ERMP 2019

Part I Questions
1. A 34 years old female patient came to regular OPD with a complaint of generalized body
weakness, malaise and back pain of 3 years duration. Associated with this he also has
constipation and back pain. For above complaint he was frequently treated with IV
antibiotics. He was admitted 1 year back with the diagnosis of femoral fracture after he failed
from standing height. What do you expect in the urine examination of this patient?
A) High Calcium and High phosphate
B) Low calcium and high phosphate
C) Low calcium and low phosphate
D) Normal calcium and low phosphate

2. 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

3. You did manual vacuum aspiration for a first trimester incomplete abortion. The pregnancy
was unplanned and unwanted. For that she went to a local traditional medicine and given
unspecified medication to swallow 4 days back. On arrival she had vaginal bleeding, high
grade fever and foul smelling vaginal discharge. She is a student and lives with her parents.
She has a boyfriend and wanted to use contraception after the procedure. Which
contraception method is best to offer the client?
A) IUCD
B) Condom
C) Injectable
D) Post pil

4. A 42 years old tailor presented, for the first time, to the medical OPD with a diagnosis of
Type 2 DM. He has multiple lab result of FBS all above 160mg/dl. On systems review, he
has no ocular or visual complaint and other systems are unremarkable. When would you
recommend this person get his eyes screened for diabetic complications?
A) As soon as possible after diagnosis of DM
B) One year after diagnosis of DM
C) Five years after diagnosis DM
D) Any time he has any ocular or visual complaints

5. While you are making a round in the labor ward a midwife consulted you to evaluate one
laboring woman who just came. She reported that on digital exam she felt a presenting part
bounded at one side by the base of nasal bone but nostrils are not felt. You did your
examination and the finding is similar with cervix 6 cm dilated. FHB is 130bpm, has 2
contractions which stays 40 seconds in 10 minutes. What is the next best management?
A) Follow fetomaternal condition and labor with a partograph
B) Prepare her for emergency cesarean section
C) Do augmentation of labor
D) Do destructive delivery

6. A 4 weeks old neonate presented with 1 week history of non bilious vomiting that occurs
immediately after feeding. After vomiting he is eager and wants to feed again. He looks
emaciated. What is the most likely diagnosis of this neonate?
A) Infantile hypertrophic pyloric stenosis
B) Late onset neonatal sepsis
C) Acute gastroenteritis
D) Inborn error of metabolism

7. A 65 year 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. Which type of urinary incontinence she is likely to
develop?
A) Urge incontinence
B) Mixed urinary incontinence
C) Functional incontinence
D) Stress urinary incontinence

8. A 67 year old female fell from a stair and hit her head against the ground associated with
this she complains projectile vomiting of 2 episodes. Up on presentation her GCS was 15/15
and mild abrasion over the forehead. What is the next best step in the management of this
patient?
A) Non-enhanced head CT
B) Brain MRI
C) Contrast enhanced CT
D) No imaging is needed.

9. A known RVI patient on HAART for the past 3 months presented with a 5 days history of
erosion over the mucosa and the upper part of the body. On exam BP=90/60mmHg,
RR=32/min, T= 38.90C & PR 120 beats/min; there are eroded plaques with hemorrhagic
crustations. What is the most likely cause of the disease?
A) Zidovudine toxicity
B) Neverapine toxicity
C) Efaverenz toxicity
D) Lamuvidine toxicity

10. A 35 years old male patient presented to the emergency room after sustaining a road
traffic accident. By following the ATLS protocol he was diagnosed with hemorrhagic shock.
The bleeding was controlled and transfusion with a cross-matched blood started. Few minutes
after the start the patient was noticed to develop fever associated with severe hypotension.
What should be the next step in the management of this patient?
A) Give antihistamines and continue transfusion
B) Stop transfusion and notify the blood bank
C) Open another IV line and resuscitate while continuing transfusion
D) Reassure the patient and give antipyretics
11. A 34 year old Para III mother from Addis Ababa comes with metromenorrhagia for the
past 3 months. Her pregnancy test is negative. Your trans vaginal ultrasound shows normal
pelvic finding with endometrial thickness of 10mm. What additional information you need to
know before you perform endometrial biopsy?
A) Her BMI
B) Her contraceptive use
C) Her age at menarche
D) Her race

12. A 58 year old Para III mother comes to regular OPD with protruding mass per vagina of 8
years duration. She usually replaces the mass to urinate. She also has urinary dribbling. On
your inspection of the external genitalia you observe pinkish mass with patches
hyperpigmentation which has central opening. What additional physical examination you
should to localize site of defect?
A) Bimanual pelvic examination
B) Speculum examination
C) Examination with valsalva maneuver
D) Pessary fitting test

13. A 24 year old patient came with nasal deviation after fall down accident in shower of 8
day duration and claim to have moderate epistaxis at time of accident which was controlled
by manual pressure application. On physical examination the pertinent finding was closed
displaced right nasal bone fracture involving mid third. What is the next best step in
management of this patient?
A) Closed reduction
B) Two view nasal bone x-ray
C) CT
D) Rhinoplasty

14. In the process of inflammation, all the inflammatory cells that migrate out of the micro-
circulation will die within hours to a few days. This occurs through various mechanisms
involving the necrotic or apoptotic pathway of cell death. But there is one exception which
can survive for months in the interstitial tissue. Which cell has the feature described above?
A) Eosinophil
B) Basophil
C) Macrophage
D) Plasma cell

15. A child with severe combined primary immunodeficiency is brought to your clinic for
routine childhood immunization. What vaccine is contraindicated to this child?
A) Diphtheria, Tetanus, Pertussis (DTaP) vaccine
B) Measles Vaccine
C) PCV (pneumococcal) vaccine
D) Hepatitis virus vaccine

16. A 20 year old male patient presented to the outpatient clinic with a complaint of right
upper quadrant abdominal mass associated with dull aching pain, early satiety & intermittent
vomiting of ingested matter. The only pertinent finding is on the abdomen which shows an
ill-defined, mildly tender mass over the right upper quadrant and hepatomegaly.
Ultrasonography revealed a big hydatid cyst in the right lobe of liver with multiple daughter
cysts. What is the best investigative modality to assess synthetic function of the liver?
A) Serum Alkaline phosphatase
B) Serum prothrombin time
C) Serum bilirubin
D) Serum aminotransferases

17. You are managing a nurse with Gene x-pert positive drug sensitive pulmonary
tuberculosis. He comes on the fourth month of anti-TB initiation. The cough has almost
disappeared and he has gained some weight. His lab technician colleague did him a repeat
Gene x-pert which is positive. He looks worried that he may not get cured. What should you
do?
A) Reassure and continue the anti-TB
B) Send sample for TB culture and sensitivity
C) Check Line Probe Assay
D) Repeat Gene x-pert as this could be false positive

18. You are a physician in primary care and noticed that many case reports of completed
suicide. You made search on the topic and found many evidences supporting higher rate of
suicide in primary care. What is the first enquiry the primary care physician should do to
prevent suicide?
A) Asking death thoughts
B) Asking plan for suicide
C) Asking suicidal ideation
D) Asking the intent to die

19. A 24 years old male sustained road traffic injury. He injured his left leg. He was taken to
health center and was referred with posterior gutter. He arrived to your ER after two hours of
the injury. At presentation he has excruciating pain over the injured leg. On examination left
leg was swollen and distal capillary refill was sluggish. What is the next appropriate
management?
A) Remove the splint
B) Give analgesic
C) Elevate the limb
D) X-ray the injured limb

20. A young man who was on treatment for schizophrenia taking phenothiazine for the last 6
months presented to medical OPD with persistent vomiting of ingested matter. What is the
most likely medication contraindicated in this patient?
A) Chlorpromazine
B) Dimenhydrinate
C) Dolasteron
D) Metoclopramide

21. A 23 years old male patient presented with generalized body swelling which started from
his face and later involved lower extremity of 3 days duration. He has decreased urine output.
On physical exam, his BP was 150/80mmHg, PR=80 bpm, RR=20bpm, T=36.5oC, he had
pale conjunctiva and pretibial edema. On investigation, U/A-protein +2, RBC with RBC casts
creatinine was 2.2, after 2 days the creatinine became 3.5mg/dl. What is the most likely
diagnosis?
A) CKD
B) RPGN
C) pre-renal azotemia
D) ATN

22. A 25 year old Para II mother was admitted with endomyometritis on her 6th post op day
after cesarean section was done for cord prolapse. She first present with high grade fever,
palpitation, foul smelling vaginal discharge with bleeding and lower abdominal pain. Her
wound is clean. She is started on broad spectrum antibiotic and on the third day all her
symptoms improved except her fever persisted and she has chills. What is the most likely
diagnosis?
A) Necrotizing fasciitis
B) Antibiotic resistance
C) Septic thrombophlebitis
D) Hospital acquired pnemonia

23. A 26 years old male patient presented with pain behind the ear followed by facial
deviation to the left and drooling of saliva of 20 hrs duration. On P/E flat nasolabial fold,
difficult in closing eyes and frauning.no other pertinent positive findings. What treatment
would you like to initiate?
A) carbamazepine
B) predinisolone with acyclovir
C) pethidine
D) amytriptyline

24. A 17 years old female presented with abdominal pain of 1 day. The abdominal pain was
initially periumbilical and now shifted to the right lower quadrant. It is worse with coughing
and movement. She had two episodes of non bilious, non bloody vomiting. She reported
recent sex and used condom. She is due to start her period next week. Physical examination
reveals BP 120/80 mmHg, PR 100 bpm, RR 18 bpm, T 37.9 OC. She has guarding and
tenderness over right lower quadrant of the abdomen. On pelvic examination she reports
tenderness when attempting to palpate her right adenexia, but no masses and there was no
cervical motion tenderness. What is the most likely diagnosis?
A) Ovarian tortion
B) Ectopic pregnancy
C) Mesenteric adenitis
D) Appendicitis

25. A 55 years old female patient presented with right side pulsatile tinnitus of 3 years
duration. On otoscopic examination, there was intact tympanic membrane with vascularized,
dome shaped mass mainly occupying hypotympanum and inferior aspect of mesotympanum.
What is the most likely diagnosis in this patient?
A) Glomus tumor
B) Adenocarcinoma
C) Chordoma
D) Squamous cell carcinoma
26. A normally growing 3 years old child was brought by his mother after he had watery
diarrhea and vomiting of 3 days. He has no fever, tenesmus or abdominal pain. On evaluation
he has PR of 166b/min, RR of 50b/min and temperature of 37.8oC. His capillary refill was 3
seconds. Based on the given history and the following picture.

What is the next appropriate management?

A) Giving 75ml/kg of NS/RL over 4hrs
B) Giving 100ml/kg of RL/NS over 3hrs
C) Giving 20ml/kg of whole blood over 4hrs
D) Giving 20ml/kg of NS/RL fast

27. A 32 years old male patient presented with oral floor swelling of 3 years duration and sub
mental mass of a year duration. Up on examination there is bluish semitransparent cystic
swelling which extend to sub mental area through oral floor. What is most likely diagnosis in
this patient?
A) Dermoid cyst
B) Plugging ranula
C) Cystic hygroma
D) oncocytoma

28. A 34 years old male patient presented with severe headache of three days duration. On
physical exam vital signs were normal. Meningeal signs were positive. LP resulted in
hemorrhagic CSF with xanthochromia. What is the most likely diagnosis?
A) Subarachnoid hemorrhage
B) Hypoxic schemic encephalopathy
C) Pyogenic meningitis
D) Chemical meningitis

29. Gravida IV Para III mother with GA of 42 completed weeks come to ANC with
appointment. And she told you she wants permanent contraception after delivery. Your
cervical examination shows 2cm cervical dilatation, 50percent effacement, soft consistency
and mid position. Fetal weight is 2600gm, cephalic presentation and reassuring BPP. What is
the appropriate next step in managing this patient?
A) Waiting for additional 1 week with BPP/2X/week
B) Induction of labor
C) Cervical ripening
D) Cesarean delivery
30. A 20 years old male patient presented with polyuria, polydypsia, abdominal pain and
vomiting of ingested matter. On physical exam he is conscious and alert with
BP=90/60mmHg, PR=120bpm, RR=24bpm, T=38oC, dry buccal mucosa. On investigation
RBS=450mg/dl, urine ketone is +3 and full of WBC on microscope. What is the first step in
the treatment of this patient?
A) initiation of antibiotics
B) Insulin administration
C) correction of hypokalemia
D) fluid administration

31. A para lll lady is diagnosed to have a left ovarian tumor after she presented with
menorrhagia of 3 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 3 months
C) ultrasound guided aspiration
D) Refer her for staging surgery

32. A 50 hours old male neonate presented with yellowish discoloration of a body of one day
duration but no irritability. The mother's blood group is O positive. On evaluation the baby
has icteric sclerae with jaundice up to the level of the sole. Otherwise there was no other
remarkable finding. Total and direct serum bilirubin were 23mg/dl 3mg/dl, respectively. Hct
was 25mg/dl. What is the most appropriate management?
A) Start intensive phototherapy with strict monitoring.
B) Refer to higher centers for exchange transfusion.
C) Start him on phenobarbital till the serum bilirubin is < 10mg/dl.
D) Investigate the baby for direct hyperbilirubinemia.

33. A 42 year old man presents with fever, confusion and cough of 05 days duration. He has
never received antibiotics nor has been admitted to health institution in the last three months.
His physical exam reveals BP 80/40mmHg, PR 120bpm, RR 36bpm, To = 38.3oC, SaO2
85percent and crackles over the left upper lobe. Chest x-ray shows left upper lobe
consolidation. What treatment do you start now?
A) Anti-TB, ceftriaxone, azithromycin, fluid and bacteriologic work up
B) Ceftriaxone, azithromycin, fluid and bacteriologic work up
C) Meropenem, vancomycin, fluid and bacteriologic work up
D) High dose cefepime, vancomycin, fluid, bacteriologic work up & HIV testing

34. A 10 years old female child developed generalized urticaria, laryngeal edema,
bronchospasm, and hypotension following the administration of benzathine penicillin for the
treatment of tonsillopharyngitis. What will be the first drug to manage this patient?
A) Epinephrine
B) Dexamethason
C) Antihistamine
D) Short acting beta agonist

35. An 18 year 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

36. Five years old known diabetic child presented with loss of consciousness of 30 minutes
duration early in the morning but has no fever, vomiting or seizure. He was adherent to his
medication. On objective evaluation he is comatous with GCS of 10/15 but no other
remarkable findings. You were to determine RBS but it was not possible for the time being.
What is your immediate next action?
A) To give 20ml/kg of normal saline over 1hr.
B) To give insulin subcutaneously.
C) To give 2-5ml/kg of 10percent dextrose push.
D) To give anti-meningeal dose of ceftriaxone.

37. A 15 years old male patient was admitted to the burn unit with a diagnosis of 60percent
total body surface area 2nd degree flame burn. On the first day of admission he was found to
have PR-108bpm & T-38.2degree C. The other physical findings were unremarkable. He was
investigated with CBC, blood culture, Urine analysis and Organ function test which were all
normal. What is the most likely diagnosis of this patient's current situation?
A) Wound site infection
B) Systemic inflammatory response syndrome
C) Severe sepsis
D) Sepsis without organ failure

38. A 45 years old para ll lady presented with non specific lower abdominal and back pain of
2 years duration. Otherwise she has no urinary or bowel habit change. On physical
examination the abdomen is soft and 2-3 cm hard nodular mass over the peri-umblical are.
On bimanual examination you appreciated a right adnexal mass which is mobile and 3 by 4
cm. you ordered tumor markers and ultrasound to assess its nature. Which finding is
suggestive of malignancy in this patient?
A) Absent septation on ultrasound
B) Absent solid component on ultrasound
C) Serum CA-125 level of 215IU/ML
D) Serum CEA level of 0.5 IU/ML

39. A 45 year old known hypertensive patient is now diagnosed to have systolic heart failure
with ejection fraction of 35percent. His BP = 90/60mmHg and PR = 92bpm. He has been on
enalapril 10mg po BID and amlodipine 5mg po daily. What is the first medication adjustment
you want to make?
A) Stop enalapril and amlodipine, start digoxin and diuretics
B) Stop enalapril, continue amlodipine, start digoxin and diuretics
C) Continue enalapril, stop amlodipine, consider digoxin and diuretics
D) Stop enalapril and amlodipine, consider digoxin and diuretics

40. A 7 years old female patient present with intensely itchy bullous lesion over the extensor
aspect of extremities of 2 months. On physical exam there are excoriated plaques and vesicles
with scratch marks. What is the most likely diagnosis?
A) Common bullous disease of childhood
B) Dermatitis herpetiformis
C) Severe atopic eczema
D) Allergic reactions

41. A 40 years old male known decompensated CLD secondary to chronic hepatitis B virus
infection was admitted with the assessment of spontaneous bacterial peritonitis. After three
days of IV diuretics and IV antibiotics, he started to have insomnia, behavioral changes like
irritability. Physical examination revealed BP=90/50mmHg, PR=120bpm, RR=20bpm,
T=36oC, dry buccal mucosa. The abdomen swelling is decreasing and has no tenderness. He
was confused and astrexis is positive. He had negative balance of 2000lit /day urine output
and his Serum electrolyte was within normal range. What is the possible precipitating factor
of his condition?
A) Spontaneous bacterial peritonitis
B) Hypovolumia
C) High-protein diet
D) Constipation

42. A 45 year old man is in your office for consultation of recent onset general malaise and
fatigability. While walking into your office he suddenly collapsed. You realized that
peripheral pulses are not palpable, apical impulse is absent, chest is not moving and you do
not feel air coming through the mouth. What is the next best step?
A) Check random blood sugar
B) Start cardiopulmonary resuscitation
C) Transport him to the emergency room
D) Check his pocket for drugs

43. A 4 years old child was admitted and put on crystalline penicillin after he presented with
cough of 4 days duration associated with fast breathing and fever. At admission he had
respiratory rate of 50/min, with inter-costal retraction and relative dullness on the posterior
right lower third chest. After fifty hours of admission his RR become 48/min, temperature
38.60C with the same chest finding. What is your immediate next action?
A) Stop crystalline penicillin and put him on chloramphenicol
B) Send blood culture
C) Send him for chest X ray
D) Insert chest tube

44. A 45 years old man presents to the OPD complaining of a recurrence of a painless mass
on his eyelid since 2 months back. He had surgery for the same lesion 6 months back. You
performed a repeat surgery and sent tissue for histopathology. What histologic feature
strongly suggests the diagnosis of chalazion?
A) Presence of lipoid tissue
B) Presence of foreign body giant cells
C) Presence of predominantly PMN inflammatory cells
D) Presence of keratin pearls

45. A 70yrs old male patient was operated 5 hours back. The operation was transevesical
prostatectomy. He was on continuous irrigation but since 30 minute the urine drainage
stopped and the patient developed severe suprapubic pain. What is the most likely cause of
pain for this patient?
A) Clot obstruction
B) Displaced urethral catheter
C) Dehiscence of repaired bladder wall
D) Foreign body

46. A 30 year Para VII woman arrives at emergency OPD with profuse vaginal bleeding. She
delivered at home before 90 minutes to a 4.1kg male neonate with labor duration of 7 hours.
Placenta and membrane are delivered spontaneously at home. On your examination she is
hypotensive and tachycardic. Uterus is 24 week sized and boggy. What could have best
prevented her postpartum hemorrhage?
A) Administration of intramuscular vitamin K
B) Early initiation of breast feeding
C) Active management of third stage of labor
D) Early arrival to the hospital after delivery

47. A 16 years old high school girl, brought by her parents to OPD, after a fainting attack in
the school. Her parents gave history of shortness of breath, palpitation, and feeling of
dizziness and fear of dying. She had two previous similar episodes. Medical evaluation and
investigations were normal. What is the most likely diagnosis?
A) Panic attack
B) Panic disorder
C) Agoraphobia without panic attack
D) Agoraphobia with panic attack

48. An apparently healthy 15 year old female adolescent presented with loss of consciousness
of 2 hours duration after she was found in her study room. Her friends found an unlabeled
bottle with a spill of liquid on the floor. On objective evaluation she is lethargic with drooling
of saliva and labored breathing and transmitted sound all over the lung fields. She
experienced one episode of vomiting at emergency and it has garlicky odor. After securing
the airway, breathing and circulation; What is the next appropriate management?
A) Whole-Bowel Irrigation
B) Doing gastric lavage
C) Starting atropine intravenously
D) Giving syrup of ipecac

49. A 3 years old child presented with tachypnea of 2 days preceded by rhinitis and cough.
On physical examination he has temperature record of 39.3oC, intercostal and subcostal
retractions and dullness on the right chest. Anthropometry is normal. Pleural tap resulted in
cloudy pleural fluid and analysis revealed 50,000 cells (90percent Neutrophils and 8percent
lymphocytes) and gram stain showed positive cocci in chains. What is the best way to
manage this patient?
A) Chest tube drainage
B) Crystalline penicillin for 3 weeks
C) Potent antibiotics such as vancomycin
D) Oxygen with face mask

50. A 45 years old man presented with back pain and lower extremities weakness of one
month duration. On physical exam, he is conscious and alert, with normal vital signs and
clear chest. He has paraparesis with sensory level at umbilicus. What investigation is most
important to diagnose the disease?
A) Sacral MRI
B) Thoraco lumbar MRI
C) Cervical MRI
D) Upper thoracic CT scan

51. A 14-years old boy sustains injury to his right knee and developed severe pain and
swelling. He subsequently develops compartment syndrome and required fasciotomy. His
knee radiograph is shown below. What artery is most likely responsible for the compartment
syndrome?
A) Peroneal
B) Posterior tibial
C) Middle geniculate
D) Anterior tibial recurrent

52. A 30 year old male presented with coughing up of blood, shortnesss of breath and chest
pain of 1 week. Associated with this he complains fatigue, nausea, vomiting and loss of
appetite. His laboratory profile revealed Hct of 34; U/A 10RBCs/HPF; Serology shows
circulating anti-glomerular basement antibodies. What will chest X-ray of this patient most
likely reveal?
A) Bilateral patchy airspace opacity.
B) Bilateral interstitial opacity.
C) Multiple cavitary lesions.
D) Bilateral pleural effusion.

53. A 27 years old female patient with hypothyroidism came with a compliant of
asymptomatic whitening of the finger tips. On exam there are depigmented macules and
patches over the finger tips and lower lip. What is the most likely cause of the
depigmentation?
A) Decrease in size of melanosomes
B) Absence of melanocytes
C) Decrease in functions of melanocytes
D) Absence of melanosomes

54. A 56 year male patient presented with lesion over the sole of the right foot of 08 months
duration associated with pain during walking & loss of weight. Two months back he also
noticed a painful swelling over the right inguinal area which is progressively increasing in
size. On P/E there is a hard 10x8 cm matted, hard, fixed & tender swelling over the right
inguinal region with an irregularly shaped plaque like dark lesion over the right sole of the
foot. A skin biopsy was taken from the lesion over the foot. What would be the biopsy result
of this patient?
A) Squamous cell carcinoma
B) Acral melanoma
C) Basal cell carcinoma
D) Lentigomaligna

55. A 30 year old female patient underwent resection of the small bowel and end to end
anastamosis with only 45cm length remaining behind for the diagnosis of gangrenous small
bowel secondary to mesenteric ischemia. Both the ileocecal valve and large bowel remained
intact. What is the best route of nutritional support in this patient?
A) Nasogastric
B) Surgical jejunostomy
C) Total Parentral
D) Nasojejunal

56. A 5 hours male neonate presented with drooling of saliva since birth. Additionally, he has
cough after each swallowing of breast milk. NG Tube insertion was tried it failed go down to
stomach. On CXR with NGT insertion shows coiled NG Tube on the upper chest. What is the
major determinate of poor outcome of this neonate?
A) Presence of other severe anomalies
B) Aspiration pneumonia
C) Hypothermia
D) Hypovolumia

57. A 35- year old male patient has presented with neck and facial swelling. He also
complained cough and shortness of breath. Physical exam revealed BP 100/70 mmHg, PR 80
bpm, RR 26 bpm, T 36.4oC. He had dilated neck veins and visible collateral veins over the
anterior chest. He has cyanosis, edema of the face and arms. CXR showed mediastinal
widening. What is the most likely diagnosis?
A) Cardiac tamponade
B) Pulmonary thromboembolism
C) Superior vena-caval syndrome
D) Aortic dissection

58. A 60 years old known alcohol abuser presents with right upper quadrant pain. On
physical examination he has a tender hepatomegaly. Lab studies show a preferential elevation
of aspartate transferase; serum bilirubin levels were within normal range. A liver core needle
biopsy shows fatty changes. What is the underlying pathogenesis for the above changes?
A) Increased Beta-oxidation of fatty acids
B) Increased synthesis of glycerol 3 phosphate
C) Decreased synthesis of VLDL (Very Low Density Lipoprotein)
D) Decreased hydrolysis of fat in adipose tissue

59. A Primigravida lady at gestational age of 27 weeks presented with crampy lower
abdominal pain of 5 hours duration. She has associated passage of watery fluid. Otherwise
she has no bleeding, has no passage of tissue. On physical examination vital signs are stable,
no abdominal tenderness, cervix is closed and watery fluid on examining finger appreciated.
On ultrasound examination cardiac activity is negative, and amniotic fluid is minimal. BPD
corresponds to 14 weeks. What is the diagnosis?
A) Missed abortion
B) Inevitable abortion
C) Threatened abortion
D) Incomplete abortion

60. A 27 years old para 4 woman gave birth at home assisted by traditional birth attendants 4
weeks ago. She has no history of anti-natal care. She is brought by her relatives to the OPD
after she started to shout, talks to herself and disturb at home. Prior to the onset of her
symptoms she was sleepless, isolate herself and lose interest in feeding the infant. What is the
immediate next step in the management of this patient?
A) Enquire the content of hallucinatory voices content
B) Enquire her feeding pattern
C) Educate the family to take the child away
D) Start her antipsychotics

61. A 3-month-old infant presented with a runny nose, cough, and rapid breathing of 5 days
after receiving his 14-weeks immunizations. On examination he has a temperature of 380C, a
respiratory rate of 60 breathes/minute, and he has a diffuse wheeze. What is the most likely
diagnosis?
A) Severe pneumonia
B) Bronchiolitis
C) Myocarditis
D) Congenital heart disease

62. A 70 year old man with 15 pack year history of smoking but who stopped smoking about
5 years ago presents with cough and weight loss. He has evidence of left pleural effusion.
Chest CT shows left upper lobe apical mass with left pleural effusion. What is the best next
diagnostic test?
A) Pleural biopsy
B) Fluid cytology
C) Fluid Adenosine diaminase (ADA)
D) Fluid GeneXpert

63. A 9 months old infant is noted to hold his arms and legs out straight with occasional
crossing-over of the legs at the ankles. He does not sit unsupported, nor does he roll over. He
was born 12 weeks premature and was very ill during the neonatal period. What is the most
likely diagnosis?
A) Cerebral palsy
B) Mitochondrial Encephalomyopathies
C) Spinal Muscular Atrophies
D) Duchenne Muscular Dystrophies

64. A 44 years old farmer came with nodular lesion over the foot of 5 years which
progressively enlarge and distort the normal biomechanics of the foot. KoH and culture show
fungal elements; on X-ray there are periosteal erosion and development of new lytic bone
lesions. Which of the following is not the classical triad of the disease?
A) Tumerification
B) Grains
C) Sinus tracts
D) Pain

65. A 45 year old man comes to you fatigability and palpitation on mild exertion. He
underwent unspecified abdominal surgery 4 years back. He was also treated for Hook worm
two months ago. He has conjunctival pallor, angular cheilosis and non-icteric sclerae. His
Hgb is 9g/dl (MCV = 120fL). Peripheral morphology shows macro-ovalocytic RBCs with
hypersegmented neutrophils. What is the next best management?
A) Iron plus mebendazole
B) Folic acid plus stool for ova of parasite
C) Vitamin B12 plus stool for ova of parasite
D) Folic acid plus vitamin B12
66. A 25 years old male patient admitted to medical ward after being diagnosed with AKI. He
presented with generalized body swelling, shortness of breath and decreased urine output. On
physical examination, BP 100/70 mmHg, PR 80 bpm, RR 24bpm, T 36.8oC, he had distant
heart sound with pericardial friction rub, pedal and pretibial edema. Investigation showed
hyperkalemia which was refractory to medical treatment. Urine output was 300ml/24hrs.
What is the next best management of this patient?
A) pericardiocentesis
B) hemodialysis
C) chest tube insertion
D) salt restriction

67. 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 evaluation, 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

68. A Gravida II Para I mother was admitted to labor ward with active first stage of labor at a
cervical dilatation of 6 cm, 0 station, and ruptured membrane with left occipito-transverse
fetal position. She had one previous cesarean scar. She has 4 strong contractions over 10
minutes. And fetal heart rate ranges between 130 to 158 beats/minute with accelerations.
After 90 minute follow up you notice prolonged fetal heart rate decelerations otherwise
maternal vital sign is normal and no vaginal bleeding. What is the likely cause of change in
fetal heart beat pattern ?
A) Imminent uterine rupture
B) Placental abruption
C) Second stage of labor
D) Cord compression

69. A 22 months old boy presented to your clinic with complaint of loss of appetite. He is a
picky eater, taking small amount of food but loves milk and drinks 6-8 bottle of whole milk
per day. CBC showed WBC 6100, Hgb 6.2mg/dl, HCT 19.8percent, Platelet 715,000, MCV
54 fl/red cell. What is the most likely diagnosis?
A) Iron deficiency anemia
B) Lead poisoning
C) Peptic ulcer disease (PUD)
D) Leukemia

70. A 6 months old prematurely delivered female infant presented with fast breathing and
cough of 3 days duration associated with feeding interruption. She has no body swelling or
fever. On objective evaluation she has PR of 155b/min with RR of 55b/min with pale
conjunctivae and non-icteric sclera. There is systolic murmur at the left 2nd and 3rd inter-
costal space and palmar pallor but no edema. What investigation do you want to do first?
A) Echocardiography
B) Electrocardiography
C) Chest X ray
D) Hematocrit

71. A 37 years old male patient sustained road traffic accident while he was crossing the
road. Up on arrival to ER he was unconscious with GCS of 12/15 V/S PR= 66BPM B/P=
170/90mmHg RR= 32 BPM. On investigation CXR was unremarkable, ABG shows
paO2=70mmHg PaCO2= 34 mmHg, serum electrolyte's Na = 134 k= 4.5. CT-scan is
unremarkable.
What initial measure would you take to improve his GCS?
A) Administer analgesics
B) Correct Electrolytes
C) Hyperventilation
D) Administer antihypertensive medication

72. A 36 years old primigravida woman visited you at your office for seeking advice about
her pregnancy at gestational age of 10 weeks. Otherwise she has no chronic medical illness or
any compliant. Which of the following best explains the client's risk?
A) she is at low risk of giving birth by cesarean section
B) She is at high risk for having a congenitally anomalous fetus
C) She is at low risk of having an increased risk of miscarriage
D) She at low risk of having an increased risk of preterm labor

73. A 35 years old male presented with a history of injury to right eye with a leaf 10 days
ago. In the last three days he developed pain photophobia and redness of the eye. What would
be the most likely pathology?
A) Anterior uveitis
B) Corneal abrasion
C) Fungal keratitis
D) Corneal laceration

74. An anesthesiologist injected 3ml of 2percent lidocaine into the trachea of a 54 year-old
obese male patient through the crico-thyroid membrane for an awake intubation. What nerve
will most likely be anesthetized?
A) Glossopharyngeal nerve
B) Hypoglossal nerve
C) Superior laryngeal nerve
D) Recurrent laryngeal nerve

75. 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
76. A known diabetic young woman with good sugar control, presented to your medical OPD
for follow up. She wanted to have a baby and asked your advice on how to proceed. When
would you recommend her to be screened for retinopathy?
A) Before conception
B) After the first trimester
C) At her own convenience
D) Around the time of delivery

77. A 37 years female patient who sustained falling down accident from 6 meter high
building came to ED. Up on evaluation GCS is 15/15 B/P is unrecordable PR is feeble
RR=28. CVS S1 and S2 well heard no murmur or gallop. No external source bleeding
noticed. What is the likely source of bleeding in this patient?
A) Depressed skull fracture
B) Pelvic fracture
C) Tibial fracture
D) Rib fracture

78. A 33 year old man presents from prison with high grade fever, headache, arthralgia, and
myalgia. His physical examination is remarkable for PR = 126bpm, BP = 120/80mmHg, RR
= 28bpm, To = 39.5oC and petechial rash scattered over the extremities. Lab shows WBC =
13,000/mm3, Hgb = 10g/dl, and platelet = 55,000/mm3. Blood film shows spirochetes. Two
hours after initiation of treatment with penicillin, patient started having shaking chills and
confusion. Vitals showed PR = 140bpm, BP = 70/40mmHg, RR = 44bpm, and SaO2 =
83percent. What is the explanation for later finding?
A) Septic shock
B) Intracranial bleeding with raised ICP
C) Anaphylactic shock
D) Jarisch-Herxheimer reaction

79. A 30 year old female patient came to the hospital after she sustained a flame burn injury
inside a small kitchen while she was cooking. She was removed from the room by her
relatives after that they put out the fire which caught her clothing. On examination she had
second degree burn of 25percent TBSA involving the face anterior chest and anterior part of
bilateral upper extremities. She has audible stridor with tachypnea and oxygen saturation of
70percent with atmospheric air. What is the best initial step of her management?
A) IV corticosteroids
B) Parentral broad spectrum antibiotics
C) Endotracheal intubation
D) Wound debridement

80. A 40 year old known ovarian tumor patient presents with right leg swelling of one week
duration. Her vitals are within normal range and she has positive Homan's sign on the right
lower limb. She developed sudden onset of shortness of breath on her way to the lab and she
is brought back to the emergency without diagnostic tests. She is breathing on face mask O2
at 10lit/min. What is the next best diagnostic work up?
A) High resolution chest CT
B) Helical chest CT
C) Doppler vascular ultrasound
D) D-dimer
81. A 25 year old male patient presented with cough, fever, and right pleuritic chest pain of
04 days duration. Physical exam revealed PR = 110bpm, RR = 26bpm, temperature 38.0oC
and evidence of right pleural effusion. Chest x-ray shows right mid lung zone homogenous
opacity with air bronchogram and moderate right pleural effusion. Fluid analysis shows
3000cells/microL (Neutrophils = 80percent, L = 20percent), glucose 15mg/dl, and protein
4mg/dl. What is the best management of this case?
A) Start antibiotics and supportive care
B) Treat as an outpatient with PO antibiotics and give short appointment
C) Start antibiotics and drain the fluid
D) Start antibiotics and further investigate the fluid

82. A 27 years old male patient was told to have gall stone measuring <4cm. Currently,
presented with severe abdominal pain, nausea, vomiting and low grade fever. On physical
examination, BP=90/60mmHg, PR=120bpm, RR=20bpm, T=36.5oC. Otherwise, there was
no pertinent positive finding. On investigation, WBC=14,500, Hct=48percent, abdominal U/S
-showed minimal retro-peritoneal fluid collection and gall bladder is normal, serum lipase
was 3x elevated. You admitted and gave him IV analgesics and ordered him to be NPO.
What is the next best management of this patient?
A) IV prophylactic antibiotics
B) ASA
C) prepare for cholesystectomy
D) IV fluid resuscitation

83. A 25 year old lady presents with epistaxis and gum bleeding of 02 weeks duration.
Physical examination is remarkable for scattered petechial rash over the extremities and
trunk. Blood test shows Hgb of 12g/dl (MCV = 85fL) and platelet of 25 x 103/microL. Liver
function and Coomb's tests are non-revealing. What is the first line treatment option?
A) Prednisolone
B) Splenectomy
C) Plasmapheresis
D) IV immunoglobulin

84. A 70 year old male patient was operated for perforated peptic ulcer disease. P/E on the
2nd post-operative day revealed BP- 140/90mmhg, PR-86bpm and abdominal examination
finding of hypoactive bowel sounds with urine output of 350ml over 24 hours. Other findings
were unremarkable. Which parentral medication should not be given to this patient
considering the current situation?
A) Potassium chloride
B) Cimetidine
C) Ceftriaxone
D) Morphine

85. You are in a swimming pool in one of the hotels. Clients are informed at the reception
that the 'Life Savor' is going to be late and individuals can only swim at their own risk.
Unfortunately, one of the clients has just near drowned. He is a young man in 20s. You
rescued him from the water. You can feel a week carotid pulse. Chest is not moving and there
is no air coming through the mouth. What is the next best measure?
A) Start chest compression
B) Flip him over on his abdomen and apply pressure over the back
C) Bring Automated External Defibrillator and apply shock
D) Give mouth-to-mouth breathing

86. A 12 month old infant came for routine checkup after his mother was diagnosed to have
smear positive pulmonary tuberculosis. He is growing well with normal systemic evaluation.
What is the most appropriate next step?
A) Chest X ray
B) Gastric aspirate for gene expert
C) Anti-tuberculosis
D) INH prophylaxis

87. A 39 years old driver sustained head on collision with a Sino truck. He sustained pelvic
ring injury. CT-scan showed left side sacral fracture with quadri-rami fracture. On
examination he is unable to dorsoflex the ankle. What is the most likely injured nerve root?
A) L4
B) L5
C) S1
D) S2

88. A middle-aged woman presented with malaise, fatigue, and night sweating. Physical
examination showed dry and red eyes, skin rashes, enlarged joints and lymph nodes in the
cervical region. Chest x-ray revealed a widened mediastinum. The biopsy report of lymph
node showed non-caseating granuloma with a range of differential diagnosis. What is the
most likely diagnosis?
A) Disseminated tuberculosis
B) Systemic lupus erythematosus (SLE)
C) Sjogren's syndrome
D) Sarcoidosis

89. A-45 years old female patient admitted and treated with H2 blocker after she presented
with severe epigastric pain and dyspepsia of two months duration, she also complains
melena. Triple therapy was given at private clinic and H-pylori eradication was confirmed.
What is the next best investigation you would do?
A) Barrium meal
B) Upper GI Endoscopy
C) colonoscopy
D) abdominal u/s

90. A 30 year old primigravida lady comes to the emergency room and has cardiac arrest.
After 3 cycles of CPR, she has return of spontaneous circulation. However, she remains
unresponsive with fixed and dilated pupils, absent corneal reflexes and Doll's eye movement.
She is intubated and put on mechanical ventilator. Her BP 100/70mmHg and PR 88bpm. All
her complete blood count, electrolytes, renal function and liver function tests are within
normal range. You could not assess drug levels and poison screening. The fetus is viable with
estimated fetal weight of 1.1kg. Which of the following is the best next step?
A) Terminate the pregnancy to salvage the baby
B) Continue supporting the mother for a few more weeks
C) Discuss with her family and execute their will
D) Discuss with your institution's ethics committee
91. A Gravida III Para II mother comes to emergency OPD with 7 hours of pushing down
sensation and 6 hours of gush of fluid per vagina. She has stable vital sign. She has 4
moderate contractions over 10 minutes. Fetal heart rate is 134beats/minute. Cervix is 8 cm
dilated station -2 with compound presentation of the fetal head in occipito anterior position
and fetal hand palpated on the right side of the head. How do you manage labor in this
mother?
A) Admission and partograph follow up
B) Admission and labor augmentation
C) Cesarean section from EOPD
D) Manipulating the prolapsed had to revert it before admission

92. A 40 years old Gravida IV Para III tested positive for HIV serology on her first perinatal
visit. Her CD4 count is 650cells/mm3. And her HIV RNA is 400copies/mL. She has 2
previous cesarean sections and planned to have elective CS for the current delivery and she is
going to have replacement feeding for her neonate. What is the proper management during
the antepartum period?
A) Start her on HAART and CPT prophylaxis
B) Start HAART, CD4 count and viral load every trimester
C) Start HAART, CD4 count and viral load every month
D) Start HAART, CPT and INH prophylaxis

93. 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

94. A 19 year old lady is known to have HIV over the past 10 years and she is currently
getting TDF/3TC/EFV. She presents with exertional dyspnea and fatigability. Physical
examination is remarkable for JVP 5cm above the angle of Louis, murmur of MR,
hepatomegaly and trace peripheral edema. Echocardiography shows dilated cardiomyopathy
with mildly depressed systolic function. What is the likely cause of the cardiomyopathy?
A) Beriberi
B) Thyrotoxicosis
C) HIV
D) Rheumatic fever

95. A 7 years old child was diagnosed to have acute tonsillopharyngitis and put on
amoxicillin. He came back with a compliant of lack of response 10 hours later. You evaluated
him and his temperature is 380C with erythematous tonsils and exudate. What is the most
appropriate next step?
A) Change amoxicillin to Augmentin
B) Change amoxicillin to erythromycin
C) Put him on intramuscular ceftriaxone
D) Continue with the same management

96. A45years old came with a complain right chick swelling of 2years duration. For this
complaint he was admitted and was operated. After 6 hours he noticed drooping of the right
side of a mouth and could not close mouth. Through which foramen does the nerve
responsible for this patient's symptom exit the skull?
A) Foramen Ovale
B) Jugular foramen
C) IAC
D) Stylomastoid foramen.

97. A 52 years old male patient presented with nasal obstruction of 6 months duration and
right side neck swelling of 2 month duration. The biopsy result showed undifferentiated
nasopharyngeal carcinoma and CT imaging showed 4x4cm nasopharyngeal mass with
extension to nasal cavity and right side of neck level 2& 3 with multiple lymphadenopathies.
What is the poor prognostic sign in this patient?
A) Histology type
B) Neck metastasis
C) Size of tumor
D) Nasal extension

98. A two years old child presented to the hospital after his family notice abdominal mass
while they are bathing the child. On examination, the child is severely wasted and
hypertensive. There was right flank mass which extend to midline but didn't cross it. Urine
analysis showed hematuria. What is the most likely diagnosis?
A) Neuroblastoma
B) Wilms' tumor
C) Hydronephrosis
D) Retroperitoneal teratoma

99. A 40 years old male a known diabetic patient presented with the complaint of numbness
and burning sensation of the lower extremity. Which sensory modality is affected?
A) position
B) pain s
C) temperature
D) pressure

100. A 44 years old male patient was operated for gangrenous small bowel volvulus 7 days
back and resection of gangrenous segment and end to end anastomosis of small bowel was
done. On the 6th post day he developed hospital acquired pneumonia and was put on
Ceftazidime and Cloxacillin. He currently develops diarrhea which is blood mixed with
mucus. What is the most likely diagnosis?
A) Anastomotic leak
B) Post operation collection
C) Pseudomembranous colitis
D) Amebic Dysentery