ERMP 2020 Part II Questions

1. A 5 years old child present to you with multiple skin cancers over the photo-exposed areas of the body. His parents are normal but his younger brother has extremely dry skin with areas of darker spots mostly over the face. What is the most likely diagnosis of this child’s condition? A) Xeroderma pigmentosum B) Gorlin syndrome C) Neurofibromatosis D) Tuberous sclerosis 2. A 36 years old male came with pruritic papules and pustules over the beard area of two days duration after shaving. After investigation he was told that it is not an infectious origin. What is the most likely diagnosis? A) Pseudofoliculaitis Barbae B) Sycosis Barbae C) Folliculitis Kelodalis D) acne keloidalis nuche 3. A 25 years old patient presented with exfoliating lesion over trauma prone areas of the body since 5 years. Morphologically the lesions are thickened, erythematous plaque with silvery white scaling; removal of the scale reveals a pin point bleeding underneath. Which system is most likely to be involved in the disease process? A) Cardiovascular B) Renal C) Gastrointestinal D) Nervous 4. The surgical wound of a 45 year old fat lady, who is on her 21st post-operative day following an open abdominal surgery for cholecystectomy, is not healing properly. When asked about her diet, the woman says that she mainly eats meat and dairy products and, as much as possible, tries to avoid fruits or vegetables. What is the most likely reason for the delay in wound healing? A) Impaired granulation tissue synthesis B) Decrease in the production of type III collagen C) Poor tensile strength of collagen D) Defect in fibrillin within elastic tissue 5. The production of the so-called acute phase reactants is increased in both acute and chronic inflammation. One of these is a sensitive indicator of necrosis associated with acute bacterial infections as well as an excellent monitor of disease activity in chronic inflammation, such as rheumatoid arthritis. What serum markers fits the above role? A) C-reactive protein (CRP) B) Fibrinogen C) Creatinine kinase D) Serum Amyloid A (SAA)

6. A 35 year old mother died just 2 hours after delivering through spontaneous vaginal delivery. The corpse was taken for autopsy. A review of the clinical records showed that her death was reported as sudden death. The only remarkable autopsy finding was a large caliber thrombi occluding one of the major branches of the pulmonary artery. Where is the most likely site of origin for the thromboemboli? A) Vena cava B) Iliac vein C) Pelvic vein D) Femoral vein 7. A 29 year old lady presented with joint stiffness, pain and swellings over fingers of both hands of 3 months duration. The joint stiffness is worse in the mornings and gets better after some activity. Lab tests showed positive Rheumatoid factor, elevated ESR and CRP. Which joints are expected to show abnormalities upon radiographic study of the hand? A) Metacarpophalangeal and proximal interphalangeal joints B) Metacarpophalangeal and distal interphalangeal joints C) Proximal and distal Interphalangeal joints D) Intercarpal and distal interphalangeal joints 8. A 60 year old postoperative patient developed abdominal pain, abdominal distension and vomiting. Erect abdominal radiography showed dilated bowel loops all over the abdomen with gas shadow in the rectum. What is the most likely diagnosis? A) Paralytic ileus B) Early small bowel obstruction C) Distal small bowel obstruction D) Generalized peritonitis 9. Ultrasound report of a lady with an anterior neck swelling showed a 2.0cm TR-5 (TI-RADS 5) thyroid nodule. What is the appropriate next step in management of this patient? A) No FNAC or follow up B) Follow up in three months C) FNAC D) Excisional biopsy 10. A20 years old male patient presented to the OPD with a complaint of progressive difficulty of breathing associated with muffled voice during speech. What is the most likely site of the lesion responsible for the patient’s complaint? A) Nasal cavity B) Oropharynx C) Glottis D) Trachea 11. A 2months old infant presents with difficulty of breathing of 6weeks duration, but no other complaint. Physical examination shows inspiratory stridor. Laryngeal examination showed the finding depicted in the picture below.

What is the most likely diagnosis? A) Ranula B) Laryngomalacia C) Subglottic stenosis D) Epiglottic hemangioma 12. A 40 years old patient presents to the ED after he sustained stich injury to the right temporal area of one day duration. Physical examination reveals severe ipsilateral infra nuclear facial palsy with decreased test sensation. Which of the following is the least likely site of facial nerve injury considering the patient’s condition? A) Mastoid cavity B) Middle ear C) Stylomastoid foramen D) Geniculate ganglia 13. A patients presents to the ED 2days after sustaining nasal trauma. The patient complains watery nasal discharge since the time of the trauma especially when leaning forward. What is the most specific laboratory study to confirm the diagnosis? A) Glucose strip test B) Protein analysis of the fluid C) Albumin level of the fluid D) B2-transferrine analysis 14. A critically ill patient was brought to emergency OPD where you are the attendant. After providing the emergency care, you decided to admit him. However, the ward nurse said there is no vacant bed to keep the patient. You know if you send the patient back home, he is not going to make it. In the meantime, the nurse insisted she cannot have him. What is the best way to handle this situation? A) Nothing can be done if the nurse says so B) Negotiate ways while trying to understand her point as well C) Do not take NO as an answer D) Report to her superior she may cooperate if she gets order 15. Mr. E. had reservations about the clinical information he had received from his surgeon regarding a lump in his testes. His doctor recommended removal of the testicle because it appeared to be enlarged, but he was uncomfortable about having the procedure. His wife

questioned whether the diagnosis was adequate as there was some confusion with the test results. He decided to check with another doctor. What might have made Mr. E decide to have second opinion? A) Test result was confusing B) Felt he had not been given sufficient information C) To avoid the surgery D) Afraid of undergoing the procedure 16. The chief resident is responsible to pass the number of duty days to the administration so that the payment can be made. At the end of the month, you realized that your payment was much lower than your expectation. When you checked the paper that was sent by the chief resident, you noticed that the number of days was lower than from the actual dates you served. What is the appropriate initial thing to do? A) file a formal complaint B) discuss with other residents about how unfair you have been treated C) wait if the same mistake is made next month D) consider that the chief resident made an honest mistake and talk to him 17. You find an interesting research topic but challenging and have worked so hard on your proposal. Yet, your research adviser was not happy about your work, he provided you with lots of comments for you to improve and you know time is against you to accommodate the feedback and meet the deadline for submission. You felt bad for not being appreciated for all the efforts you put on the paper. What is the appropriate response to your situation? A) Absorb the comments to improve the paper B) Look for another research advisor who is accommodating and understanding C) appeal to the department so that the advisor does not put pressure on you D) Drop the current proposal and consider simpler one 18. You were faculty at one of the medical schools and you secure a grant to undertake large scale study which is expected to improve quality of clinical care. With plenty of unforeseen circumstances, you failed to meet deadline to submit the result of the finding and financial report on how you used the money. What would be the appropriate communication with the grant financer? A) Explain to the funder how the unforeseen circumstances failed you and appeal for extension B) discuss with your institution on how you can get support to proceed with the research C) Explain to the funder you take full accountability and appeal for extension D) notify the funder as you cannot accomplish the research 19. A22 years old man who sustained a subdural hematoma and brain contusion needs a blood transfusion in order to have a lifesaving surgery done. He was in coma thus his parents were asked for consent. However, the parents refuse to allow the transfusion based on their religious beliefs. What should be done? A) Honor the parents’ wishes B) Inform your medical director to handle it C) Give the blood without the consent D) Inform legal authority and wait for formal hearing 20. A 75 years old man who is on treatment for myocardial infarction and stroke that left him in a persistent vegetative state was under your care. He is a widow and left no written

evidence of his wishes for himself. His daughter wants to continue all forms of therapy and his son and patient’s brother wants to stop everything. Both parties believe they know the wishes of the patient. What should you do first? A) Stop all forms of therapy for the patient B) Decide in the best interest of your patient C) Encourage discussion amongst the family D) Order seeking a court appointed guardian 21. You were called for a ward consultation. The consulting resident shows you the patient and went to the operation room to attend an emergency surgery. When evaluating the patient, she tells you that she is allergic to penicillin. After completing your evaluation, while writing treatment plan on the order sheet, you noticed that crystalline penicillin is already prescribed on the order sheet. Which one of the following is the most appropriate in handling the issue? A) complain to the ward nurses that the ward resident should have taken drug allergy history B) cross out the penicillin order, sign on it C) try contact the consulting resident to revise the order D) remove the former order sheet, write new order 22. You are assigned in an isolation site for COVID-19 to take care of suspected cases. You have an elderly parent having comorbid diseases whom you visit on weekly basis. What would be your reaction? A) Tell the director you are not psychologically ready B) Explain your situation why you cannot accept the assignment C) Take the assignment D) Take a vacation till the pandemic is over 23. A 30 years old female patient has mitral valve replacement before 5 years. Now, she is admitted to ICU with tumor lysis syndrome after being treated for leukemia. After 5 days of ICU admission, she was diagnosed to have Staphylococcus aureus bacterial endocarditis. What is the most possible risk factor of endocarditis for this patient? A) Prosthetic valve endocarditis B) Native valve endocarditis C) Urinary catheter associated endocarditis D) Nosocomial endocarditis 24. A 60 years old known diabetic and hypertensive patient has been on maximal dose of a calcium channel blocker and lifestyle management for two months. Her current BP is 150/100 mmHg. What is the most appropriate next step in managing this patient? A) Continue the same treatment and appoint her to come after one month B) Add angiotensin converting enzyme inhibitor to her treatment C) Add furosemide to her treatment D) Add a beta blocker to her treatment 25. A 19 years old university student presented with shortness of breath on moderate exertion. On history, he recalls that he had an episode of fever, pain and swelling of her knees 9 years ago that was severe enough to keep him off school for two weeks. Echocardiography revealed a thickened mitral valve with moderate mitral regurgitation. Which intervention could have prevented the cardiac lesion? A) Oral aspirin, three tablets of 325 mg each, 6 hourly when he was 10years old B) Benzathine penicillin 1.2 million units at the initial episode and then given monthly

C) Valve surgery at the time of the initial episode D) Oral prednisolone at the time of the initial episode 26. A 20 years old man is newly diagnosed with rheumatic valvular heart disease. You counsel him to start prophylactic penicillin. The nurse gave him an intramuscular injection of 1.2 millionunits benzathine penicillin. The patient suddenly developed urticaria, flushing, pruritus, shortness of breath, nausea and vomiting. On physical examination, his BP is 80/50 mmHg and PR is 135 bpm. There is diffuse inspiratory and expiratory wheezing. What is the most appropriate treatment for this patient? A) Give 1 mg epinephrine I.V., and I.V. steroids at OPD and observe at ER B) Administer oxygen, give I.M. steroids at OPD, and observe at ER C) Give oral antihistamines and oral prednisone and continue to watch the patient for further clinical deterioration for 6 hours D) Administer oxygen, give I.V. fluids, I.V antihistamines, I.M. epinephrine, start steroids and admit to emergency care 27. A 36 years old man presented with cold intolerance, weight gain, change in voice and constipation. His TSH level was elevated and the free T4 level was very low. What is the most common cause of this condition worldwide? A) Graves’ disease B) Hashimoto’s thyroiditis C) Iatrogenic hypothyroidism D) Iodine deficiency 28. A 22 years old known type I diabetes mellitus female is brought with nausea, vomiting, and lethargy. She ran out of insulin two days back. On examination, she is lethargic, and has dry mucous membranes. Her PR is 120 bpm, and BP is 75/40 mmHg. Chestis clear and heart sounds are normal. She is weak but responsive and oriented. RBS is 540 mg/d, serum sodium is 124 meq/L, Potassium is 4.3 meq/L, Cl is 88 meq/L, BUN is 76 mg/dL, and creatinine is 2.2 mg/dL. Which management is least appropriate for this patient? A) Intravenous fluids B) 3 Percent sodium solution C) Intravenous insulin D) Intravenous potassium 29. A 20 years old female visited ER with a complaint of upper abdominal pain of 3 month which worsens over the past 3 days. The pain gets aggravated with feeding and improves up on fasting. Recently she started to notice weight loss. What is the most likely diagnosis of this patient? A) Gastric ulcer B) Duodenal ulcer C) Atrophic gastritis D) Gastric carcinoma 30. W/ro B presents with recurrent vomiting of coffee ground material of two days duration with associated dizziness, easy and epigastric pain. Her V/S shows BP- 90/60mmHg on supine and 70/40mmHg on sitting position, PR- 120bpm and RR- 28bpm. What is the best initial management of this patient? A) Transfusion of Blood product B) Administration of crystalloid C) Give IV proton pump inhibitor

D) Put her on intranasal oxygen 31. A 30 years old woman with history of dyspepsia presented with easy fatigability, dizziness and history of picca. Her hemoglobin was 9 gm/dL. Which lab test is least consistent with the underlying condition of her case? A) Microcytic hypochromic RBC’s B) Decreased serum ferritin C) Decreased total iron-binding capacity (TIBC) D) Low reticulocyte response 32. A 60 years old male patient comes for medical checkup to medical OPD. He doesn’t have any complaint at all, but you got a spleen of 5cms below left costal margin. His CBC shows WBC-10000/micro L(granulocyte 82 percent lymphocyte 10 percent), Hgb-11gm/dl, Plt - 205,000/micro L. Peripheral morphology shows all series of granulocyte (neutrophils, bands, myelocytes, metamyelocytes, promyelocytes, and blasts cells) in the peripheral blood. What is the most likely problem of this patient? A) AML B) ALL C) CML D) CLL 33. A 21 years old male patient was diagnosed to have TB pericarditis with effusion and was started on anti-tuberculosis drugs and glucocorticoids. What is the benefit of adding glucocorticoids for this patient? A) To prevent constriction B) To prevent worsening of effusion C) To prevent heart failure D) To prevent arrhythmia 34. A 40years old Ethiopian woman who was recently working at Democratic Republic of Congo developed severe fever and muscle pain while waiting for a connection flight. What additional finding is most likely to develop in this particular patient? A) Skin rash B) Cough C) Loss of consciousness D) Bleeding 35. A 22years old male presented with high fever, chills and rigors. No other findings were found on examination expect T-39.8degree Celsius and PR-104bpm. On investigation, blood film showed multiple spirochetes. What is the first line treatment for this patient? A) Doxycycline B) Procaine penicillin C) Ciprofloxacin D) Norfloxacin 36. A 50 years old male visited the cold OPD for a regular heath checkup. On reviewing his previous medical record, he had history of road traffic accident for which removal of hematoma and splenectomy was performed. For which condition should he get a vaccination for? A) Staphylococcus aureus

B) Escherichia coli C) Hemophilus influenzae D) Pseudomonasaeruginosa 37. Ato T who is a newly diagnosed HIV patient is told to have renal disease, hypertension and type II DM five months ago and was on follow up very 3months. He has no compliant except for generalized discomfort and easy fatiguability. Initial lab findings done 5months back showed FBS - 155 mg/dl, Cr -1.6, BUN -27, U/A: albumin +2. On his current visit FBS - 200 mg/dl while RFT and U/A results were the same to the previous one. Abdominal U/S showed bilaterally shrunken kidney. What could contribute for development of CKD in this patient? A) Diabetes B) Hypertension C) HIV associated D) Drug related 38. A 30 year old woman with preeclampsia developed acute kidney injury. After giving birth, she was transferred to medical side for follow up of her kidney status. She starts to have left side pleuritic chest pain which worsens on supine position, but gets better on sitting position since yesterday. Her UOP is 350 mL/ 24 hr. Her last Cr -3.5mg/dl, BUN - 88, serum Sodium- 130 meq/L, Potassium-5.7 meq/l. The ward team decided to do dialysis. What is the indication for dialysis in this patient? A) The serum Potassium level B) The serum Sodium level C) The urine out put D) The chest pain 39. A60 years old man with a history of coronary arterial disease experiences an out of hospital cardiac arrest. He is resuscitated in the ER but didn’t have a perfusing rhythm for approximately 25 minutes. On examination, he doesn’t respond to external stimuli but has preserved brainstem reflexes. Which part of the brain is profoundly affected by this scenario? A) Medulla B) Spinal cord C) Cerebellum D) Midbrain 40. A 50 years old male known hypertensive patient presents with a day history of severe headache which awaken him form sleep. Associated with this he has also vomiting of ingested matter several times. He had no previous history of such headache. On physical examination he is confused. Brain CT without contrast is shown below.

Which result of diagnostic study is most likely? A) Basal meningitis B) Subarachnoid hemorrhage C) Intra-cerebral hemorrhage D) Fungal infection of the basal meninges 41. A 45 years old woman presents with a complaint of two episodes of abnormal body movement with loss of conciseness each lasting for 4minutes without regaining her consciousness. Associated with this she has tongue bite and incontinence. Physical examination revealed GCS of 11/15. What is the most appropriate next step in managing this patient? A) Load her with phenytoin B) Start phenytoin 100mg PO TID C) Wait for the another attack to occur D) Wait till investigation results arrive 42. A 70 years old female patient visited the emergency OPD with a complaint of shortness of breath, yellowish productive sputum and fever. On physical examination, PR- 100bpm, RR- 34bpm, BP-120/74 mmHg and T- 39.8degree Celsius Chest examination showed signs of respiratory distress and bronchial breath sound on the left lower lung field. What is the best method for the diagnosis of this patient? A) Chest x ray B) Sputum culture C) Lung biopsy D) Blood culture 43. A 70year sold male was diagnosed with pneumococcal pneumonia and was admitted to the ward for treatment. He doesn’t have history of regular alcohol consumption. On the second day of his admission, he has progressive change in behavior and later lost

consciousness. Upon re-evaluation, he has mild nuchal rigidity and the level of his fever didn’t reduce. Which one best explains the patient’s deterioration? A) Myocardial infarction B) Metastatic infection C) Hospital acquired infection D) Cerebro-vascular accident 44. An 18 years old female patient is a known asthmatic patient who was taking Albuterol puff for the past two years. Now, she complains that she is unable to control her wheezing with Albuterol puff being taken more than three days a week. What is the next step in treating this patient at this time? A) Long acting beta 2 agonists B) Short acting beta 2 agonists C) Inhalational glucocorticoids D) Oral glucocorticoids 45. A 20 years old nullipara lady is worried in case she is pregnant because she is amenorrheic for the past 5 months. She has also associated nausea and vomiting in the morning, and breast enlargement. What confirm the diagnosis? A) Positive Chadwick’s sign B) Fetal quickening C) Positive urine HCG D) Fetal movement seen 46. A 18 years old primigravida lady who started ANC comes at 36 weeks of gestation. You sent routine investigation and her CBC result shows Hgb - 6.5gm/dl with microcytic and hypochromic RBCs otherwise other cell lines are not affected. She has no symptoms of anemia and her vital sign is in the normal range and she feels well throughout her pregnancy.What is the proper management for this patient? A) Packed RBC transfusion B) Therapeutic iron till 3 months post delivery C) Transfuse whole blood during labor D) IV iron dextran 47. A 65 years old Para VII woman who has underwent surgery after diagnosed with pelvic organ prolapse with anterior and apical defect with POP-Q stage IV. No urodynamic test was done before the procedure. After surgery excellent anatomic restoration was achieved and she is not experiencing any bulge symptoms. What type of urinary incontinence she is likely to develop? A) Urge incontinence B) Mixed urinary incontinence C) Functional incontinence D) Stress urinary incontinence 48. A para III lady is diagnosed to have a left ovarian tumor after she presented with menorrhagia of three months. On ultrasound the tumor is 3 by 3 cm mono locular, the other ovary is ok and there is no ascites seen. What is the best next management of this patient? A) Do MRI/CT, tumor markers, chest x -ray B) Repeat ultrasound after three months C) ultrasound guided aspiration

D) Refer her for staging surgery 49. A 20 years old pregnant lady Pap smear result shows high grade squamous epithelial lesion at her eight week gestation. Her colposcopy result turns out to be satisfactory. What is the next step in the management of this patient? A) Pregnancy termination and Cone biopsy after 6 weeks B) Endocervical curettage at 6 weeks C) Continuing pregnancy and postpartum conization D) Continuing pregnancy and Pap and colposcopy every 6 weeks 50. Gravida II Para I mother presented with sudden onset vaginal bleeding of three hours duration. Gestational age from unreliable LMP is 34 weeks. On examination; her BP is 90/50 mmHg, PR 110, RR 22, uterus is 34 wk sized and tender, has no contraction, FHB is not audible, breech presentation, has minimal bleeding per vagina. What is the most likely cause of the bleeding? A) Placenta previa B) Abruption placenta C) Vasa previa D) Uterine rupture 51. Gravid V Para I abortion III (1 spontaneous,2 induced) is diagnosed to have ectopic pregnancy. She was treated for pelvic inflammatory disease a year back. Otherwise she has no history of cigarette smoking or alcohol drinking. She has six lifetime sexual partners. What is the strongest risk factor for ectopic pregnancy? A) History of Induced abortion B) History of Pelvic inflammatory disease C) History of spontaneous abortion D) History of 6 sexual partners 52. You diagnose preterm labor at gestational age of 34 weeks on a primigravida lady. She is admitted at cervical dilatation of 5cm. You are planning to follow fetal heart beat with fetoscope. She had uneventful ANC and no chronic medical illness. How frequent should you auscultate the fetal heart beat during active first stage of labor? A) Every 5 minutes B) Every 15 minutes C) Every 30 minutes D) Every 1 hour 53. You have admitted a primigravida laboring mother at a cervical dilatation of 7 cm, right occipito-posterior position, Station zero, ruptured membranes and clinically adequate pelvis. The estimated fetal weight is 3800gm. After four hours she has 5 moderate contractions over 10 minutes. Your digital examination finding is: Cervix 8 cm, OP position, Station zero, and no caput or molding. What is the next step in the management? A) Labor augmentation B) Cesarean delivery C) Re- evaluating her after 2 hours D) Vacuum delivery 54. A 28 years old primigravida lady comes after she was kicked on her abdomen by her husband before two hours. Her gestational age is 32 weeks. She has moderate abdominal pain

but no passage of liquor or vaginal bleeding. Fetal heart rate ranges between 120–160 beats per minute. She has two mild contractions over 10 minutes and mild abdominal tenderness. What would be the best modality to detect abruption in this patient? A) Serial hematocrit determination B) Obstetric ultrasound C) Clinical signs and symptoms D) Continuous fetal monitoring 55. A 35 years old para IV mother is in a follow-up for pelvic pain for the past one year. The pain is cyclical and sometimes responds to analgesics. She has regular menses with a reasonable amount. Abdominal examination is unremarkable. Ultrasound does not reveal anything. On pelvic examination uterus is normal sized, adnexa are free, and you feel nodularity on cul-de-sac. What is the most likely cause? A) Endometriosis B) Adenomyosis C) Chronic PID D) Subserousmyoma 56. A Para I mother on her immediate post op period after she gave birth by elective cesarean section developed fever. Her temperature is 38.5degree Celsius. Otherwise, she has no chronic medical illness. What is the most likely diagnosis? A) Foreign body in the abdomen B) Physiologic C) Wound infection D) Endometritis 57. A 30 years old Para V mother wanted to limit her family size. You discussed options of family planning methods and she opted for oral combined hormonal contraceptives. On further discussion you mentioned other benefits of this method beyond contraception. What are additional benefits of this contraception method? A) Decreased risk of ectopic pregnancy B) Decreased risk of venous thrombo embolism C) Decreased risk of Endometrial cancer D) Decreased risk of breast cancer 58. While you are working in an emergency OPD, a teenager brought to you by her family after she developed sudden onset right lower quadrant abdominal pain and minimal vaginal bleeding. She denied any history of sexual intercourse but her last menses was 5 weeks back. Her blood pressure is normal, not febrile but she is tachycardia. On examination right lower quadrant abdominal tenderness but no sign of fluid collection. What is the initial investigation you would order? A) Ultrasound B) Urine HCG C) Serum HCG level D) Hematocrit/hemoglobin 59. A 28 years old who had IUCD insertion before four months come with foul smelling vaginal discharge of three days duration and lower abdominal pain. On physical examination she has cervical motion and right adnexal tenderness. On pelvic ultrasound she has minimal

fluid collection in the cul-de-sac and IUCD is seen in place.What is the appropriate management in this patient? A) IUCD removal and antibiotics B) Antibiotics while IUCD is in situ C) Antibiotics and change IUCD after 48 hours D) IUCD removal, culdocentesis and antibiotics 60. A 43 banker has developed difficulty of reading small texts on his cell phone and as well as his desktop network. She had never had any problem with her eyes and afraid that the prolonged use of computer for in workplace resulted in his problem. What is the most likely cause of the banker’s condition? A) Hyperopia B) Computer vision syndrome C) Presbyopia D) Myopia 61. An adult male patient presented with inward sunkening of right eye and double vision. On systemic review, he reported a minor fighting incident with fist 4 weeks back. On examination the physician found inferiorly positioned right eye with upward limitation? What orbital bone is the most likely affected? A) Right Maxillary bone fracture. B) Right ethmoidal bone fracture C) Right zygomatic bone fracture D) right lacrimal bone fracture 62. A 2 years old child brought to OPD after his mom witnessed whitish reflex from inside the left eye for 2 weeks. The general practitioner noted white pupil reflex when he does red reflex test associated with nasal deviation of the left eye. For which of the following condition is the child most at risk? A) Strabismus B) Cataract C) Amblyopia D) Retinoblastoma 63. A general practitioner at a private clinic examined a 35 years old patient who came for annual medical checkup who on systemic review has blurring of vision and headache. The patient was sent for Consultation and the feedback report from an ophthalmologist includes macular star exudates and silver wiring of retinal vessels in both eyes. What is the best initial evaluation recommended for this patient? A) Echocardiography evaluation B) Blood pressure measurement C) Blood lipid profile D) Carotid artery angiography 64. A 9 months old infant came to immunization clinic after he lost to follow up. He took vaccination up to the 10th week. Currently he is growing well and stable. What vaccine are you going to give him? A) Measles today and Penta3, PCV3, OPV3 after 4 weeks. B) Penta3, PCV3, OPV3 with measles today. C) Start the whole vaccine schedule as a new.

D) Only measles vaccine is enough. 65. An apparently healthy 10 years old child presented with difficulty of breathing and cough of 2 weeks duration. He also has bilateral leg swelling for 5 days. With this, he has high grade fever, chest pain and orthopnea of 2 pillows. On physical examination, he has PR of 180bpm, RR of 50bpm, temperature of 38.9 degree Celsius. He is in respiratory distress and has bilateral posterior lower third crepitation. The precordium is quiet with barely heard heart sounds and gallop rhythm but no murmur heard. His BMI for age is below negative 3 Z score. Chest-X- ray showed cardiomegaly. What is the most likely diagnosis? A) Congestive heart failure secondary to rheumatic heart disease. B) Congestive heart failure secondary to myocarditis. C) Congestive heart failure secondary to pericarditis D) Congestive heart failure secondary to anemia 66. A 3 months old infant has frequent constipation but no vomiting or abdominal pain. He has weak cry and is less active. He is the best of all well-behaved babies that the mother had in her life. Objective evaluation showed PR- 70bpm, RR-30bpm and T- 35.3 degree Celsius. He doesn’t show social smile, has umbilical hernia and wide anterior fontanel. Otherwise he has no other remarkable findings. What is the best initial test you order? A) Trans-fontanel ultrasound B) Rectal suction biopsy C) Thyroid function test D) Abdominal ultrasound 67. A 7 months old normally growing infant had bloody diarrhea of 2 days associated with vomiting of ingested matter and intermittent high pitched cry but no failure to suck or fever. On evaluation you noticed palpable mass over the right upper abdomen and has PR of 155bpm, RR of 48bpm and Temp of 37.8 degree Celsius with capillary refill of 2 seconds. What is the immediate appropriate fluid management for this child? A) Giving 600ml of ORS over 4hrs B) Giving 800ml of NS/RL over 6hrs C) Giving 600ml/ of NS/RL over 4hrs D) Giving 50-100ml of ORS per each loss 68. A 12 months old infant can request for food and water, tries to feed himself with spoon and releases the spoon when asked. He can creep and sit unsupported. He can wave his hands saying bye and comes when called. Which part of his developmental millstone is in problem? A) Fine motor B) Gross motor C) Language D) Cognitive 69. A 5 years old girl with cirrhosis and portal hypertension experiences increasing abdominal distention and fever. Shifting dullness is noted on physical examination. Paracentesis revealed cloudy fluid. What is the most likely organism revealed on culture of the ascetic fluid? A) Hemophilus influenza B) E. Coli C) Pseudomonas D) Pneumococci

70. A 12 hours old term macrosomic neonate was sent to NICU for evaluation. The labor and delivery was uneventful with outcome of 4200gm male neonate with APGAR of 8 and 9 at first and fifth minutes. On examination- he has RR of 50 bpm, red-purple face and trunk with sustained sucking reflex. On laboratory investigation- WBC- 20,000cells/mm3 (56percent neutrophil), Hgb - 25mg/dl, Plt- 340,000cells/mm3 and RBS - 56mg/dl. What is the most next appropriate step? A) Double exchange transfusion B) Hydration with normal saline C) Volume to volume exchange transfusion. D) Partial exchange transfusion 71. A 5-day-old neonate who was delivered at home presents with a history of not able to breathe properly for a few hours and difficulty of feeding. He has no fever or vomiting. On examination, he appears as shown in the picture (Figure below) with RR of 56 bpm, PR of 120 bpm and temperature of 37.4 degree Celsius.

What is the most likely diagnosis? A) Meningitis B) Hypocalcemia C) Neonatal tetanus D) Epilepsy 72. The blood smear of a 4 years old child who presented with fever and prostration revealed trophozoites of P. falciparum. You decided to start him on intravenous quinine for the reason that artesunate was out of stock. What life threatening complication do you anticipate during administration of the drug? A) Hypoglycemia B) Pulmonary edema C) Acute renal failure D) Ototoxicity

73. A 14 years old adolescent was diagnosed to have malaria after blood film result showed trophozoite stage of P. falciparum, and P. vivax. What is the most appropriate therapy? A) Chloroquine with coartem. B) Quinine C) Coartem D) Quinine with coartem 74. A 10 days old neonate who was in a good state of health came with chief complaint of yellowish discoloration of the eyes of 1 day. His blood group is O-Negative. Direct bilirubin was 5.5mg/dl and indirect was 0.9mg/dl. What diagnosis best explain his condition? A) Hemolytic disease of the new born B) Type II Crigler-Najjar disease C) Neonatal hepatitis D) Breast milk jaundice 75. An 8 days old preterm neonate was on treatment in NICU for the diagnosis of preterm (30weeks), LBW (1450gm) and HMD. Currently the baby is off of oxygen, on NGT expressed breast feeding and her weight is 1400gm with temperature of 36.0degreeCelsius but no other remarkable finding. What is your next management plan? A) Discharging her with close follow up B) Continue the incubator care with strict monitoring C) Start the baby on kangaroo mother care D) Put her on preterm formula 76. A 7 years old boy who had history of sore throat 2 weeks back presented with generalized body swelling of 03 days associated with cola colored urine. Urine analysis showed RBC casts. Which is the least likely complication in this patient? A) Hypertensive encephalopathy B) Heart failure C) Acute renal failure D) Hypercalcemia and hypophosphatemia 77. A 6 years old child presented with progressive bilateral lower extremity weakness of 5 days duration with associated tingling and burning sensation. He has no fever, headache or change in mention. On examination- he has normal vital signs, conscious and oriented, has flaccid lower extremities with absent deep tendon reflexes and lower extremities power is zero bilaterally with intact sensation. What is the most likely diagnosis? A) Guillain-Barre Syndrome B) Transverse myelitis C) Poliomyelitis D) Botulism 78. A 10months old child presented with generalized body swelling of one week duration associated with watery diarrhea of 2 weeks duration. He is on cow’s milk diluted with two hands of water since the age of 6 months. His mother noticed sunkening of the eyeball today with decreased feeding. On evaluation, he has feeble pulse with weight for length of below negative 3 Z score plus pedal edema. He is lethargic. Laboratory: RBS- 55mg/dL, Hct -18mg/dL. What is the appropriate next step of management? A) Give 20ml/kg of lactate ringer fast B) Give 5-10ml/kg of resomal every 30 minutes for 2 hours

C) Give 10ml/kg of packed RBC over 3 hours D) Give 15ml/kg of Darrow’s solution over 1 hour 79. A 3 year old child presented with high grade fever, hyper extended neck and drooling of saliva. The child prefers to assume sitting upright position and leaning forward with his chin up and mouth open while bracing on the arms. What is contraindicated in this patient? A) Tracheotomy B) Ceftriaxone C) Oxygen with face mask D) Laryngoscope at the OPD 80. A 32years homeless was admitted to a hospital. On arrival, he was noted to be an asthenic, poorly nourished man with dilated pupils, hyperactive tendon reflexes, and a pulse rate of 120bpm. After admission nurses observed him showing mannerisms, laid down on the floor, pulled at his foot, made undirected violent striking movements, struck attendants, grimaced, assumed rigid and strange postures, refused to speak, and appeared to be having auditory hallucinations. What is the most likely diagnosis from the information given above? A) Brief psychotic disorder B) Schizoaffective C) Schizophrenia D) Schizophreniform 81. A 26years old young man presented with that he suffered from the frequent attempt to look backward constantly, from fear that he might have overlooked something important behind him. These ideas were predominant he might have injured an insect by stepping on it; or an insect might have fallen on its back and need his help. The patient was also afraid of touching anything, and whenever he had touched an object he had to convince himself that he had not destroyed it. What is the most likely diagnosis? A) Obsessive compulsive disorder B) Obsessive compulsive personality disorder C) Schizophrenia D) Delusional disorder 82. A 29years old female, widowed, mother of two, had experienced several manic and depressive episodes that had responded to unspecified medication. Currently, she presented with severe manic symptoms at district hospital. You have decided to start treatment until you get the investigation results. What medication you must to choose to get improvement shortly? A) Lamotrigine B) Lithium C) Chlorpromazine D) Trifuoperazine 83. You are supervising an intern interviewing a patient. She nodes her head and responds to the patient “That must have been very difficult for you”. What is the most likely reason the intern used the above phrase? A) To establish rapport B) To establish therapeutic relationship C) To express her empathy D) To express her sympathy

84. A 65 year old male known COPD patient on follow up came with a complaint of groin mass of 3 years duration, which disappears while lying supine. On physical examination, there is 4x5cm globular, soft to firm and reducible mass on the right groin. Cough pulse is positive. After proper work up and optimization he was scheduled for laparoscopic surgery. What is the most important landmark for diagnosis? A) Inferior epigastric artery B) Ilioinguinal nerve C) Deep inguinal ring D) Femoral vein 85. A 13 year old boy presents with severe right iliac fossa pain of sudden onset. No abnormality is detected on abdominal examination. His right testis is moderately tender but there is no erythema of the overlying scrotal skin. He came in the early night shift. What is the most appropriate next step? A) Scrotal ultrasound B) Admit for observation C) Doppler ultrasound D) surgical exploration 86. A patient presented after sustaining blunt lower abdominal trauma. CT urography showed extra peritoneal bladder rupture with normal other organs. What is the best management for this patient? A) Suprapubic cystostomy B) Transurethral catheterization C) Exploration and bladder repair D) Drainage of extravasated urine 87. A fifty eight year old male known type-II DM patient who has been on metformin and glybenclamide for six years, is admitted to surgical ward with an additional diagnosis of benign prostatic enlargement with low urinary tract symptoms. His HgA1C is 5. What pre-anesthetic work up is mandatory for this patient? A) Electrocardiography B) Echocardiography C) Chest Radiography D) Lumbosacral Radiography 88. A patient who has deep venous thrombosis was on warfarin for the past one week. She developed bleeding from the IV lines and also noticed blood in her urine. What is the appropriate step in the management? A) Transfuse with whole blood B) Vitamin K C) Activated charcoal D) Factor XI replacement 89. A 55 year old patient who came to ER after sustaining burn injury was found to have a potassium level of 6.8mEq/l with flattened P waves on ECG. What is the best management plan of this patient? A) Hemodialysis B) Calcium gluconate

C) Insulin and glucose D) Kayexalate 90. A 40 year old woman complains of a painless lump in her right breast of several months duration. On ipsilateral axilla there is a discharging recurrent abscess. What is the diagnosis? A) Fat necrosis B) Breast abscess C) Tuberculosis D) Chronic mastitis 91. A 12 year old boy sustained injury to his left knee are while playing football with his peer group. On examination the left knee was swollen and he was unable to bear weight on his left leg. X-ray of left knee was taken and shown below.

What is the diagnosis? A) Salter-Harris type I distal femur fracture B) Salter-Harris type II distal femur fracture C) Salter-Harris type III distal femur fracture D) Salter-Harris type IV distal femur fracture 92. A one month old neonate was brought to your OPD because his parents noticed and were concerned that he is not moving his right upper extremity. The mother had uneventful ANC

follow up. During delivery, presentation was breech and birth weight is 4 kg. The clinical position of the neonate’s limb at OPD is shown below.

What is the initial management of the patient? A) expectant passive exercise therapy B) microsurgical nerve grafting C) nerve transfer D) latissimus dorsi and teres major tendon transfer 93. A 65 years old male patient who is a known diabetic patient came with wound over the plantar side of his left foot. This is the second time when this happens. On examination there is clean 2cm by 2cm deep wound on plantar aspect of left foot over the area of second metatarsal head. What is the best management for this patient? A) wound care B) shoe modification C) total contact casting D) ray’s amputation 94. A 3 day old neonate with persistent bilious vomiting and refusal to breast feed is brought to clinic by his parent. Associated with these he has progressive abdominal distention. After preparation he was taken to OR and intra-operation finding is displayed. What is the likely cause of neonate’s condition? A) Abnormal Rotation B) Cell migration failure C) Vascular Occlusion D) Recanalization failure 95. A 3 month male infant brought to ER because of persistent crying of 4 hours duration. He was born to a 29 year old primi mother prematurely. Physical examination: acutely sick looking with stable vital signs, right groin swelling which extends to the scrotum and no

overlying skin color change. While you were examining, mass returned back and he started to breast feed soon after. What is the most appropriate next step? A) Admit the patient for PPV ligation B) Advice mother and discharge C) Send abdominal ultrasound D) Emergency explorative laparatomy 96. A 34-year-old man is admitted with an ulnar-sided wrist laceration having fallen onto glass. What is the expected sign of ulnar nerve transaction in this patient? A) Loss of flexor digiti minimi function B) Loss of the index finger flexor digitorum profundus function C) Loss of sensation in the radial 3 digits D) Loss of thumb abduction 97. A 32yearold woman has near complete paralysis of the lower portion of the left side of the face 3 years after onset of Bell’s palsy. There has been no return of nerve function for the past year. Examination shows adequate function of the orbicularis oculi muscle and a good Bell’s reflex. What is the most appropriate management? A) Continued observation. B) Hypoglossal nerve transfer. C) Placement of a gold weight in the eyelid and static brow lifting. D) Neurotized free muscle transfer 98. A twenty five year old male patient presented to ESOPD after he was stabbed one hour back. On examination, his breathing is deranged with RR of 40beats per minute and oxygen saturation of 80 percent with room air, BP is 90/60mmHg and PR of 106 beats per minute. On chest, there is 3cm wound on the left side at sixth ICS 4cm posterior to the mid-axillary line with decreased air entry. What is the most likely diagnosis of this patient? A) Massive hemothorax B) Sucking chest wound C) Extensive lung laceration D) Secondary pneumothorax 99. A thirty two year old pedestrian brought to Emergency OPD after he was hit by a fast moving truck 30 minutes back. He lost consciousness since then and had one episode of vomiting. He had no history of alcohol intake. On examination he is comatose with a GCS of 6/15 (E2V1M3). He has asymmetric pupil, the left one being fixed and dilated. He also has preference of the left extremity. What is the most appropriate initial step in the management of this patient? A) Load him with Mannitol B) Put him on concentrated oxygen with face mask C) Endotracheal intubation D) Do immediate craniotomy 100. A twenty eight year old male farmer presented with left testicular swelling of six months duration. The swelling has minimal discomfort and he has no urinary complaint. On examination, he is well looking with stable vital signs. He has 8 by 10 cm firm and non-tender swelling of the left hemi-scrotum. Its upper boarder is reachable. There are no significantly enlarged inguinal LAPs. What is the most appropriate investigation for the initial work up of this patient?

A) Scrotal ultrasound B) FNA biopsy C) Abdominopelvic CT D) Serum b-HCG