COC 2022 reviwed

For acadamic purpose only

prep by ; Dr Brook G

Choose the correct answer from the given alternatives

1. A 26 year old male patient presented with headache, fever and neck pain. On physical
examination he has a temperature of 39.2 degree celcius and all meningeal signs are
positive. All of the following findings of CSF analysis suggest pyogenic meningitis
EXCEPT:
A. A CSF WBC count of 10,000 per microliter
B. A CSF glucose concentration of 28mg/dl
C. A CSF protein concentration of 20mg/dl
D. An intracellular gram negative diplococcic on gram stain

2. A 33 years old female patient from Chencha is admitted to E ward after presenting with a
compliant of reddish discoloration of urine of 2 days duration. In addition to this she has
also a Blood pressure record of 150/100mmHg and bilateral pitting leg edema. Urinalysis
showed many dysmorphic RBs and proteinuria of +3. Her creatinine level is 5.4mg/dl. 4
months back she had a creatinine measurement of 1.1mg/dl. What is the most likely
diagnosis?
A. Nephrotic Syndrome
B. Acute glomeluronephritis
RFT is normal in nephrotic syndrome unless it has
C. Acute pyelonephritis nephritic componenet

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 D. CKD

3. Which one of the following laboratory investigation is important to make a definitive

diagnosis of UTI?
A. >5 WBC/HPF on urine microscope
B. Bacteria on gram stain of clean catch urine
C. Culture
D. Leukocytosis
-For all patients with suspected acute complicated UTI
, we send urine for both urinalysis (either by
microscopy or by dipstick) and culture with
susceptibility testing. Urinalysis results inform the
diagnosis. Since pyuria is present in almost all patients
with UTI; its absence suggests an alternative
diagnosis, particularly in patients who present with
nonspecific symptoms. uptodate 2022.

- I would say C, since it says definitive. although

routine dx needs only SX + Pyuria.
-The presence of pyuria (10 WBC/mm3 of
uncentrifuged urine) alone is not sufficient for
diagnosis of UTI or bacteriuria. More than 60% of
samples in women with asymptomatic pyuria have no
bacteriuria.(STG)
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 4. Which one the following is not common complication of malaria on pregnancy
- general, parasitemia is more prevalent in pregnant
A. High-level parasitemia with anemia compared with nonpregnant women , with increased risk as
early as the first trimester.
B. Hypoglycemia - Anemia is a common complication of malaria in pregnancy;
approximately 60 percent of pregnant women presenting with
C. Acute pulmonary edema. malaria infection are anemic [53,54], and anemia may be
one of the few signs of the disease. uptodate 2022
D. Convulsions

Compared with nonpregnant women, pregnant women experience more severe

disease, including more hypoglycemia and more respiratory complications
(pulmonary edema, acute respiratory distress syndrome) [46]. For example,
hypoglycemia occurs in 58 percent of pregnant women [47] versus
approximately 8 percent of nonpregnant adults [48].uptodate 2022

-Severe anaemia, exacerbated by malaria, is an important complication of

pregnancy in many tropical
countries
- in non-immune women, severe malaria symptoms (hypoglycaemia, cerebral
malaria, and pulmonary oedema being particular problems) are more common in
pregnancy. Malaria National guideline 2022

- i would say D, because ,

convulsion is the less mentioned complication in national guideline and none
mentioned in uptodate

5. One the following is not part of management of cerebral malaria

A. Give artesunate as protocol
B. Put on intra nasal oxygen
C. Insertion of NG tube for feeding and catheterization
D. None

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 6. In chronic hepatitis B virus infection, presence of hepatitis B e antigen signifies which of
Hepatitis B e antigen (HBeAg) is a secretory protein that is processed
the following? from the precore protein. It is an early antigen and not an envelope
antigen. It is generally considered to be a marker of HBV replication
A. Development of liver fibrosis and infectivity
B. Increased likelihood of an acute fare in the next 1–2 weeks
C. Ongoing viral replication
D. Resolving infection
According to the CDC, a hepatitis B blood test result (or serologic marker) varies depending on whether the infection is
a new acute infection or a chronic infection.

HBsAg (hepatitis B surface antigen) is the first serologic marker to appear in a new acute infection, which can be
detected as early as 1 week and as late as 9 weeks, with an average of one month after exposure to the hepatitis B
virus (HBV).
- HBsAg is detectable for a variable amount of time, along with the HBV DNA, though about 50% of persons will test
HBsAg and HBV DNA negative 7 weeks after symptoms.

- All persons who spontaneously recover from an infection will test negative for HBsAg and negative for HBV DNA about
15 weeks after the appearance of symptoms.

Anti-HBs or HBsAb (hepatitis B surface antibody) – this becomes detectable on a blood test after the disappearance of
HBsAg in persons who are able to get rid of the virus and avoid a chronic infection. The presence of anti-HBs following
a new acute infection generally indicates recovery and a person is then protected (or “immune”) from re-infection with
hepatitis B.

Anti-HBc or HBcAb (hepatitis B core antibody) – this blood test remains positive indefinitely as a marker of past HBV
infection.

HBeAg (hepatitis B e-antigen) is generally detectable in patients with a new acute infection; the presence of HBeAg is
associated with higher HBV DNA levels, thus, increased infectiousness.

IgM anti-HBc – a positive blood test result indicates a person has a new acute hepatitis B infection.IgM anti-HBc is
generally detectable at the time symptoms appear and declines to sub-detectable levels within 6 - 9 months.

Note: An acute exacerbation (or liver flare) in a chronic HBV infection can also result in a positive anti-HBc IgM test
result. So follow-up testing after 6 months is required.
IgG anti-HBc – this blood test remains positive indefinitely as a marker of past HBV infection.
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 7. One of the following management in tetanus used for eradication of c. Tetani
A. Human tetanus immune globulin (tig By Halting the toxin production and neutralization of
the unbound toxin
B. Tetanus anti toxin-
Antimicrobial treatment as a means for halting
C. Metronidazole toxin production by killing the anerobic replicating
bacteria
D. Diazepam Control of muscle spasms and prevent serious complications like laryngeal spasm

There is no effective treatment against rabies.it is almost always fatal ; Recovery

is exceedingly rare and has only occurred in cases where intensive respiratory
and cardiac supports were available
encephalitic rabies include ; Confusion, delirium, altered mentation, agitation, hallucinations.Spasms in response to
touch, noise, visual, or olfactory stimuli. Phobic spasms: hydrophobia (fear of water) and aerophobia (fear of air):
strong evidence for rabies. Autonomic system dysfunction: enlarged pupils, increased production of saliva, tears,
perspiration and Generalized arousal or hyperexcitability associated with disorientation, fluctuating consciousness,
restlessness, agitation, and visual or auditory hallucinations.Fever is in a prodrome phase not in Encephalitic rabies
phase.
Postexposure prophylaxis (PEP) ; Decide on post-exposure vaccination and
immunoglobulin use depending on the type of contact with the rabid animal
Category of exposure.

Category I ; Touching or feeding animals, licks on the skin, contact of intact skin with
secretions or excretions of rabid animal or person.
;- No PEP is required , only Wash exposed skin Surfaces.

Category II ; Nibbling of uncovered skin, minor

scratches or abrasions without bleeding
;- Wound washing and immediate vaccination , no need of IG

Category III ; Single or multiple transdermal bites or scratches, licks on broken skin,
contamination of mucous membrane with saliva from licks; exposure to bat bites or
scratches
;- Wound washing and mmediate vaccination and administration of rabies
immunoglobulin
8. Which one the following true about rabies
A. There is not definitive or curative treatment for rabid patients
B. The classic presentation of encephalitic rabies includes fever, hydrophobia,
pharyngeal spasms
C. Post exposure rabies prophylaxis, in previously unimmunized persons, should
always include both passive and active immunization.
D. All

9. 57 years old known hypertensive patient presented with exertional dyspnea of 2 weeks
duration. On examination there is dullness on the Right lower 1/3 of posterior chest with

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 decreased tactile fremitus and PMI shifted to lateral of left MCL. Which one is true
regarding this patient?
A. No need for pleural fluid analysis
B. Normal CXR is expected in this patient
C. ACE inhibitors do not have benefit for this patient
D. The precordial examination findings are normal

10. Abeba is known asthmatic for the past 06 years, presented with compliant of shortness of
breath which doesn’t respond for Salbutamol. She has history of repeated hospital
admission. On examination RR=54, SO2 =81%. She uses her accessory muscles and she
cannot able to speak. Chest is hyper-resonant on auscultation. Which one of the following
is not true regarding management of this patient?
A. Oxygen, 2–4 L/min nasal cannula or 40–60% by mask
B. Salbutamol 6 puff every 20 min for 01 hr

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 C. IV Hydrocortisone 100mg QID
D. Ceftriaxon 01 grm IV BID with Azythromycin 500 mg PO daily

11. Which one of the following combination of drugs is appropriate for secondary prevention
after acute myocardial infarction?
when ever encountering such like Q, choose options with the
A. Aspirin, Simvastatin, Morphine & Nitrates f.f 3 drugs ' BB +ASPRIN/CLOPIDOGREL+STATINS ' as
they are the back bone for prevention as well for acute RX of
B. Enalapril, Simvastatin, Digoxin &Aspirin atherosclerotic CVD.
- Additional drugs will be there depending on clinical
C. Aspirin, Enalapril, Metoprolol& Simvastatin scenario of the pt.
- BB has additional anti pain role in preventive /therapeutic
D. Amlodipine, Aspirin, Morphine &Simvastatin mx of atheroschelorotic CVD , so may take the role of nitrites
in these question .

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 12. Tamirat is a known cardiac patient, develops dyspnea and PND. On P/E PMI is shifted to
lateral of MCL & CXR shows cardiomegaly. His echocardiography report is consistent
with dilated cardiomyopathy. Which one of the following causes of DCMP has grave
prognosis? Compared with those with an idiopathic cardiomyopathy, which served
A. HIV related CMP as the reference group, the following findings were noted (figure 1):

Survival was better in patients with peripartum cardiomyopathy (HR 0.

B. Peripartum CMP 31).
C. Alcoholic CMP Survival was worse in patients with infiltrative myocardial disease,
particularly amyloidosis or hemochromatosis (HR 7.41 and 8.88,
D. Idiopathic CMP respectively), HIV infection (HR 5.86), doxorubicin therapy (HR 3.46),
ischemic heart disease (HR 1.52), or connective tissue disease (HR 1.
75).

Survival was the same in patients with hypertension, myocarditis,

sarcoidosis, substance abuse, or other causes.

a better prognosis with alcohol-induced cardiomyopathy

than with idiopathic dilated cardiomyopathy

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 13. What is the leading cause of MS?
A. Rheumatoid arthritis
B. Rheumatic fever
C. Infective endocarditis
D. Dilated CMP

- Rheumatic heart disease (RHD) is the most common cause of mitral stenosis (MS); other causes are much less frequent . However, only
50 to 70 percent of patients with MS report a history of rheumatic fever.

- other causes of MS are ;

-Mitral annular calcification is a common disorder, particularly in older adults, that rarely leads to hemodynamically significant MS
- Radiation-associated valve disease
- Congenital causes of MS
- rare conditions include Fabry disease, Whipple disease, mucopolysaccharidosis, methysergide therapy, carcinoid valve disease,
endomyocardial fibrosis, and systemic rheumatic disease (such as systemic lupus erythematosus and rheumatoid arthritis).

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Test Iron deficiency anemia Alpha or beta thalassemia Anemia of chronic disease/inflammation

Hemoglobin Decreased Decreased Decreased

Mean corpuscular volume (MCV) Decreased Decreased Normal to decreased
Red cell distribution width (RDW) Increased Increased or normal Normal to increased
Red blood cell count Decreased Increased or normal Decreased
Iron studies
Serum iron Decreased Normal or increased Decreased
Total iron-binding capacity (TIBC); transferrin Increased Normal Decreased
Transferrin saturation (TSAT) Decreased Normal Normal to decreased
Serum ferritin Decreased Normal or increased Increased
Erythrocyte protoporphyrin* Increased Normal or increased Increased
Soluble transferrin receptor* Increased Increased Normal
Reticulocyte hemoglobin equivalent Decreased Decreased Normal
C-reactive protein Normal Normal Increased
Serum hepcidin* Decreased Normal to decreased increased

14. A 50-year-old woman has complained of pain and swelling in her proximal
interphalangeal joints, both wrists and knees. She complains of morning stiffness. She
has had a hysterectomy 10 years ago. Physical exam shows swelling and thickening of
the PIP joints.Hemoglobin is 10.3 g/dL, MCV 80 fl, serum iron 8 μmol/L, ironbinding
capacity 40 μmol/L (normal: 45 to 66), saturation 20%. The most likely explanation for
this woman’s anemia is
A. Occult blood loss The iron studies in Anemia of Chronic Disease ACD/AI show low circulating but
sufficient storage iron, with the following findings typically seen :
B. Vitamin deficiency
Serum iron concentration is low (normal range, 60 to 150 mcg/dL [0.6 to 1.5 mg/L];
C. Anemia of chronic disease 11 to 27 microM/L).

D. Sideroblastic anemia Transferrin (also measured as total iron binding capacity [TIBC]) is low (normal
range, 300 to 360 mcg/dL [3 to 3.6 mg/L]; 54 to 64 microM/L).

Transferrin saturation (TSAT) is low (<20 percent in approximately four-fifths of

cases; normal range, 20 to 45 percent). It may be "pseudo-normal" if patients have
very low transferrin concentrations (eg, <200 mcg/dL) [18].

Ferritin is normal or increased; generally >100 mcg/L (normal ranges, 30 to 200

mcg/L [30 to 200 ng/mL] for women and 30 to 300 mcg/L [30 to 300 ng/mL] for
men); in some countries the upper threshold may be up to 400 mcg/L.

Some of these findings are also characteristic of iron deficiency anemia, including
low serum iron and low TSAT (table 2). (See 'Differential diagnosis' below.)

In contrast, unlike ACD/AI, in iron deficiency, transferrin is generally increased and

ferritin is generally decreased (ferritin typically <30 mcg/L in absolute iron
deficiency

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 15. A 70-year-old intensive care unit patient complains of fever and shaking chills. The
patient develops hypotension, and blood cultures are positive for gram-negative bacilli.
The patient begins bleeding from venipuncture sites and around his Foley catheter. Hct:
38% WBC: 15.00 _ 103 mm ,Platelet count: 40,000 per mm3 (normal: 130,000 to
400,000) Peripheral blood smear: fragmented RBCs PT: elevated PTT: elevated Plasma
fibrinogen: 70 mg/dL (200 to 400).The best course of therapy in this patient is;

A. Begin heparin
B. Treat underlying disease
C. Begin plasmapheresis
D. Give vitamin K

TREATMENT of DIC

Treat the underlying cause — DIC is a process of ongoing thrombin generation and fibrinolysis, and resolution of
these abnormalities depends on elimination of the stimulus for these processes.

Thus, the major principle in the management of DIC is treatment of the underlying cause in order to eliminate the
stimulus for ongoing coagulation and thrombosis. (See 'Causes of DIC' above.)

Supportive measures — The need for additional supportive measures is individualized for each patient.

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 16. A 22 year old female C-II medical student presented EOPD with complaint of
fever ,shaking chills of 04 day duration. She has non- productive cough and pleuritic
chest pain of the same duration . she has no significant past medical history . physical
examination revealed crepitation on the posterior lower chest bilaterally . Which one is
the best initial investigation to confirm the diagnosis ?
A. Gene expert
B. Gram stain of sputum
C. Chest X –ray
D. culture of sputum

17. A 33 year old male patient from Konso presented with complaint of high grade
fever ,chills ,rigor and significant weight loss of 03 week duration . On physical
examination there is huge splenomegaly . Which of the following is best investigation
modality to confirm the diagnosis ?
A. Ultrasound
B. Bone marrow aspiration

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 C. Skin smear
D. Splenic aspiration
Investigations and diagnosis of Visceral leshimaniasis include ,
Investigations: CBC, blood film of malaria, LFT, RFT, serum albumin and total protein
Diagnosis

Clinical case definition: Although the clinical definition of VL is not specific, patients fulfilling the case it should have either parasitologic and/
or immunologic tests for designed for the diagnosis.
Clinical case definition of VL: A person who lives in VL endemic area or having travelled to an endemic area presenting with fever for more
than two weeks after exclusion of malaria or treating for malaria and one or more of the followings
1. Splenomegaly ( with or without lymphadenopathy)
2. Weight loss
3. Cytopenia: anemia or leucopenia or bi/pancytopenia

A confirmation of the diagnosis requires identification of the parasite.

Although they have limitations, immunologic tests are also helpful in diagnosis.

- Parasitologic confirmation: detection of the amastigote stage of the parasite

of Specimen:

1 Splenic aspirate: it is the preferred specimen; has the highest yield (sensitivity of 93-99%). It should be by an experienced trained person
and be avoided in patients with low platelet count, coagulopathy or active bleeding due the risk of splenic hemorrhage which could be fatal.
2 Bone aspirate: safe, variable but reasonable sensitivity (53-86%)
3 Lymph node aspirate: safe, relatively low sensitivity (53-65%)
o Staining: Giemsa
o The Amastigote (LD body): small spherical or ovoid shaped structures with
prominent nucleus and deeply stained rod-like structure in the cytoplasm (called
kinetoplast). They could be found within macrophages or extracellularly

-Visceral leshimaniasis endemic areasc in ethiopia include northwest (gonder , humera , lubokemkem), central, south and southwestern
(Konso , around omo basin)

18. A 35 year old male athlete with heart failure is confortable at rest and during walking
nearby . He develops dysnea and fatigue when he runs more than 10m distance .what is
the stage and functional class of this patient ?
A. Stage C Class II NYHA CLASIFICATION

B. Stage C Class I CLASS 1 Sxtic when heavy activity like running , climbing, machine operation, heavy lifiting
CLASS 2 Sxtic when doing ordinary activities like Gardening , walking , sanitizing
C. Stage B Class III CLASS 3 sxtic when hair combing , eating , clothing
CLASS 4 sxtic even at rest
D. Stage B Class II
American Heart Association ;
E. Stage B Class I stage A ; at risk for HF (HTN, CAD) but without structural heart ds nor SXTIC
Stage B; structural heart disease (left ventricular dysfunction)but asxtic
Stage C ; structural heart disease and symptomatic
Stage D; refractory / advanced Heart failure requring special intervention

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 19. A 45 year old male known hypertensive patient for past 12 year presented with
compliant of SOB ,night cough and PND of 01 month .physical examination revealed
tender hepatomegaly and cardiothoracic ratio of 60 % . He has no pertinent finding on
respiratory system and his ejection fraction is 65% . What is the most likely diagnosis?
A. Systolic heart failure
B. Diastolic heart failure
C. Corpulmonale
D. All Systemic hypertension.... hypertrophy.... increased cardio thoracic ratio.
If the cardiac enlargement was due to chamber dialation .. EF would have
been reduced , or even if it was systolic dysfn with preserved EF, How
would we explain the CTR of 60% With EF 65

Night cough means .. left heart likely than Corpulmonal ....

from left hear failure , demo it seems diastolic

There is no such category anymore

This has to be question of 2009

As per current practice This is likely ....Hfpef 2r to HHD ''

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 20. A known CLD patient from konso present with a compliant of abdominal pain, fever and
on physical examination abdominal tenderness; peritoneal fluid analysis reveals
WBC=670cells/mm3.The diagnosis considered as Spontaneous Bacterial Peritonitis, the
most likely etiologic agent?
A. S.aureus, C. E.Coli
B. Enterococcus sp. D. Tuberculosis

the development of SBP is a disturbance in gut flora with overgrowth and

extraintestinal dissemination of a specific organism, most commonly Escherichia coli

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 21. Which antibiotics are the first line treatments for the above diagnosis?
A. Ceftriaxone
B. Gentamycin
C. Azithromycin Spontaneous bacterial peritonitis
Treatment of Spontaneous bacterial peritonitis
D. Amoxicillin o First line: Ceftriaxone, 1000mg, IV, BID for 7-10 days
o Alternative: Ciprofloxacin, 200mg, IV, BID for 7-10 days

summary for prophylaxis and treatment of SBP

- Primary prophylaxis for SBP is recommended in patients with ascitic fluid protein <1.5 g/dl along with impaired renal function
(creatinine 1.2 mg/dl or 106 micromol/L), BUN 25 mg/dl or 8.9 mmol/L or Na 130 mEq/L or 130 mmol/L, or liver failure (Child-Pugh
score 9 and bilirubin 3 mg/dl or 51 micromol/L).
;- ciprofloxacin (PO) 400mg 24hourly for 10-14days OR cotrimoxazole (PO) 960mg 24hourly for 10-14days

Secondary prophylaxis should be instituted in all patients who were diagnosed with SBP
;-in the form of a daily fluoroquinolone, cip- rofloxacin or norfloxacin, or double strength
trimethoprim-sulfamethoxazole.
;-Patients with known ascites who develop gastrointestinal
bleeding should receive intrave- nous ceftriaxone for 7 days to prevent bacterial infections.

Community Acquired Spontaneous bacterial peritonitis treatment:

;- Ceftriaxone (IV) 1g 12-24 hourly for 5- 10days OR amoxicillin-clavulanic acid (FDC) (IV) 1-2g 6-8hours for 5-10days OR
ciprofloxacin (IV) 200mg 12hourly for 5–10days or administration of albumin dose is 1.5 g/kg on day 1 and 1 g/kg on day 3.

22. In which of the following clinical scenarios is the diagnosis of an acute coronary
syndrome less likely?
A. A 58 year old male presented with retrosternal squeezing chest pain that radiates to
the left arm and associated with palpitations
B. A 64 year old male patient presented with a left anterior chest pain which is piercing
type and that worsens with inspiration and that is relieved on leaning forward

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 C. A 58 year old female diabetic presented with epigastric pain associated with dyspnea,
sweating and nausea
D. A 67 years old known hypertensive patient who developed cardiac arrest while
having sex with his wife
atypical features are common in elder female /or
diabetic pt

B,
- it typically seems acute pericarditis

terms in tetanus and their prognostic value

-The incubation period = the time from presumed infection (injury) to the
first symptom.
-The period of onset = the time between the first symptom and first spasm.
- incubation period of less than 7 days and a period of onset of 48 hr
considered to indicate poor prognosis.
-However, the time from first symptom to hospitalization and the presence
of spasms at presentation have greater prognostic significance Prognosis
also depends on the severity

23. A 40 year old male patient was brought to your health center with chief complaint of lock
jaw of 7 days. He has muscle spasm of 3 day duration .He had sustained injury to his foot
two week back. He was vaccinated two times .P/E General appearance: He is in
opisthotonos position. He has hypertonia .His vital signs all in normal range .Which of
the following is true about this patient? Prevention ; Immunization and Post
exposure
A. He has poor prognosis because he is in opisthotonos position. o Clean wound and minor wounds;
Vaccination alone
B. His period of onset is 4 day indicating poor prognosis sign. o All other wounds:
- Human tetanus immunoglobulin IM
250 IU. Because it is not available, TAT
C. He should be vaccinated at discharge. is used: TAT: 1,500 IU IM
PLUS
D. Diazepam alone suffices to control spasm. -Vaccination (TT) for previously not fully
vaccinated or vaccinated before 5-10
years).
17 | P a g e - Immunization of pregnant or
diazepam + childbearing age women reduces
chlorpromazine + mg neonatal tetanus
sulfphate mortality by more than 90 %.
Improving hygiene during home births is
also help to prevent neonatal tetanus.
Treatment of Tetanus
-Airway management and other general supportive management
-Control of muscle spasms and prevent serious complications like laryngeal spasm
-Halting the toxin production and neutralization of the unbound toxin
-Management of dysautonomia

Supportive treatment
Admit patients to a quiet, low-light(darker) , and in severe cases, to an intensive care unit if possible for continuous cardio-pulmonary
monitoring. in severe tetanus, early tracheostomy and mechanical ventilation are needed.
In mechanically ventilated patients higher doses of diazepam. Neuromuscular
blockage can also be safely employed.
-Bed sore prevention, thromboembolism prophylaxis, stress ulcer prophylaxis are
needed.
-Avoid stimuli.
-Nutritional support and hydration measures are important.

Pharmacologic
Patients with severe tetanus should be managed in the intensive care setting where mechanical ventilator and appropriate medication are
available. This may necessitate referral of most patients to specialized centers.

-Control of spasms
Diazepam, 10 mg I.V. should be given every 4 hourly, the dose being titrated
depending on the response.
o Large doses (as high as 250mg in 24 hour) can be used, in mechanically ventilated
patients only. As large doses can cause respiratory depression.

PLUS
Chlorpromazine, 25-50mg IM alternating with diazepam.
PLUS
Magnesium sulphate, loading dose of 40mg/kg IV over 30 min, followed by IV infusion of 2g/h for patients over 45kg and 1.5g/h for patients
45kg or under. It is used in patients with severe tetanus for whom tracheostomy has been done)

Neuromuscular blockade Neuromuscular blocking agents are used when sedation alone is inadequate.

o Suxamethonium, 20-100mg I.V. depending on the effect with mechanical ventilation may be employed in patients with severe laryngeal
spasm.
- Halting toxin production and neutralizing circulating toxins
-Wound debridement , removing necrotic tissue and foreign bodies
-Antimicrobial treatment
o Metronidazole, 500mg I.V, TID for 7-10 days
- Neutralization of circulating (unbound) toxin.
o Tetanus antitoxin (TAT) 10,000 IU IM after a skin test (a skin test done by 0.1
ml in a 1:10 dilution)
- If available: Human Tetanus immunoglobulin (HTG) 500IU, IM stat (preferred
over TAT)

-Control of Autonomic dysfunction

Magnesium sulphate (see above)
PLUS
Labetalol : 0.25 to 1.0 mg/min infusion
o Beta blockade alone, like propranolol, should be avoided because of reports of
sudden death.
PLUS
Morphine sulfate (0.5 to 1.0 mg/kg per hour by continuous intravenous infusion) can
be added.

24. A 60 year old male patient presented to you with chief complaint of loss of consciousness
of four hrs. Duration. The attendants gave you history of headache, neck stiffness and
high grade fever of five day duration. He has history of abnormal body movement
involving all extremities of one episode staying five minutes.His vital sign: Blood
Pressure: 140/90 mmHg .Pulse Rate: 56RespiratoryRate: 34 irregular T: 38.4 .Pupils are
7 mm bilaterally in size and reactive.Which of the following is false about this patient?

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 A. This patient is likely to have increased intracranial pressure.
B. Has poor prognosis features.
C. Listeria Monocytogenes is likely to be considered as one of etiologic agent.
D. Antibiotics shouldn’t be started blindly unless gram stain is done because this will
promote drug resistance.

25. Abebech is a previously healthy 25-year-old woman. Two weeks prior, she had bacterial
pharyngitis with 3 days of fever. She has symptomatically completely recovered now.
She is working on her engineering degree and enjoys collecting and analyzing data. Thus,
she has taken her temperature orally every hour for the past 2 weeks and brings in her
temperature log to you. Which of the following statements regarding her expected body
temperature pattern is true?
A. During the febrile illness, the normal diurnal variation in body temperature is absent.
B. Lowest body temperatures will occur at approximately noon.

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 C. Normal daily temperature variations are currently a bit higher than individuals in
the normal population.
D. Oral temperature accurately reflects body core temperature.
E. Ovulations will not affect her body temperature.

- Normal body temperature varies over the course of the day, controlled in the thermoregulatory center located in
the anterior hypothalamus. The normal early morning to late afternoon daily increase is typically 0.5°C (0.9°F)
However, in some individuals recovering from a febrile illness, this daily variation can be as high as 1.0°C

- Low levels occurred at 6 AM and higher levels at 4 to 6 PM. The maximum normal oral temperature at 6 AM
was 37.2°C (98.9°F), and the maximum level at 4 PM was 37.7°C (99.9°F), both values defining the 99th
percentile for healthy subjects.

- In menstruating women, the morning temperature is generally lower during the two weeks prior to ovulation,
rising by about 0.6°C (1.0°F) with ovulation and remaining at that level until menses occur
- During a febrile illness, the daily low early morning and high evening temperature difference is maintained but
shifted upwards to higher levels.

- Peripheral methods of monitoring temperature (tympanic membrane, temporal artery, axillary, and oral
thermometry) are not as accurate as central methods (pulmonary artery catheter, urinary bladder, esophageal,
and rectal thermometry)

26. of the following are risk factors for COPD EXCEPT:

A. Airway hyper responsiveness
B. Coal dust exposure
C. Passive cigarette smoke exposure
D. Recurrent respiratory infections
E. Use of biomass fuels in poorly ventilated areas

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 27. A 62-year-old woman is admitted to the hospital with a community-acquired pneumonia
with a 4-day history of fever, cough, and right-sided pleuritic chest pain. The admission
chest x-ray identifies a right lower and middle lobe infiltrate with an associated effusion.
All of the following characteristics of the pleural effusion indicate a complicated effusion
that may require tube thoracostomy EXCEPT:
A. Loculated fuid
B. Pleural fuid pH <7.20
C. Pleural fuid glucose <60 mg/dL
D. Positive Gram stain or culture of the pleural fuid
E. Recurrence of fuid following the initial thoracentesis

types of parapneumonic effution and their mx

- Uncomplicated parapneumonic effusion (antibiotics alone) — Uncomplicated parapneumonic

effusions are small to moderate-sized (ie, less than half the hemithorax) free-flowing effusions
with no evidence of infection by culture or chemistry [2] that generally resolve with antibiotics
alone and generally do not need drainage. In such cases, the diagnosis and therapy with
antibiotics alone are empiric

- Complicated pleural effusion and empyema (antibiotics plus drainage) — In addition to

appropriate antibiotic therapy, PROMPT drainage is indicated in patients when there is clinical
concern for or evidence of infection in the pleural space, based upon the following features
=Empyema (ie, overtly purulent pleural fluid)

=Positive pleural fluid Gram stain or culture

= Loculated pleural effusion

= Large free-flowing effusions (ie, 0.5 hemithorax)

= Effusions associated with thickened parietal pleura

= Sepsis from a pleural source

= A pleural fluid pH of <7.2 is also an indicator of infection in the pleural space. However, other
pleural diseases can have a low pleural fluid pH (eg, malignant effusions, rheumatoid and lupus
pleurisy, urinothorax, and saline from a misplaced central venous catheter) Therefore, the
decision to drain fluid from the pleural space based on a low pleural fluid pH alone should be
made after pleural fluid analysis is complete.

28. All of the following are minor criteria in the Modified Duke Criteria for the clinical
diagnosis of infective endocarditis EXCEPT:
A. Immunologic phenomena (glomeluronephritis, Osler nodes, Roth spots)
B. New valvular regurgitation on transthoracic echocardiogram

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 C. Predisposing condition (heart condition, intravenous drug use)
D. Temperature >38°C
E. Vascular phenomena (e.g., arterial emboli, septic pulmonary emboli, Janeway
lesions)
Clinical criteria (major and minor) for the diagnosis of IE

Major clinical criteria include :

=Positive blood cultures (one of the following):

Typical microorganisms consistent with IE from two separate blood cultures (Staphylococcus aureus, viridans streptococci, Streptococcus gallolyticus
[formerly S. bovis], HACEK [Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella] group, or community-acquired enterococci in the
absence of a primary focus) OR

=Persistently positive blood cultures

-For organisms that are typical causes of endocarditis: At least two positive blood cultures from blood samples drawn >12 hours apart

-For organisms that are more commonly skin contaminants: Three or a majority of 4 separate blood cultures (with first and last drawn at least one
hour apart), OR

Single positive blood culture for Coxiella burnetii or phase I IgG antibody titer >1:800 [23]

=Evidence of endocardial involvement (one of the following):

Echocardiography positive for IE

-Vegetation (oscillating intracardiac mass on a valve or on supporting structures, in the path of regurgitant jets, or on implanted material, in the
absence of an alternative anatomic explanation), OR
-Abscess, OR
-New partial dehiscence of prosthetic valve
New valvular regurgitation
Minor clinical criteria include (table

Predisposition – Intravenous drug use or presence of a predisposing heart condition (prosthetic heart valve or a valve lesion associated with
significant regurgitation or turbulence of blood flow)
Fever – Temperature 38.0°C (100.4°F)
Vascular phenomena – Major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, or
Janeway lesions
Immunologic phenomena – Glomerulonephritis, Osler nodes, Roth spots, or rheumatoid factor
Microbiologic evidence – Positive blood cultures that do not meet major criteria OR serologic evidence of active infection with organism consistent
with IE

29. Which of the following statements regarding the epidemiology of and risk factors for
urinary tract infections (UTIs) is true?
A. About one-third of all women will experience at least one UTI in their lifetime.
B. Across all ages, UTI is 2–3 times more common among females.
C. Asymptomatic bacteriuria is a common and incidental finding in pregnancy that does
not require treatment.
D. Contrary to popular wisdom, sexual intercourse is not a risk factor for UTI.
E. In infancy, UTI is more common among males than females

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- The incidence of bacteriuria in pregnant women is approximately the same as that in nonpregnant women;
however, recurrent bacteriuria is more common during pregnancy. Additionally, the incidence of pyelonephritis is
higher than in the general population, likely as a result of physiologic changes in the urinary tract during pregnancy

. Urinary tract infections (UTIs) are more common among women than men, although the prevalence in elderly
men and women is similar

- Asymptomatic bacteriuria occurs in 2 to 7 percent of pregnant women [1,2]. It typically occurs during early
pregnancy, with only approximately a quarter of cases identified in the second and third trimesters and should be
rx in px mom unlike other conservative mx of other popln

- Cystitis among females is extremely common [2,3]. The shorter distance from the anus to the urethra likely
explains why females are at higher risk for urinary tract infections (UTIs) than men. Among otherwise healthy
females, risk factors for cystitis include recent sexual intercourse and a history of UTI [4,5]. Use of spermicide-
coated condoms, diaphragms, and spermicides alone are also associated with an increased cystitis risk.

- Female infants have a two- to fourfold higher prevalence of UTI than male infants [4]. This has been presumed to
be the result of the shorter female urethra. However, because the incidence of UTI in male neonates is as high, if
not higher, than in female neonates, the importance of the length of the urethra in the pathogenesis of UTI has
been questioned. Alternatively, the propensity of bacterial attachment to the female periurethral mucosa may
account for this difference.

30. All of the following statements regarding HIV transmission are true EXCEPT:
A. Genital ulcerations increase the risk of HIV transmission.
B. HIV may be transmitted to infants in maternal breast milk.
C. HIV may be transmitted via a mosquito or tick bite.
D. The probability of acquiring HIV is greater during receptive anal intercourse than
insertive anal intercourse.
E. The quantity of HIV in plasma is a primary determinant of the risk of HIV
transmission

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 31. Which one of the following is the first step in approaching a child presenting with seizure?
A. Search for potentially life-threatening causes of seizure and treating them
B. Evaluating the patient to determine whether the seizure has a focal onset of is
generalized
C. Managing the patient according to the ABC approach
D. Giving IV diazepam

32. All are diagnostic criteria for febrile seizure except

A. Prior history of afebrile seizure
B. Absence of CNS infection and other metabolic imbalance
C. Age between 6 month and 5 years
D. Temperature greater than 380c

A febrile seizure refers to an event in infancy or childhood, usually occurring between six
months and five years of age, associated with fever but without evidence of intracranial
infection or defined cause. Seizures with fever in children who have suffered a previous
nonfebrile seizure are excluded from this definition. Febrile seizures are not considered a
form of epilepsy

24 | P a g e
the pentads for febrile seizure are ;-

- A convulsion associated with an elevated temperature greater than 38°C

- A child older than six months and younger than five years of age

- Absence of central nervous system (CNS) infection or inflammation

- Absence of acute systemic metabolic abnormality that may produce convulsions

- No history of previous afebrile seizures

33. Which one of the following is preventable cause of seizure

A. Developmental disorders
B. Perinatal asphyxia
C. Genetic disorders
D. Idiopathic

34. The commonest type of neonatal seizure is

A. Tonic clonic seizure Neonatal seizures, as with any other type of seizure, are paroxysmal,
repetitive and stereotypical events. They are usually clinically subtle,
B. Atonic seizure inconspicuous and difficult to recognise from the normal behaviours of
the inter-ictal periods or physiological phenomena. There is no
C. Absence seizure recognisable post-ictal state. Generalised tonic clonic seizures (GTCS)
are exceptional. The most widely used scheme is by Volpe20 of five main
D. Subtle seizure types of neonatal seizure.

Subtle seizures (50%)

Tonic seizures (5%)
Clonic seizures (25%)
Myoclonic seizures (20%)
Non-paroxysmal repetitive behaviours

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 35. The feared complication of DM during physical exercise is
A. Hyperglycemia
B. DKA
C. Hypoglycemia
D. Diabetic foot ulcer

36. One of the following does not contribute for weight loss in diabetic patient
A. Polyuria
B. Polydipsia
C. Proteolysis
D. Lipolysis

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 37. A good indicator of diabetic patient’s disease control over near past is
A. Serial blood sugar levels
B. Clinical signs and symptoms
C. Hemoglobin A1C level
D. All of the above

38. Not a physiologic jaundice

A. Visible jaundice appearing after 24 hrs
B. Total bilirubin rise by >5mg/dl
C. Jaundice which disappears within 1 week in term and 2 weeks in preterm
D. Total bilirubin rise by <5mg/dl

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 39. A 2 year old male child presented with cough, high grade fever and coryza associated
with this he has skin rash that progressed from head to trunk and redness of the eye of 3
days duration.
On P/E- V/S- PR-144 RR-40 T-37.8
Integ – multiple maculo papular rashes over the face and trunk. All of the following are
false about the above problem, except?
A. The most likely diagnosis is chickenpox
B. Mostly caused by toxic bacteria
C. It is not contagious
D. Infection confers life-long immunity

MEASLES ;-
Clinical diagnosis is sufficient though virus isolation is possible
Case definition: Patient with 3C(Cough, coryza, conjunctivitis) and generalized maculo- papular rash
= clinical features include,
-Catarrhal stage: high fever, Koplik‘s spots (diagnostic) runny nose, barking cough, and
conjunctivitis , Misery, anorexia, vomiting, diarrhea
- Later: generalized maculopapular skin rash followed by desquamation after few days

40. A 12 years old female child presented with high grade fever of one day duration
associated with this she has loss of appetite, vomiting and flank pain. Two days back she
had pain and frequency of urination. The most likely diagnosis is?
A. Malaria
B. Cystitis
C. Pyelonephritis
D. Al

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 41. A 5 year old female child presented with generalized body swelling of 1wk duration. She
has history of skin rash a month back. And has hx of cola colored urine of 3 days
duration. On P/E- V/S: PR: 110, RR: 28, T-37, BP: 140/80 and Urine analysis reveals
full of RBC.

The most likely diagnosis of this patient is:

A. Nephrotic syndrome
B. post streptococcal glomerulonephritis
C. disseminated TB
D. none

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 42. Which of the following is complication of nephrotic syndrome?
A. Thrombosis
B. Spontaneous bacterial peritonitis
C. sepsis
D. All nephrotic syndrome cause loss of

- anti thrombinIII ; Causing thrombosis

- loss of opsonin protiens , hence low level in the peritoneum and blood ,
exposing the pt for SBP and Sepsis respectively

43. Which one of the following statement is not true about childhood asthma?

A. Parent asthma is one of the minor criteria of asthma predictive index in children
B. Asthma predictive index is useful to assess future risk
C. genetic predisposition has role
D. A & C -family history — The influence of genetics in the development of asthma has not
been fully defined [43,60-66]. Because families also share environments, determining
E. none the influence of the genetic contribution to asthma is complicated. Nonetheless, a
family history of asthma or other atopic disease (ie, allergic rhinitis, atopic dermatitis,
or food allergy) certainly strengthens the likelihood that a child with a compatible
history has asthma.

- Children with one asthmatic parent are 2.6 times more likely to have asthma; with
two asthmatic parents, the odds ratio rises to 5.2 [60]. Maternal asthma appears to
make a bigger contribution than paternal asthma to asthma in offspring, although this
finding is inconsistent

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Asthma Predictive Index (API) — The API was derived from an unselected multiethnic population of children who had
wheezed at least once during the first three years of life .
- The major criteria were clinician-diagnosed eczema or parental asthma.
- The minor criteria were clinician-diagnosed allergic rhinitis, wheezing apart from colds, and eosinophilia 4 percent.

-A positive loose index was defined as any parental/caregiver report of wheezing on the surveys at two or three years of
age and either one major criterion or two minor criteria.

= Children with a positive loose index were four times more likely to have active asthma during a subsequent survey at
6, 8, 11, or 13 years of age (sensitivity 42 percent, specificity 85 percent).

A positive stringent index was defined as frequent wheezing on these same surveys (score of 3, scale: 1 to 5, from "
very rarely" to "on most days") plus the same combination of major or minor criteria.

= Children with a positive stringent index were seven times more likely to have active asthma in at least one of these
school-aged surveys (sensitivity 16 percent, specificity 97 percent).

- in addition, the positive likelihood ration (LR), the probability of a child with active asthma classified as at risk divided
by the probability of a child without active asthma classified as at risk, of the API is 7.43 at age six years [61].
-The negative LR, the probability of a child with active asthma classified as not at risk divided by the probability of a
child without active asthma classified as not at risk, is 0.75 at age six years

44. Most common route of transmission of UTI in children is

A. Sexual abuse
B. Ascending infection
C. Hematogenous spread
D. None
The bacteriology of UTI, along with the observation that a minority (4 to 9 percent) of children with
UTI are bacteremic , is consistent with the hypothesis that most UTI beyond the newborn period are
the result of ascending infection.

Colonization of the periurethral area by uropathogenic enteric pathogens is the first step in the
development of a UTI.
The presence of pathogens on the periurethral mucosa, however, is not sufficient to cause UTI .
Pathogens attach to the uroepithelial cells via an active process mediated by glycosphingolipid
receptors on the surface of epithelial cells .

Bacterial attachment recruits toll-like receptors (TLR), a family of transmembrane coreceptors

involved in the recognition of pathogen-associated protein patterns . TLR binding triggers a cytokine
response, which generates a local inflammatory response.

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 45. A developmental disorder starting at or soon after birth and occurring most frequently in
infants with immature lungs is?
A. Meconium aspiration syndrome
B. Transient tacypenia of newborn
C. Hyaline membrane disease
D. Congenital pneumonia

46. If you encounter a neonate with a scaphoid abdomen, having respiratory distress and
upon auscultation there is bowel sound heard on the left side of the chest. What could be
the possible diagnosis for this neonate?
A. Chonal atresia
B. Diaphragmatic hernia
C. Tracheoesophageal fistula
D. None of the above

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 47. Among the different vaccine which is available in our country which vaccine is
protective and has a good efficiency in preventing tuberculosis?
A. PCV
B. BCG
C. OPV
D. Pentavalent
CONTRAINDICATIONS
Potential contraindications to LP include:

1 Increased intracranial pressure (ICP) — Children with elevated ICP are at risk for cerebral herniation when an LP is
performed [1,2]. Consequently, in children with clinical suspicion for elevated ICP based upon physical examination or
predisposing illness, LP should not be performed until neuroimaging is performed to identify cerebral edema, space-
occupying lesion, or obstructive hydrocephalus, any one of which would contraindicate the procedure [3]. (See '
Preprocedure evaluation' below and 'Cerebral herniation' below.)

Furthermore, normal neuroimaging does not absolutely exclude the presence of elevated ICP or the possibility that
elevated ICP will develop at a later time. Nevertheless, LP can usually be safely performed within six hours of a normal
CT scan when no other contraindications are present.

2 Respiratory distress — Children with respiratory compromise may become hypoxemic or apneic while undergoing LP
, especially in the lateral recumbent position [3]. Thus, careful assessment and support of airway and breathing should
be provided, as needed, before and during the procedure in patients with significant respiratory distress. Patients who
cannot maintain their airway or who are in respiratory failure should undergo endotracheal intubation prior to LP.

48. Which of the following is not a contraindication to do lumbar puncture in patient you
suspected neonatal meningitis?
A. Bulging fontanel
B. Focal neurologic deficit
C. Thrombocytopenia
D. Infection at the site of LP
E. None of the above

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3 Hemodynamic instability — Children with shock should undergo appropriate resuscitation before LP. As an
example, a hemodynamically unstable patient with septic shock who may have bacterial meningitis should
undergo emergency fluid resuscitation, have a blood culture obtained, and receive empiric antibiotics as soon as
possible; LP should be deferred until the child's condition stabilizes.

4 Soft tissue infection at the puncture site — Meningitis or other infections such as epidural abscess, vertebral
osteomyelitis, discitis, or intramedullary spinal abscess can be induced if the LP is performed through cellulitis or
soft tissue infection (eg, epidural abscess) at the site of puncture [4-6]. For this reason, local infection at the
puncture site is a contraindication to performing LP.

5 Bleeding disorder — Because of the risk of spinal hematoma formation, we generally do not advise performing
LP in patients with coagulation defects who are actively bleeding, have severe thrombocytopenia (eg, platelet
counts <50,000/microL), or have an international normalized ratio (INR) >1.4 without correcting the underlying
abnormalities. When LP is considered essential for a patient with an abnormal INR or platelet count in whom the
cause is not obvious, we suggest consultation with a hematologist to provide the best advice for safe correction of
the coagulopathy prior to performing the LP. In cases in which LP is considered necessary but the risk of
bleeding is considered to be high, it may be useful to perform the procedure under fluoroscopy or ultrasound
guidance to reduce the chance of accidental injury to small blood vessels.
49. Which could not be possible causes of neonatal conjunctivitis?
A. N. Gonrrehea
B. C. Tracomatis
C. S. Aures
D. None
E. All
The common causes of neonatal conjunctivitis are chemical, bacterial, and viral:

1 Chemical conjunctivitis is caused by eye drops used to prevent gonococcal infection. They are
commonly made of silver nitrate. In the United States, this prophylaxis method has been replaced by
tetracycline or erythromycin ointment. Chemical conjunctivitis usually appears 6 to 8 hours after the eye
drops are administered. It usually disappears spontaneously after 24 to 96 hours.

2 Bacterial conjunctivitis is the most common cause of ophthalmia neonatorum. The bacteria gets
transferred from the mother to the baby during birth. The most common type of bacterial conjunctivitis is
- chlamydial conjunctivitis, caused by Chlamydia trachomatis. In the United States, 2% to 40% of neonatal
conjunctivitis cases are caused by chlamydia. VERSUS

-Gonococcal conjunctivitis is the next most common bacterial conjunctivitis. It is caused by Neisseria
gonorrhoeae. N. gonorrhoeae causes the sexually transmitted infection gonorrhea. Gonorrhea causes less
than 1% of cases of neonatal conjunctivitis.

other bacterial causes ; Haemophilus species , Streptococcus pneumoniae , Staphylococcus aureus ,

Staphylococcus epidermidis , Streptococcus viridans ,Escherichia coli. Pseudomonas aeruginosa

Viral or infectious conjunctivitis is caused by a virus. Herpes Simplex Virus (HSV) and adenovirus are the
most common causes. Adenoviral conjunctivitis is extremely contagious, and caregivers should use
extreme caution and keep their hands clean to prevent the virus from spreading to others.

50. Which one is not a poor prognostic sign of SAM among the following?
A. Jaundice
B. Low serum Na level
C. Age < 6 month
D. None
E. All

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 51. Which one of the following is NOT a disease of URTI (upper respiratory tract infections)?
A. Croup
B. Common cold
C. Epiglottitis
D. None Upper respiratory infections include: Common
cold. Epiglottitis. Laryngitis. Pharyngitis. Sinusitis
& CROUP.

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 52. Which one of the following is NOT true about croup disease?
A. Preceding URTI is common to present
B. The commonest age of presentation is 5 mo to 5yr
C. Bacterial etiology is the known cause
D. Barking cough, hoarseness of voice, inspiratory stridor is common presentation
- The term "croup" has been used to describe a range of upper respiratory conditions in children. For the purpose of this
topic review, we will use the term "croup" to refer to viral laryngotracheitis'

= Viral croup — Viral croup (also called classic croup) refers to the typical croup syndrome that occurs commonly in
children six months to three years of age. As the name implies, it is caused by respiratory viruses and so viral symptoms
(eg, nasal congestion, fever) are usually present. Viral croup is usually a self-limited illness; the cough typically resolves
within three days.

= Spasmodic croup — Spasmodic croup also occurs in children six months to three years of age [1]. Spasmodic
croup always occurs at night. The onset and cessation of symptoms are abrupt, and the duration of symptoms is short,
often with symptoms subsiding by the time of presentation for medical attention. Fever is typically absent, but mild upper
respiratory tract symptoms (eg, coryza) may be present. Episodes can recur within the same night and for two to four
successive evenings [3]. A striking feature of spasmodic croup is its recurrent nature, hence the alternate descriptive
term "frequently recurrent croup.
NB ; Early in the clinical course, spasmodic croup may be difficult to distinguish from viral croup. Over time, the episodic
nature of symptoms and relative wellness of the child between attacks differentiate spasmodic croup from viral croup, in
which the symptoms are continuous.

ETIOLOGY OF CROUP ;
- Viral causes – Croup is usually caused by viruses , mostly Parainflun virus 1 > RSV & Adeno virus next common
causes > influnza virus - uncommon cause > others like SARS-COV2 covid virus> measles are atributed
bacterial causes - Croup is rarely caused by bacterial infection with the exception of Mycoplasma pneumoniae, which
can cause a mild croup-like illness.
- However, bacterial infection may occur secondarily. The most common bacterial pathogens in this
setting include Staphylococcus aureus, Streptococcus pyogenes, and Streptococcus pneumoniae

53. For a patient having typical clinical manifestation of congestive heart failure, what
investigation can we send to support our diagnosis?
A. CXR
B. Echocardiography
C. ECG
D. All of the above

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 54. A 7 yrs old male patient presented to you at pediatric emergency OPD complaining of
generalized body swelling of week duration. Additionally, he has history low grade fever
and decreased urine amount, severe headache and one episode of abnormal body
movement but, he denies of having urine color change. Two weeks back he had history of
sore throat at which it resolved out spontaneously without treatment.
On P/Ex he has puffy face, V/S: BP 150/100mmHg PR: 110 bpm RR: 28 T: 37.6
He has grade II bilateral pitting edema
On U/A there is microscopic hematuria (dysmorphic RBCs)
Which one is the most likely diagnosis and it’s feared complication for this patient?
A. Nephrotic syndrome- uremic encephalopathy
B. Severe acute malnutrition- hypoglycemia
C. Nephtitic syndrome- hypertensive encephalopathy
D. Acute rheumatic fever- rheumatic heart disease

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 55. A 10 years old female known asthmatic patient whom on follow up presented to
emergency OPD with dyspnea, cough but no fever. On examination v/s: PR: 110 RR: 50
T: 37.4 oC and the pulse oximetry reads 88% of O2 saturation in room air. She has sign
of distress and diffuse wheezing over the whole chest and no other pertinent finding.
What would be your next best stepyou should follow in the of management this patient?
A. Send her immediately for CXR
B. Put on her Oxygen therapy and start salbutamol challenge
C. Hold on any treatment and call for anesthesiologist for endotracheal intubation
D. Provide her IV antibiotics obviously this pt needs O2 for the preogressive
airway blockage and target SPo2 is controvertion
but up to 92% in most pt, upto 94 in pregnant. then
after we can send the pt for Xray

56. At which stage of growth and developmental child would normally develop an emotion
of fearing darkness?
A. Infancy age
B. Preschool age
C. School age A fear of the dark usually first occurs around the age
of 3 or 4 when a child’s imagination is beginning to
D. Adolescent age expand

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 57. What is the risk of goat milk if initiated at 4 month of age
A. B12deficiency
B. B iron deficiency anemia
C. C folic acid deficiency
D. D hemolytic anemia
Goat milk is low in folate, and infants fed exclusively goat milk
may not receive adequate folic acid [40,41]. Some powdered
goat milk is supplemented with folic acid, but use of a
commercial infant formula is preferable

58. one of the following is not diagnostic investigation of HIV for 8 month infant

39 | P a g e
 A. DNA PCR
B. RNA PCR
C. Antibody test
D. All are diagnostic

59. one of the following is absolute contraindication of LP for meningitis

A. cardiorespiratory distress
B. bulged fontanel
C. LP site infection
D. thrombocytopenia

60. one of the following is not true about CSF finding in normal child
A. CSF glucose < 75% of blood glucose
B. CSF protein 20-45g/dl
C. cell count 0-5/microlitter
D. opening pressure of 50-85mmhg

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 normal new born normal children bact meningitis viral menigni
leukocyte ; 0-30 preterm,0-15 T 0-6 >1000 100-500
neutrophil % ; 2-3 0 80-95 < 40
glucose ; 30-120 40-80 (60% of serum) <40 (<40% of serum) <30-70
protien ; 20-150 20-30 >100 50-100
gram stain ; NO NO +++ NO
opening presure 7-22 mmhg

61. Which of the following is NOT a risk factor for ovarian cancer?
A. Nulliparity
B. Infertility
C. Combination oral contraceptive pill use
D. Hereditary nonpolyposis colon cancer (HNPCC)
when ever we r asked for R/F for ovarian CA consider these 2
major class of R/F

= 0vulation related R/F common risk factors for ovarian tummor

are uninterupted monthly ovulation , which causes minor trauma
to ovarian epithelium then causing infn later predisposing the
cells to malignant transformation , hencec early menarche , late
menopause , infertility , nulli parity are risk factors,

- in contrast, condition that decrease monthly ovulation like COC,

pregnacy , lactation are protectrive for ovarian tummor

= Genetic R/F ; HNPCC, BRCA1 & 2

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 62. Which one of the following is a criteria for low forceps?
A. The fetal head leading point should be above +2
B. Rotation is less than 45 degree
C. The fetal head is on the pelvic floor
D. The fetal head leading point should be below +2

in obstetrics , during PV exam for station , ''Below''

corosponds to the GROUND , ''above'' corrosponds to
the the abdomen

63. A 25yrs old G3P2 mother with GA of 35wks + 2D present with compliant of gush of
fluid per vagina of 1days duration, on sterile speculum examination there is pooling of
posterior vaginal fornix. Which of the following is NOT appropriate management:-
A. Strict Bed rest Management of near-term PROM (34-37 weeks) ;
In this Gestational age range, Induction-then termination of px or expectant
B. Corticosteroid management is acceptable management options depending on local
resources. what ever the option of mx, all pt should be provided bed rest and
C. Prophylactic antibiotics Antibiotics, and followed with PROM and FETAL KICK chart. but role of
steroids is controvertial in this GA range and read the ff statments ;-
D. Kick chart
- A course of corticosteroids can be considered for patients who present with
PPROM at 34+0 to 36+6 weeks of gestation who are going to be managed
expectantly, have not received a previous course of steroids, and who are
scheduled for delivery in >24 hours and <7 days

- if preterm birth is considered imminent, treatment for short duration still

improves fetal lung maturity and chances of neonatal survival. Therefore, the
first dose of corticosteroids should be administered even if the ability to give
the second dose is thought to be unlikely.

- STG says nothing on PROM, but in APH , upto 37 wk steroid is given.

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 64. A 30yrs old nulliparous women presents with compliant of inability to conceive of 3yrs
duration on pelvic US she has Four submucosal myomas, Hematocrit is 27%. What is the
appropriate management?
A. Transfusion & Hysterectomy
B. Hysterectomy without transfusion
C. Transfusion & Myomectomy
D. Myomectomy without transfusion
since it is a mjor surgery the HCT should atleast be
30, hence need atleast 1 unit of whole blood

since She is nulliparous , myomectomy is the prefered

option to preserve the fertility potential.

65. A 25yrs old laboring multiparous mother is on second stage of labor for 2hrs, she has two
moderate contractions and station is +2. What is the next appropriate management?
A. Do cesarean section
B. Forceps delivery - prolonged 2nd stage of labor is defined labor in 2nd stage lasting
1hr 2 hr respectively for multi and nulli without epid anesthesia
C. Vacuum delivery and 2 hr & 3 hr for multi & primi with epidural anesthesia

D. Waite for vaginal delivery mx of prolonged seconf stage ;

- it is strongly recoomended extending the duration of second
stage by 1 hr for a mom who is being followed in the same
institutioon with reasuring feto mom condn
- if problem is with power , augment
- if problem is passenger or passage , instrumental delivery
- if prerequsites for instrumental is not fullfilled or feto mom non
reasuring , C/S

- B , in this case, this multi mother was given additional 1 hr but

the contraction is moderate and 2, obviously there is a problem in
power , and she has used the additional 1 hr to wait for vx
delievery... if option of augmentation was mentioned it would be
choosen , from the choices given , i would say B , WHICH DOES
NOT NEED MOM effort , and station is low.
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 66. Which one of the following is the least commonest degenerative change of myoma
A. Sarcomatous degeneration
B. Red degeneration
C. Hyaline degeneration
D. Septic degeneration
MOST common

67. A primipara is in labor and an episiotomy is about to be cut. Compared with a midline
episiotomy, an advantage of mediolateral episiotomy is
A. Ease of repair episotomy
B. Less extension of the incision mediolateral ;
C. Less blood loss - less risk of anal spninicter injury and
D. Less dyspareunia extention
- more bleeding , more post procedure pain
and dysparenunia

midline incition

- more risk of anal sphinicter injury and

extention
- less risk of bleeding , post op pain and
dyspareunia

44 | P a g e
 68. Multiparous patient who has received no prenatal care presents to Labor and Delivery
with a complaint of vaginal bleeding. Her fundal height is 24 cm. Which of the following
laboratory tests supports the diagnosis of preeclampsia?
A. Creatinine 1.5 mg/dL
B. Platelet count 103,000/μL
C. Hct 40%
D. Total protein of 258 mg in a 24-hour urine collection

Criteria for the diagnosis of preeclampsia

= Preeclampsia refers to the new onset of hypertension and proteinuria or the new onset of hypertension and significant end-organ
dysfunction with or without proteinuria after 20 weeks of gestation or postpartum in a previously normotensive patient
HOW TO DX
Systolic blood pressure 140 mmHg and/or diastolic blood pressure 90 mmHg on at least 2 occasions at least 4 hours apart after 20
weeks of gestation in a previously normotensive patient AND the new onset of 1 or more of the following*:

- Proteinuria 0.3 g in a 24-hour urine specimen or protein/creatinine ratio 0.3 (mg/mg) (30 mg/mmol) in a random urine specimen or
dipstick 2+ if a quantitative measurement is unavailable
- Platelet count <100,000/microL
- Serum creatinine >1.1 mg/dL (97.2 micromol/L) or doubling of the creatinine concentration in the absence of other renal disease
- Liver transaminases at least twice the upper limit of the normal concentrations for the local laboratory
- Pulmonary edema
- New-onset and persistent headache not accounted for by alternative diagnoses and not responding to usual doses of analgesics¶
- Visual symptoms (eg, blurred vision, flashing lights or sparks, scotomata)

69. A 23 yrs old primigravida lady with GA of 28wk presented at antenatal care clinic and
her blood group is A- and her husband blood group is B+ so what should be done next for
this patient? to cheek if she is not sensitized ,

A. Administration of anti D - the fact that she is primigravid , does not assure that she
might not have undetected sponteous abortion or atleast in
B. Appoint her at 36 wks of gestation the early weeks of the gestation

C. Indirect coomb’s test - if indirect combs test is negative --- she is not sensitized ,
so then we shall give anti D.
D. Direct coomb’s test - if indirect combs is positive , enroll the pt as sensetized
to high risk clinic , and follow pt with serial titer
measurment then mx accordingly depending on the titer
45 | P a g e and US study of the fetus
 70. Which of the following is not an admission criterion for PID?
A. Failure to respond for outpatient treatment
B. PID with uncertain diagnosis
C. PID with TOA
D. Older Age
Most females with PID can be safely treated in outpatient settings. Indications for hospitalization and
parenteral antibiotics include :

= Severe clinical illness (eg, fever 38.5°C [101°F], nausea and vomiting)

= Complicated PID with pelvic abscess (including tubo-ovarian abscess)

=Possible need for invasive diagnostic evaluation for alternate etiology (eg, appendicitis or ovarian
torsion) or surgical intervention for suspected ruptured tubo-ovarian abscess

= Inability to take oral medications

= Pregnancy

= Lack of response or tolerance to oral medications

INPT MX
- Ceftriaxone (1 g intravenously every 24 hours) plus doxycycline (100 mg orally or intravenously
every 12 hours) plus metronidazole (500 mg orally or intravenously every 12 hours) OR
-Cefoxitin (2 g intravenously every six hours) plus doxycycline (100 mg orally or intravenously every 12
hours) OR
-Cefotetan (2 g intravenously every 12 hours) plus doxycycline (100 mg orally or intravenously every
12 hours)
out pt mx
- A single intramuscular dose of a long-acting cephalosporin plus doxycycline (100 mg orally twice
46 | P a g e daily for 14 days) plus metronidazole (500 mg orally twice daily for 14 days)
 71. A woman who is currently pregnant presents to your office for antenatal care. She had
two abortions, one ectopic pregnancy, fetal death at 36weeks of gestation and three live
births. How are you going to describe her obstetric history?
A. G7 P3 A3 E1
B. G7 P4 A3 E1
C. G8 P4 A2 E1
D. G8 P3 A3 E1

72. One of the following IS NOT among the classic clinical triad of ectopic pregnancy?
A. Amenorrhea
B. Foul Smelling Vaginal Discharge
C. Abdominal Pain
D. Vaginal Bleeding

47 | P a g e
 73. Assume you are responsible physician at ANC clinic and a 45 year old known
hypertensive pregnant mother comes to you for first evaluation. Under which WHO
follow up category do you put her for next follow up?
A. Specialized care
B. Basic component
C. Can be reclassified in basic component follow-up, if her blood pressure one’s well
controlled
D. must be referred to territory hospital
Women with one or more of the following medical, surgical, psychiatric disorders or ob/gyn
problems needs specialized care
Chronic obstructive lung disease
Chronic hypertension
Cardiac disease
Chronic renal failure
Chronic hepatic disease
Diabetes mellitus
Thyroid dysfunction (hypo or
hyperthyroidism)
Hematologic disorders
Epilepsy on treatment
Autoimmune disease
HBV or HCV infection
Severe psychiatric disorders
Malignancy
Obesity (BMI 30 kg/m2)
Surgical problem/scar
All severe anemia, mild to moderate anemia
not responding to iron treatment
Multiple pregnancy
Post-term pregnancy
Having a previous uterine scar
Decreased fetal movement/growth
History of or diagnosed to have:
Recurrent miscarriage, small-for-gestationalage or preterm birth, stillbirth, antepartum
hemorrhage, prelabor rupture of fetal membranes
Gross congenital anomaly
Cerclage, LEEP, cone biopsy of cervix
Diagnosed to have severe pre-eclampsia/eclampsia
Rh sensitized
Placental accreta syndrome
Puerperal psychosis
Pelvic mass, extensive genital wart
Mullerian anomaly
48 | P a g e FGM (Type III scar)
Transverse lie or breech at term
Suspected macrosomia or fetal growth restriction
 74. You are at emergency OPD and a mother with profuse vaginal bleeding of 5 hrs is
brought to you by her family after she gave birth vaginal. On physical examination she is
unconscious and pale. How do you proceed with the management of this particular
patient?
A. You have to secure double IV line and resuscitate with crystalloid
B. You have to take sample for cross mach
C. Call for help
D. You have to do bimanual compression
All options are approprate but calling for help is the first step

49 | P a g e
 75. The diagnosis of post partum hemorrhage is considered if;
A. Estimated blood loss is greater than 1000ml after vaginal delivery
B. 10% drop in hematocrit as we compare with health adult women hematocrit
C. There is vital signs derangement with hypovolemia
D. Estimated blood loss greater than 1000ml after abdominal hysterectomy
PPH can be defined by one of the f.f defn , but the 2nd and the 4th defn are widely used defn
1 PPH is bleeding in excess of > 500 for Vaginal Delievery of singleton, > 750 for VD with
episotomy , > 900 for VD of twin > 1000 ml for C/S delievery , >1.5 L hysterectomy , > 2L for
repeated C/S
2 symptomatic hemodynamic v/s derangement (hypotention , hypovolemia , anemia)
3 need for RBC transfution
4 drop in HCT by 10% from pre-partum value ( not preconceptional value )
5 continiously oozing blood (50-100 ml / hr )
6 loss of 20% of plasma volume

76. A 35 year old G3P2 mother who claims to be amenorrhic for the last 8 months present to
emergency OPD with vaginal bleeding of 06hr duration. She has history of 1 previous
C/S scare and you proceed with P/E. Which one of the following is true for this case
scenario?
these multi parous with 1 c/s scar mom is at risk
A. Abdominal examination should be avoided. for both placental abruption and placenta perevia ,
B. Digital vaginal examination is contraindicated. but since PP is not ruled out yet , DVE is
contraindicated for PP, unless there is no U/S to
C. Double set-up examination should be done first dx pp ; only by which time we do double set up
examination ( PV in OR setup) to DX PP
D. External genital examination should be avoided

should always be done , because the most common

known causes of APH are local causes, that need
external genital examination

50 | P a g e
 77. Which one of the following is True about abnormal uterine bleeding?
A. Pregnancy must be considered in any reproductive age group mother who present
with vaginal bleeding.
B. It can be caused by wide variety of local and systemic disease or drugs
C. Most common cause of AUB is anovulatory
D. All

78. You are with your family on vacation, and one of your cousins need advise after she
missed four pills of companied oral contraceptive in row in the first week of her normal
menstrual cycle. She has no history of sexual contact in the last 5 days. What will be your
best advice?
A. To take her pills as soon as possible, but no problem for missed pills
B. To take her pills as soon as possible, and to use condom for the next 7 days
C. To stop the pills as pregnancy is more likely and as it is teratogenic
-To obtain maximum efficacy and promote regular use, most manufacturers offer dispensers thatprovide
D. All 21 sequential color-coded tablets containing hormones,followed by seven inert tablets of another color.
-Some newer, lower-dose pill regimens continue active hormones for 24 days, followed by 4 days of
inert pills . The goal of these 24/4 regimens is to improve the efficacy of very low-dose COCs.

-During COC use, if one dose is missed, conception is unlikely with higher-dose monophasic COCs.
When this is recognized, taking that day's pill plus the missed pill will minimize breakthrough bleeding.
The remainder of the pill pack is then completed with one pill taken daily.

-If several doses are missed, or if a dose is missed with the lower-dose pills, then two pills are taken but
an effective barrier technique is added for the subsequent 7 days. The remainder of the pack is
completed with one pill taken daily. OR Alternatively, a new pack can be started and a barrier method
added as additional contraception for a week.

51 | P a g e - With any scenario of missed pills, if withdrawal bleeding does not occur during the placebo pills, the
pills are continued, but the woman should seek medical attention to exclude pregnancy. Fortunately,
CHCs are not teratogenic if taken accidentally during early pregnancy
- in this particular woman , the safest 1st week is already gone , she is on her 2nd week now, by which
time she has a potential to get px hence need to take barrier method as well
 79. A 19 year-old female patient presents with recurrent non-foul smelling curd like whitish
vaginal discharge. Her current episode started a week back. She never had any sexual
intercourse. She has no other oral, hair nail or skin lesions. What is the most likely
diagnosis?
A. Gonorrhea
B. Vaginal candidiasis
C. Chlamydia
D. Primary syphilis

N.Gonnorhea ; thick pussy discharge

C.trachomitis ; thin discharge , non itchy
B. vaginosis ; thin discharge , fishy offensive smell , with out hx of sexual intercou
T. vaginalis ; green discharge, offensive , itchy
candidiasis ; white curd like discharge, itchy , with out hx of sexual interco

80. A 37 year-old female HIV patient with presents with a persistent painful ulcer involving
the genital area and the inter-gluteal cleft of two years duration. She recalls that the initial
lesions were vesicles which easily ruptured. What is the most likely diagnosis?
A. Pressure ulcer
B. Herpes simplex
C. Herpes zoster
D. Aphthous ulcer

52 | P a g e
 Intrapartum care of RVI + mom:
-Safe delivery practices and avoiding invasive procedures whenever possible:
o Avoid artificial rupture of membranes to shorten labor and expedite delivery whenever there is a
spontaneous rupture of the membrane.
o Avoid routine episiotomy.
o Limit use of vacuum extraction and prefer obstetric forceps whenever instrumental delivery is indicated
o Avoid repeated vaginal examinations during labor. o Treat chorioamnionitis with appropriate antibiotics
0 Provide essential newborn care (ENC).

Mode of delivery:-
- For women on HAART, If the viral load is > 1000 copies/ml elective cesarean section at gestational
age of 38 weeks should be considered.

- If the viral load is 1000 copies/ml there is no added benefit from cesarean section. Hence, the mother
should be counseled on vaginal delivery.

-In the absence of viral load, a woman adherent to HAART for at least one
month is considered to have lower viral load. Clinical judgment of the
provider in consultation with the woman can be the way to decide the route
of delivery.
81. A 25 year old gravida2 para1mother comes to your clinic for a quest of transfer to other
hospital for delivery. She is currently 36 weeks. She was diagnosed to have HIV at first
screening and was put on HAART since then. Her pregnancy otherwise was
uncomplicated. A recent viral Load was 2000 copies/ml. What is the most likely method
and timing of delivery to reduce the risk of mother to child transmission is?
A. Cesarean delivery at 38 week
B. Vaginal delivery at 37 weeks
C. Vaginal delivery at 39 weeks
D. Cesarean delivery at 39 week
Antepartum care by visit and trimester of pregnancy:

-In addition to the routine ANC, HIV positive pregnant women need special care and should have more visits. As soon as
the patient has a missed period she should visit the antenatal care clinic and have pregnancy test.
-Once pregnancy is confirmed, careful clinical evaluation (detailed history and physical examination). All HIV positive
pregnant, laboring and lactating women should be retested at the initiation of HAART in order to ensure correct diagnosis.
-All HIV positive pregnant, laboring and lactating mothers will be initiated on
HAART for life (TDF, 3TC and DTG).

-HIV positive woman already on ART at time of pregnancy should continue and stay on the same regimen.
-Pregnant women with WHO clinical stage 1 and 2 can safely be initiated on ART in ANC; however, those diagnosed with
advanced HIV disease at ANC (WHO stage 3 and 4) and opportunistic infections should promptly be referred to ART
clinic for diagnosis and treatment of OI and initiation of ART. However, following which, at the discretion of the ART clinic
provider, they can be transferred back to PMTCT unit for their on-going care and treatment.
- Monitoring and support for HAART adherence.

-Early ultrasound for determination of gestational age. Routine laboratory screening tests like in any pregnant women
(VDRL, HBsAg, CBC, Blood group and Rh, and others as needed).
There is no need to wait for CD4 count to initiate treatment. But CD4 count is important to monitor response to treatment-
If available, however, viral load monitoring is more effective to detect emergence of treatment failure. Viral load
monitoring to detect emergence of treatment failure. Advise the mother on the importance of having strict ANC follow up
-Discuss with the mother the risk of MTCT and the possible complications that can occur due to the HIV infection
including IUGR.
53 | P a g e
- Administer vaccinations like TD.
- Nutritional supplementation like in other pregnant women.
- Follow the fetal growth with serial US every 3-4 weeks. and Discuss on the mode of delivery based on the national
PMTCT guideline. Individualize birth plan based on the viral load and the duration of HARRT.
 82. A 25yrs old para2 gravida 1 mother whose GA is 36wk fromelnmp comes to
emergency opdwith compliant of pain full vaginal bleeding of 2hr duration at
presentation her Bp =80/40 PR=128 with paper white conjuctia & 34 WK sized uterus
FHB=184 for 10 min ultrasound shows fundal placenta with hypoechoic mass at
retroplacental area what will the diagnosis of thise patient?
A. Grade1 abruptio placenta
B. Grade2 abruptio placenta
C. Grade3A abruptio placenta
D. Grade3B abruptio placenta
degree of separation vx bleeding uterine irritablity mom PR & BP FHR fibrinogen level
grade 0 asxtic , dx retrospectively after delievery

grade 1 1/3 of placenta < 400ml abscent or minimal unaffected fine unaffected

grade 2 2/3 of placenta 400-1000ml UX tenderness always + PR ^, BP fetal distress may decre
increase,maintained sth death

grade 3 > 2/3 >1L marked tense shock is pronounced fetal death <150 +DIC
is the rule evidence
3A With out couglopathy
3B with coagulopathy

83. What should be the definitive management for the above patient?
A. Resuscitation &termination of pregnancy with induction
B. Resuscitation & continue with conservative management
C. Resuscitation with fluid & prepare cross match blood then c/s at 39 WK
D. Correcting the shock with fluid &blood transfusion then emergency c/s
TREATMENT of Abruptio placenta:
- Resuscitate and stabilize on arrival, and admit the patient. +Assess maternal and fetal wellbeing. + Prepare
cross matched blood (at least 2 units).

A) Expectant management: <37 weeks, patient in stable condition and reassuring fetal condition
Dexamethasone 6 mg IM BID or Betamethasone 12 mg IM every 24 hrs for 48 hours. Anti D 300µg IM if Rh
negative and not sensitized. Closely monitor maternal and fetal conditions. Prevent and treat anemia.

B) Immediate delivery: Gestational age is >37 weeks or estimated fetal weight is >2.5 Kg, deranged vital signs,
heavy bleeding, NRFHRP, IUFD, malformed fetus, established labor.
54 | P a g e
=Mode of delivery:
1 Vaginal delivery is preferred. Cervical ripening and induction of labor, amniotomy.
2 Emergency cesarean section: For severe bleeding endangering maternal life, NRFHR or other obstetric
indications.
Answer question 84&85 based on the given scenario

A 23-year-old G1P0 presents to labor and delivery at 39 weeks complaining of irregular uterine
contractions for the past several hours, some of which are painful. The discomfort is located
primarily in her lower abdomen. She reports good fetal movement and denies any vaginal
bleeding or leakage of fluid. The nurses place the patient on an external fetal monitor. The
monitor indicates that she is contracting every 2 to 10 min, and the nurses tell you that the
contractions are mild to palpation. Cervical
exam is 50/1–2/−1, vertex. This exam is unchanged from that in the office 1 week ago. The fetal
heart rate is reactive without any decelerations. The patient is tired of being pregnant and wants
to deliver as soon as possible.

84. What is this patient’s most likely diagnosis?

A. Active labor
B. Latent labor
C. False labor
D. Stage 1 of labor

DIAGNOSTIC CRITERIA OF TRUE LABOR

= ;- Regular, rhythmic uterine contractions ( 2 contractions in 10 minutes) with one or more of
the following:
-Rupture of the membranes.
- Cervical dilatation of 4 centimeters.
- Cervical effacement of 80 %.
- Bloody show (If fetal membranes are ruptured or if digital vaginal examination was done within the
past 48 hours, show shouldn't be used as diagnostic criteria.)

= NOTE: Always rule out false labor to avoid unnecessary interventions.

False Labor
- False labor is irregular contractions of the uterus prior to actual labor pains resembling those of
normal labor.
Signs of false labour are ;-
-Mild pain and irregular contractions.
-There is no mucous blood-stained discharge (show).
-No progressive cervical dilatation observed on follow up

ADMISSION CRITERIA
- For a woman without known risk and intact membrane if cervical dilation is 4 cm.
- Those women with ruptured membranes & known risk factor can be admitted at any
55 | P acervical
ge dilatation.
 85. What is the most appropriate next step in the management of this
patient?
A. Send her home
B. Admit her for an epidural for pain control
C. Do artificial rupture of membrane
D. Administer terbutaline
i would say A , GN
false labor new , she is on her 39 wk , was falsely labouring for z last
1 week , and shec want to terminate the px. inducing her seems to
be an option . plus lelochu options dess ayilum

MANAGEMENT OF FIRST STAGE ABNORMALITIES

Management is directed towards the stage and cause of abnormal labor.

RULING OUT FALSE LABOR

False labor is characterized by no change in cervical effacement and dilatation after
4 to 8 hours of revaluation.
=Once false labor is ascertained
-explain to the woman (and accompanying relatives)
about false labor, true labor and danger symptoms of pregnancy and labor. Rehydrate if there
is sign of dehydration.
-Give psychological support for the mother.
-Discharge the woman if she has no other problem requiring inpatient management.

86. A 69-year-old postmenopausal woman is being admitted for surgical treatment of

endometrial cancer. She has no health insurance and would like to know which is the
most important preoperative screening test to look for metastasis?
A. chest X-ray
B. hysterosalpingogram
C. pelvic ultrasound
D. intravenous pyelogram (IVP)

pre tretment metastatic evaluation of endometrial ca pt include ;

Imaging studies — A chest radiograph should be performed as part of the initial assessment to exclude lung
metastases.

Abdominal and pelvic imaging is rarely performed in patients with type 1 EC but is often used to exclude metastasis
from type 2 EC. The goal of preoperative axial imaging in patients with type 2 cancers is to detect peritoneal disease
and anticipate the need for laparotomy and cytoreduction rather than a minimally invasive approach. In such patients,
additional chest imaging with CT is often performed to exclude metastatic disease even when chest radiography is
negative.
56 | P imaging
- Infrequently, age is performed for the purpose of clinical staging (although standard EC staging is surgical). This
occurs when surgery is not planned because the patient cannot tolerate surgery or fertility preservation is desired.
For clinical staging, contrast-enhanced magnetic resonance imaging (MRI) appears to be the best radiographic
modality for detecting myometrial invasion, cervical involvement, or lymph node metastases when compared with
nonenhanced MRI, ultrasound, or CT .
 87. Which one of the following FALSE about augmentation of labour?
A. It is a means of correcting obstructed labour by using oxytocin
B. Its indication is poor progress of labour due insufficient uterine actions
C. When there is gross CPD labour should not be augmented
D. None of the above
we augment when the abnormality in the progress of labor is due to
problem in POWER

OBSTRUCTED LABOR ; is A neglected labor where vaginal delivery is

not possible in spite of passage of unreasonably long time in good strong
labor due to mechanical obstruction to the passage of the fetus or failure
of decent of the fetus in the birth canal for mechanical reasons in spite
of good uterine contraction.

88. Which one is an absolute contraindication for induction of labour?

A. Grand multiparity all of the options are CI to
induction and option A is relative
B. One upper uterine segment scare CI, the other 3 are absloute CI
C. Twin pregnancy
D. One lower uterine segment scar
Contraindications of INDUCTION— In each of the following settings, there is general consensus that the maternal/fetal
risks associated with labor and vaginal birth, and therefore induction, are greater than the risks associated with cesarean
birth; therefore, induction of labor is contraindicated.
-Prior classical or other high-risk cesarean incision

-Prior uterine rupture

-Prior extensive complete transmural uterine incision

-Active genital herpes simplex infection

-Placenta previa or vasa previa

-Umbilical cord prolapse or persistent funic presentation

-Transverse fetal lie

57 | P a g e
- Invasive cervical cancer

-Category III fetal heart rate tracing UPTODATE 2022

 89. A 21 year old woman has presented for first prenatal visit. Her LNMP was 12 wks ago,
which she was certain about. Upon abdominal examination you noted bilaterally
enlarged adnexae and the uterus is about 20 wks sized. Abdominal Ultrasound depicted a
snowstorm pattern in the uterus. What is the specific next step management?
A. Admit and prepare x-matched blood
B. Put her on oxytocin
C. Evacuate the content GTD is an emergency or potentially emergency
D. Primary hysterectomy early px compln

90. With typical use, which of the following contraceptive methods has the highest failure
rate within the first year of use?
withdrwal method is not considered as a contraceptive
A. Withdrawal method because it is ' ALL OR NONE '
B. Spermicides
C. Male condom 4 tier of contraceptives ; failure w 1yr use
1st tier ; implant , IUD , surgical methods <2%
D. Progestin-only pills 2nd tier ; all hormonal other than implant, including LAM method 3-9%
3rd tier ; condom , diaphram ,fertility awarness 10-20%
4th tier ; spermicidal 21-30%

58 | P a g e
 91. Surgical infection that is erythematous and edematous with shiny skin, sever pain and
fever but has no sharply circumscribed border/edge is most characteristic of:

A. Cellulitis

B. Abscess
Edematos shiny skin With unclear border is typical for
C. Boils (Furuncle) cellulitis , as does Edematos shiny skin
With clear border for erispelas
D. Carbuncle

59 | P a g e
 92. One of the following is NOT included in post operative infections:

A. Pancratitis

B. Parotitis

C. Ludwig angina

D. Septic thrombophilebitis

93. Dead bone in patients with chronic osteomylities is called------------

A. Osteomalacia
B. Involucrum
C. Sequestrum
D. Cloaca

60 | P a g e
 94. Which of the following is not true about acute osteomyelitis
A. Its common in pediatrics age group
B. The commonest causative organism in neonates is Staph. aures only
C. It is usually caused by a single organism
D. Bone scan can be useful in early phase

95. which one of the following is the most common cause of small bowl obstraction
A. Hernia
B. Post op adhesion
C. Intussesuption
D. Volvules

96. the definative diagnosis of BOO is made through

A. history and physical examination

61 | P a g e
 B. ultrasound
C. pressur -flow studies
D. based on PSA level

97. Which one of the follwing is different from others

A. Poor flow
B. Hesitency
C. Frequency
D. Dribbling

98. Most accurate method of diagnosing achalasia?

A. Barium swallow
B. CT scan
C. Manometry
D. MRI Scan

62 | P a g e
 99. A 55 years old male presents with progressive dysphagia which is more for solids,
weight loss and he is alcoholic since the age of 15. Examination entirely normal.
Diagnosis is?
A. Esophageal stricture
B. Achalasia
C. Diffuse esophageal spasm
D. Esophageal Cancer

100.65 years old male patient presented with compliant failure to urinate of a day duration during
DRE he has smooth convex and elastic prostate with mobile rectal mucosa .Which diagnosis go
with DRE finding

A. Prostatic ca C. Prostatic caliculi

B. BPH D. Prostatitis
101.Among the blood products one can be used beyond 5 years

E. Whole blood

63 | P a g e
 F. Cryoprecipitate
G. Fresh frozen plazma
H. Platelet

102. On arrival at E-OPD of MVA, You observe a significant bruising on the chest/seat belt
sign. You suspected the patient has a pericardial tamponade. Which of the following is not a sign
of Beck triad?

A. Hyperresonant chest sounds

B. Hypotension
C. Jugular vein distention
D. Muffled heart tones

64 | P a g e
103.True about nodular goiter

A. There is persistent stimulation of TSH

B. Nodules may be cystic or solid

C. More single nodule than multiple

D. Cyst is common complication lead to calcification

104.Diffuse toxic goiter (graves’ disease) NOT characterized by

A. Thyroid enlargement

B. Overproduction of TSH

C. Exophthalmos

65 | P a g e
105.Which of the following is true about shock?

A. Anaphylactic shock is a type of Obstructive shock.

B. Multiorgan failure is expected in compensated stage of shock.
C. In cardiogenic shock pulmonary capillary wadge pressure decrease.
D. A and C
E. None of the above

106. A 25 years old male patient presented 1hrs after he sustained road traffic accident. At
presentation the vital signs were BP: 80/40mmHg PR:108b/m RR:26 Temp:36.7. He has no site
of bleeding but has a bilateral femoral shaft deformity. He has no other site of injury. What
should be your first step in Emergency management of this patient ?

A. Send him for X-ray

B. Secure double IV line and start resuscitation
C. Splint the extremity to prevent further injury
D. Follow the ATLS protocol

66 | P a g e
107.Not true about appendix and acute appendicites

A. peak age of acute appendicites is b/n 2nd and 3rd decade of life
B. appendicites is poly microbial infection
C. pelvic appendixe is most common position of appendix
D. all are true

108.Which one of the following is NOT a clinical indication for laparatomy in management of
Abdominal injury?

A. Hemodynamic stability

B. Clear and persistent signs of peritoneal irritation

67 | P a g e
 C. Radiologic evidence of pneumoperitonium

D. Evisceration

109.Which one of the following combination is TRUE about Abdominal trauma?

A. Blunt abdominal trauma ----- Organs with largest surface area are prone to injury

B. Penetrating abdominal trauma ----- Mostly inelastic tissues injured

C. Blunt abdominal trauma ----- Adjacent structures are commonly injured

D. Penetrating abdominal trauma ----- Damage localized to the path of an object

68 | P a g e
110.A single most practical method of assessing adequacy of fluid resuscitation in trauma patient
is:

A. Blood pressure

B. Pulse rate

C. Urine output

D. Daily weight monitoring

111.A victim of road traffic accident is brought to emergency room unconscious and with blood
pressure of 80/60 mmHg. The first step in management of this patient is:

A. IV fluid resuscitation

B. Skull x-ray

C. To establish adequate airway

D. Neurologic evaluation

69 | P a g e
 112. the most common immediate cause of death in a major trauma includes:

A. Bleeding in the chest and abdomen

B. Lethal injury to brain, heart & major blood vessels

C. Extensive fractures and increased intracranial injuries

D. Sepsis and organ failure

113.Alemitu is 18 years old female patient who was admitted in the surgical ward with a
diagnosis of severe anemia secondary to acute blood loss secondary to unstable pelvic
fracture.she was investigated with CBC and her hgb was 2mg/dl and her platelet count was
80,000.you were the one who manage her in the emergency, what is your first choice to treat
the severe anemia?

A. Whole blood
B. Plasma
C. Platlet
D. Ringer lactate

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114.Based on the above case, What is your next choice?

A. Whole blood
B. Platelet
C. Normal saline
D. Albumin

115.If you want to give platelet to Alemitu, how many units do you want to transfuse her to
attain the lowest normal level of platelet count?

A. 5 units D. 4 units
B. 7 units
C. 8 units

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116.Which one of the following is H type spectrum of EA and TEF?

A. Isolated atresia

B. Blind end proximal limb and distal fistula

C. Fistula without atresia

D. All

117.Neck x-ray finding of patient with goiter can be?

A. Lateral view –tracheal shift

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 B. AP view- tracheal compretion

C. Calcification

118.Which of the following is not predisposing factor for adenocarcinoma of the esophagus?

A. Barrett’s esophagus
B. Esophageal web
C. Obesity
D. Smoking

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119.While performing an assessment on a patient involved in MVA, you observe decreased
breath sounds, and upon percussion of the chest, you note hyper resonance and has no any
additional finding. What will be the diagnosis?

A. Hemothorax
B. Open pneumothorax
C. Simple pneumothorax
D. Tension pneumothorax

120.22years old male patient presented with abdomenal pain of a day duration wich was intially
around periumbalical region later on shifted to RLQ and has associated anorexia during physical
examinatin he has pain on right lower quadrat during palpation of LLQ.....which sign is posetive
in this patient

A. Rovsing sign
B. psoas sign
C. obturater sign
D. Pointing sign

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