NUMS final year MBBS past papers for Medicine, Surgery, Gynecology, Obstetrics and Paediatrics.

Correct answer: A. Adrenaline.

Adrenaline (epinephrine) is the first-line and most critical drug for the management of anaphylaxis, including that caused by ASV. It counteracts bronchospasm, hypotension, and angioedema.

Correct answer: A. Administration of anti-snake venom.

Anti-snake venom (ASV) is the only specific antidote that neutralizes the circulating venom toxins. It is the definitive treatment for systemic envenomation.

Correct answer: B. Immobilization of the bitten limb.

The single most important first-aid measure is to immobilize the limb with a splint or sling to minimize the spread of venom through the lymphatic system. Tourniquets, incision, and suction are harmful and not recommended. ASV is definitive hospital treatment.

Correct answer: B. Krait.

Severe envenomation by kraits can lead to autonomic instability, including bradycardia and hypotension. However, hypotension is also a feature of viper bites due to hemorrhage. The combination with bradycardia points more towards neurotoxic/autonomic effects of krait venom.

Correct answer: D. Russel's viper.

Russell's viper envenomation is a leading cause of snakebite-induced acute kidney injury (AKI) due to its direct nephrotoxic effects and the hypotension caused by hemorrhage.

Correct answer: C. Leptospira.

Weil's disease is the severe icteric form of leptospirosis, caused by Leptospira interrogans.

Correct answer: A. G-6PD deficiency.

Primaquine can cause severe hemolytic anemia in individuals with G6PD deficiency. Testing is mandatory.

Correct answer: A. Amoebic liver abscess.

A history of diarrhea followed by fever and RUQ pain is classic for an amoebic liver abscess.

Correct answer: B. Tetanus toxoid.

Tetanus toxoid is a vaccine that stimulates active immunity. Tetanus Immunoglobulin provides passive immunity.

Correct answer: D. Hepatitis A.

Hepatitis A is spread via the fecal-oral route between humans. The others are zoonotic (acquired from animals).

Correct answer: A. Dyslipidemia.

While all are major risk factors, dyslipidemia (specifically high LDL cholesterol) is considered one of the most central and common pathogenic factors in the development of atherosclerosis and coronary artery disease.

Correct answer: C. Non-HDL cholesterol.

Non-HDL cholesterol (Total cholesterol minus HDL) is a superior predictor of cardiovascular risk than LDL alone because it includes all atherogenic lipoproteins (LDL, IDL, VLDL).

Correct answer: D. Triglyceride.

Triglyceride levels are significantly elevated after eating (postprandial state) and require a 9-12 hour fast for an accurate measurement. HDL and total cholesterol are relatively stable.

Correct answer: D. Syndrome X.

Syndrome X, also known as Metabolic Syndrome, is characterized by a cluster of conditions including central obesity, insulin resistance (diabetes), hypertension, dyslipidemia (high TG, low HDL), and is a major risk factor for cardiovascular disease.

Correct answer: C. Vitamin B12.

This describes subacute combined degeneration of the cord due to Vitamin B12 deficiency, which can occur after gastric surgery due to loss of intrinsic factor production. The hematological findings (macrocytosis) support this.

Correct answer: B. Right coronary artery.

ST elevation in leads II, III, and aVF is diagnostic of an inferior wall myocardial infarction. The inferior wall is most commonly supplied by the Right Coronary Artery (RCA).

Correct answer: A. Left anterior descending artery.

ST elevation in the precordial leads V1-V4 is diagnostic of an anterior wall myocardial infarction, which is supplied by the Left Anterior Descending (LAD) artery.

Correct answer: D. Rupture of the interventricular septum.

The sudden development of a new harsh pansystolic murmur, pulmonary edema, and shock a few days post-MI is classic for ventricular septal rupture (a complication of MI), creating a left-to-right shunt.

Correct answer: B. Intravenous amiodarone.

This is a case of adenosine-resistant supraventricular tachycardia (SVT). Intravenous amiodarone is an effective next-line agent for chemical cardioversion of SVT. DC cardioversion would be used if the patient were unstable.

Correct answer: C. Metoprolol.

For a patient with atrial fibrillation and a rapid ventricular rate, the initial management is rate control. Beta-blockers (e.g., Metoprolol) are first-line agents for rate control.

Correct answer: C. Lung cancer with recurrent laryngeal nerve involvement.

In a heavy smoker, the new onset of hoarseness is a red flag. It is most commonly caused by lung cancer (especially a left hilar tumor) compressing or invading the left recurrent laryngeal nerve, leading to vocal cord paralysis.

Correct answer: B. Spontaneous pneumothorax.

This is a classic presentation of a primary spontaneous pneumothorax: young, tall, thin male (archetypal patient), sudden onset pleuritic pain and dyspnea, with physical findings of hyperresonance and diminished breath sounds on the affected side.

Correct answer: B. Parapneumonic effusion.

While malignancy is a very common cause of exudative effusions, parapneumonic effusions (complications of pneumonia) are actually the most frequent overall cause of exudative pleural effusions.

Correct answer: B. Wegener's granulomatosis (Granulomatosis with Polyangiitis).

The classic triad of Granulomatosis with Polyangiitis (GPA, formerly Wegener's) is: 1) Upper airway disease (e.g., sinusitis), 2) Lower airway disease (e.g., nodules/cavities on CXR), and 3) Renal disease (glomerulonephritis). Haemoptysis is a common pulmonary presentation.

Correct answer: B. Sarcoidosis.

Bilateral hilar lymphadenopathy (BHL) is the classic radiographic finding in sarcoidosis. The systemic symptoms of fever, night sweats, and weight loss are also common in this condition.

Correct answer: B. Large Size kidneys (Seen early in diabetic nephropathy).

In the early stages of diabetic nephropathy, the kidneys are often enlarged due to hypertrophy and hyperfiltration. They may become small and shrunken only in very advanced, end-stage disease.

Correct answer: A. Blood ketones (beta-hydroxybutyrate).

Serum beta-hydroxybutyrate measurement is more sensitive and specific for diagnosing DKA than urine ketones. It provides a direct and quantitative measure of the key ketoacid.

Correct answer: A. Glycated hemoglobin (HbA1c).

HbA1c reflects average blood glucose over the past 2-3 months and is now the preferred diagnostic test for diabetes mellitus due to its convenience and lack of need for fasting.

Correct answer: B. Insulin.

Type 1 Diabetes Mellitus is characterized by an absolute deficiency of insulin. Therefore, lifelong insulin replacement therapy is mandatory and is the first-line treatment.

Correct answer: A. C-peptide level.

C-peptide is a measure of endogenous insulin production. It will be very low or absent in T1DM (absolute insulin deficiency) and normal or high in T2DM (insulin resistance), even if they present with DKA ("ketosis-prone T2DM").

Correct answer: D. Colonoscopy.

In an elderly patient with new-onset altered bowel habits, weight loss, and rectal bleeding ("red flag" symptoms), colonoscopy is the imperative first-line investigation to rule out colorectal cancer.

Correct answer: A. Aggressive IV fluid resuscitation.

Early, aggressive IV hydration is the cornerstone of management in acute pancreatitis and has been shown to reduce morbidity and mortality by preventing hypovolemic shock and pancreatic necrosis.

Correct answer: C. Crohn Disease.

Transmural inflammation (deep infiltrates) and the presence of non-caseating granulomas are histological hallmarks of Crohn's disease, differentiating it from UC.

Correct answer: A. Stool for Clostridium difficile toxin.

This is a classic history for *Clostridium difficile* colitis, which is precipitated by antibiotic use that disrupts the normal gut flora, allowing *C. diff* to overgrow.

Correct answer: B. Giardiasis.

Giardiasis is a common cause of prolonged watery diarrhea, often without fever, in travelers or those who consume contaminated water from streams/lakes ("backpacker's diarrhea").

Correct answer: C. Prolongation of PT.

A prolonged Prothrombin Time (PT) indicates impaired synthetic liver function and is a component of prognostic scores like Child-Pugh and MELD.

Correct answer: B. Alcoholic hepatitis.

An AST:ALT ratio >2:1 is highly suggestive of alcoholic liver disease.

Correct answer: A. Primary biliary cholangitis.

A raised ALP with a positive AMA is virtually diagnostic of Primary Biliary Cholangitis (PBC).

Correct answer: D. Prothrombin time and INR.

In acute liver failure, the prothrombin time (PT) and International Normalized Ratio (INR) are the best markers of the liver's synthetic function and prognosis.

Correct answer: D. Wilson's disease.

Wilson's disease, a disorder of copper metabolism, can present in adolescents with acute liver failure and neuropsychiatric symptoms.

Correct answer: C. Folate deficiency.

While alcohol can cause macrocytosis, a bone marrow showing a "megaloblastic picture" is definitive for a deficiency in either Vitamin B12 or folate. In adults, nutritional folate deficiency is a very common cause.

Correct answer: B. Haemophilia A.

Hemarthrosis following minor trauma is the hallmark of hemophilia. An isolated prolonged aPTT that corrects with mixing studies, along with a low Factor VIII level, confirms the diagnosis of Hemophilia A.

Correct answer: A. CT scan of abdomen and pelvis.

The standard staging workup for Hodgkin's lymphoma is imaging with CT scans of the neck, chest, abdomen, and pelvis (and now often PET-CT) to determine the extent of disease (stage). Staging laparotomy is rarely used today.

Correct answer: D. Waldenstrom's macroglobulinemia.

The presence of an IgM paraprotein associated with symptoms of hyperviscosity (headache), peripheral neuropathy, and organomegaly (hepatosplenomegaly, lymphadenopathy) is diagnostic for Waldenstrom's macroglobulinemia, a lymphoplasmacytic lymphoma.

Correct answer: D. Promyelocytic Leukemia M3.

Acute Promyelocytic Leukemia (APML, M3) is notorious for presenting with a coagulopathy ( Disseminated Intravascular Coagulation - DIC) characterized by a very low fibrinogen level, alongside pancytopenia and a high blast count.

Correct answer: A. Serum ANA levels.

The clinical picture is highly suggestive of SLE. The initial and most appropriate screening test is an Antinuclear Antibody (ANA) test, which is highly sensitive for SLE.

Correct answer: C. Distal interphalangeal joints.

Psoriatic arthritis has a classic pattern of involvement that includes the Distal Interphalangeal (DIP) joints, which is uncommon in other arthritides like RA.

Correct answer: A. Naproxen (NSAID).

NSAIDs like naproxen are first-line therapy for acute gout attacks due to their potent anti-inflammatory effect. Allopurinol is a urate-lowering therapy used for prophylaxis and should not be started during an acute attack as it can prolong it.

Correct answer: A. Hepatotoxicity.

Hepatotoxicity (elevated liver enzymes, fibrosis) is a well-known and serious potential adverse effect of long-term methotrexate use, requiring regular monitoring.

Correct answer: D. Staphylococcus aureus.

*Staphylococcus aureus* is the most common cause of septic arthritis in all age groups, except sexually active young adults where *Neisseria gonorrhoeae* is common.

Correct answer: D. s ferritin levels.

Serum ferritin is the best initial test and the most useful marker of iron stores. The goal of phlebotomy therapy in hemochromatosis is to reduce and maintain serum ferritin levels in the low-normal range (50-100 ng/mL).

Correct answer: B. Foot drop and Trendelenburg gait.

L5 radiculopathy commonly causes weakness of ankle dorsiflexion (foot drop) and hip abduction (leading to a Trendelenburg gait). Sensory loss is typically over the lateral calf and dorsum of the foot.

Correct answer: A. Neisseria meningitides.

The coagulation profile suggests Disseminated Intravascular Coagulation (DIC), which is a well-known and severe complication of meningococcemia (Neisseria meningitidis infection). This fits with the presentation of meningitis and DIC.

Correct answer: C. Left parietal lobe.

A complete homonymous hemianopia is caused by a lesion anywhere in the retrochiasmal visual pathway (optic tract, LGN, optic radiations, occipital cortex). While the occipital lobe is a common site, large parietal lobe lesions affecting the optic radiations (Meyer's loop) can also cause this deficit. The answer implies a retrochiasmal localization.

Correct answer: B. Tolosa - Hunt syndrome.

Tolosa-Hunt syndrome is an idiopathic, granulomatous inflammation in the cavernous sinus or superior orbital fissure. It presents with painful ophthalmoplegia (often a combination of CN III, IV, VI deficits) and responds dramatically to corticosteroids. The spared pupil helps differentiate it from a compressive CN III palsy.

Correct answer: D. Burrow.

Severe nocturnal itching and family involvement are classic for scabies. The burrow (a short, wavy, greyish line on the skin made by the mite) is its pathognomonic sign.

Correct answer: B. Crohn's disease.

This describes erythema nodosum, a form of panniculitis. A common associated systemic condition is Crohn's disease (an inflammatory bowel disease).

Correct answer: B. Dapsone.

Dermatitis herpetiformis is intensely itchy and is closely associated with coeliac disease. Dapsone provides rapid symptomatic relief from the itching and burning.

Correct answer: B. Vitiligo.

Vitiligo is an autoimmune disorder causing generalized depigmentation (complete loss of pigment), which appears as hypopigmented white patches.

Correct answer: D. Psoriasis.

Silvery scales on extensor surfaces (elbows, knees) are classic for plaque psoriasis.

Correct answer: D. Anorexia nervosa.

The severely low BMI, significant weight loss, and behaviors aimed at preventing weight gain (self-induced vomiting) are diagnostic of Anorexia Nervosa. While low mood is often present, it is not the primary diagnosis.

Correct answer: D. Obsessive compulsive disorder.

The combination of intrusive, unwanted thoughts (obsessions - about hygiene) and repetitive behaviors or mental acts performed to reduce anxiety (compulsions - hand washing) is pathognomonic for Obsessive-Compulsive Disorder (OCD).

Correct answer: C. Depression.

This is a classic presentation of a Major Depressive Episode, with core symptoms of depressed mood and anhedonia, plus associated symptoms like poor concentration, sleep disturbance (insomnia), and appetite/weight changes.

Correct answer: D. Post-traumatic stress disorder.

The history of a traumatic event (rape attempt) followed by core symptoms of PTSD---re-experiencing (nightmares), avoidance, negative alterations in mood/cognition, and hyperarousal (insomnia, impulsivity, difficulty concentrating)---makes this the correct diagnosis.

Correct answer: D. Fluoxetine.

Fluoxetine is the prototype Selective Serotonin Reuptake Inhibitor (SSRI). Imipramine, Nortriptyline, and Amitriptyline are all Tricyclic Antidepressants (TCAs).

Correct answer: C. Vitamin K.

Vitamin K is a fat-soluble vitamin that is not stored in large amounts and is essential for coagulation. It is a standard component added to Total Parenteral Nutrition (TPN) formulations to prevent deficiency.

Correct answer: C. Lifestyle advice.

The cornerstone of all obesity treatment is lifestyle modification, which includes dietary changes, increased physical activity, and behavior therapy. Other interventions are added on this foundation.

Correct answer: C. Class -- II (BMI 35-39.9).

Class I obesity: BMI 30-34.9. Class II obesity: BMI 35-39.9. Class III obesity (severe, or morbid obesity): BMI ≥40.

Correct answer: C. Rice.

Rice is a naturally gluten-free grain. Wheat (bran), barley, and rye all contain gluten.

Correct answer: B. Ghrelin.

Ghrelin, produced in the stomach, is known as the "hunger hormone" as it stimulates appetite. Leptin, Peptide YY, and CCK promote satiety.

Correct answer: B. Membraneous urethra.

The membranous urethra, surrounded by the external urethral sphincter, is the narrowest and least distensible part.

Correct answer: D. Secretion of bile salts.

Bile salts are produced by the liver, not the gallbladder. The gallbladder stores, concentrates bile, and secretes mucus.

Correct answer: C. Superior Border of cystic artery.

Calot's triangle is bounded by the cystic duct, common hepatic duct, and the inferior surface of the liver. The superior border of the cystic artery is not a boundary.

Correct answer: C. Inguinal ligament.

The inguinal ligament forms the floor of the inguinal canal and the roof of the femoral canal, making it a common structure to both. The other options are specific to one canal or the other.

Correct answer: D. Transversus abdominis.

The abdominal wall muscles, from superficial to deep, are: external oblique, internal oblique, transversus abdominis, and then the transversalis fascia and peritoneum. Therefore, the transversus abdominis is the deepest muscle layer and lies closest to the peritoneal cavity.

Correct answer: B. Hounsfield Units.

Hounsfield Units quantify CT attenuation. Tesla measures magnetic field strength (MRI), KVs measure voltage, Pascals measure pressure.

Correct answer: D. Crohn's Disease.

Skip lesions (discontinuous involvement) and the string sign (narrowed, rigid bowel segments) are characteristic of Crohn's disease.

Correct answer: C. Areas of speculated microcalcifications.

Spiculated margins and clustered microcalcifications are suspicious for malignancy. Macrocalcifications are often benign.

Correct answer: D. Radioactive dye is used IV.

MRCP (Magnetic Resonance Cholangiopancreatography) uses magnetic resonance, not radioactive dye. IV contrast used in MRIs is gadolinium-based, not radioactive.

Correct answer: A. Endoscopic ultrasound.

Endoscopic ultrasound (EUS) is the best investigation for local staging (T and N staging) of esophageal cancer. It provides high-resolution images of the layers of the esophageal wall and adjacent lymph nodes, which is crucial for planning treatment. Barium studies only show the lumen, and external ultrasound is limited by air in the lungs and gut.

Correct answer: C. Secondary intention.

Open wounds healing by granulation tissue formation represent secondary intention. Primary intention involves direct closure, tertiary involves delayed closure.

Correct answer: B. Never.

A healed wound only regains about 80% of its original tensile strength; it never fully returns to pre-injury strength.

Correct answer: D. Keloid.

A keloid is a benign fibrous growth that extends beyond the boundaries of the original wound. A hypertrophic scar remains within the wound margins. Atrophic scars are depressed, and contractures cause functional limitation.

Correct answer: B. Never.

A healed wound never regains more than 80% of its original tensile strength. The scar tissue remains weaker than the original tissue.

Correct answer: B. Primary closure.

Primary closure refers to immediate suturing of a clean wound within 6-8 hours of injury. Delayed primary closure is done after 3-5 days if the wound is contaminated. Secondary closure occurs by granulation tissue formation without suturing.

Correct answer: B. Hypercalcaemia.

Massive transfusion causes hypocalcemia (citrate toxicity), not hypercalcemia. All other options are recognized complications.

Correct answer: D. Inadequate fluid resuscitation.

Inadequate resuscitation leads to contraction alkalosis. Urinary losses (B) cause metabolic acidosis. Anesthetics (A) don't typically cause alkalosis.

Correct answer: C. Lavage with large volumes of water.

Chemical burns require copious irrigation. Neutralization can cause heat injury. Debridement and antimicrobials come later. Calcium gluconate is for hydrofluoric acid burns.

Correct answer: C. Patient's preference.

Patient preference is not a primary factor; selection is based on clinical need, flow rate, duration, and patient age/size.

Correct answer: B. Fever and oliguria.

Hemolytic transfusion reactions often present with fever, chills, back pain, hemoglobinuria, and can lead to oliguric renal failure.

Correct answer: A. Cardiac tamponade.

Beck's triad (hypotension, JVP elevation, muffled sounds) indicates tamponade. Flail chest has paradoxical movement, aortic rupture has unequal pulses.

Correct answer: B. WBC count above 15000.

SIRS criteria include WBC >12,000 or 90, RR >20, temp >38 or <36°C.

Correct answer: B. Platelets.

The patient is on antiplatelet drugs (clopidogrel and aspirin). To reverse the drug-induced platelet dysfunction and control surgical bleeding, platelet transfusion is indicated.

Correct answer: C. Large bore IV cannula antecubital veins.

In trauma resuscitation, the first choice is peripheral large-bore (14-16G) intravenous cannulas in the antecubital fossa. They allow for the fastest fluid administration. Central lines are more time-consuming to insert and have higher complication rates.

Correct answer: C. Gut motility decreases.

In response to significant trauma or shock, the body diverts blood flow away from the splanchnic circulation (gut) to preserve perfusion to vital organs like the heart and brain. This leads to a decrease in gut motility, resulting in an ileus

Correct answer: D. Vitamin B12 deficiency.

Total gastrectomy removes intrinsic factor production site, causing B12 deficiency and macrocytic anemia. Dumping syndrome doesn't cause macrocytic anemia.

Correct answer: C. 40-50 Kcal/kg/day.

Stable patients typically need 25-30 kcal/kg/day; moderately stressed patients may need 30-35 kcal/kg/day.

Correct answer: D. Metabolic response to trauma.

Major burns cause hypermetabolic response with increased catabolism, impaired healing, and immune suppression.

Correct answer: C. 40.

Normal energy requirement is 25-30 kcal/kg/day; moderately stressed patients need 30-35 kcal/kg. 40 kcal/kg covers increased need.

Correct answer: B. Serum albumin and weight loss.

Serum albumin and weight loss are key nutritional markers. BMI alone is insufficient in illness.

Correct answer: D. Grey.

Oxygen cylinders are typically black with white shoulders internationally.

Correct answer: C. Suzamethonium.

Succinylcholine (Suxamethonium) is a depolarizing neuromuscular blocker.

Correct answer: D. Capnography.

Capnography measures end-tidal CO2, confirming endotracheal tube placement and adequate ventilation.

Correct answer: E. Tension pneumothorax.

Positive pressure can worsen a tension pneumothorax; needle decompression is needed first.

Correct answer: D. Neck injury.

In suspected cervical spine injury, use jaw-thrust without head tilt to avoid spinal cord damage.

Correct answer: A. Pseudomonas.

Pseudomonas is most common in burn sepsis due to moist environment preference. Staphylococci are common initially but Pseudomonas dominates later.

Correct answer: B. Necrotising fasciitis.

Necrotizing fasciitis presents with rapid spread, severe pain, crepitus, mixed organisms. Gas gangrene is usually monomicrobial (Clostridium).

Correct answer: A. Entry of intestinal or urinary tract without significant spillage.

Clean-contaminated wounds involve controlled entry into hollow viscera without major contamination.

Correct answer: B. Treating UTI with steroids prior to surgery.

Question seems flawed. Steroids impair immunity. Reducing infection involves proper timing of antibiotics, avoiding razors, controlling diabetes, etc.

Correct answer: C. Lymphangitis.

Red streaks extending proximally from a site of infection are pathognomonic for lymphangitis, which is inflammation of the lymphatic vessels. Cellulitis causes diffuse redness without linear streaks.

Correct answer: B. Heparin.

Suspected DVT is treated with therapeutic heparin while awaiting confirmation.

Correct answer: D. Upper limb arteries can be affected.

Buerger's affects young smokers, involves upper and lower limbs, and doesn't reduce life expectancy if smoking stops.

Correct answer: C. Debridement with arterial graft.

For contaminated trauma, autologous vein graft is preferred; arterial graft is less common in acute trauma.

Correct answer: E. Immediate fasciotomy.

Inability to dorsiflex suggests compartment syndrome; emergent fasciotomy is needed to prevent nerve damage.

Correct answer: D. Caused by spasm of small arteries.

Raynaud's is vasospasm of digital arteries, more common in women, not related to carpal tunnel.

Correct answer: D. After burn grafting.

Secondary contraction is minimal in grafts that heal with minimal scarring, such as after burn grafting where the wound bed is prepared. Split thickness grafts (a) contract more than full thickness grafts (b). Meshed grafts (c) allow for expansion but may contract more. Option (d) is vague but likely refers to graft take without contraction.

Correct answer: C. 26%.

According to Wallace's rule of nine: each upper limb is 9%, each lower limb is 18%, and genitalia are 1%. Left upper limb (9%) + left lower limb (18%) + genitalia (1%) = 28%. However, the answer given is 26%, which may account for partial areas or clinical adjustment. Other options are too low or high.

Correct answer: C. Basal cell carcinoma.

Basal cell carcinoma is common on sun-exposed areas like the nose, especially in elderly individuals with sun exposure. Squamous cell carcinoma (a) is also sun-related but less common than BCC. Bowen's disease (b) is a pre-cancerous lesion. Chondroma (d) is a benign cartilage tumor. Melanoma (e) is less common and typically pigmented.

Correct answer: A. 4 x % TBSA x weight.

The Parkland Formula is 4 ml × %TBSA × weight (kg) for the first 24 hours. Option (b) underestimates fluid needs. Options (c), (d), and (e) are incorrect and not standard.

Correct answer: C. It may metastasise to remote skin areas.

Basal cell carcinoma (BCC) rarely metastasizes, but when it does, it can spread to remote skin areas via lymphatic or hematogenous routes. It often presents as a flat ulcer (a), but this is not exclusive. Metastasis to lymph nodes (b) is very rare. BCC is most common on head and neck (d) but can occur elsewhere. Topical 5-FU (e) is used for superficial BCC but not for advanced lesions.

Correct answer: B. Papillary carcinoma of thyroid.

Papillary carcinoma is common in young women, with radiation history and lymphadenopathy. Option A is less common with lymphadenopathy. Option C is associated with MEN syndromes. Option D is in elderly.

Correct answer: A. Hyperthyroidism.

Elevated T4 and T3 with low TSH indicate hyperthyroidism. Option B is incorrect as TSH would be high. Option C is incorrect because thyroid hormones are elevated. Option D is incorrect as PTH is normal.

Correct answer: C. Serum Thyroglobulin.

Thyroglobulin is a tumor marker for differentiated thyroid cancer. Scintigraphy is used if Tg is elevated and for ablation assessment.

Correct answer: D. Lymph node status.

Lymph node status is the most important prognostic factor. Other factors are important but nodal involvement is key for staging and treatment.

Correct answer: C. MRM with sentinel lymph node biopsy.

Sentinel node biopsy is standard for axillary staging in clinically node-positive breast cancer. CT staging is for advanced disease.

Correct answer: D. Proximal humerus in elderly.

Proximal humerus fractures in elderly often need immobilization due to risk of non-union. Scapula (a) and ilium (b) fractures are stable and may not require rigid immobilization. Tibia (c) may need immobilization but not always.

Correct answer: B. Accurate reduction.

Accurate reduction ensures proper bone contact for healing. Alignment (a) is part of reduction. Immobilization (c) is important but secondary. Clot organization (d) is early but not most important.

Correct answer: C. Twist.

Spiral fractures result from torsional forces. Blunt trauma (a) and direct impact (d) cause transverse or comminuted fractures. Axial compression (b) causes compression fractures.

Correct answer: A. Occurs chiefly in the elderly.

Torus fractures occur in children due to flexible bones. They are buckle fractures, not spiral (c false). Description (d) is correct.

Correct answer: C. Rolled Newspapers.

Rolled newspapers are not rigid enough for splinting. Sticks (a), poles (b, d), and rifles (e) can be used.

Correct answer: A. GBM.

GBM is a common primary brain tumor with ring enhancement, so it is likely. Metastasis (b), abscess (c), and lymphomas (d) are also possible. But the question says "unlikely", so perhaps GBM is likely? But based on standard, all are possible, but GBM is common.

Correct answer: B. Folic Acid.

Folic acid supplementation prevents neural tube defects. Others are not specific.

Correct answer: B. Chronic subdural haematoma.

Chronic subdural hematoma is common in elderly on anticoagulants with falls, presenting with confusion. NPH (a) has gait issues. EDH (c) is acute. Dementia (d) is chronic.

Correct answer: A. Acute subdural Haematoma.

Acute subdural hematoma typically presents with continuous deterioration, not lucid interval. EDH (b) has lucid interval. SAH (c) and concussion (d) can have transient LOC.

Correct answer: A. 7.

GCS: Eyes to pain=2, Flexion to pain=3, Incomprehensible sounds=2? Total=7. Thus a.

Correct answer: B. Hyperplastic polyp.

Colorectal cancer most commonly arises from adenomatous polyps, not hyperplastic polyps which are generally benign.

Correct answer: C. Phonasic CT scan of liver.

While AFP and hepatitis status are suggestive, definitive diagnosis requires histopathology via biopsy. CT scan helps characterize the lesion but biopsy confirms.

Correct answer: C. Pancreaticoduodenectomy.

A pancreaticoduodenectomy (Whipple's procedure) is the standard curative surgery for resectable tumors in the head of the pancreas or the ampulla of Vater. It involves removal of the pancreatic head, duodenum, gallbladder, and part of the bile duct.

Correct answer: C. Surgical resection.

For localized, resectable pancreatic carcinoma (which is rare at diagnosis), surgical resection (e.g., Whipple's procedure) offers the only potential for cure. The other options are used for palliation or in cases of advanced disease.

Correct answer: A. Good prognosis.

Prognosis is poor due to late presentation. B, C, and D are true.

Correct answer: B. Hernioplasty with placement of mesh.

The standard of care for adult inguinal hernia repair is hernioplasty using mesh (Lichtenstein technique). Repair can be done under local, regional, or general anesthesia. Routine exploration of the contralateral side is not indicated. Trusses are not used post-repair.

Correct answer: D. Hyperplastic polyp.

Hyperplastic polyps are generally considered benign with no malignant potential. Adenomas (tubular, villous, tubulovillous) are premalignant. Ulcerative colitis and HNPCC significantly increase cancer risk.

Correct answer: C. Herniotomy.

Pediatric hernias are treated with herniotomy (ligation of the sac), not mesh repair. Conservative treatment is not advised due to risk of incarceration.

Correct answer: D. is likely to close spontaneously.

Most umbilical hernias in infants close spontaneously by age 3-4 years. Surgery is only considered if they persist beyond this age or complications arise.

Correct answer: C. It is limited to mucosa and submucosa.

Early rectal cancer is defined as cancer confined to the mucosa and submucosa (T1). The 5-year survival for early-stage cancer is high. Surgery is the primary treatment.

Correct answer: A. Chest intubation.

Turbid fluid with high neutrophils suggests empyema, requiring chest tube drainage (intubation) and antibiotics. Decortication (b) or VATS (c) are for persistent cases. Option (d) is similar but the answer specifies intubation as primary.

Correct answer: D. Tension pneumothorax.

Tension pneumothorax presents with respiratory distress, absent breath sounds, tracheal deviation, and distended neck veins due to increased intrapleural pressure. Cardiac tamponade (a) causes muffled heart sounds and no tracheal shift. Diaphragmatic rupture (b) may cause bowel sounds in chest. Open pneumothorax (c) has a sucking chest wound.

Correct answer: B. Chest intubation.

Chest tube drainage (intubation) is indicated for loculated empyema with high cell count. Ultrasound-guided aspiration (a) is diagnostic but not therapeutic. Bronchoscopy (c) is for airway issues. Decortication (d) is for failed drainage.

Correct answer: D. Is a treatment of choice for 2nd stage empyema.

The Clagett procedure is used for stage 2 (fibrinopurulent) empyema when tube drainage fails. It is not for debilitated patients (a) or stage 3 (b). Stage 1 (c) is treated with antibiotics and drainage.

Correct answer: B. VATS.

Video-assisted thoracoscopic surgery (VATS) is minimally invasive and effective for draining empyema after failed conservative treatment. Decortication (a) is open surgery for advanced cases. Thoracoplasty (c) is rarely used. Eloesser flap (d) is for chronic empyema but VATS is preferred initially.

Correct answer: C. Pituitary adenoma.

Prolactin-secreting pituitary adenoma is the most common cause of pathological galactorrhea.

Correct answer: C. Bone.

Bone is the most common site of distant metastasis in breast cancer, followed by lung and liver.

Correct answer: B. Modified radical mastectomy.

With extensive DCIS and invasive cancer, modified radical mastectomy (mastectomy + axillary dissection) is appropriate.

Correct answer: A. Fat necrosis.

Post-traumatic fat necrosis can cause hard, tender mass with skin retraction mimicking carcinoma.

Correct answer: C. Fibroadenoma.

Fibroadenoma is common in young women - mobile, firm, rubbery, well-circumscribed 'breast mouse'.

Correct answer: B. Submandibular gland excision.

Excision is diagnostic and therapeutic for persistent solid mass. Neck dissection is for confirmed cancer.

Correct answer: C. Thyroglossal cyst.

Sistrunk's removes thyroglossal cyst with midportion of hyoid bone.

Correct answer: A. Sjogren's syndrome.

Sjogren's has dry eyes, mouth, and parotid enlargement. Sarcoid can have parotid involvement but not typically with dryness.

Correct answer: C. Unilateral recurrent laryngeal nerve.

Unilateral RLN injury causes hoarseness. Bilateral causes stridor. Superior laryngeal causes voice fatigue.

Correct answer: C. Blocked salivary gland duct.

Symptoms suggest salivary duct obstruction, likely a blocked submandibular (Wharton's) or parotid (Stensen's) duct. Mealtime swelling and post-meal resolution are characteristic.

Correct answer: C. Hydrocele.

Hydrocele presents as painless, transilluminant scrotal swelling without cough impulse. Testicular tumor (a) is solid and may not transilluminate. Diaphanography (b) is not a diagnosis. Option (d) is incorrect.

Correct answer: C. Surgical detorsion +/- orchiopexy.

Testicular torsion requires emergency detorsion and fixation. Orchiectomy if non-viable.

Correct answer: A. Reassurance and follow-up.

Varicocele in adolescents is usually benign, but follow-up needed. Surgery if symptomatic or growth arrest.

Correct answer: B. Vesicoureteral reflux.

Reflux nephropathy causes polar scars and contralateral hypertrophy. PUJ obstruction causes hydronephrosis.

Correct answer: C. Hydrocele.

Painless scrotal swelling that transilluminates is classic for hydrocele. No cough impulse rules out hernia.

Correct answer: A. Tracheal intubation and suctioning.

Immediate suctioning via intubation is crucial to clear airways. Steroids and PEEP may be used later but not initially.

Correct answer: B. Hypokalemia.

Hypokalemia causes paralytic ileus due to impaired smooth muscle contraction. Other electrolytes have less direct effect.

Correct answer: B. Double bubble sign.

Double bubble sign shows dilated stomach and duodenum due to atresia. Bird's beak is for esophageal issues.

Correct answer: C. Indirect inguinal hernia.

Indirect inguinal hernia is most common in females. Femoral hernias are more common in females than males but still less common than indirect inguinal.

Correct answer: C. Peritoneal irritation.

Pain localizes to RLQ when inflamed appendix contacts parietal peritoneum (peritoneal irritation).

Correct answer: B. Left-sided chest tube intubation.

Air-fluid levels in chest suggest hemopneumothorax or diaphragmatic injury. Chest tube drainage is priority in a stable patient. CT scan (a) may be done later. Laparotomy (c) is for abdominal injuries if unstable. NG tube (d) is supportive but not definitive.

Correct answer: B. 1mm per day.

Nerve regeneration occurs at approximately 1 mm per day. Options (a) and (d) are too fast. Option (c) is incorrect as only (b) is accurate.

Correct answer: C. Tinel's sign.

Tinel's sign involves tapping along the nerve to detect tingling, indicating nerve regeneration. Homan's sign (a) is for DVT. Chvostek's sign (b) is for hypocalcemia. Battle's sign (d) is for basilar skull fracture.

Correct answer: B. Chest intubation.

Air-fluid level with NG tube suggests diaphragmatic injury or hemopneumothorax. Chest tube drainage (intubation) is the initial step in a stable patient. Thoracotomy (a) is for instability. Pleural tap (c) is diagnostic. Peritoneal lavage (d) is for abdominal trauma. Observation (e) may delay necessary intervention.

Correct answer: A. Needle thoracostomy in 2nd intercostal space mid-clavicular line.

Needle decompression is the immediate emergency treatment for tension pneumothorax.

Correct answer: A. Androgen insensitivity syndrome.

In Complete Androgen Insensitivity Syndrome (CAIS), patients have a 46,XY karyotype but are phenotypically female. They present with primary amenorrhea, normal breast development (due to aromatization of androgens to estrogens), but scant or absent pubic/axillary hair due to end-organ resistance to androgens.

Correct answer: D. Turner syndrome.

The clinical features of short stature, webbed neck, and shield chest in a patient with primary amenorrhea are pathognomonic for Turner syndrome (45,XO).

Correct answer: C. Turner's syndrome.

Short stature, sexual infantilism (no breast development), and classic somatic features like webbed neck and cubitus valgus are characteristic of Turner's Syndrome (45,XO).

Correct answer: A. Complete androgen insensitivity syndrome.

The patient has primary amenorrhea despite normal breast development (indicating functional testes producing estrogen via aromatization). The absence of pubic/axillary hair suggests end-organ resistance to androgens. A blind-ending vaginal pouch is consistent with Complete Androgen Insensitivity Syndrome (CAIS).

Correct answer: D. Urinary.

Mullerian duct anomalies (like a bicornuate uterus) are frequently associated with concurrent anomalies in the development of the kidneys and urinary tract due to the close embryological association.

Correct answer: D. Unexplained infertility.

When all standard investigations (ovulation, tubes, semen) are normal, the diagnosis is unexplained infertility.

Correct answer: C. Tubal factor.

A history of Pelvic Inflammatory Disease (PID) is a major risk factor for tubal factor infertility due to scarring and blockage of the fallopian tubes.

Correct answer: A. Anovulation.

In the presence of regular periods, anovulation is less likely. However, globally and in the context of this question, anovulation (e.g., from PCOS) is one of the most common causes of female infertility. In populations with high rates of PID, tubal factor may be more common, but anovulation remains a leading cause.

Correct answer: A. Inhibition of ovulation.

As above, the primary mechanism is inhibition of ovulation. Thickening of cervical mucus and endometrial changes are secondary mechanisms.

Correct answer: B. Inhibition of ovulation.

The primary mechanism of action of combined oral contraceptive pills is the suppression of gonadotropin-releasing hormone (GnRH), leading to inhibition of the mid-cycle surge of FSH and LH, thereby preventing ovulation.

Correct answer: B. Hysterectomy.

For a woman who has completed her family and desires definitive treatment for heavy menstrual bleeding, hysterectomy is the most appropriate and curative surgical option.

Correct answer: C. Polycystic ovary syndrome.

The combination of oligomenorrhea, hirsutism, and obesity is the classic triad for Polycystic Ovary Syndrome (PCOS). Acne and acanthosis nigricans (signs of insulin resistance) are common associated features.

Correct answer: A. Adenomyosis.

The triad of menorrhagia (heavy periods), secondary dysmenorrhea (increasingly painful periods), and a symmetrically enlarged, boggy, tender uterus is characteristic of adenomyosis.

Correct answer: D. Uterine fibroids.

The combination of heavy menstrual bleeding and an enlarged, irregularly-contoured uterus in a perimenopausal woman is classic for uterine fibroids (leiomyomas).

Correct answer: B. Endometriosis.

The classic triad of secondary dysmenorrhea, deep dyspareunia, and tender nodularity in the pouch of Douglas is highly suggestive of endometriosis.

Correct answer: D. Pelvic inflammatory disease.

The classic triad for Pelvic Inflammatory Disease (PID) is lower abdominal pain, cervical motion tenderness, and adnexal tenderness.

Correct answer: D. Honey moon cystitis.

"Honeymoon cystitis" is a colloquial term for a urinary tract infection (UTI) that occurs in sexually active women, often shortly after initiating sexual activity, due to the introduction of bacteria into the urethra.

Correct answer: D. Honey moon cystitis.

"Honeymoon cystitis" is a colloquial term for a urinary tract infection (UTI) that occurs in sexually active women, often shortly after initiating sexual activity.

Correct answer: D. Nelsseria gonorrhea.

*Neisseria gonorrhoeae* is a Gram-negative diplococcus, which is its characteristic appearance on microscopy.

Correct answer: A. Ceftriaxone.

Gram-negative intracellular diplococci are characteristic of *Neisseria gonorrhoeae*. Ceftriaxone is the recommended first-line treatment for gonorrhea.

Correct answer: C. Premature ovarian insufficiency.

The onset of menopausal symptoms (hot flushes, amenorrhea) and elevated FSH in a woman under 40 years is diagnostic of Premature Ovarian Insufficiency (POI).

Correct answer: A. Menopause.

Menopause is diagnosed retrospectively after 12 consecutive months of amenorrhea in a woman of typical age, accompanied by symptoms like hot flushes and night sweats.

Correct answer: C. Local estrogen.

This describes the Genitourinary Syndrome of Menopause (GSM). Atrophic changes in the urethra and bladder trigone due to estrogen deficiency cause urinary symptoms like frequency and urgency. Local vaginal estrogen is the first-line treatment.

Correct answer: D. Tibolone therapy.

Tibolone has androgenic properties which can be beneficial for symptoms like decreased libido and tiredness in postmenopausal women, in addition to providing estrogenic and progestogenic effects.

Correct answer: D. Tibolone therapy.

This patient has significant risk factors for osteoporosis (low BMI, family history, smoking). Even with minimal vasomotor symptoms, she is a candidate for HRT for osteoporosis prevention. Tibolone is an alternative that provides bone protection and can be used in postmenopausal women.

Correct answer: B. Ectopic pregnancy.

A patient of reproductive age with *abdominal pain and a positive pregnancy test* must be considered to have an *ectopic pregnancy* until proven otherwise.

Correct answer: D. Threatened miscarriage.

A *threatened miscarriage* presents with vaginal bleeding in the first half of pregnancy, with a *closed cervical os* and a *viable fetus* on ultrasound.

Correct answer: B. Inevitable miscarriage.

An *inevitable miscarriage* is characterized by vaginal bleeding and an *open cervical os*, indicating that the products of conception are likely to be expelled.

Correct answer: C. Missed miscarriage.

A *missed miscarriage* (or early fetal demise) is defined as a non-viable pregnancy with a *closed cervical os*. A threatened miscarriage has a closed os with a viable fetus. An inevitable miscarriage has an open os.

Correct answer: B. Ectopic pregnancy.

This is a classic presentation of a ruptured ectopic pregnancy: amenorrhoea, positive pregnancy test, acute abdominal pain, signs of hypovolemic shock (tachycardia, hypotension, syncope), and an empty uterus with an adnexal mass on ultrasound.

Correct answer: C. Endometrial hyperplasia.

Women with PCOS have chronic anovulation and unopposed estrogen stimulation of the endometrium, leading to a very high risk of endometrial hyperplasia.

Correct answer: A. Atrophic vaginitis.

Anticoagulant therapy can cause or exacerbate bleeding from any source, including a fragile atrophic endometrium or vagina. However, the underlying cause (atrophy) is still the most common, and the anticoagulant is a precipitating factor.

Correct answer: A. Atrophic vaginitis.

In a low-risk patient (normal BMI, no other risk factors), atrophic vaginitis remains the most common cause, though investigation is still mandatory.

Correct answer: A. Atrophic vaginitis.

While on HRT, breakthrough bleeding can occur, but atrophic changes are still common. However, any bleeding on HRT must be investigated to rule out pathology.

Correct answer: D. Endometrial hyperplasia.

Tamoxifen has a partial estrogen agonist effect on the endometrium, which significantly increases the risk of endometrial hyperplasia and endometrial cancer.

Correct answer: D. Uterine prolapse.

The descent of the cervix indicates uterine prolapse. A cystocele is descent of the bladder (anterior wall), a rectocele is descent of the rectum (posterior wall), and an enterocele is a herniation of the pouch of Douglas.

Correct answer: C. Stress incontinence.

Stress urinary incontinence is defined as the involuntary leakage of urine upon effort or exertion, or upon sneezing or coughing.

Correct answer: B. Midstream urine test.

As above, the initial step is to rule out infection with a simple midstream urine test.

Correct answer: B. Midstream urine.

The first investigation for urinary incontinence is a urinalysis or midstream urine test to rule out a urinary tract infection, which can cause or exacerbate incontinence.

Correct answer: B. Stress incontinence.

Leakage coinciding with increased intra-abdominal pressure is the hallmark of stress urinary incontinence.

Correct answer: A. Laparoscopy.

The history of cyclical pain and ultrasound findings are suggestive of endometriosis. Laparoscopy is the gold standard for definitive diagnosis, as it allows direct visualization and biopsy of endometrial implants.

Correct answer: A. Hysteroscopic resection of fibroid.

For a submucous fibroid causing HMB in a woman who wishes to avoid medication and preserve her uterus, hysteroscopic resection is the ideal treatment.

Correct answer: C. Speculum examination.

The first step in evaluating postcoital bleeding is a thorough speculum examination to visualize the cervix and vagina for obvious lesions, polyps, cervicitis, or ectropion.

Correct answer: C. Pipelle biopsy.

The essential investigation for postmenopausal bleeding is endometrial sampling. A Pipelle biopsy is an effective outpatient method for this.

Correct answer: A. Endometrial biopsy.

In a woman over 40 with HMB, even if the ultrasound is normal, an endometrial biopsy is indicated to rule out hyperplasia or carcinoma.

Correct answer: D. She needs to take the iron supplements to meet the demands of pregnancy, even though she is not anemic.

Iron requirements increase significantly during pregnancy to support the expansion of maternal red cell mass and fetal growth. A normal hematocrit at 12 weeks does not indicate sufficient iron stores for the entire pregnancy. Prophylactic iron supplementation is recommended to prevent iron deficiency anemia later in pregnancy, which is common and can have adverse effects.

Correct answer: B. Low dose Aspirin.

This is a repeat of the concept from the previous question, confirming its importance. A history of pre-eclampsia is a major risk factor, and low-dose aspirin is the standard for prophylaxis.

Correct answer: A. Aspirin.

Low-dose aspirin (typically 150mg daily from 12 weeks until birth) is recommended for women at high risk of pre-eclampsia, which includes those with a history of hypertension in a previous pregnancy. Hydralazine (b) and Labetalol (c) are used for treating, not preventing, hypertension in pregnancy. Methyldopa (d) is an antihypertensive used for chronic hypertension in pregnancy.

Correct answer: C. Sodium valproate.

While many AEDs have teratogenic potential, sodium valproate is associated with the highest risk of major congenital malformations (especially neural tube defects) and neurodevelopmental disorders. If a woman on valproate presents early in pregnancy, the medication should be reviewed urgently by a neurologist, and switching to a safer alternative is strongly considered. It is the most teratogenic of the listed options.

Correct answer: C. 5 mg once.

Many antiepileptic drugs (e.g., valproate, carbamazepine) are teratogenic and are associated with an increased risk of neural tube defects. Therefore, women on these medications are advised to take a high dose of folic acid (5 mg daily) before conception and during the first trimester to reduce this risk.

Correct answer: B. Diamniotic dichorionic.

The "twin peak" or lambda sign on ultrasound is a characteristic finding in dichorionic twin pregnancies. The "thick intertwin membrane" also supports this. Dichorionic twins always have two amniotic sacs (diamniotic).

Correct answer: C. Low MSAFP, low estriol, high hCG, high inhibin A.

The quad screen pattern for Down syndrome (Trisomy 21) is: Low MSAFP (Maternal Serum Alpha-Fetoprotein), Low Unconjugated Estriol (uE3), High hCG, and High Inhibin A. This pattern is used to calculate a risk score for the condition.

Correct answer: A. Crown rump length.

In the first trimester (up to 13-14 weeks), the Crown-Rump Length (CRL) is the most accurate sonographic measurement for determining gestational age, with an accuracy of ±5-7 days.

Correct answer: C. Crown rump length.

Crown-Rump Length (CRL) is the most accurate parameter for dating a pregnancy between 7 and 14 weeks. After 14 weeks, other parameters like Biparietal Diameter (BPD) are used.

Correct answer: D. G5P4+0.

Gravida 5 (current pregnancy is 5th), Para 4 (3 alive children + 1 infant death = 4 total births), +0 (no miscarriages/abortions before 20 weeks).

Correct answer: C. Fetal kidney.

After approximately 16-20 weeks, the primary source of amniotic fluid is fetal urine produced by the kidneys. The fetal lungs also contribute, but fetal urine is the major component.

Correct answer: C. Placental insufficiency.

The combination of maternal hypertension (suggesting pre-eclampsia), a small-for-gestational-age fetus, and oligohydramnios is highly indicative of uteroplacental insufficiency. The placenta is not functioning optimally, leading to reduced fetal renal perfusion and, consequently, reduced urine output (a major contributor to amniotic fluid).

Correct answer: C. normal.

A normal Amniotic Fluid Index (AFI) at this gestation is between 5 cm and 25 cm. An AFI of 15 cm is well within the normal range.

Correct answer: A. Defective fetal swallowing.

Amniotic fluid volume is regulated in part by fetal swallowing. Conditions that impair fetal swallowing lead to a buildup of fluid, causing polyhydramnios.

Correct answer: B. Multicystic kidney.

Diabetes, multiple gestation, and anencephaly are common causes of polyhydramnios. Multicystic dysplastic kidney disease, however, typically leads to oligohydramnios because the fetal kidneys are not producing urine, making it the exception.

Correct answer: C. Low birth weight.

Maternal smoking is a major cause of intrauterine growth restriction (IUGR) due to placental insufficiency and chronic fetal hypoxia, leading to babies being born with low birth weight.

Correct answer: A. Fetal anomalies.

The greatest and most specific risk of heavy, chronic alcohol use during pregnancy is a spectrum of permanent birth defects known as Fetal Alcohol Spectrum Disorders (FASD), which can include facial dysmorphism, growth restriction, and neurodevelopmental disorders.

Correct answer: C. Symptomatic treatment and continue pregnancy.

This describes Hepatitis C in pregnancy. HCV is not an indication for termination. Treatment with direct-acting antivirals is now possible but often deferred until postpartum. Management is largely symptomatic and supportive, with continuation of pregnancy.

Correct answer: C. Low molecular weight heparin.

Low Molecular Weight Heparin (LMWH) does not cross the placenta and is safe throughout pregnancy. Warfarin is teratogenic in the first trimester.

Correct answer: C. Serum TSH.

The symptoms described are classic for hypothyroidism. The first-line test is a Thyroid-Stimulating Hormone (TSH) level.

Correct answer: B. General.

For a manual removal of the placenta in a patient who is unstable or in shock, general anesthesia is the preferred method. It provides rapid onset of anesthesia and allows for control of the airway. Regional anesthesia is relatively contraindicated in hypovolemic shock.

Correct answer: B. Increase of hypothalamic prolactin.

Suckling stimulates the hypothalamus to release Prolactin-Releasing Hormone (or inhibit dopamine, which is a prolactin-inhibiting factor). This leads to an increase in prolactin secretion from the anterior pituitary, which is essential for milk production.

Correct answer: A. Breast binder.

For a mother who is not breastfeeding, management of breast engorgement involves suppressing lactation. This is achieved by avoiding breast stimulation, using a tight breast binder or supportive bra, and applying cold packs for comfort.

Correct answer: A. Lovset.

The Lovset maneuver is specifically used for delivering the shoulders in a breech presentation. It involves rotating the fetal trunk to bring the anterior shoulder to the posterior position, facilitating its delivery.

Correct answer: B. Engagement.

Engagement is defined as the passage of the widest diameter of the presenting part (usually the biparietal diameter in a vertex presentation) through the pelvic inlet. It is confirmed when the presenting part is at station 0 or below.

Correct answer: A. Erb palsy.

The posture described ("waiter's tip" position - arm adducted and internally rotated, forearm extended and pronated) is classic for Erb-Duchenne palsy. This is a brachial plexus injury (specifically C5-C6 roots) that can occur during shoulder dystocia due to excessive lateral traction on the head.

Correct answer: C. Pelvic contraction.

A transverse lie requires ample room in the uterus. Conditions that increase uterine space or prevent engagement predispose to transverse lie. Pelvic contraction reduces space and would more likely lead to a persistent cephalic presentation or non-engagement, not a transverse lie.

Correct answer: C. Emergency LSCS.

This is a complex scenario: a primigravida with uncontrolled diabetes (risk of macrosomia and shoulder dystocia) and a breech presentation. The safest mode of delivery for a term breech, especially with other risk factors, is Caesarean section.

Correct answer: A. Transverse diameter at inlet is 13.5 cm.

In a gynecoid pelvis, the transverse diameter of the inlet is approximately 13.5 cm, which is wider than the anteroposterior diameter (11 cm).

Correct answer: B. The normal bipartial diameter is 9.5cm.

The average biparietal diameter at term is 9.5 cm. The anterior fontanelle is diamond-shaped, and the posterior is triangular.

Correct answer: B. Placental abruption.

Classic signs of severe abruption: pain, bleeding, shock, tense uterus, fetal distress.

Correct answer: C. Uterine rupture.

The triad of severe abdominal pain, maternal shock, and absent fetal heart sounds is highly suggestive of a catastrophic uterine rupture, especially in a grand multiparous woman (G4P3).

Correct answer: A. Placenta previa.

This is the classic presentation of placenta previa: painless vaginal bleeding with a soft, non-tender uterus and a normal fetal heart rate.

Correct answer: B. Placental abruption.

This is a classic presentation of a severe placental abruption: sudden onset of pain, vaginal bleeding (often dark), a tender and tense ("woody") uterus, maternal shock, and fetal distress.

Correct answer: D. Vasa previa.

The classic triad for vasa previa is: 1) Rupture of membranes, 2) Sudden onset of painless vaginal bleeding, and 3) Fetal bradycardia. The bleeding is fetal blood from ruptured fetal vessels running in the membranes over the cervix. The history of a low-lying placenta earlier in pregnancy is also a risk factor.

Correct answer: A. Fetal aneuploidy.

The vast majority (~50-60%) of first-trimester miscarriages are caused by chromosomal abnormalities in the fetus, with autosomal trisomies being the most common.

Correct answer: C. Nasal hypoplasia.

Warfarin is a known teratogen. Exposure in the first trimester can cause a specific pattern of anomalies known as Fetal Warfarin Syndrome (or embryopathy), which includes nasal hypoplasia, stippled epiphyses, and eye/central nervous system abnormalities. Neural tube defects are associated with other medications (e.g., valproate) and folate deficiency.

Correct answer: C. Sodium valproate.

Sodium valproate carries the highest teratogenic risk among common AEDs, including neural tube defects, cardiac anomalies, and neurodevelopmental disorders. If a woman presents early in pregnancy on valproate, it should be reviewed urgently by a neurologist with the aim of switching to a safer alternative.

Correct answer: B. Rh isoimmunization.

A history of progressively worse fetal outcomes (hydrops) in subsequent pregnancies is classic for Rh isoimmunization. The maternal antibodies attack fetal red blood cells in each subsequent pregnancy, leading to severe anemia, heart failure, and hydrops.

Correct answer: B. Genetic abnormalities.

The most common cause of recurrent first-trimester miscarriage is fetal chromosomal abnormalities.

Correct answer: B. Retained products of conception.

Secondary PPH (bleeding after the first 24 hours up to 12 weeks postpartum) is most commonly caused by retained products of conception or endometritis.

Correct answer: D. Uterine atony.

Uterine atony (failure of the uterus to contract after delivery) is the most common cause of primary postpartum hemorrhage, accounting for about 80% of cases.

Correct answer: B. General.

For a manual removal of the placenta in a patient who is unstable or in shock, general anesthesia is the preferred method. It provides rapid onset of anesthesia, allows for control of the airway and ventilation, and enables the procedure to be performed quickly and safely. Regional anesthesia (epidural/spinal) is relatively contraindicated in hypovolemic shock due to the risk of profound hypotension.

Correct answer: C. LMWH 60mg per day for 6 weeks postnatally.

This patient has multiple high-risk factors for VTE: age >35, high BMI (>30), cesarean delivery, and multiple pregnancy. In such high-risk scenarios, guidelines recommend thromboprophylaxis with LMWH for 6 weeks postpartum. The dose (e.g., 60mg) would be a prophylactic or intermediate dose based on her BMI and local protocol.

Correct answer: B. 2° degree.

A second-degree perineal tear involves the skin, vaginal mucosa, and perineal muscles (bulbocavernosus, transverse perineal) but does not involve the anal sphincter.

Correct answer: C. Rotavirus.

The rotavirus vaccine is a live attenuated oral vaccine. It is contraindicated in infants with known severe combined immunodeficiency (SCID) and should be avoided in infants with HIV infection, depending on the degree of immunosuppression. Since the infant's status is unknown and there is a known risk of HIV exposure, it is safest to withhold the live vaccine until the immune status is confirmed. IPV, DTaP, and Hib are inactivated or subunit vaccines and are safe.

Correct answer: C. MMR.

Immunosuppressive therapy like high-dose steroids is a contraindication for live attenuated vaccines due to the risk of uncontrolled viral replication. MMR is a live vaccine. Cholera (killed), Hepatitis B (recombinant), and Pertussis (component of DTaP, which is inactivated) are safe.

Correct answer: B. Continue breast feeding and start INH.

Breastfeeding should not be interrupted due to its immense nutritional and immunological benefits. The infant is at high risk of infection and should receive Isoniazid (INH) prophylaxis. The baby does not need isolation if the mother is on treatment and wearing a mask, but the key intervention is chemoprophylaxis for the infant.

Correct answer: B. MMR vaccine.

Live attenuated vaccines contain weakened versions of the virus that can replicate without causing disease, provoking a strong and lasting immune response similar to natural infection. MMR is a classic example. Hepatitis B is recombinant, DTaP contains toxoids and purified components, and Hib is a conjugate vaccine---all are inactivated.

Correct answer: B. Diphtheria, tetanus, pertussis, Hib, hepatitis B.

The Pentavalent vaccine is a combination vaccine that reduces the number of injections. It contains antigens for Diphtheria (toxoid), Tetanus (toxoid), Pertussis (killed/acellular), Haemophilus influenzae type b (conjugate polysaccharide), and Hepatitis B (recombinant surface antigen). It does not contain antigens for meningococcus, pneumococcus, polio, or rotavirus.

Correct answer: A. 2 SD below mean.

Pathological (or significant) short stature is statistically defined as a height that is more than 2 standard deviations below the mean for age and sex.

Correct answer: D. X-linked Recessive.

The clinical picture (calf pseudohypertrophy, Gower's sign, progressive weakness) is classic for Duchenne Muscular Dystrophy (DMD). DMD is caused by a mutation in the dystrophin gene on the X chromosome and follows an X-linked recessive pattern, primarily affecting males.

Correct answer: B. 3 months.

This question tests the same conceptual milestone cluster as question 13, reinforcing that visual tracking, head control, social smile, and response to sound are consolidated at 3 months.

Correct answer: D. Positive Ortolani test.

Asymmetrical skin folds and a history of breech presentation are red flags for Developmental Dysplasia of the Hip (DDH). The Ortolani test (a "clunk" felt as the dislocated femoral head reduces into the acetabulum) is a specific maneuver to diagnose DDH in infants.

Correct answer: D. Karyotype / Blood chromosome analysis.

The clinical description is classic for Down syndrome (Trisomy 21). The definitive diagnostic test is karyotype analysis to confirm the extra chromosome 21. Other tests might be used to screen for associated conditions but cannot confirm the diagnosis.

Correct answer: B. Kwashiorkor.

The presence of edema is the cardinal sign that distinguishes Kwashiorkor from Marasmus. Additional features like hair changes (sparse, depigmented), skin changes, and irritability are also characteristic of Kwashiorkor, which is protein deficiency despite adequate caloric intake.

Correct answer: A. Vitamin-A.

Keratomalacia is the softening and ulceration of the cornea due to severe Vitamin A deficiency, which can lead to blindness.

Correct answer: C. Foods such as eggs should be avoided.

This question seems to be testing outdated or specific regional guidelines. Historically, allergenic foods like eggs were avoided. Current evidence suggests early introduction may prevent allergies. However, among the options, the one that was a common recommendation is to avoid certain foods like eggs. The other options are incorrect: Cow's milk can be introduced at 12 months, milk remains an important part of the diet beyond 1 year, and food textures should advance progressively, not remain liquidized until 18 months.

Correct answer: D. IgA anti-endomysial antibody positive.

The child has chronic diarrhea, failure to thrive, and an aversion to gluten-containing foods (bread, pasta). This is highly suggestive of celiac disease. The IgA anti-endomysial antibody is a highly specific serological test for celiac disease. The Delta F508 mutation is for cystic fibrosis, which also causes FTT and diarrhea, but the food aversion is more specific to celiac.

Correct answer: D. Lactose intolerance.

Secondary (acquired) lactose intolerance is a common sequelae of viral gastroenteritis (e.g., rotavirus) which damages the intestinal brush border, temporarily reducing lactase enzyme. This leads to acidic stools (low pH) and positive reducing substances due to undigested lactose fermenting in the gut.

Correct answer: D. Shigella.

Shigella is one of the most common causes of bloody diarrhea (dysentery) worldwide, especially in children. It invades the colonic mucosa, causing inflammation, ulceration, and bloody stools.

Correct answer: B. Vibrio cholera.

Vibrio cholerae causes a profuse, watery "rice-water" diarrhea without blood or pus. In contrast, Shigella, Salmonella, Campylobacter, and enteroinvasive E. coli can cause invasive, inflammatory diarrhea with blood (dysentery).

Correct answer: A. E.coli.

Escherichia coli is responsible for approximately 80-90% of community-acquired UTIs in children, due to its virulence factors that promote colonization and invasion of the urinary tract.

Correct answer: D. Urinary tract infection.

Similar to the previous question, the acute presentation with irritative voiding symptoms and pyuria points to UTI. Posterior urethral valves and AGN present differently.

Correct answer: C. Urinary tract infection.

The combination of fever, dysuria, and urinalysis showing pyuria (pus cells) and hematuria is classic for a urinary tract infection (UTI). AGN typically presents with hypertension, edema, and cola-colored urine without dysuria.

Correct answer: C. Non-invasive ventilation.

When a child with status asthmaticus fails to respond to maximal medical therapy (SABA, steroids, magnesium), the next step is respiratory support. Non-invasive ventilation (like CPAP or BiPAP) can be tried to reduce work of breathing and improve gas exchange while medical therapy takes effect. Intubation is the last resort.

Correct answer: B. IV magnesium sulphate.

In a severe asthma exacerbation not responding to SABA and systemic steroids (so-called "status asthmaticus"), IV Magnesium Sulphate is a recommended next-line therapy. It acts as a bronchodilator and is particularly useful in severe cases.

Correct answer: D. Oral corticosteroids.

For an acute asthma exacerbation not responding adequately to initial SABA therapy, systemic corticosteroids (oral or IV) are the next critical step to reduce airway inflammation. They have a delayed onset of action (several hours) so should be given early.

Correct answer: A. Inhaled salbutamol.

This is an acute asthma exacerbation. The first-line treatment is a short-acting beta-2 agonist (SABA) like salbutamol via nebulizer or MDI with spacer to provide rapid bronchodilation. Other agents can be added if the response is poor.

Correct answer: A. Asthma.

While all can be associated with pneumothorax, asthma is the most common underlying lung disease in children that leads to spontaneous pneumothorax due to hyperinflation and rupture of blebs.

Correct answer: A. Wilson disease.

The combination of liver disease, neuropsychiatric symptoms (choreiform movements, cognitive decline), and a family history is classic for Wilson's disease (copper accumulation).

Correct answer: A. He likely has hypochloremic metabolic alkalosis.

In pyloric stenosis, the loss of gastric acid (HCl) from persistent vomiting leads to hypochloremic, hypokalemic metabolic alkalosis. It is more common in males.

Correct answer: A. A healthy 15-month-old with severe paroxysmal abdominal pain and vomiting.

Intussusception typically occurs in previously healthy infants and toddlers (peak 3 months to 3 years) and presents with paroxysmal abdominal pain and vomiting.

Correct answer: C. Necrotizing enterocolitis.

NEC is a common condition in preterm, low birth weight infants, especially after perinatal stress. The triad of vomiting, abdominal distension, and bloody stools is classic.

Correct answer: D. Pyloric stenosis.

Pyloric stenosis.

Correct answer: C. Subgaleal hemorrhage.

A subgaleal hemorrhage is a collection of blood in the potential space between the galea aponeurotica and the periosteum. It can cross suture lines, is fluctuant, and can lead to massive blood loss and shock (pallor, tachycardia) as it expands.

Correct answer: A. Cephalhematoma.

Cephalhematoma is a collection of blood under the periosteum of a skull bone. Because it is bound by the periosteal attachments at the suture lines, it does NOT cross them.

Correct answer: B. Caput succedaneum.

Caput succedaneum is a subcutaneous, serosanguinous fluid collection external to the periosteum that crosses suture lines. It is caused by pressure on the presenting part during delivery. Cephalhematoma is a subperiosteal hemorrhage that does NOT cross suture lines.

Correct answer: A. Congenital diaphragmatic hernia.

This is a classic presentation of a left-sided congenital diaphragmatic hernia: respiratory distress at birth, absent breath sounds on the affected side, and mediastinal shift (apex beat to the right).

Correct answer: C. Esophageal atresia.

Esophageal atresia (often with Tracheoesophageal Fistula) prevents the fetus from swallowing amniotic fluid, leading to polyhydramnios. After birth, it presents with respiratory distress due to aspiration of oral secretions.

Correct answer: B. Mitral stenosis.

An opening snap followed by a mid-diastolic rumble is the classic auscultatory finding in Mitral Stenosis. In children, this is almost always due to Rheumatic Heart Disease.

Correct answer: C. Mitral regurgitation.

A holosystolic murmur at the apex radiating to the axilla is the hallmark of Mitral Regurgitation. In infants, severe MR can lead to heart failure, manifesting as failure to thrive, tachypnea, and hepatomegaly. This could be due to congenital anomaly or as a sequela of rheumatic carditis.

Correct answer: A. Aortic stenosis.

A systolic ejection murmur loudest at the right upper sternal border (aortic area) that radiates to the neck (carotids) is characteristic of Aortic Stenosis. Exercise intolerance is a common symptom.

Correct answer: C. Truncus arteriosus.

In Truncus Arteriosus, there is only one great artery arising from the heart, so there is only one semilunar valve. This results in a single, loud second heart sound. Cyanosis is present due to mixing of systemic and pulmonary venous blood.

Correct answer: B. Rheumatic fever.

Elevated ASO titer provides evidence of a preceding Group A Streptococcal infection, which is required for the diagnosis of Acute Rheumatic Fever (ARF) according to the Jones Criteria. The presence of arthritis, rash (erythema marginatum), and carditis (murmur) are major criteria.

Correct answer: B. Guillain barre syndrome.

The acute onset of ascending flaccid paralysis with areflexia following an acute gastroenteritis (AGE) is classic for GBS.

Correct answer: A. Infantile spasms.

Infantile spasms are characterized by clusters of brief, symmetric contractions (salaam spells) and developmental regression.

Correct answer: B. Spastic CP.

Spastic CP is due to damage to the motor cortex or pyramidal tracts. Athetoid CP is due to basal ganglia damage, and ataxic CP is due to cerebellar damage.

Correct answer: D. Lumbar puncture.

The presentation of fever and seizures in an infant warrants a lumbar puncture to rule out meningitis, especially because the fontanelle is not bulging (which can be absent even in meningitis) and there are no focal signs.

Correct answer: C. Febrile fit.

Febrile seizure.

Correct answer: C. Peritonitis.

This is a repeat question emphasizing the high risk of spontaneous bacterial peritonitis in children with nephrotic syndrome, especially those on steroids.

Correct answer: C. Peritonitis.

This is a repeat question emphasizing the high risk of spontaneous bacterial peritonitis in children with nephrotic syndrome, especially those on steroids.

Correct answer: C. Peritonitis.

This is a repeat question emphasizing the high risk of spontaneous bacterial peritonitis in children with nephrotic syndrome, especially those on steroids.

Correct answer: C. Peritonitis.

This is a repeat question emphasizing the high risk of spontaneous bacterial peritonitis in children with nephrotic syndrome, especially those on steroids.

Correct answer: C. Peritonitis.

This is a repeat question emphasizing the high risk of spontaneous bacterial peritonitis in children with nephrotic syndrome, especially those on steroids.

Correct answer: D. Expansion of bone marrow spaces.

The bone deformities (skull, facies) in thalassemia major are a direct result of massive expansion of the bone marrow in an attempt to compensate for the severe anemia. Iron overload is a complication of treatment, not the cause of the morphological features.

Correct answer: C. Hb Electrophoresis.

Hemoglobin electrophoresis is the definitive test for diagnosing thalassemia, as it identifies the abnormal hemoglobin pattern (elevated HbA2, HbF).

Correct answer: D. Von Willebrand's disease.

The combination of a prolonged bleeding time with normal platelet count, normal PT, and normal PTT is classic for Von Willebrand Disease (VWD). Hemophilia would have a prolonged PTT. The anemia is likely due to chronic blood loss.

Correct answer: A. Iron deficiency anemia.

Exclusive cow's milk feeding in infancy is a classic cause of iron deficiency anemia, as cow's milk is low in iron and can cause microscopic gut blood loss.

Correct answer: A. Beta thalassemia.

The combination of severe microcytic anemia, hepatosplenomegaly, growth retardation, and classical facies (frontal bossing, maxillary overgrowth) with elevated HbF is diagnostic for Beta Thalassemia Major.

Correct answer: B. Vesico ureteric reflux.

Vesicoureteric reflux (VUR) is the most common underlying anatomical abnormality found in children with recurrent UTIs.

Correct answer: A. E.coli.

Escherichia coli is the most common causative organism for UTIs in children, accounting for the vast majority of community-acquired infections.

Correct answer: D. Urinary tract infection.

This presentation is dominated by lower urinary tract symptoms (dysuria, frequency, urgency) and pyuria, which is classic for a Urinary Tract Infection (UTI), specifically cystitis, which can cause gross hematuria.

Correct answer: B. Acute glomerulonephritis.

Gross hematuria in a child with an unremarkable exam is most suggestive of a glomerular disease like Acute Glomerulonephritis. While UTI can cause hematuria, it's less likely to be the primary cause of gross hematuria without prominent dysuria.

Correct answer: C. Protein:Creatinine ratio.

The specific investigation to confirm nephrotic-range proteinuria is a spot urine protein-to-creatinine ratio, which is a practical and reliable alternative to a 24-hour urine collection in children.