C	PSGN: 1-3 weeks post-streptococcal, low C3, nephritic syndrome.
9	A	Sepsis with septic shock requires antibiotics within 1 hour.
10	A	Oral ciprofloxacin is first-line for uncomplicated typhoid.
11	C	Dengue critical phase. Aggressive fluid resuscitation.
12	C	Achalasia. Heller's cardiomyotomy is definitive.
13	A	Ulcerative colitis. Oral mesalazine for moderate disease.
14	C	AF with CHA2DS2-VASc >=2 requires oral anticoagulation.
15	B	SAH: 85% due to ruptured berry aneurysm.
16	B	Infectious mononucleosis. Monospot is confirmatory.
17	A	Hepatic encephalopathy. GI bleeding is a major precipitant.
18	A	New-onset type 2 DM (trace ketones, near-normal pH). SC insulin + oral fluids.
19	C	Dermatomyositis: proximal weakness + heliotrope rash.
20	B	SLE with lupus nephritis requires steroids + mycophenolate.
21	C	Acute gout. Colchicine or NSAIDs. Allopurinol NOT during acute attack.
22	B	COPD. LAMA (tiotropium) is first-line maintenance.
23	B	Iron deficiency with negative stool occult blood still needs GI endoscopy.
24	B	Beta-thalassaemia major. Regular transfusions + iron chelation.
25	B	ITP. Oral corticosteroids are first-line.
26	A	CML: massive splenomegaly, basophilia, low LAP score.
27	B	AML: MPO-positive blasts with Auer rods are pathognomonic.
28	B	Guillain-Barré syndrome. IVIG or plasmapheresis.
29	B	Migraine with aura. Propranolol is first-line prophylaxis.
30	B	Hemiballismus = contralateral subthalamic nucleus lesion.
31	B	Alzheimer's disease. Donepezil (cholinesterase inhibitor) is first-line.
32	B	Bulimia nervosa. Vomiting leads to hypokalaemic metabolic alkalosis.
33	B	Acute pancreatitis. Aggressive IV fluids + analgesia.
34	C	Painless haematuria + bladder mass = bladder cancer until proven.
35	B	Painless jaundice + Courvoisier's gallbladder = pancreatic head carcinoma.
36	A	Positive stress test in symptomatic patient warrants coronary angiography.
37	C	AF. IV diltiazem or beta-blocker for rate control in stable patients.
38	B	Sarcoidosis: bilateral hilar lymphadenopathy, elevated ACE.
39	B	Central DI: urine concentrates after desmopressin.
40	B	Hashimoto's: hypothyroidism with elevated anti-TPO.
41	C	Stone <6 mm, no hydronephrosis, no infection then conservative.
42	B	Double duct sign + painless jaundice + Courvoisier's GB = pancreatic head carcinoma.
43	B	Megaloblastic anaemia. Pernicious anaemia most common cause of B12 deficiency in young woman.
44	B	UIP pattern: honeycombing, traction bronchiectasis, restrictive PFTs.
45	C	Acute gout. NSAIDs (indomethacin), colchicine, or steroids.
46	B	Spironolactone corrects hypokalaemia AND reduces mortality in HFrEF.
47	B	Prolactinoma. Dopamine agonists (cabergoline) are first-line.
48	A	S. pneumoniae. Oral amoxicillin is first-line outpatient CAP.
49	C	Diabetic foot with ABI 0.5 = significant PAD. Vascular revascularisation is critical.
50	A	Plummer-Vinson = iron deficiency + oesophageal web + dysphagia.
51	B	SBP: PMN >=250. IV ceftriaxone is treatment.
52	B	Symptomatic cholelithiasis. Laparoscopic cholecystectomy is definitive.
53	B	IV furosemide provides rapid symptom relief in acute decompensated heart failure (reduces preload).
54	B	New-onset type 2 DM with trace ketones, near-normal pH, stable. SC insulin + oral fluids.
55	A	Resectable distal oesophageal/GOJ adenocarcinoma. Neoadjuvant chemotherapy (perioperative FLOT) followed by surgery is standard.
56	B	Mesothelioma: asbestos exposure, nodular pleural thickening, exudative effusion.

Section B — SURGERY & ALLIED

Q	Ans	Brief Explanation
57	B	Acute appendicitis (Alvarado >=7). Laparoscopic appendicectomy is definitive.
58	B	Adhesive SBO is most common cause in patients with prior abdominal surgery.
59	B	Pancreatic abscess: infected collection after 2-4 weeks with fever and mass.
60	C	Acute cholecystitis. Early laparoscopic cholecystectomy within 72 hours.
61	C	Splenic injury with haemodynamic instability then emergency laparotomy.
62	B	Epidural haematoma. Mannitol + urgent surgical evacuation.
63	B	Distal oesophageal/GOJ adenocarcinoma = Barrett's oesophagus.
64	B	Acute limb ischaemia. AF is embolic source. IV heparin + embolectomy.
65	B	Irreducible tender inguinal hernia suggests incarceration/strangulation.
66	B	Acute urinary retention then immediate urethral catheterization.
67	C	Testicular torsion. Surgical exploration within 6 hours.
68	B	Male breast cancer. Core needle biopsy is definitive.
69	B	Suspicious thyroid nodule then FNAC.
70	B	Rectal cancer. CT chest/abdomen/pelvis is standard staging.
71	C	Median nerve injury at wrist: palmar sensation over lateral 3.5 fingers, thumb opposition weakness.
72	C	DVT post-surgery. Therapeutic anticoagulation with LMWH is first-line.
73	B	Lactational mastitis. Antibiotics + continued breastfeeding.
74	A	Cardiac tamponade (Beck's triad). Needle pericardiocentesis.
75	A	Achalasia. Oesophageal manometry is gold standard.
76	B	Baker's cyst: transilluminant, firm, non-tender mass in popliteal fossa.
77	B	Oesophageal SCC = smoking and alcohol.
78	B	Erysipelas: well-demarcated, raised, shiny erythema.
79	B	Transverse myelitis: sensory level at T10, MRI shows cord lesion.
80	B	Pancreatic head carcinoma. Whipple's procedure is curative.
81	B	Perianal abscess. I&D under anaesthesia.
82	B	Spinal cord compression. Surgical decompression is definitive.
83	B	Chlamydial epididymitis. Doxycycline or azithromycin.
84	B	Severe AR with symptoms and LV dilation then aortic valve replacement.
85	A	Mitral stenosis. Symptomatic severe MS with suitable valve then balloon valvuloplasty.
86	B	CMV oesophagitis: large, deep, linear ulcers in immunocompromised.
87	B	Mesothelioma: asbestos exposure, pleural plaques, nodular pleural thickening.
88	B	Constrictive pericarditis. Pericardiectomy is definitive.
89	B	Infected pancreatic necrosis. IV antibiotics + ICU monitoring.
90	A	Fibroadenoma: young woman, firm, mobile, well-circumscribed mass.
91	B	BPH. Alpha-blockers (tamsulosin) are first-line for symptom relief.
92	C	DVT post-surgery. Therapeutic anticoagulation with LMWH is first-line.
93	B	Distal oesophageal/GOJ adenocarcinoma = Barrett's oesophagus.
94	B	Acute gout. Colchicine, NSAIDs, or steroids.
95	B	Oesophageal SCC = smoking and alcohol.
96	B	Erysipelas: well-demarcated, raised, shiny erythema.
97	A	SAH: sudden severe headache, neck stiffness, hyperdensity in Sylvian fissure on CT.
98	B	Oesophageal SCC. Surgical resection is treatment of choice for operable disease.
99	D	Triple assessment = clinical exam + imaging (mammography/USG) + tissue diagnosis (FNAC/core biopsy). CT is for staging, not part of initial triple assessment.
100	C	Necrotizing fasciitis: crepitus, blistering, severe systemic toxicity. Surgical emergency.
101	B	Suspected prostate cancer (hard, irregular prostate, PSA >4). TRUS-guided biopsy is diagnostic.
102	B	Acute gout. Colchicine, NSAIDs, or steroids. Allopurinol NOT during acute attack.
103	B	Spinal cord compression. Surgical decompression is definitive.
104	B	Transverse myelitis: sensory level at T10, MRI shows cord lesion.
105	A	Resectable distal oesophageal/GOJ adenocarcinoma. Neoadjuvant chemotherapy followed by surgery is standard.
106	B	Mesothelioma: asbestos exposure, nodular pleural thickening, exudative effusion.

Section C — OBSTETRICS & GYNAECOLOGY

Q	Ans	Brief Explanation
107	B	Ruptured ectopic pregnancy (unstable, free fluid). Emergency laparoscopy + salpingectomy.
108	C	HELLP: haemolysis, elevated liver enzymes, low platelets.
109	C	Placenta previa (stable, preterm) then expectant management.
110	A	PPH due to uterine atony. Oxytocin + uterine massage.
111	B	Genital TB: beaded appearance on HSG is characteristic.
112	B	Postmenopausal bleeding + endometrial thickness >4 mm then endometrial biopsy.
113	B	Abruptio placentae: painful bleeding, tender hard uterus, fetal death.
114	B	Eclampsia. IV magnesium sulphate is first-line.
115	A	PCOS. Clomiphene citrate is first-line for ovulation induction.
116	C	Uterine fibroids: heavy bleeding, symmetrically enlarged uterus, myometrial masses.
117	A	Intrahepatic cholestasis of pregnancy. Ursodeoxycholic acid + deliver at 36-37 weeks.
118	B	Term breech with failed ECV then elective caesarean section.
119	B	Cervical cancer. Cervical biopsy is definitive.
120	A	Gestational diabetes. Initial management is medical nutrition therapy and exercise.

Section D — PAEDIATRICS

Q	Ans	Brief Explanation
121	B	ABO incompatibility: mother O, baby A/B, Coombs positive.
122	B	Croup. Nebulized epinephrine + dexamethasone.
123	C	Epiglottitis. Secure airway in OT. Do NOT examine throat.
124	B	IMCI: RR >=50/min in infant = pneumonia (non-severe if no chest indrawing).
125	B	Nephrotic syndrome in child. Minimal change disease most common in ages 1-10.
126	B	Kawasaki disease. IVIG + aspirin to prevent coronary aneurysms.
127	C	PDA: continuous machinery murmur at left infraclavicular area.
128	B	TOF: boot-shaped heart, cyanosis, squatting.
129	A	RDS. Surfactant + CPAP is standard.
130	C	Severe dehydration: lethargy, sunken eyes, skin pinch >2 seconds.
131	B	Measles (Koplik spots). Vitamin A supplementation reduces morbidity/mortality.
132	B	Asthma. ICS is first-line maintenance for persistent asthma.
133	A	Neonatal resuscitation: HR <100 then PPV.
134	B	TB meningitis: lymphocytic pleocytosis, high protein, low glucose.

Section E — OPHTHALMOLOGY

Q	Ans	Brief Explanation
135	A	Acute angle-closure glaucoma. Acetazolamide + pilocarpine.
136	B	CRAO: sudden painless vision loss, cherry-red spot on pale retina.
137	B	Moderate NPDR: dot-blot haemorrhages, hard exudates, cotton-wool spots.
138	A	Optic neuritis: painful vision loss, colour desaturation.
139	B	Cataract. Phacoemulsification with IOL is definitive.
140	B	CRVO: blood and thunder fundus, dilated tortuous veins.

Section F — ENT

Q	Ans	Brief Explanation
141	B	Foreign body aspiration. Rigid bronchoscopy for removal.
142	B	Epistaxis from Little's area. Chemical cautery is first-line.
143	A	Acute otitis media. Oral amoxicillin is first-line.
144	B	CSOM tubotympanic: central perforation, conductive hearing loss.
145	B	Suspected acoustic neuroma. MRI with contrast is gold standard.
146	B	Ménière's disease: episodic vertigo + tinnitus + aural fullness + SNHL.

Section G — APPLIED PATHOLOGY

Q	Ans	Brief Explanation
147	A	CA19-9 is the primary tumour marker for pancreatic adenocarcinoma.
148	B	Dysplasia: increased mitoses, nuclear pleomorphism, loss of polarity.
149	B	AML: MPO-positive blasts with Auer rods are pathognomonic.
150	C	Granulation tissue: proliferation of fibroblasts and new blood vessels in chronic inflammation.
151	B	Megaloblastic anaemia. Pernicious anaemia most common cause of B12 deficiency.
152	B	Reed-Sternberg cells are pathognomonic of Hodgkin lymphoma.
153	B	Transudate: low protein (<2.5 g/dL), low specific gravity (<1.012), few cells.
154	B	Sarcoma = mesenchymal tumour. Carcinoma = epithelial tumour.
155	B	Chronic aortic regurgitation causes volume overload (increased preload) leading to left ventricular eccentric hypertrophy and dilation.
156	B	Pernicious anaemia is confirmed by anti-intrinsic factor antibodies (and anti-parietal cell antibodies).
157	D	Pancreatic head carcinoma commonly invades surrounding structures including the CBD, duodenum, and superior mesenteric vessels.

Section H — APPLIED ANATOMY

Q	Ans	Brief Explanation
158	B	Axillary nerve injury: deltoid weakness, regimental badge area numbness.
159	C	Radial nerve injury at spiral groove: wrist drop, dorsal first web space numbness.
160	B	Median nerve injury at cubital fossa: DIP flexion loss, palmar sensation loss.
161	C	Ulnar nerve injury: claw hand, medial 1.5 fingers numbness.
162	B	Common peroneal nerve injury at fibular neck: foot drop, dorsum numbness.
163	B	Lacunar strokes of internal capsule = lenticulostriate branches of MCA.
164	C	Deep ring = opening in transversalis fascia.
165	B	Oesophageal varices = most life-threatening site.
166	B	Recurrent laryngeal nerve enters larynx posterior to cricothyroid joint.
167	B	Oesophageal hiatus = T10. Aortic hiatus = T12. Caval opening = T8.
168	B	Femoral triangle: superior = inguinal ligament, lateral = sartorius, medial = adductor longus.

Section I — APPLIED PHYSIOLOGY

Q	Ans	Brief Explanation
169	A	Low pH, low HCO3 = metabolic acidosis. Low PaCO2 = appropriate respiratory compensation.
170	A	Winter's formula: Expected PaCO2 = 1.5 x HCO3 + 8 ± 2. For HCO3 16: range 30-34.
171	B	High pH, low PaCO2 = respiratory alkalosis. Normal HCO3 = acute.
172	B	Low pH, high PaCO2 = respiratory acidosis. Elevated HCO3 = chronic with compensation.
173	A	Anion gap = Na - (Cl + HCO3) = 140 - (110+12) = 18. Diarrhoea = normal anion gap metabolic acidosis.
174	B	Hypercalcaemia shortens QT interval. Hypocalcaemia prolongs QT.
175	B	Aldosterone deficiency leads to sodium loss + potassium retention.
176	B	Dopamine inhibits prolactin release.
177	B	Frank-Starling: increased preload (up to optimal point) increases stroke volume.
178	B	PE blocks perfusion to ventilated alveoli then increased dead space ventilation.

Section J — CLINICAL PHARMACOLOGY

Q	Ans	Brief Explanation
179	B	Metformin contraindicated if eGFR <30 (risk of lactic acidosis).
180	B	Valproate is teratogenic. Switch to lamotrigine + folic acid.
181	B	Non-selective beta-blockers block beta-2 receptors then bronchoconstriction.
182	A	In bilateral RAS, ACE inhibitors dilate efferent arteriole then reduced GFR.
183	A	INR >7 with bleeding: hold warfarin + IV vitamin K.
184	B	Rifampicin induces CYP450 then reduced OCP efficacy.
185	A	Amiodarone: pulmonary fibrosis is the most serious long-term adverse effect.
186	B	Spironolactone causes hyperkalaemia.

Section K — APPLIED BIOCHEMISTRY

Q	Ans	Brief Explanation
187	B	G6PD deficiency: oxidative stress then haemolysis with Heinz bodies and bite cells.
188	B	PKU: phenylalanine hydroxylase deficiency.
189	A	B12 is cofactor for methylmalonyl-CoA mutase.
190	A	Wernicke's encephalopathy. Thiamine is cofactor for pyruvate dehydrogenase.
191	B	Osteomalacia: vitamin D deficiency then low Ca, low PO4, elevated ALP.
192	B	Acute intermittent porphyria: PBG deaminase deficiency.

Section L — COMMUNITY MEDICINE

Q	Ans	Brief Explanation
193	C	Cohort study measures incidence by following a disease-free population over time.
194	B	Specificity = TN/(TN+FP) = 850/900 = 94.4%.
195	B	RCT provides the strongest evidence for efficacy.
196	C	Pakistan EPI: measles at 9 months (second dose at 15 months).
197	B	Point prevalence = proportion with disease at a given time.
198	B	DOTS: Directly Observed Therapy is the cornerstone.

Section M — FORENSIC MEDICINE & TOXICOLOGY

Q	Ans	Brief Explanation
199	A	CO poisoning: cherry-red discoloration (carboxyhaemoglobin).
200	A	Organophosphate: cholinergic excess (SLUDGE) + miosis + fasciculations + garlic odour.