1101. A lady comes with a missing IUCD thread. Her LMP was 2wks ago.

What is the single most

appropriate next step in management?
a. Abdominal US
b. Prescribe contraceptives
c. CT
d. Serum BHCG
e. Vaginal exam
Ans. The key is A. Abdominal US. It is wrong key! Correct key is E. Vaginal exam. [LOST THREAD:
First confirm the thread is not in position by vaginal examination. If not present ultrasound
should be arranged to locate the device.
If ultrasound does not locate the device and there is no definite history of expulsion then
abdominal X-ray should be performed to look for an extrauterine device.
Expulsion should not otherwise be assumed.
Hysteroscopy can be helpful if ultrasound is equivocal.
Surgical retrieval of an extrauterine device is advised].
 
1102. A 32yo woman presents with hx of lower abdominal pain and vaginal discharge. She had
her
menses 4wk ago. She has a temp of 38.6C. What is the most suitable dx?
a. Acute appendicitis
b. Acute PID
c. Endometriosis
d. Ectopic pregnancy
e. UTI
 
Ans. The key is B. Acute PID. [Fever, lower abdominal pain and vaginal discharge are features of
PID].
 
1103. A 40yo female was on COCP which she stopped 6m ago. But she has not had her periods
since
then. Labs: FSH=22, LH=24, prolactin=700, estradiol=80. What is the most appropriate dx?
a. Hypothalamic amenorrhea
b. Post pill amenorrhea
c. Prolactinoma
d. Pregnancy
e. Premature ovarian failure
 
Ans. The key is E. Premature ovarian failure. [ FSH and LH are raised in ovarian failure; an FSH
level ≥20 IU/l in a woman aged around 40 with secondary amenorrhoea indicates ovarian
failure. In POF there is also a mild to moderate rise in prolactin].
 
1104. A 25yo woman presents with a single lump in the breast and axilla. The lump is mobile
and hard
in consistency. The US, mammogram and FNA turn out to be normal. What is the most
appropriate inv to confirm the dx?
a. FNAC
b. MRI
c. Punch biopsy
d. Genetic testing and counselling
e. Core biopsy
 
Ans. The key is E. Core biopsy. [The lump is suspicious but US, mammogram and FNA turn out
to be normal. So most appropriate investigation to confirm diagnosis is core biopsy. It is often
the preferred biopsy method because it is accurate and does not involve surgery].
 
*1105. A 37yo lady stopped taking COCP 18m ago and she had amenorrhea for 12m duration.
Labs:
FSH=8, LH=7, prolactin=400, estradiol=500. What is the cause?
a. Hypothalamic amenorrhea
b. PCOS
c. Prolactinoma
d. Post pill amenorrhea
e. POF
Ans. The key is D. Post pill amenorrhea. [Post pill amenorrhea= failure to resume menses within
6 months of stopping pill, but she was amenorrheic for 12 months!!].
 
1106. A lady with a firm smooth breast lump in outer quadrant had a FNAC done. Results
showed
borderline benign changes. She also has a fam hx of breast cancer. What is the your next?
a. Mammography
b. US
c. Core biopsy
d. Genetic testing and counselling
e. Punch biopsy
Ans. The key is D. Genetic testing and counselling. Probably wrong key! Correct one should be
C. Core biopsy. [Genetic testing is done for asymptomatic patients in their 30s and if positive
SERMs are given which cause significant reduction in cancer .
Since patient has firm breast lump in upper outer quadrant ( most common location for cancer)
and FNAC has shown borderline benign changes plus patient is high risk for cancer , so I must go
for core biopsy to confirm whether it is cancer or not].
1107. A pt presents with mild dyskaryosis. 1y ago smear was normal. What is the most
appropriate
next step?
a. Cauterization
b. Repeat smear
c. Swab and culture
d. Cone biopsy
e. Colposcopy
Ans. The key is E. Colposcopy. [In mild dyscariosis colposcopy should be done with HPV test].
 
1108. An African lady presents with heavy but regular periods. Her uterine size correlates to
14wks
pregnancy. What is the most appropriate dx?
a. Blood dyscrasia
b. Hematoma
c. Fibroids
d. Adenomyosis
e. Incomplete abortion
Ans. The key is C. Fibroids. [Regular heavy menstruation in a uterus of 14 wk size is highly
suggestive of fibroid].
 
1109. A 29yo at 38wks GA presents with a 2h hx of constant abdominal pain. She then passes
100ml of
blood per vagina. What is the next appropriate inv?
a. USS
b. CTG
c. Clotting screen
d. Hgb
e. Kleihauer Betke test
Ans. The key is A. USS. [Ultrasonogram scan can detect placental abrubtion and fetal heart beat
as well. So it is the preferred key over CTG].
 
1110. A 26yo woman had amenorrhea for 10wks and is pregnant. She experiences
hyperemesis. Now
she presents with vaginal bleed. Exam: uterus=16wks, closed os. What is the most probable dx?
a. Thyrotoxicosis
b. Hyperemesis gravidarum
c. Twins
d. Wrong dates
e. Molar pregnancy
Ans. The key is E. Molar pregnancy. [In hytaditidiform mole uterus becomes more in size than
actual gestational age and due to production of large amount of gonadotrophin by moles
patient suffers from severe vomiting i.e. hyperemesis. There also occurs vaginal bleeding].
 
1111. A pregnant woman of G2, GA 11wks presents with heavy vomiting, headache and
reduced urine
output. Urine analysis shows ketonuria. Choose the next best step?
a. US
b. Oral fluid replacement
c. Serum BHCG
d. Parental anti-emetics
e. IV fluids
Ans. The key is E. IV fluids. [Hyperemesis gravidarum with oliguria and ketonuria. IV fluid should
be started to prevent renal failure].
 
1112. A pt had inflammatory changes on cervical smear. There is no vaginal discharge, no pelvic
pain
and no fever. What is the next step?
a. Repeat smear in 6m
b. Take swab
c. Treat with antibiotics
d. Colposcopy
e. Cone biopsy
Ans. The key is B. Take swab. This is a wrong key! Correct key is A. Repeat smear in 6 months.
[Ref: Samson notes].
 
1113. A 37yo infertile lady with 5cm subserosal and 3cm submucosal fibroid is trying to get
pregnant.
Which is the most suitable option?
a. Clomifen therapy
b. IVF
c. Myomectomy
d. Hysterectomy
e. IU insemination
Ans. The key is C. Myomectomy. [Fibroids are preventing from her being pregnant.
So  myomectomy is the most suitable option to let her get pregnant].
 
1114. A young tall man and his wife are trying for babies and present at the infertility clinic. On
inv the
man has primary infertilitiy and azoopermia. What other inv should be done?
a. Testosterone
b. LSH
c. FSH
d. Estradiol
e. Karyotyping
Ans. The key is E. Karyotyping. [The likely diagnosis is Klinefelter’s syndrome for which
Karyotyping should be done to make the diagnosis established].
 
1115. A woman who is on regular COCP presented to you for advice on what to do as she has to
now
start to take a course of 7d antibiotics. What would you advice?
a. Continue regular COC
b. Continue COCP and backup contraception using condoms for 2d
c. Continue COCP and backup contraception using condoms for 7d
d. Continue COCP and backup contraception using condoms for 2wks
Ans. The key is D. Continue COCP and backup contraception using condoms for 2wks. This is
wrong key! Correct key should be A. Continue regular COCP. [Before it was thought that
antibiotics alter the gut flora and ethinyloestradiol is not conjugated. There is more
ethinyloestradiol passed in the stool. So pregnancy and breakthrough bleeding can occur. But
later it was established that except for strong enzyme inducer like Rifampicin and Rifabutin
other antibiotics practically does not reduce potency of COCP and hence except only rifampicin
or rifabutin for other antibiotics no additional precautions are needed]. 
 
1116. A lady presents with hot flashes and other symptoms of menopause. What is the tx
option?
a. Raloxifen
b. HRT
c. Bisphosphonate
d. COCP
e. Topical estrogen
Ans. The key is  B. HRT
 
1117. A 28yo woman at 34wks GA for her first pregnancy attends antenatal clinic. Her blood
results:
Hgb=10.6, MCV=95, MCHC=350. What do you do for her?
a. Folate
b. Dextran
c. Ferrous sulphate
d. None
e. IV FeSO4
f. Explain this physiologic
hemodynamic anemia
g. Blood transfusion
Ans. The key is F. Explain this physiologic hemodynamic anemia. [According to NICE, cut offs for
iron supplements:
at booking (8-10 weeks)- if less than 11 
at 28 weeks and further- if less than 10.5
if less than these values=> give iron].
1118. A 34yo woman who never had fits or high BP developed fits 6h after delivery of a term
healthy
child. What is the most likely dx?
a. Eclampsia
b. Preeclampsia
c. Epilepsy
d. Pulmonary embolism
e. Pregnancy induced HTN
Ans. The key is A. Eclampsia. [In eclampsia seizers occurs within 24 hours mostly and majority
within 12 hours. Also single seizure doesn’t support epilepsy strongly. So likely answer is A.
Eclampsia].
 
1119. A 30yo lady who already has one child through a prv C-section demands a reversible
contraception. She presently experiences heavy and painful periods. What is the most
appropriate contraceptive you will recommend for her?
a. COCP
b. POP
c. Implanon
d. Danazol
e. Mirena
f. IUCD
Ans. The key is E. Mirena.
1120. A 32yo woman comes with intermenstrual bleeding. Her last cervical smear was 1y ago
and was
negative. What test would you recommend for her initially?
a. Colposcopy
b. Cervical smear
c. Endocervical swab
d. Transvaginal US
e. Pelvic CT
Ans. The key is B. Cervical smear. This is a wrong key! Correct key is C. Endocervical swab.
[Smear can only be done if it is due or overdue, not in any time or not as needed basis].
 
1121. A 20yo woman has had abdominal pain in the LIF for 6wks duration. Over the past 48h,
she has
severe abdominal pain and has a fever of 39.1C. Pelvic US shows a complex cystic 7cm mass in
the LIF. What is the most likely dx?
a. Endometriosis
b. Dermoid cyst
c. Ovarian ca
d. Tubo-ovarian abscess
e. Ectopic pregnancy
Ans. The key is D. Tubo-ovarian abscess.
 
1122. A woman is 16wk pregnant and she is worried about abnormal chromosomal anomaly in
her
child. What is the definitive inv at this stage?
a. Amniocentesis
b. CVS (Chorionic Villous Sampling)
c. Parents karyotyping
d. Coomb’s test
e. Pre-implantation genetic dx
Ans.  The key is A. Amniocentesis. [Amniocentesis is done between 14 to 16 weeks of gestation.
CVS is done prior to 15 weeks. So the option is A. Amniocentesis].
 
1123. A 28yo lady with a fam hx of CF comes for genetic counselling and wants the earliest
possible dx
test for CF for the baby she is planning. She is not in favor of termination. What would you
recommend for her?
a. CVS (Chorionic Villous Sampling)
b. Amniocentesis
c. Pre-implantation genetic dx
d. Chromosomal karyotyping
e. Maternal serum test
f. Reassure
Ans. C. Pre-implantation genetic dx. [Patient is not yet pregnant but planning for
pregnancy.  Earliest possible diagnostic test for CF is Pre-implantation genetic
dx. Preimplantation genetic diagnosis (PGD) is a procedure used prior to implantation to help
identify genetic defects within embryos created through in vitro fertilization to prevent certain
diseases or disorders from being passed on to the child].
 
1124. A 39yo woman in her 36th week GA with acute abdominal pain is rushed for immediate
delivery.
Her report: BP=110/60mmHg, Hgb=low, bilirubin=22, AST=35, Plt=60, APTT=60, PT=30,
Fibrinogen=0.6. What is the cause?
a. Pregnancy induced hypertension
b. DIC
c. HELLP syndrome
d. Acute fatty live
e. Obstetric cholestasis
Ans. The key is B. DIC.  [It is not HELLP syndrome as liver enzyme is not elevated. Acute
abdominal pain may indicate concealed abruption placenta  which may lead to DIC].
1125. A 36wk pregnant woman presents with sudden onset of uterine pain and bleeding, uterus
is
tender, no prv LSCS. What is the most appropriate cause?
a. Preeclampsia
b. DIC
c. Placental abruption
d. Placental previa
e. Ectopic pregnancy
f. Missed abortion
g. Ectropion
Ans. The key is C. Placental abruption. [Painful bleeding at 36 th week is placental abruption
(either revealed or mixed type)].
 
1126. A 28wk pregnant woman presents with uterine bleeding after sexual intercourse. What is
the
most appropriate cause?
a. Preeclampsia
b. DIC
c. Placental abruption
d. Placental previa
e. Ectopic pregnancy
f. Missed abortion
g. Ectropion
Ans. The key is G. Ectropion. [Post coital bleeding can be either placenta previa or cervical
ectropion. But as ectropion is commoner in pregnancy so it is the option here].
 
1127. A 6wk pregnant woman presents with abdominal pain. She has prv hx of PID. What is the
most
likely dx?
a. Preeclampsia
b. DIC
c. Placental abruption
d. Placental previa
e. Ectopic pregnancy
f. Missed abortion
g. Ectropion
Ans. The key is E. Ectopic pregnancy. [H/O PID is a recognized cause of ectopic pregnancy. Also
pain without bleeding at 6th week support the diagnosis of ectopic pregnancy].
 
1127. A 6wk pregnant woman presents with abdominal pain. She has prv hx of PID. What is the
most
likely dx?
a. Preeclampsia
b. DIC
c. Placental abruption
d. Placental previa
e. Ectopic pregnancy
f. Missed abortion
g. Ectropion
Ans. The key is E. Ectopic pregnancy. [H/O PID is a recognized cause of ectopic pregnancy. Also
pain without bleeding at 6th week support the diagnosis of ectopic pregnancy].
 
1128. A 33wk pregnant woman presents with vaginal bleeding, low Hgb, low plt, increased
bilirubin,
AST normal, APTT & PT increased. What is the most likely dx?
a. Preeclampsia
b. DIC
c. Placental abruption
d. Placental previa
e. Ectopic pregnancy
f. Missed abortion
g. Ectropion
Ans. The key is B. DIC.
 
1129. A 25yo lady at her 28th week GA came for check up. Her BP=160/95mmHg, protein in
urine=6g/d.
What is the most likely dx?
a. Essential HTN
b. Gestational HTN
c. Chronic HTN
d. Preeclampsia
Ans. The key is D. Preeclampsia.
 
1130. A 32yo woman has a hx of spontaneous abortions at 6wks, 12wks, and 20wks. She is now
keen
to conceive again. Which of the following would you prescribe for the next pregnancy?
a. MgSO4
b. Aspirin
c. Warfarin
d. Mefenemic acid
e. Heparin
Ans. The key is B. Aspirin. [Patient of antiphospholipid syndrome had 3 fetal losses and no
thromboembolic event and now wants to be pregnant. In such case prophylactic treatment
with low dose aspirin is indicated].
1131. A 6yo child presents with hx of recurrent jaundice. Between the episodes he is totally
fine.
Mother gives hx of jaundice being brought about by ongoing infections. What is the most likely
dx?
a. Hereditary spherocytosis
b. G6PD deficiency
c. Thalassemia
d. Sickle cell disease
e. Congenital storage disorder
Ans. The key is B. G6PD deficiency. [There are some precipitating factors of hemolysis causing
jaundice in patients with G6PD deficiency among which infection is a recognized one].
 
1132. A 42yo woman who smokes 20 cigarettes/d presents with complains of heavy bleeding
and
prolonged menstrual period. What is the most appropriate tx for her?
a. Tranexemic acid
b. COCP
c. Mefenemic acid
d. IUCD
e. Norethisterone
Ans. The key is D. IUCD. This is wrong key. Correct key is A. Tranexemic acid.
 
1133. A 17yo senior school girl with complain of prolonged irregular menstrual period and
heavy blood
losses. What is the most appropriate tx for her?
a. Mefenemic acid
b. COCP
c. POP
d. IUCD
e. Mirena
Ans. The key is B. COCP. [In irregular period: COCP except the contraindications for it and in that
case POP should be used].
 
1134. A 32yo presents with heavy blood loss, US: uterine thickness>14mm. What is the most
appropriate tx for her?
a. Mefenemic acid
b. COCP
c. POP
d. IUCD
e. IU system (mirena)
Ans. The key is E. IU system (mirena). [Simple endometrial hyperplasia without atypia responds
to high-dose progestogens, with repeat histology after three months. This can be effectively
delivered by the levonorgestrel intrauterine system (IUS). Source: patient.info].
 
1135. A 37yo woman presents with heavy bleeding. Inv show subserosal fibroid=4cm and
intramural
fibroid=6cm. Which is the most appropriate tx?
a. UAE
b. Abdominal hysterectomy
c. Hysteroscopic Myomectomy
d. Vaginal Hysterectomy
e. Abdominal myomectomy
Ans. The key is E. Abdominal myomectomy. [As patient is young we should go for myomectomy.
As hysteroscopic myomectomy is suitable for mainly submucosal fibroids. We should go for
Abdominal myomectomy which will deal with both subserosal and intramural fibroids].
 
1136. A woman with sickle cell disease complains of heavy menstrual blood loss. What is the
most
appropriate tx?
a. COCP
b. Mirena
c. Depot provera
d. Copper IUS
e. Transdermal patch
Ans. The key is C. Depot provera. [Hormone and barrier methods are all acceptable choices but
intrauterine devices are not recommended, as they may be associated with uterine bleeding
and infection. Depot contraceptive (Depo-Provera®) is safe and has been found to improve the
blood picture and reduce pain crises. Source: patient.info].
 
1137. A 70yo woman is admitted with diarrhea, vomiting and dehydration. Exam: yellow visual
halos in
her eyes, ECG=bradycardia. She has a hx of chronic A-fib. Which drug causes the above
mentioned side effects?
a. Nifedipine
b. Ramipril
c. Atenolol
d. Lithium
e. Digoxin
 
Ans. The key is E. Digoxin. [Digoxin toxicity causes diarrhea, vomiting, dehydration, xanthopsia
(yellow halos around light), bradicardia. History of atrial fibrillation is also a clue of digoxin use].
 
1138. A 33yo lady who is a drug addict wants to quit. She says she is ready to stop the drug
abuse. She is supported by her friends and family. What drug tx would you give her?
a. Benzodiazepines
b. Diazipoxide
c. Lithium
d. Methadone
e. Disulfiram
 
Ans. The key is D. Methadone. [Methadone is an opioid medication. Methadone reduces
withdrawal symptoms in people addicted to heroin or other narcotic drugs without causing the
"high" associated with the drug addiction and thus used to help a drug addict to quit from drug
addiction].
 
1139. A 50yo lady has been suffering from chronic RA and is on methotraxate and naproxen.
Her CBC
shows microcytic anemia. What is the most likely cause?
a. Anemia of chronic disease
b. GI hemorrhage
c. Menorrhagia
 
Ans. The key is B. GI hemorrhage. [Anemia of chronic disease is mostly normocytic and
methotrexate causes folate deficiency which may lead to macrocytosis. So for this microcytic
anemia NSAIDs induced GI hemorrhage is the most likely cause].
 
1140. A 15yo male noticed swelling on the left knee following a fall while playing. The swelling
has not
subsided in spite of rest and analgesia. Exam: full knee movement with slight tenderness. He
has
painless palpable mass in left inguinal region. What is the most probable dx?
a. Osteosarcoma
b. Ewing’s sarcoma
c. Chondrosarcoma
d. Lymphangiosarcoma
e. Osteodosteoma
 
Ans. There are two keys i) Osteosarcoma ii) Ewing’s sarcoma. But the likely correct key is
probably A. Osteosarcoma. [Both occurs in children and young adults but the occurrence of
painful symptom during playing is usually a feature of osteosarcoma. In case of osteosarcoma
teenagers who are active in sports often complain of pain in the lower femur, or immediately
below the knee. If the tumor is large, it can present as overt localised swelling. Sometimes a
sudden fracture is the first symptom, because affected bone is not as strong as normal bone
and may fracture abnormally with minor trauma].
 
1141.  A 45yo female looking pale has bluish discoloration of hands whenever she goes out in
the cold.
She has also noticed some reddish spots on her body. She has symmetrical peripheral
arthropathy for the last yr. What is the most probable dx?
a. RA
b. Osteosarcoma
c. Limited systemic sclerosis
d. Diffuse systemic sclerosis
e. Chondrosarcoma
 
Ans. The key is C. Limited systemic sclerosis. [Raynaud’s phenomena, telangiectasia,
sclerodactyly  indicates to the dx of CREST syndrome or Limited systemic sclerosis].
 
1142. A 60yo female has pain and stiffness in her right hip joint. Pain is not severe in the
morning but
increases as the day progresses. She has noticed some nodules in her hands. Inv: Hgb=low.
What
is the most probable dx?
a. RA
b. Osteoarthritis
c. Gout
d. Pseudogout
e. Multiple myeloma
 
Ans. The key is B. Osteoarthritis. [Stiffness and pain of right hip increasing as the day
progresses, nodules in hands (Hebarden or Bouchard’s nodes), anemia (probably secondary to
prolonged NSAIDs use)  indicates osteoarthritis].
 
1143. A 30yo female has chronic diarrhea, mouth ulcers and skin tags. She complains of visual
prbs,
low back pain and morning stiffness. Inv: ESR & CRP=raised, Hgb=10mg/dl. What is the most
probable dx?
a. SLE
b. Reactive Arthritis
c. Gout
d. Pseudogout
e. Seronegative arthritis
 
Ans. The key is E. Seronegative arthritis. [Chronic diarrhea, mouth ulcers and skin tags are
features of IBD. There is a well known association between IBD and seronegative arthritis
(particularly AS). Here low back pain, visual problem, morning stiffness, raised ESR and CRP, low
hemoglobin indicates the diagnosis of Seronegative arthritis].
 
1144. A 28yo woman has been on tx for RA for 3yrs. She has gradual loss of vision in both eyes.
Her
IOP is normal. Red reflex is absent in both eyes. What is the single most likely dx?
a. Cataract
b. DM retinopathy
c. Hypermetropia
d. Macular degeneration
e. HTN retinopathy
 
Ans. The key is A. Cataract. [Prolonged use of steroid (here in RA) is a known cause of cataract].
 
1145. An elderly man with recently dx HF has been treated with diuretics. He now develops
severe
joint pain in his left ankle with swelling and redness. What is single most likely inv?
a. XR of bone
b. Plasma RF
c. Joint fluid uric acid crystals
d. ESR
Ans. The key is B. Plasma RF. It is a wrong key. Correct key should be C. Joint fluid uric acid
crystals. [Thiazide diuretics may increase uric acid levels in blood causing or precipitating gout
and joint fluid may show uric acid crystals].
 
1146. A 60yo lady with a hx of HTN and suffering from RA since the last 10y now presents with
hot,
swollen and tender knee joint. What inv would you do for her?
a. XR
b. C&S of joint aspirate
c. US
d. MRI
e. CT
Ans. The key is B. C&S of joint aspirate. [RA itself is a