NRE System — Full Picture Report

Layer	File / location	What it holds	Role in the picture
Recalled papers	Past Papers/	822 questions across 5 real sittings	Ground truth — what the exam actually asked
Intelligence reports	Exam Intel/Intelligence Reports/	Per-sitting analysis, 822 MCQs synthesized	Where weightage and recurrence numbers come from
Prediction bank	Exam Intel/Predictions/prediction_questions.json	200 MCQs, 14 subjects, answer + rule + distractor logic	The October-facing engine
Prediction master list	Exam Intel/Predictions/NRE Oct 2026 Prediction Master List.docx	200 rows: topic · question shape · answer · key fact · trap	Printable map of the prediction bank
Core master	NRE Essentials/nre_core_master.txt	439 questions analyzed → 567 keyword → answer lines in 26 systems	Cram-ready recognition layer
Official syllabus	Syllabus/	NRE Syllabus 2024 (DOCX + PDF)	Topic scope spine
MedCORE books	MedCORE Systems/	15 system books, 50 MCQs each + kill tables + algorithms	Deep review layer per system

Subject	Predicted	Share	Recalled	Share	Δ (pp)	Read
Medicine	83	41.5%	358	43.6%	-2.1	deliberate floor
Surgery	23	11.5%	96	11.7%	-0.2	locked
Paediatrics	20	10.0%	81	9.9%	+0.1	locked
Obstetrics & Gynaecology	17	8.5%	69	8.4%	+0.1	locked
Pharmacology	14	7.0%	58	7.1%	-0.1	locked
Anatomy	6	3.0%	24	2.9%	+0.1	locked
Community Medicine	6	3.0%	23	2.8%	+0.2	locked
ENT	6	3.0%	21	2.6%	+0.4	tight
Ophthalmology	6	3.0%	13	1.6%	+1.4	deliberate floor
Forensic Medicine	5	2.5%	19	2.3%	+0.2	locked
Physiology	4	2.0%	17	2.1%	-0.1	locked
Biochemistry	4	2.0%	18	2.2%	-0.2	locked
Pathology	4	2.0%	17	2.1%	-0.1	locked
Psychiatry	2	1.0%	8	1.0%	+0.0	locked

#	Subject	Topic	Times recalled	Sittings	Status
1	Medicine	Diabetes Mellitus	18	ALL 5	guaranteed repeat
2	Medicine	Seizures / Epilepsy	11	ALL 5	guaranteed repeat
3	Surgery	Hernias	9	ALL 5	guaranteed repeat
4	Medicine	Cirrhosis / Portal HTN	9	ALL 5	guaranteed repeat
5	Medicine	Coagulation / DIC	8	ALL 5	guaranteed repeat
6	Medicine	Anemia — Iron Deficiency	8	ALL 5	guaranteed repeat
7	Medicine	Thyroid Disorders	8	ALL 5	guaranteed repeat
8	Anatomy	Lower Limb	8	ALL 5	guaranteed repeat
9	Surgery	Burns	8	4/5	strong recurrer
10	Medicine	Tuberculosis	8	4/5	strong recurrer
11	Medicine	Hepatitis	7	ALL 5	guaranteed repeat
12	Anatomy	Upper Limb	7	4/5	strong recurrer
13	Pharmacology	Antibiotics / Antimicrobials	7	4/5	strong recurrer
14	Medicine	Anemia — B12/Folate	7	4/5	strong recurrer
15	Surgery	Fractures / Orthopedics	7	4/5	strong recurrer
16	Pharmacology	Cardiac Drugs / Digoxin	7	4/5	strong recurrer
17	Pharmacology	Drug Toxicity / Overdose	7	4/5	strong recurrer
18	Medicine	Acid Base	7	4/5	strong recurrer
19	Medicine	Electrolyte Disorders	7	2/5	strong recurrer
20	Medicine	Sepsis / Septic Shock	7	2/5	strong recurrer
21	Medicine	Glomerulonephritis	6	ALL 5	guaranteed repeat
22	Medicine	Adrenal Disorders	6	ALL 5	guaranteed repeat
23	Medicine	Meningitis / Encephalitis	6	4/5	strong recurrer
24	Pathology	Chromosomal / Genetic	6	4/5	strong recurrer
25	Paediatrics	Congenital Heart Disease	5	4/5	strong recurrer

Core Master Inventory — all 26 system sections with examples

nre_core_master.txt · 439 questions → 567 lines

The recognition layer: KEYWORDS → ANSWER [confirming fact]. The header states 439 questions analyzed (50 Exact + 200 Academy + 189 Recalled); those questions compress into 567 recognition lines across 26 systems, assembled from 50 Exact + 200 Academy + 189 Recalled questions. Every section below shows its item count and two live examples from the file — the full 704-line master is the source of truth.

01 · CARDIOLOGY 19 items
Central crushing chest pain + ST elevation II,III,aVF → INFERIOR MI → Reperfusion therapy Central crushing chest pain + ST elevation V1-V4 → ANTERIOR MI (LAD occlusion) → Reperfusion	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

02 · ENDOCRINOLOGY 19 items
Weight gain + muscle weakness + purple striae + HTN + eosinopenia → CUSHING SYNDROME Hyperpigmentation + hyponatremia + hyperkalemia + weight loss → ADDISON DISEASE	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

03 · INFECTIOUS DISEASE / SEPSIS 31 items
Fever + tachycardia + hypotension + source → SEPSIS → Cultures → Abx within 1 hour → Fluids 30 mL/kg Hypotension + lactate >2 despite fluids → SEPTIC SHOCK → Norepinephrine (NOT dopamine)	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

04 · NEPHROLOGY / ELECTROLYTES 13 items
Periorbital edema + cola-colored urine + sore throat 2 weeks ago → PSGN (post-streptococcal GN) Generalized edema + dark scanty urine + sore throat 2 weeks ago + BP 130/90 → PSGN	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

05 · GASTROENTEROLOGY / HEPATOLOGY 33 items
Severe epigastric pain radiating to back + vomiting + raised amylase/lipase → ACUTE PANCREATITIS Pancreatitis + steatorrhea → LIPASE deficiency is cause	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

06 · HEMATOLOGY 17 items
Pallor + bone pain + bruising + WBC 42k + 85% immature granulocytes + normal 3 months ago → ACUTE MYELOID LEUKEMIA (AML) Fever + anemia + abdominal pain + gum hyperplasia + blasts + Auer rods + MPO positive + WBC 42k → AML	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

07 · NEUROLOGY 37 items
Sudden weakness + aphasia within 2 hours + CT no hemorrhage → ISCHEMIC STROKE → IV thrombolysis Weakness + aphasia + 4 hours + CT normal → Ischemic stroke (IV thrombolysis if within window)	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

08 · RHEUMATOLOGY 13 items
Symmetrical joint pain + morning stiffness >1 hour + swollen MCP → RHEUMATOID ARTHRITIS RA + rheumatoid factor + anti-CCP → DMARDs (methotrexate first-line)	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

09 · SURGERY — ACUTE ABDOMEN 18 items
Periumbilical → RIF pain + fever + nausea + rebound at McBurney → APPENDICITIS → Appendectomy RIF pain + McBurney tenderness + fever → Appendicitis → Appendectomy	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

10 · SURGERY — TRAUMA / VASCULAR 19 items
Gunshot abdomen + stable (pulse 100, BP 130/80) → FAST (first investigation) Bullet injury abdomen + stable → FAST	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

11 · UROLOGY 16 items
Testicular torsion + sudden severe pain + vomiting + high-riding testis + absent cremasteric → SURGERY (6-hour window) Testicular torsion → Absent cremasteric reflex + high-riding testis → Emergency exploration	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

12 · BREAST / THYROID 22 items
Painless mobile firm breast lump 2cm upper outer quadrant → FIBROADENOMA → Reassurance + follow-up Hard irregular breast lump + peau d'orange → BREAST CANCER → FNAC/core biopsy	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

13 · OBSTETRICS 18 items
BP 160/110 + proteinuria + edema at 32 weeks → PREECLAMPSIA Preeclampsia + seizure at 38 weeks → MAGNESIUM SULFATE (treatment of choice)	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

14 · GYNECOLOGY 13 items
Primary amenorrhea + webbed neck + low hairline + streak ovaries + short stature → TURNER SYNDROME (45X0) Heavy prolonged menstrual bleeding since menarche + negative pregnancy test + normal coagulation → ANOVULATORY CYCLES	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

15 · PEDIATRICS — NEONATOLOGY 18 items
Premature 28 weeks + respiratory distress + ground-glass X-ray → RDS → SURFACTANT Preterm baby 1.2kg at 28 weeks + ground-glass → Surfactant	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

16 · PEDIATRICS — GENERAL 44 items
Fever + drooling + stridor + tripod position → EPIGLOTTITIS → Secure airway (DO NOT examine throat) Epiglottitis in unimmunized children → HAEMOPHILUS INFLUENZAE type b	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

17 · OPHTHALMOLOGY 13 items
Sudden painful vision loss + headache + halos + mid-dilated fixed pupil + ↑IOP → ACUTE ANGLE-CLOSURE GLAUCOMA Sudden severe eye pain + redness + halos + mid-dilated fixed pupil → Acute angle-closure glaucoma	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

18 · ENT 16 items
Fever + drooling + stridor + tripod position → EPIGLOTTITIS → Secure airway (NO throat exam) Barking cough + stridor + hoarseness + worse at night + steeple sign → CROUP	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

19 · APPLIED PATHOLOGY 20 items
Autoimmune hemolytic anemia + Coombs positive → TYPE II hypersensitivity (antibody-mediated) SLE → TYPE III (immune complex-mediated)	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

20 · APPLIED ANATOMY 19 items
C5-C6 injury → Waiter's tip + loss lateral forearm → Upper trunk brachial plexus Lower trunk injury (breech) → Hand weakness + clawing + Horner → Lower trunk brachial plexus	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

21 · APPLIED PHYSIOLOGY 13 items
Positive feedback → Opening of Na+ channels during action potential Pain inhibited by tactile stimulation → Beta-type A fibers (mechanoreceptors)	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

22 · CLINICAL PHARMACOLOGY 34 items
Warfarin overdose + bleeding → Vitamin K (antidote) Heparin monitoring → aPTT	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

23 · APPLIED BIOCHEMISTRY 16 items
Ketone body synthesis → HMG-CoA SYNTHASE (acetyl-CoA → HMG-CoA) Maple syrup urine disease → Valine, leucine, isoleucine (branched-chain amino acids)	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

24 · COMMUNITY MEDICINE / EPIDEMIOLOGY 16 items
Population growth 2% annually → Doubling time ~35 years (Rule of 70: 70/2 = 35) EPI schedule: measles vaccine → AT 9 MONTHS	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

25 · FORENSIC MEDICINE 20 items
Cherry-red postmortem staining + closed room + smoke → CARBON MONOXIDE poisoning Body in water + white froth + overdistended lungs → DROWNING	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

26 · MISCELLANEOUS HIGH-YIELD 50 items
Most common cause CAP → STREP PNEUMONIAE Most common UTI organism → E. COLI	recognition format KEYWORDS → ANSWER [fact]	Feed: Exact 50 + Academy 200 + Recalled 189. Cram-ready, no fluff — recognition only.

How the master files feed the bank

The core master tells you which keywords the recalled and academy questions actually hit; the prediction bank tells you which of those patterns October will repeat. When we build the Medicine / Surgery / Paediatrics correlation documents, the master is the cross-check index — a keyword that appears in both places is a double-confirmed hit.

Prediction Bank — all 200 MCQs, full

Every question, no compression

The complete prediction bank, grouped by subject, in order. Every stem in full, the correct answer letter, and the one-line rule that discriminates it. This is the raw material the October-facing exam is built from — nothing shortened, nothing summarized away.

ANATOMY — 6 questions

#	Question	Ans	Rule
1	During a thoracotomy, the surgeon counts the ribs by first palpating a surface landmark that lies at the level of the second costal cartilage. At which vertebral level does this landmark, the sternal angle (Angle of Louis), lie?	D	Sternal angle = T4/T5 disc.
2	A radiology resident traces the main arterial trunk supplying the foregut on a CT angiogram of the abdomen. At which vertebral level does the celiac trunk arise from the abdominal aorta?	D	Celiac trunk arises at T12 from aorta.
3	A 45-year-old man with a C4 spinal cord injury develops progressive respiratory failure and requires ventilatory support. The attending physician explains that his breathing difficulty is due to loss of motor supply to the diaphragm. Which nerve provides this motor innervation?	B	Diaphragm motor innervation = phrenic nerve (C3-C5).
4	A 40-year-old man presents with a swelling in the right groin that appears on standing and disappears on lying down. During surgical repair of his inguinal hernia, the surgeon identifies the structures within the inguinal canal. Which of the following structures passes through the inguinal canal in males?	D	Inguinal canal in males = spermatic cord.
5	During a laparoscopic cholecystectomy, the surgeon identifies the triangle of Calot before clipping any structures. Which of the following does NOT form a boundary of the triangle of Calot?	D	Triangle of Calot: cystic duct + common hepatic duct + liver edge. Cystic artery is inside.
6	A 30-year-old woman requires a lumbar puncture for suspected meningitis. The physician explains that the procedure is safe below the level where the spinal cord ends. In adults, at which vertebral level does the conus medullaris typically end?	C	Conus medullaris ends at L1/L2.

PHYSIOLOGY — 4 questions

#	Question	Ans	Rule
7	A physiology student is asked to identify the nephron segment responsible for reclaiming the largest fraction of the glomerular filtrate. In which segment of the nephron does the majority of filtered sodium and water reabsorption take place?	D	PCT reabsorbs 65-70% of filtered Na+ and water.
8	A 55-year-old man with unilateral renal artery stenosis develops worsening hypertension. Reviewing the renin-angiotensin system, which of the following is the primary stimulus for aldosterone secretion?	B	Angiotensin II is the primary stimulus for aldosterone.
9	During a physiology practical, a student measures the resting membrane potential of a neuron with intracellular microelectrodes. The resting membrane potential is primarily determined by the permeability of which ion?	C	Resting membrane potential = K+ permeability (Nernst equation).
10	A 45-year-old man relaxes after a meal; his heart rate is 62/min, his pupils are constricted, and his gut is actively digesting. Which division of the autonomic nervous system is responsible for this 'rest and digest' state?	C	Parasympathetic = rest and digest.

BIOCHEMISTRY — 4 questions

#	Question	Ans	Rule
11	A 44-year-old woman with short bowel syndrome has been on total parenteral nutrition for six weeks and develops a scaly dermatitis over her face and extremities along with poor wound healing. Which deficiency is the most likely cause of these findings?	A	EFA deficiency in TPN = dermatitis, growth failure.
12	A 6-week-old infant is brought for poor feeding and developmental delay. He has fair skin, eczema, and a musty odor to his urine. Newborn screening shows markedly elevated phenylalanine. Deficiency of which enzyme is most likely responsible?	A	PKU = phenylalanine hydroxylase deficiency.
13	A 3-month-old infant with Down syndrome is noted to have a murmur. Echocardiography shows an ostium primum atrial septal defect. Which congenital heart defect is the most common in Down syndrome?	B	Down's syndrome + CHD = ASD (ostium primum).
14	A 2-year-old child in a resource-limited setting presents with pitting edema of both feet, an enlarged fatty liver, sparse discolored hair, and muscle wasting. Which of the following is NOT a feature of kwashiorkor?	D	Kwashiorkor = edema + fatty liver + low albumin.

PATHOLOGY — 4 questions

#	Question	Ans	Rule
15	A 2-year-old boy presents with fever, irritability, and refusal to bear weight on the right leg. MRI of the tibia shows a metaphyseal abscess. Which organism is the most common cause of acute osteomyelitis at this age?	D	Acute osteomyelitis in child = Staphylococcus aureus.
16	A 24-year-old woman starts a combined oral contraceptive pill for contraception. Her physician explains the primary mechanism by which the pill prevents pregnancy. Which mechanism of action is most accurate?	A	COCP mechanism = inhibit ovulation via progestin.
17	A 43-year-old woman's routine cervical cytology is reported as showing dysplastic squamous cells. Colposcopy-directed biopsy confirms dysplastic changes confined to the cervical epithelium. What is the most likely diagnosis?	A	Abnormal Pap + dysplastic cells = CIN.
18	A 27-year-old woman with fair skin presents with a pigmented lesion on her back that has recently increased in size, changed shape, and become darker. Dermoscopy shows asymmetry, irregular borders, and color variation. What is the most likely diagnosis?	A	Changing mole = melanoma (ABCDE criteria).

PHARMACOLOGY — 14 questions

#	Question	Ans	Rule
19	A 40-year-old farmer is brought to the emergency department with profuse salivation, lacrimation, diarrhea, and pinpoint pupils after spraying insecticide in a closed field. He is diagnosed with organophosphate poisoning. Which drug should be administered to directly antagonize the muscarinic symptoms?	A	Organophosphate + muscarinic symptoms = atropine.
20	A 35-year-old woman has a dry, hacking cough that has persisted for a week after a viral upper respiratory infection. She is prescribed dextromethorphan. Which best describes its primary therapeutic action?	B	Dextromethorphan = antitussive, acts on cough center.
21	A 26-year-old woman with iron-deficiency anemia is prescribed ferrous sulfate. She is also prescribed an antibiotic for acne. Her pharmacist warns that taking them together reduces iron absorption. Ferrous sulfate exhibits pharmacological antagonism with which of the following?	C	Ferrous sulfate + tetracyclines = absorption antagonism.
22	A 58-year-old man with gout and tophi is started on a drug that lowers serum uric acid by increasing its renal excretion. Which drug acts by this uricosuric mechanism?	A	Uricosuric drug for gout = probenecid.
23	A 42-year-old woman undergoes total thyroidectomy for a large multinodular goiter. On the first postoperative day she develops hoarseness, a weak cough, and inspiratory stridor. What is the most likely complication?	A	Thyroidectomy + hoarseness + dyspnea = recurrent laryngeal nerve injury.
24	A 3-year-old boy accidentally ingests kerosene oil that had been stored in a soft drink bottle. He is brought to the emergency department coughing but conscious and in no respiratory distress. Which of the following should NOT be administered?	B	Kerosene ingestion: do NOT induce vomiting (syrup of ipecac).
25	A 5-year-old child accidentally ingests several of her grandmother's diazepam tablets. On arrival she is drowsy but rousable, with stable vital signs and no respiratory depression. Which is the most appropriate management?	C	Benzodiazepine ingestion in child = charcoal + supportive care.
26	A 28-year-old woman develops sudden generalized urticaria, angioedema, wheezing, and hypotension within minutes of receiving an intravenous antibiotic. Which drug is the first-line treatment?	A	Acute anaphylaxis = epinephrine (first-line).
27	A 19-year-old woman presents 8 hours after ingesting an overdose of paracetamol tablets in a suicide attempt. She is nauseated but hemodynamically stable; the plasma paracetamol level is in the toxic range on the Rumack-Matthew nomogram. Which drug is the specific antidote?	A	N-acetylcysteine replenishes glutathione and prevents hepatic necrosis in paracetamol poisoning.
28	A 30-year-old man is found unconscious at home with pinpoint pupils and a respiratory rate of 6 breaths per minute; needle marks are visible on both forearms. Which drug should be administered immediately?	B	Miosis + respiratory depression + depressed consciousness = opioid overdose; naloxone is the antagonist.
29	A 68-year-old man with atrial fibrillation is anticoagulated with warfarin. He asks how the drug works. Warfarin produces its anticoagulant effect through which mechanism?	C	Warfarin blocks vitamin K epoxide reductase, reducing synthesis of factors II, VII, IX, and X.
30	A 55-year-old woman with a proximal deep vein thrombosis is started on an intravenous heparin infusion. Which laboratory test is used to monitor and adjust the heparin dose?	A	Unfractionated heparin is monitored and dose-adjusted by aPTT.
31	A 60-year-old man with coronary artery disease takes low-dose aspirin daily for secondary prevention. His surgeon notes that the antiplatelet effect persists for 7-10 days after stopping the drug. Low-dose aspirin produces this long-lasting antiplatelet effect because it:	D	Aspirin irreversibly acetylates COX-1, blocking thromboxane A2 for the platelet's lifetime (7–10 days).
32	A 26-year-old woman with chronic hypertension controlled on enalapril discovers that she is 8 weeks pregnant. Which is the most appropriate action regarding her antihypertensive?	C	ACE inhibitors are teratogenic in pregnancy (fetal renal damage); methyldopa is the safest first-line option.

COMMUNITY MEDICINE — 6 questions

#	Question	Ans	Rule
33	Following a bus accident, a field triage area is set up. A conscious patient with a closed forearm fracture who is able to walk is assigned a color tag indicating that treatment can be safely delayed. Which triage color is used for patients who do not need immediate life-saving intervention?	A	Triage yellow = delayed/minor injuries.
34	Public health officials note that the number of new cases of dengue in a district this season has risen well above the numbers usually expected for that region and time of year. This pattern is best described as:	C	Increased incidence above expected = epidemic.
35	An epidemiologist investigates a cluster of diarrhea among guests who attended a single wedding dinner. When asked whether the cluster constitutes an outbreak, the minimum number of cases required is best described as:	D	Outbreak definition depends on disease and context.
36	According to the national immunization program, a newborn receives which vaccines at birth?	C	BCG + Hepatitis B at birth.
37	During an outbreak investigation at a primary school, the epidemiologist estimates the basic reproduction number (R0) to assess transmissibility. The approximate R0 of measles is:	D	Measles R0 = 12-18 (highly infectious).
38	A new rapid diagnostic test for tuberculosis is applied to 100 patients in whom pulmonary tuberculosis has been confirmed by sputum culture; 85 of them test positive. What is the sensitivity of the new test?	A	Sensitivity = true positives / all diseased = 85/100 = 85%.

MEDICINE — 83 questions

#	Question	Ans	Rule
39	A 55-year-old man presents with crushing substernal chest pain radiating to the left arm and associated sweating for the past 2 hours. His ECG shows ST-segment elevation in leads II, III, and aVF. Which is the most likely diagnosis?	C	Crushing chest pain + radiating + ST elevation = inferior STEMI.
40	A 65-year-old woman with a history of hypertension presents with sudden-onset severe dyspnea at rest, coughing up pink frothy sputum. Auscultation reveals bilateral crackles. Which is the most likely diagnosis?	D	Pink frothy sputum + crackles + dyspnea = acute LVF.
41	A 50-year-old man presents with palpitations and mild exertional dyspnea. His radial pulse is irregularly irregular, and the ECG shows absent P waves with variable R-R intervals. Which is the most likely diagnosis?	B	Irregularly irregular + absent P waves = atrial fibrillation.
42	A 72-year-old woman presents after a syncopal episode while climbing stairs. Auscultation reveals a systolic ejection murmur at the right upper sternal border that radiates to the carotids. Which is the most likely diagnosis?	B	Syncope on exertion + radiating to carotids = aortic stenosis.
43	A 60-year-old man with a previous myocardial infarction presents with progressive dyspnea on exertion and orthopnea. Echocardiography shows a left ventricular ejection fraction of 30%. Which is the most likely diagnosis?	B	Progressive dyspnea + orthopnea + EF 30% = HFrEF.
44	A 35-year-old woman is found on routine examination to have a midsystolic click that moves earlier in systole with standing and the Valsalva maneuver. Which is the most likely diagnosis?	B	Midsystolic click + posture change = mitral valve prolapse.
45	A 52-year-old man with a 30 pack-year smoking history and refractory hypertension undergoes renal angiography, which shows bilateral renal artery stenosis at the ostia. Which is the most likely cause of the stenosis?	B	Age 50 + bilateral R stenosis = atherosclerotic.
46	A 23-year-old woman describes recurrent episodes of sudden-onset rapid, regular palpitations that terminate abruptly. An ECG captured during an episode shows a narrow-complex tachycardia at 180/min with no visible P waves. Which is the most likely diagnosis?	B	Young woman + rapid regular narrow complex = AVNRT.
47	A 75-year-old man presents with exertional dyspnea. Auscultation reveals a pansystolic murmur that is loudest at the apex and radiates to the axilla. Which is the most likely diagnosis?	A	Apical murmur radiating to axilla = mitral regurgitation.
48	A 40-year-old man presents with sharp retrosternal chest pain that is worse when lying flat and improves on sitting up and leaning forward. Which is the most likely diagnosis?	C	Chest pain + improves sitting forward = pericarditis.
49	A 57-year-old woman with known atrial fibrillation presents with sudden-onset right-sided weakness and aphasia. CT of the head shows an acute infarct in the left middle cerebral artery territory. Which is the most likely mechanism of her stroke?	C	AF + stroke = cardioembolic.
50	A 28-year-old man presents with exertional dyspnea and presyncope. Auscultation reveals a mid-systolic murmur that becomes louder with the Valsalva maneuver. Which is the most likely diagnosis?	D	Click + louder with Valsalva = HCM.
51	A 52-year-old man with a history of gallstones presents with severe epigastric pain radiating to the back, worse after eating, and repeated vomiting. Serum amylase and lipase are markedly elevated. Which is the most likely diagnosis?	D	Epigastric + back + elevated amylase/lipase = pancreatitis.
52	A 68-year-old woman presents with painless progressive jaundice, pale stools, dark urine, and 6 kg weight loss. CT of the abdomen shows a mass in the head of the pancreas. Which is the most likely diagnosis?	C	Jaundice + pale stools + pancreatic head mass = pancreatic cancer.
53	A 42-year-old man presents with long-standing heartburn and intermittent dysphagia to solid food. Upper GI endoscopy shows concentric rings in the esophagus. Which is the most likely diagnosis?	A	Esophageal rings + dysphagia = eosinophilic esophagitis.
54	A 30-year-old woman presents with migratory abdominal pain now localized to the right lower quadrant, associated with fever and rebound tenderness. CT confirms acute appendicitis. Which is the most appropriate management?	D	Appendicitis confirmed = appendectomy.
55	A 68-year-old man presents two years after a Billroth II (gastrojejunostomy) with crampy epigastric pain, distension, and large-volume bilious vomiting that relieves his discomfort. Which is the most likely diagnosis?	B	Bilious emesis after gastric bypass = efferent loop obstruction.
56	A 55-year-old woman presents with recurrent episodes of right upper quadrant pain that begin about an hour after fatty meals and last several hours. Ultrasound shows gallstones with a normal gallbladder wall. Which is the most likely diagnosis?	B	RUQ pain after fatty meals + gallstones = biliary colic.
57	A 24-year-old tall man presents with sudden-onset sharp right-sided chest pain and dyspnea. Chest X-ray shows a large pneumothorax with the lung edge more than 2 cm from the chest wall. Which is the most appropriate management?	D	Large pneumothorax = chest tube insertion.
58	A 60-year-old man with a 30 pack-year smoking history has had a productive cough most days for 3 months in each of the last 2 years, along with wheeze. Which is the most likely diagnosis?	A	Cough + sputum + wheezing = chronic bronchitis.
59	A 43-year-old woman presents with a dry cough, fatigue, and tender red nodules over both shins. Chest X-ray shows bilateral hilar lymphadenopathy. Which is the most likely diagnosis?	A	Bilateral hilar lymphadenopathy + erythema nodosum = sarcoidosis.
60	A 70-year-old man with a 40 pack-year smoking history presents with hemoptysis, weight loss, and a solitary pulmonary nodule on chest X-ray. Which is the most likely diagnosis?	A	Hemoptysis + weight loss + solitary nodule = lung cancer.
61	A 35-year-old woman presents with progressive exertional dyspnea of 6 months' duration. Chest X-ray shows bilateral reticular opacities and spirometry is restrictive. Which is the most likely diagnosis?	B	Progressive dyspnea + reticular opacities = ILD.
62	A 24-year-old woman presents with visible hematuria one day after an upper respiratory tract infection. Urinalysis shows proteinuria and she reports transient joint pains and a purpuric rash over the legs. Which is the most likely diagnosis?	C	Hematuria + proteinuria + rash = IgA nephropathy.
63	A 55-year-old man with septic shock develops progressive oliguria despite adequate fluid resuscitation. Urine microscopy shows muddy brown granular casts and serum creatinine is rising. Which is the most likely diagnosis?	C	Oliguria + muddy brown casts = ATN.
64	A 30-year-old woman presents with hemoptysis, hypertension, hematuria, and proteinuria. Serum anti-glomerular basement membrane antibodies are positive. Which is the most likely diagnosis?	B	HTN + hematuria + proteinuria + anti-GBM = Goodpasture.
65	A 65-year-old man on long-term lithium for bipolar disorder presents with polyuria, polydipsia, and hypernatremia. His urine osmolality is low and remains low after desmopressin administration. Which is the most likely diagnosis?	C	Polyuria + low urine osmolality + no response to DDAVP = nephrogenic DI.
66	A 42-year-old woman presents with painless gross hematuria and right flank pain. CT shows a 3 cm solid enhancing mass in the right kidney. Which is the most likely diagnosis?	B	Flank pain + hematuria + renal mass = renal cell carcinoma.
67	A 32-year-old woman presents with weight loss, heat intolerance, palpitations, and a fine tremor. Her ECG shows atrial fibrillation and TSH is suppressed. Which is the most likely diagnosis?	D	Weight loss + heat intolerance + AF + suppressed TSH = Graves disease.
68	A 55-year-old woman presents with fatigue, hyperpigmentation of the knuckles and buccal mucosa, hypotension, and hyponatremia. Early-morning cortisol is low and plasma ACTH is elevated. Which is the most likely diagnosis?	A	Hyperpigmentation + hypotension + hyponatremia + elevated ACTH = Addison disease.
69	A 45-year-old woman presents with a solitary thyroid nodule. Fine-needle aspiration shows follicular cells, and the pathologist notes that malignancy cannot be distinguished from benignity on cytology alone. Which is the most likely diagnosis?	C	Thyroid nodule + follicular cells = follicular neoplasm.
70	A 30-year-old woman presents with galactorrhea and secondary amenorrhea of 6 months. Serum prolactin is markedly elevated and MRI shows a pituitary microadenoma. Which is the most likely diagnosis?	A	Galactorrhea + amenorrhea + elevated prolactin = prolactinoma.
71	A 23-year-old man presents with polyuria, polydipsia, and 5 kg weight loss over 3 weeks. Random blood glucose is 320 mg/dL and C-peptide is low. Which is the most likely diagnosis?	A	Polyuria + polydipsia + low C-peptide = Type 1 DM.
72	A 28-year-old woman presents with episodic severe headache, palpitations, sweating, and blood pressure of 190/120 mmHg. Twenty-four-hour urinary vanillylmandelic acid is elevated. Which is the most likely diagnosis?	B	Episodic HTN + headache + palpitations + elevated VMA = pheochromocytoma.
73	A 34-year-old woman presents with symmetric joint pain, a malar rash after sun exposure, and oral ulcers. ANA is positive at high titer. Which is the most likely diagnosis?	B	Joint pain + malar rash + photosensitivity + positive ANA = SLE.
74	A 44-year-old woman presents with progressive difficulty swallowing, Raynaud phenomenon, and thickening and tightening of the skin over the fingers and face. Which is the most likely diagnosis?	B	Dysphagia + Raynaud + sclerodactyly = scleroderma.
75	A 28-year-old man presents with chronic low back pain and morning stiffness of 6 months' duration that improves with exercise. X-ray shows sacroiliitis with squaring of the vertebrae and HLA-B27 is positive. Which is the most likely diagnosis?	B	Back pain + stiffness + fusion + HLA-B27 = ankylosing spondylitis.
76	A 26-year-old woman presents with bilateral knee pain, warmth, and effusions. ANA is positive and serum uric acid is normal. Which is the most likely diagnosis?	A	Young woman + bilateral knee + ANA+ = SLE.
77	A 32-year-old woman with heavy menstrual periods presents with fatigue and pallor. Hemoglobin is 9 g/dL with microcytic hypochromic indices and serum ferritin is low. Which is the most likely diagnosis?	B	Microcytic hypochromic + low ferritin = iron deficiency anemia.
78	A 60-year-old man presents with fatigue, weight loss, night sweats, and a painless enlarged cervical lymph node. Excisional biopsy shows Reed-Sternberg cells. Which is the most likely diagnosis?	D	Fatigue + weight loss + painless lymphadenopathy + RS cells = Hodgkin lymphoma.
79	A 24-year-old woman presents with menorrhagia and easy bruising. Bleeding time is prolonged while PT, PTT, and platelet count are normal. Which is the most likely diagnosis?	D	Prolonged bleeding time + normal PT/PTT = von Willebrand disease.
80	A 52-year-old man presents with fatigue, pallor, and bruising. Hemoglobin is low with normocytic indices and a low reticulocyte count; white cell and platelet counts are also reduced. Which is the most likely diagnosis?	C	Normocytic + reticulocytopenia = aplastic anemia.
81	A 38-year-old woman presents with a deep vein thrombosis and a history of three recurrent first-trimester miscarriages. Which is the most likely diagnosis?	D	DVT + recurrent miscarriages = antiphospholipid syndrome.
82	A 32-year-old man presents with fatigue, intermittent jaundice, and splenomegaly. Peripheral smear shows spherocytes and the MCHC is elevated. Which is the most likely diagnosis?	D	Fatigue + jaundice + splenomegaly + spherocytes = hereditary spherocytosis.
83	A 58-year-old man with hypertension and diabetes presents with sudden-onset right-sided weakness and slurred speech of 2 hours' duration. Non-contrast CT of the head shows no hemorrhage. Which is the most likely diagnosis?	B	Sudden weakness + slurred speech + no hemorrhage = ischemic stroke.
84	A 25-year-old woman describes recurrent episodes of a zigzag visual disturbance lasting about 20 minutes, followed by a unilateral throbbing headache with nausea. Which is the most likely diagnosis?	C	Visual disturbance + headache = migraine with aura.
85	A 64-year-old man presents with a resting tremor of the right hand, cogwheel rigidity, bradykinesia, and a shuffling gait. Which is the most likely diagnosis?	D	Tremor + rigidity + bradykinesia = Parkinson disease.
86	A 28-year-old woman presents with a 2-week history of blurred vision in the right eye and intermittent numbness in both legs. MRI of the brain shows multiple periventricular white matter lesions. Which is the most likely diagnosis?	B	Numbness + optic neuritis + white matter lesions = multiple sclerosis.
87	A 55-year-old man presents with progressive personality change, apathy, disinhibition, and difficulty with language over 2 years, while memory remains relatively preserved in the early stages. Which is the most likely diagnosis?	A	Progressive dementia + aphasia + motor weakness = FTD or vascular dementia.
88	A 65-year-old man presents with persistent back pain, fatigue, and confusion. Labs show hypercalcemia, anemia, and an elevated total protein with an M spike on electrophoresis. Which is the most likely diagnosis?	C	Back pain + fatigue + confusion + hypercalcemia = multiple myeloma.
89	A 55-year-old man with a known rheumatic valve lesion presents with 2 weeks of low-grade fever, night sweats, and fatigue. Examination reveals a new regurgitant murmur and splinter hemorrhages. Which is the most likely diagnosis?	A	Rheumatic heart + prolonged fever = subacute endocarditis.
90	A 52-year-old woman presents with progressive exertional dyspnea. Her ECG shows atrial fibrillation, and auscultation reveals a mid-diastolic murmur with an opening snap. Which is the most likely cardiac cause?	C	AF + progressive dyspnea = mitral stenosis.
91	A 35-year-old woman presents with weight gain, moon facies, proximal muscle weakness, easy bruising, and purple striae over the abdomen. Which is the most likely diagnosis?	D	Moon face + purple striae + weight gain = Cushing syndrome.
92	A 60-year-old man presents with acute fever, productive cough with rusty sputum, and right-sided pleuritic chest pain. Chest X-ray shows lobar consolidation with air bronchograms. Which organism is the most likely cause?	D	Rusty sputum + lobar consolidation = classic pneumococcal pneumonia.
93	A 35-year-old man presents with 3 weeks of low-grade evening fever, night sweats, weight loss, and productive cough. Chest X-ray shows cavitation in the right upper lobe. Which is the most likely diagnosis?	A	Chronic constitutional symptoms + upper lobe cavitation = pulmonary tuberculosis.
94	A 40-year-old woman presents 5 days after pelvic surgery with sudden dyspnea and pleuritic chest pain. She is tachycardic at 115/min and SpO2 is 88% on room air; ECG shows sinus tachycardia. Which is the most likely diagnosis?	A	Post-surgical immobility + sudden dyspnea + tachycardia + hypoxia = pulmonary embolism.
95	A 22-year-old man with type 1 diabetes presents with vomiting, abdominal pain, and deep sighing (Kussmaul) respiration. Blood glucose is 480 mg/dL, arterial pH is 7.18, and urine ketones are strongly positive. Which is the most likely diagnosis?	C	Hyperglycemia + ketoacidosis + Kussmaul breathing in type 1 diabetes = DKA.
96	A 65-year-old man with small cell lung cancer presents with confusion. Serum sodium is 118 mmol/L; he is euvolemic with high urine osmolality and high urine sodium. Which is the most likely cause?	A	Euvolemic hyponatremia with concentrated urine and high urine sodium in small cell lung cancer = SIADH.
97	A 55-year-old man with chronic kidney disease presents with muscle weakness and palpitations. ECG shows tall peaked T waves and a widened QRS, and serum potassium is 7.2 mmol/L. Which is the first step in management?	C	Peaked T waves + widened QRS = cardiotoxic hyperkalemia; IV calcium stabilizes the myocardium first.
98	A 58-year-old woman with stage 4 chronic kidney disease (eGFR 22 mL/min) presents with fatigue. Hemoglobin is 9.2 g/dL with normocytic indices and normal ferritin. Which is the most likely cause of the anemia?	A	Normocytic anemia with normal iron stores in advanced CKD = erythropoietin deficiency.
99	A 40-year-old woman presents with 8 weeks of morning stiffness lasting over an hour and symmetric swelling of the MCP and PIP joints of both hands. X-rays show periarticular osteopenia. Which is the most likely diagnosis?	A	Symmetric small-joint polyarthritis with morning stiffness over 1 hour = rheumatoid arthritis.
100	A 50-year-old man is woken from sleep by excruciating pain and swelling of the first metatarsophalangeal joint. Joint aspiration shows needle-shaped, negatively birefringent crystals. Which is the most likely diagnosis?	D	First MTP podagra + needle-shaped negatively birefringent crystals = gout (monosodium urate).
101	A 30-year-old man presents with jaundice and fatigue. Serology is positive for HBsAg, IgM anti-HBc, and HBeAg. Which serological pattern does this indicate?	C	HBsAg + IgM anti-HBc + HBeAg = acute hepatitis B with active replication and high infectivity.
102	A 58-year-old man with cirrhosis and ascites presents with fever and abdominal pain. Diagnostic paracentesis shows an ascitic fluid neutrophil count of 400/mm3. Which is the most likely diagnosis?	A	Ascitic PMN count ≥250/mm³ with fever in cirrhosis = spontaneous bacterial peritonitis.
103	A 50-year-old man with known cirrhosis presents with hematemesis. Endoscopy shows actively bleeding esophageal varices. In addition to IV fluids and antibiotics, which is the most appropriate immediate treatment?	D	Active variceal bleeding = vasoconstrictor (terlipressin) plus endoscopic band ligation.
104	A 26-year-old woman with known asthma presents with wheeze and dyspnea. Peak expiratory flow is 55% of her personal best; she can speak in full sentences and SpO2 is 95%. Which is the most appropriate initial management?	C	Moderate acute asthma (PEF 50–75%) with ability to speak = inhaled short-acting beta-agonist first.
105	A 30-year-old man presents with fever, severe headache, and neck stiffness. CSF is turbid with neutrophil predominance, glucose 30 mg/dL (blood glucose 110), and protein 150 mg/dL. Which is the most likely diagnosis?	A	Turbid CSF with neutrophils, low glucose, and high protein = acute bacterial meningitis.
106	A 30-year-old man presents with progressive symmetric ascending weakness and absent reflexes 2 weeks after a diarrheal illness. CSF shows protein 120 mg/dL with a normal cell count. Which is the most likely diagnosis?	C	Ascending flaccid paralysis after infection with albuminocytologic dissociation = Guillain-Barré syndrome.
107	A 7-year-old child has multiple daily episodes of brief staring with unresponsiveness lasting a few seconds; EEG shows 3 Hz generalized spike-and-wave discharges. Which is the first-line treatment?	D	Childhood absence epilepsy with 3 Hz spike-and-wave = ethosuximide first-line.
108	A 22-year-old man presents with 10 days of step-ladder fever, relative bradycardia, abdominal discomfort, and rose-colored spots on the trunk. Blood culture grows Gram-negative rods. Which is the most likely diagnosis?	B	Step-ladder fever + relative bradycardia + rose spots + Salmonella on blood culture = typhoid fever.
109	A 30-year-old man returning from rural Sindh presents with paroxysms of high fever with rigors and drenching sweats. Peripheral smear shows ring forms inside red blood cells. Which is the most likely diagnosis?	A	Fever paroxysms + ring forms (trophozoites) inside RBCs on smear = malaria.
110	A 28-year-old woman presents on day 4 of high fever with severe retro-orbital headache and myalgias. Platelets are 60,000/mm3 with a rising hematocrit; she has now developed abdominal pain and persistent vomiting. Which is the most likely diagnosis?	D	Retro-orbital headache + thrombocytopenia + hemoconcentration + abdominal pain and vomiting = dengue with warning signs (plasma leakage risk).
111	A 40-year-old woman presents with weight gain, cold intolerance, constipation, and menorrhagia. TSH is 25 mIU/L with a low free T4. Which is the most likely diagnosis?	C	High TSH with low free T4 = primary hypothyroidism (thyroid gland failure).
112	A 6-year-old child presents with petechiae and gum bleeding 2 weeks after a viral illness. Platelet count is 18,000/mm3 with normal hemoglobin and white cell count; the smear shows large platelets. Which is the most likely diagnosis?	A	Isolated thrombocytopenia after a viral illness in a well child with normal hemoglobin and WBC = immune thrombocytopenia.
113	A 45-year-old man presents with fatigue, left upper abdominal fullness, and weight loss. WBC count is 180,000/mm3 with myeloid cells at all stages of maturation and platelets of 600,000/mm3. Which is the most likely diagnosis?	C	Massive leukocytosis with the full myeloid spectrum and thrombocytosis = CML (confirm with BCR-ABL).
114	A 48-year-old obese man is newly diagnosed with type 2 diabetes (HbA1c 7.8%). His renal function is normal. Which is the first-line drug therapy?	B	Metformin is first-line in type 2 diabetes — weight-neutral with low hypoglycemia risk.
115	A 55-year-old woman with a 10-year history of type 2 diabetes has BP 140/90 mmHg and microalbuminuria confirmed on two occasions. Which drug class slows progression of diabetic nephropathy beyond its blood-pressure effect?	D	ACE inhibitors reduce intraglomerular pressure and proteinuria — renoprotective in diabetic nephropathy.
116	A 65-year-old woman presents with right knee pain worsened by activity and relieved by rest, morning stiffness of 15 minutes, and crepitus. X-ray shows asymmetric joint space narrowing with osteophytes. Which is the most likely diagnosis?	A	Weight-bearing joint pain with brief stiffness, crepitus, and osteophytes = primary osteoarthritis.
117	A 70-year-old woman presents with 6 weeks of bilateral shoulder and pelvic-girdle stiffness that is worse in the morning, along with malaise. ESR is 85 mm/hr and muscle power is normal. Which is the most likely diagnosis?	C	Age over 50 + bilateral girdle stiffness without true weakness + high ESR = polymyalgia rheumatica.
118	A 55-year-old vegetarian man presents with fatigue and numbness in both feet. Hemoglobin is 8.9 g/dL, MCV is 112 fL, and the smear shows hypersegmented neutrophils. Which is the most likely diagnosis?	D	Macrocytic anemia with hypersegmented neutrophils and neurological signs in a vegetarian = vitamin B12 deficiency.
119	A 24-year-old man being evaluated for mild anemia has hemoglobin 11 g/dL, MCV 62 fL, an elevated RBC count of 6.2 million/mm3, normal ferritin, and target cells on the smear. Which is the most likely diagnosis?	B	Microcytosis with a HIGH red cell count, normal ferritin, and target cells = beta-thalassemia trait (Mentzer index under 13).
120	A 45-year-old man with pulmonary tuberculosis presents with dyspnea and hypotension. BP is 85/60 with a 15 mmHg drop on inspiration, JVP is raised, and heart sounds are muffled. Which is the most likely diagnosis?	A	Beck triad — hypotension, raised JVP, muffled heart sounds — with pulsus paradoxus = cardiac tamponade.
121	A 40-year-old man presents with a 3-year history of increasing shoe and ring size, coarse facial features, and profuse sweating. Visual field testing shows bitemporal hemianopia. Which is the most likely diagnosis?	C	Acral growth + coarse features + bitemporal hemianopia from a pituitary mass = acromegaly (GH excess, raised IGF-1).

SURGERY — 23 questions

#	Question	Ans	Rule
122	A 55-year-old man presents with recurrent right upper quadrant pain after meals. Ultrasound shows gallstones. Which is the most appropriate management?	B	Symptomatic gallstones = cholecystectomy.
123	A 30-year-old woman is diagnosed with acute appendicitis on CT. Which is the most appropriate management?	D	Acute appendicitis = appendectomy.
124	A 65-year-old man is found on ultrasound to have an asymptomatic abdominal aortic aneurysm measuring 6 cm in maximum diameter. Which is the most appropriate management?	B	AAA >5.5 cm = elective repair.
125	A 40-year-old man presents with a reducible bulge in the right groin that appears on standing and disappears on lying down. Which is the most likely diagnosis?	D	Reducible inguinal bulge in male = indirect inguinal hernia.
126	An 18-year-old man presents with sudden severe left testicular pain and nausea. Ultrasound shows absent blood flow to the left testis. Which is the most appropriate management?	A	Testicular torsion = emergency orchiopexy.
127	A 55-year-old man with acute left lower quadrant pain and fever undergoes CT, which shows sigmoid diverticulitis complicated by a 4 cm pericolic abscess. Which is the most appropriate management?	D	Diverticulitis + abscess = percutaneous drainage.
128	A 70-year-old man presents with symptomatic internal hemorrhoids that bleed with defecation and prolapse but reduce spontaneously. Which is the most appropriate management?	A	Symptomatic hemorrhoids = rubber band ligation.
129	A 45-year-old woman presents with sudden severe lower abdominal pain, vaginal bleeding, and signs of shock; laparoscopy confirms a ruptured ectopic pregnancy. Which is the most appropriate management?	B	Ruptured ectopic = emergency salpingectomy.
130	A 35-year-old man presents with acute severe epigastric pain and vomiting; serum lipase is markedly elevated. He is hemodynamically stable. Which is the most appropriate initial management?	D	Acute pancreatitis = NPO + IV fluids.
131	A 50-year-old woman has a breast mass; core biopsy confirms invasive ductal carcinoma. Which is the most appropriate management?	D	Invasive ductal carcinoma = mastectomy with staging.
132	A 62-year-old woman presents with spontaneous bloody discharge from a single duct of the right nipple; no mass is palpable. Which is the most likely diagnosis?	A	Bloody nipple discharge = intraductal papilloma or cancer.
133	A 55-year-old woman presents with a rapidly enlarging, firm, erythematous breast with skin thickening and a peau d'orange appearance but no discrete mass. Which is the most likely diagnosis?	C	Peau d'orange = inflammatory breast cancer.
134	A 45-year-old woman undergoes lumpectomy for ductal carcinoma in situ with clear margins. What is the next step in management?	A	DCIS after lumpectomy = radiation therapy.
135	A 65-year-old man presents with urinary frequency, urgency, nocturia, and a weak stream. Digital rectal examination shows a symmetrically enlarged, smooth prostate. Which is the most likely diagnosis?	B	Frequency + urgency + nocturia in older male = BPH.
136	A 38-year-old man presents with a painless, firm mass in the left testis that does not transilluminate. Which is the most likely diagnosis?	C	Testicular mass = testicular cancer.
137	A 55-year-old man with a 40 pack-year smoking history presents with painless hematuria. Cystoscopy shows a papillary bladder tumor. Which is the most likely diagnosis?	C	Hematuria + bladder tumor = bladder cancer.
138	A 58-year-old man with diabetes and a long smoking history presents with calf pain on walking two blocks, relieved by rest; peripheral pulses are weak. Which is the most likely diagnosis?	C	Claudication = peripheral arterial disease.
139	A 70-year-old woman presents with a non-healing ulcer just above the medial malleolus, surrounded by brown pigmentation and varicose veins. Which is the most likely diagnosis?	B	Medial malleolus + non-healing = venous ulcer.
140	A 48-year-old man who is obese and recently underwent knee surgery presents with a painful, swollen, warm left leg. Which is the most likely diagnosis?	B	Painful + swollen + warm leg = DVT.
141	A 75-year-old woman falls at home and presents with right hip pain, a shortened and externally rotated leg, and inability to bear weight. Which is the most appropriate management?	A	Hip fracture = surgical fixation.
142	A 24-year-old man falls onto his shoulder and presents with pain over the mid-clavicle; X-ray shows a minimally displaced midshaft clavicle fracture. Which is the most appropriate management?	A	Clavicle fracture = sling immobilization (most cases).
143	A 24-year-old footballer sustains a twisting knee injury and feels a 'pop'; MRI confirms a complete anterior cruciate ligament tear. Which is the most appropriate management?	B	Complete ACL tear in active patient = reconstruction.
144	A 25-year-old man is brought in after a road traffic accident with an open fracture of the tibia and a contaminated wound. Which is the most appropriate management?	B	Open fracture = emergency debridement + fixation.

PAEDIATRICS — 20 questions

#	Question	Ans	Rule
145	A 2-year-old child presents with high fever, irritability, and a bulging anterior fontanelle. Which is the most likely diagnosis?	C	Fever + irritability + bulging fontanelle = meningitis.
146	A 3-day-old term neonate develops jaundice; total bilirubin is 15 mg/dL and rising. The infant is otherwise well, feeding and passing stools normally. Which is the most appropriate management?	B	Neonatal jaundice + 15 mg/dL = phototherapy.
147	A 1-day-old neonate presents with respiratory distress and a scaphoid abdomen; bowel sounds are audible over the left chest. Which is the most likely diagnosis?	D	Respiratory distress + scaphoid abdomen = congenital diaphragmatic hernia.
148	A 28-week premature infant develops progressive respiratory distress with grunting, retractions, and cyanosis within hours of birth; chest X-ray shows ground-glass opacities. Which is the most likely diagnosis?	D	28-week preemie + RDS = hyaline membrane disease.
149	A 5-year-old child presents with a barking cough and inspiratory stridor that worsen at night, preceded by two days of coryza. Which is the most likely diagnosis?	C	Bark-like cough + stridor + nighttime = croup.
150	A 6-month-old infant is found to have a harsh pansystolic murmur at the left lower sternal border and poor weight gain. Which is the most likely diagnosis?	D	Harsh systolic murmur in infant = VSD (most common CHD).
151	A 4-year-old child presents with hematuria, oliguria, and periorbital edema two weeks after a streptococcal throat infection. Which is the most likely diagnosis?	B	Hematuria + oliguria + post-strep = PSGN.
152	A 2-year-old child presents with failure to thrive, chronic diarrhea, and abdominal distension. Which is the most likely diagnosis?	D	Failure to thrive + diarrhea + distension = celiac disease.
153	A 3-year-old child presents with a limp and mild hip pain after a recent viral infection; he is afebrile and otherwise well. Which is the most likely diagnosis?	A	Limp + hip pain in young child = transient synovitis.
154	A 10-year-old child presents with fever for 6 days, bilateral conjunctival injection, a strawberry tongue, and a polymorphous rash. Which is the most likely diagnosis?	B	Fever + rash + conjunctivitis = Kawasaki disease.
155	An 8-year-old child presents with secondary bedwetting and daytime urinary frequency along with dysuria. Which is the most likely diagnosis?	B	Bedwetting + frequency = UTI (must rule out first).
156	A 5-year-old child presents with a palpable abdominal mass and hematuria. Which is the most likely diagnosis?	C	Abdominal mass + hematuria in child = Wilms tumor.
157	A 12-year-old boy presents with knee pain and swelling; X-ray shows a lytic lesion with a sunburst periosteal reaction in the distal femur. Which is the most likely diagnosis?	B	Knee pain + lytic lesion in adolescent = osteosarcoma.
158	A 4-year-old child presents with a purpuric rash over the buttocks and lower legs, abdominal pain, and swollen ankles. Which is the most likely diagnosis?	D	Purpuric rash on buttocks/legs in child = HSP.
159	A 5-month-old infant presents in winter with 3 days of coryza followed by cough, tachypnea, subcostal recession, and poor feeding; examination shows widespread fine crackles and wheeze. Which is the most likely diagnosis?	A	Infant with coryza progressing to tachypnea, recession, and diffuse crackles in winter = bronchiolitis (RSV).
160	A 4-week-old first-born male presents with non-bilious projectile vomiting after every feed; examination shows a firm olive-sized mass in the right upper quadrant. Electrolytes show hypochloremic, hypokalemic metabolic alkalosis. Which is the most likely diagnosis?	C	Projectile non-bilious vomiting + olive mass + hypochloremic hypokalemic metabolic alkalosis = pyloric stenosis.
161	An 8-month-old previously healthy infant presents with paroxysms of screaming and drawing up the legs alternating with quiet periods, and now passes a stool mixed with red jelly-like mucus. Which is the most likely diagnosis?	B	Colicky episodic pain with red currant jelly stool in an infant = intussusception.
162	An 18-month-old child presents after a single generalized tonic-clonic seizure lasting 3 minutes at home during a febrile illness (39C). He is now alert, playing, and neurologically normal. Which is the most likely diagnosis?	D	Generalized seizure under 5 years with rapid fever, lasting under 15 minutes, no focal features, full recovery = simple febrile seizure.
163	A 3-year-old is diagnosed with Kawasaki disease on day 6 of fever with conjunctival injection, strawberry tongue, and a rash. Which treatment most reduces the risk of coronary artery aneurysms?	A	IVIG within 10 days plus high-dose aspirin reduces coronary aneurysm risk in Kawasaki disease.
164	A 4-year-old boy presents with periorbital and generalized edema. Urinalysis shows 4+ proteinuria without hematuria; serum albumin is 1.8 g/dL with elevated cholesterol. Which is the most likely diagnosis?	C	Edema + heavy proteinuria + hypoalbuminemia + hyperlipidemia without hematuria in a young child = nephrotic syndrome, usually minimal change disease.

OBSTETRICS & GYNAECOLOGY — 17 questions

#	Question	Ans	Rule
165	A 30-year-old G1P0 woman at 12 weeks gestation presents for her first prenatal visit. Which is the most appropriate next step?	C	First prenatal visit at 12 weeks = confirm gestational age with ultrasound.
166	A 28-year-old primigravida at 28 weeks gestation presents with headache, blood pressure 150/100 mmHg, proteinuria, and edema. Which is the most likely diagnosis?	D	HTN + proteinuria + edema = preeclampsia.
167	A 35-year-old woman at 38 weeks gestation presents with regular contractions and a cervical dilatation of 4 cm. Which is the most appropriate management?	D	Active labor at 38 weeks = allow to progress.
168	A 25-year-old woman at 6 weeks gestation with a positive pregnancy test presents with mild vaginal spotting; ultrasound shows a viable intrauterine pregnancy and the cervical os is closed. Which is the most likely diagnosis?	D	Positive test + intrauterine + spotting = threatened abortion.
169	A 30-year-old woman at 32 weeks gestation presents with regular contractions and cervical change. Membranes are intact. Which is the most appropriate management?	A	Preterm labor at 32 weeks = betamethasone + tocolysis + magnesium.
170	A 28-year-old woman at 10 weeks gestation presents with severe nausea and vomiting resulting in a 4 kg weight loss and ketonuria. Which is the most likely diagnosis?	A	Severe nausea + vomiting + weight loss = hyperemesis gravidarum.
171	A 35-year-old woman at 40 weeks gestation in labor has a fetal heart rate of 170 bpm with good variability and no decelerations. Which is the most appropriate next step?	C	FHR 170 = tachycardia, continue monitoring first.
172	A 45-year-old woman presents with heavy, prolonged, and irregular menstrual bleeding for 6 months. Which is the most appropriate initial evaluation?	C	Abnormal uterine bleeding in perimenopause = endometrial biopsy.
173	A 32-year-old woman presents with dysmenorrhea and heavy menstrual bleeding; ultrasound shows a 5 cm intramural fibroid. She wishes to preserve fertility. Which is the most appropriate management?	B	Dysmenorrhea + heavy bleeding + fibroid = medical management first.
174	A 35-year-old woman presents with a dominant ovarian cyst on ultrasound that persists on repeat imaging and causes pelvic discomfort. Which is the most appropriate management?	D	Dominant ovarian cyst = laparoscopic cystectomy (if symptomatic/complex).
175	A 52-year-old woman presents with vaginal bleeding two years after menopause. Which is the most likely diagnosis?	C	Postmenopausal bleeding = endometrial cancer until proven otherwise.
176	A 25-year-old woman presents with irregular menses, hirsutism, and acne. Which is the most likely diagnosis?	D	Irregular menses + hirsutism = PCOS.
177	A 42-year-old woman presents with a sensation of a bulge per vagina and a third-degree uterine prolapse that is symptomatic. She desires definitive treatment. Which is the most appropriate management?	D	Symptomatic prolapse = surgical repair (if patient desires).
178	A 28-year-old woman presents with acute lower abdominal pain, fever, and purulent vaginal discharge; bimanual examination shows cervical motion tenderness. Which is the most likely diagnosis?	B	Pelvic pain + cervical motion tenderness + fever = PID.
179	A 28-year-old woman with 6 weeks of amenorrhea presents with right iliac fossa pain and vaginal spotting. Beta-hCG is 2500 IU/L and transvaginal ultrasound shows an empty uterus with no adnexal mass. Which is the most likely diagnosis?	D	Positive β-hCG above the discriminatory zone with an empty uterus = ectopic pregnancy until proven otherwise.
180	A 32-year-old woman at 30 weeks gestation presents with painless bright-red vaginal bleeding; ultrasound shows the placenta covering the internal os. Which is the most appropriate next step?	B	Painless bleeding with placenta over the internal os = placenta previa; digital examination can trigger catastrophic hemorrhage.
181	A 28-year-old woman at 26 weeks gestation with no risk factors for diabetes. Which is the most appropriate screening test for gestational diabetes?	C	Universal screening for gestational diabetes is the OGTT at 24–28 weeks, when placental anti-insulin hormones peak.

PSYCHIATRY — 2 questions

#	Question	Ans	Rule
182	A 25-year-old woman presents with persistent low mood, loss of interest in previously enjoyed activities, poor sleep, and poor concentration for 6 weeks. Which is the most likely diagnosis?	B	Persistent sadness + anhedonia + sleep disturbance = MDD.
183	A 30-year-old man presents with auditory hallucinations, paranoid delusions, and disorganized speech of 3 months' duration, along with declining function at work. Which is the most likely diagnosis?	B	Auditory hallucinations + paranoia for 3 months = schizophrenia.

ENT — 6 questions

#	Question	Ans	Rule
184	A 7-year-old boy presents with 2 weeks of repetitive sneezing, clear nasal discharge, and conjunctival folds (Dennie-Morgan lines) during the pollen season. Which is the most likely diagnosis?	B	Child + sneezing + clear discharge + folds = allergic rhinitis.
185	A 28-year-old woman with asthma presents with progressive bilateral nasal obstruction and anosmia. Endoscopy shows pale, grape-like masses in the nasal cavities. Which is the most likely diagnosis?	C	Nasal obstruction + anosmia = nasal polyps.
186	A 45-year-old woman presents with unilateral purulent nasal discharge, facial pressure, and fever for 10 days that worsened after an initial viral illness. Which is the most likely diagnosis?	D	Unilateral purulent discharge = bacterial sinusitis.
187	A 30-year-old schoolteacher presents with hoarseness of 4 weeks' duration that worsens by the end of the day and with heavy voice use. Laryngoscopy shows bilateral symmetrical swellings at the junction of the anterior and middle thirds of the vocal cords. Which is the most likely diagnosis?	D	Persistent dysphonia in a voice user with bilateral vocal cord swellings at the junction of the anterior and middle thirds = vocal cord nodules.
188	A 5-year-old child presents with hearing difficulty and recurrent ear infections. Otoscopy shows a retracted tympanic membrane with a fluid level behind it. Which is the most likely diagnosis?	A	Hearing loss + recurrent ear infections = otitis media with effusion.
189	A 45-year-old woman presents with recurrent episodes of severe vertigo lasting hours, accompanied by unilateral tinnitus, aural fullness, and fluctuating hearing loss. Which is the most likely diagnosis?	C	Recurrent vertigo lasting hours with fluctuating sensorineural hearing loss, tinnitus, and fullness = Meniere disease (endolymphatic hydrops).

OPHTHALMOLOGY — 6 questions

#	Question	Ans	Rule
190	During an eye examination, a 24-year-old woman with painful vision loss in the left eye is found to have a relative afferent pupillary defect on the swinging flashlight test. Which is the most likely diagnosis?	B	RAPD = optic neuritis.
191	A 34-year-old woman presents with fluctuating ptosis and diplopia that worsen at the end of the day and improve after rest. Which is the most likely diagnosis?	D	Ptosis + diplopia + worse at day = myasthenia gravis.
192	A 46-year-old man presents with sudden, painless loss of vision in the right eye. Fundoscopy shows a cherry-red spot at the macula. Which is the most likely diagnosis?	D	Sudden vision loss + cherry red spot = CRAO.
193	A 55-year-old man presents with gradual, painless loss of peripheral vision in both eyes. Intraocular pressure is elevated and the optic discs show increased cupping. Which is the most likely diagnosis?	C	Gradual vision loss + elevated IOP = glaucoma.
194	A 28-year-old woman presents with blurred vision in the left eye that is worse with eye movement and associated with retro-orbital pain. Which is the most likely diagnosis?	A	Blurred vision + painful eye movement = optic neuritis.
195	A 60-year-old woman presents with sudden floaters and flashes of light in the left eye. Fundoscopy shows an annular Weiss ring. Which is the most likely diagnosis?	B	Floaters + flashes = posterior vitreous detachment.

FORENSIC MEDICINE — 5 questions

#	Question	Ans	Rule
196	In a forensic identification case, the examiner classifies the fingerprints of an unknown deceased person. Which is the most prevalent fingerprint pattern in the general population?	A	Most common fingerprint pattern = loops.
197	A 70-year-old man's body is brought to the mortuary several days after death. The forensic examiner notes the sequence of putrefaction of the internal organs. Which organ undergoes putrefaction LAST?	B	Putrefaction order: liver first, prostate last (dense tissue).
198	A 30-year-old woman presents within 12 hours of a sexual assault. What is the most appropriate forensic evidence collection?	C	Sexual assault = full forensic kit within 72 hours.
199	A 30-year-old man is brought to the emergency department with intentional self-inflicted knife wounds to the forearm. Besides treating the wounds, what is the forensic priority?	C	Self-harm = preserve scene, document injuries, assess intent.
200	A victim of a fatal assault, conscious and aware that death is near, makes a statement naming his assailant and dies shortly afterward. What is the legal status of this statement?	A	A statement by a person who believes death is imminent, relating to the cause of death, is a dying declaration and admissible as evidence.

Star ratings

In the master list DOCX, 22 items carry ★★★★★ (topic depth confirmed across recalled papers) and 36 carry ★★★★☆; the remaining 142 are ★★★ (pattern-derived, not independently re-confirmed). The stars are honest — the legend in the DOCX states their basis. This report keeps every item visible; the stars live in the master list.

Backbone topic	Predicted MCQs	Key discriminator / evidence	Type of hit
GYNECOLOGY
1. Menstrual cycle in detail, safe vs unsafe days	Q12	Hirsutism + irregular menses = PCOS	exact family
2. Primary and secondary amenorrhea	Q15	Amenorrhea + pain + spotting = ectopic first	adjacent
3. Dysmenorrhea (primary vs secondary), endometriosis vs adenomyosis	Q9	Dysmenorrhea + fibroid = medical first	adjacent
4. Contraceptive methods (hormonal, IUCD, barrier, permanent, emergency pill)	—	No direct bank MCQs; background high-yield	pattern
5. Congenital adrenal hyperplasia (with tables), infertility	—	No direct bank MCQs; tables only	pattern
6. Vaginitis with types, urinary incontinence with types	Q14	Pain + fever + cervical motion tenderness = PID	exact family
7. Toxic shock syndrome, pelvic organ prolapse	Q13	Symptomatic 3rd-degree prolapse = surgical repair	exact
8. Fibroid types, endometrial carcinoma, ovarian cancer	Q8, Q9, Q10, Q11	PMB = cancer until proven otherwise; AUB = biopsy; cyst = cystectomy	exact cluster
OBSTETRICS
1. GPA vs GTPAL, labor with stages, EDD, fetal period	Q1, Q3, Q5, Q7	12-wk booking = US dates; active labor = progress; preterm = triple therapy	exact cluster
2. Chronic/gestational HTN, preeclampsia, eclampsia, HELLP, ectopic	Q2, Q15	HTN + proteinuria = preeclampsia; empty uterus above zone = ectopic	exact
3. GDM, placental abnormalities, abruptio placentae, placenta previa	Q16, Q17	Previa = painless bleeding, never digital exam; GDM = OGTT 24–28 wk	exact
4. Abortion and its types, postpartum hemorrhage	Q4	Viable IUP + spotting + closed os = threatened	exact
5. Sheehan syndrome, breastfeeding, bottle feeding, mastitis	—	No direct bank MCQs; Sheehan links to topic 4	pattern
6. Molar pregnancy (complete vs incomplete), malpresentation, Rh incompatibility	—	No direct bank MCQs; mole appears as distractor	pattern
7. Shoulder dystocia, C-section in detail, amniotic fluid (oligo/polyhydramnios)	—	No direct bank MCQs; C-section is surgery-adjacent	pattern
FLAGGED GAPS
Hyperemesis gravidarum	Q6	Severe vomiting + weight loss + ketonuria = hyperemesis	predicted, not on backbone
Preterm labor management detail	Q5	Betamethasone + tocolysis + MgSO₄ triple	predicted, not on backbone

Claim	Confidence	Basis	Verdict
The architecture — subject weightage	~90%+	All 14 subjects sit within ±2.1pp of recalled reality, most within ±0.5pp. The distribution held across 5 different sittings; the exam does not reshuffle its weightage.	supported
Topic families inside OB/GYN	~75–85%	The classic discriminators (preeclampsia spectrum, abortion classification, previa, GDM, ectopic, fibroids, PMB, prolapse, PID, PCOS) recur across sittings in some form.	supported
Verbatim exact questions	<10%	Pattern-derived, not leaked. No per-item provenance exists. Anyone selling verbatim certainty is lying to you.	do not expect

Tier	Subjects	Why
Tier 1 — build now	Medicine (83) · Surgery (23) · Paediatrics (20)	73.5% of the predicted bank; 12 of the top-25 recurring topics
Tier 2 — quick wins	Pharmacology (14) · ENT · Ophthalmology · Forensic · Community Medicine · Anatomy	Small numbers but recur in every sitting; cheap to build
Tier 3 — bundle	Physiology · Biochemistry · Pathology · Psychiatry	4-or-fewer items each — one combined volume beats nine thin documents

NRE System — The Full Picture

The Evidence Base — every source, counted

Subject Weightage — predicted vs recalled, all 14 subjects

Recurrence League — the top 25 repeating topics

Core Master Inventory — all 26 system sections with examples

Prediction Bank — all 200 MCQs, full

OB/GYN Deep Dive — the 17 questions, dissected

Backbone Correlation Map — topics to predicted MCQs

Confidence Model — what we can and cannot claim

Where the Risk Sits — and what to do next

Where October is really won

What the next build should be