Q#1. Define Wilson disease. Briefly describe its pathogenesis.

(2) [Supple 2019 held in2020]

Definition: It is an autosomal recessive disorder caused by mutation of the ATP7B gene, which results in impaired copper
excretion into bile and a failure to incorporate copper into ceruloplasmin.
Pathogenesis

Cu+2 transpoter Cu+2 accumulation

ATP7b mutation Hepatocye injury
decrease in hepatocytes

Cholestatic Diseases

Q#1. Enumerate any two causes of: [Supple 2015 held in 2016]
a) Predominantly unconjugated hyperbilirubinemia
b) Predominantly conjugated hyperbilirubinemia

Unconjugated ❖ Excess production of Bilirubin

Hyperbilirubenemia ✓ Hemolytic anemia & Inaffective erythropoiesis
❖ Reduced Hepatic Uptake
✓ Drug interference with membrane carrier system
❖ Impaired bilirubin Conjugation
✓ Physiological jaundice of newborn
✓ Viral or drug induced hepatitis
Conjugated ❖ Decreased Hepatocellular excretion
Hyperbilirubinemia ✓ Drug induced canalicular membrane dysfunction (oral
contraceptives)
✓ Hepatocellular damage or toxicity (Viral, drug induces or Systemic
infection)
❖ Impaired intrahepatic or extrahepatic bile flow
✓ Inflammatory destruction of intrahepatic bile ducts (peimary biliary
cirrhosis, primary sclerosing cholangitis, Graft-vs-Host reaction &
Liver transplant)
✓ Gallstones
✓ External compression (carcinoma of pancreas)

Q#2. A 1-month-old infant presenting with jaundice is diagnosed with extrahepatic biliary atresia. [Annual 2007]
a) What are the major histological features on liver biopsy?
• Inflammation of bile ducts
• Fibrosing stricture of bile ducts
• If uncorrected, it leads to cirrhosis
b) What two enzymes are likely to be raised in this condition?
Answer: ALP & GGT

Autoimmune Cholangiopathies

Q#1. Compare and contrast between primary biliary cirrhosis and primary sclerosing cholangitis. (2)
[Supple 2019 held in 2020]

Features Primary biliary Cholangitis Primary Sclerosing

 Preeclampsia and Eclampsia

Q#1. Give placental morphology in preecclempsia and ecclempsia. (Annual 2022)

Gross
➢ Red or tan appearance, Placental hypoplasia
Microscopic
➢ Infarcts
➢ Reteroplacental hemorrhages
➢ Premature maturation of placental villi (villous edema, hypovascularity, and increased production of syncytial
epithelial knots)
➢ Fibrinoid necrosis and focal accumulation of lipid laden macrophages (acute atherosis) of decidual vessels.

Q#2. A primigravidae presents with symptoms of hypertension, proteinuria, edema feet in the last trimester of pregnancy
and later on developed convulsions and disseminatedintravascular coagulation.
a) Name the disease from which this woman is suffering from? (1)
Answer: Preecclempsia (Toxemia of pregnancy)
b) What is the pathogenesis of this disease? (4)

Insufficient
maternal blood Decreased Altered release of angiogenesis Endothelial cell
flow to placenta uteroplacental regulating factors (Increase anti- dysfunction, vascular
seconday to blood flow leads to angiogenetic factors sFIt1 & hyperreactivity, and
inadequate sEng, decreased pro-angiogenic end organ
placental hypoxia
remodeling of factors VEGEF) microangiopathy
& dysfunction
spiral arteries

Gestational Trophoblastic Disease

Q#1. A 30 years old female presented with spontaneous miscarriage. Her serum beta-hCG levels exceeded those of a
normal pregnancy. At 6 months follow-up beta-hCG levelsreturned to non-pregnant levels. [Supple 2017 held in 2018]
a) What is most likely diagnosis? (1)
Answer: Hydatidiform mole
b) Write the differences between the two common types/variants of this disease.(4)
Features Complete Mole Partial Mole
Karyotype 46(XX/XY) 69(XXY)
Villous edema All villi Some villi
Trophoblast proliferation Diffuse Focal
Serum hCG Elevated Less elevated
Tissue hCG ++++ +
Risk of subsequent 2% Rare
choriocarcinoma
Expression of p27 No Yes

Q#2. A young female in her 15th week of pregnancy presents with uterine bleeding and passage of a small amount of
watery fluid and tissue. Her uterus is much larger than estimated by her gestational dates and on examination, it is found
to be filled with cystic, a vascular, grapelike structures that do not penetrate the uterine wall. No fetal parts are found.
Immunostaining for p57 was negative in the cytotrophoblast and villi mesenchyme. [Supple 2016 held in 2017]
a) What is most likely diagnosis?
Answer: Complete hydatidoform mole
b) 2% to 3% of such cases gives rise to malignant tumor. Name this tumor. Give its characteristics and mention
the sites of its metastasis.
Gestational choriocarcinoma
Characteristics
• Hemorrhagic necrotic mass; chorionic villi are not formed
• More likely at higher CD4+ counts (>200 cells/mm3) – Bacterial Pulmonary Infection caused by Usual organisms
i.e.“Streptococcus Pneumoniae, S. Aureus and Hemophilus species.
• Pulmonary Infection caused by Opportunistic organisms includes:
(a) At CD4+ counts (<200 cells/mm3) – PCP (Lung infection caused by Pneumocystis (Carinii) Jirovecii)
(b) At CD4+ counts (< 50 cells/mm3) – TB (MAC infection), Fungal Infectionsand CMV infections.

Lung Tumors

1. A 60 years old male, heavy smoker for many years, now for the last several months complains of cough sputum
(sometimes with blood), chest pain, dyspnea and has lost weight. X-ray chest reveals a 3cm radio-dense lesion in middle
of his right lung region. His sputum cytologic examination reveals atypical cells with high N/C ratio suspicion of
malignancy. [Supple 2021 held in 2022]
(a) Enumerate major histologic classes of malignant epithelial lung tumors? (2)

Reference: Robbins and Cotran; Pathologic basis of disease (10th edition)

(b) Give microscopic features of small cell carcinoma lung. (2)

Light (a) Tumor is Comprised of relatively small cells with:
Microscopic • Scant cytoplasm
Features: • Finely granular nuclear chromatin (Salt and Pepper / Stippled pattern), and absent
OR inconspicuous nucleoli.
(b) The cells are round, oval, or spindle-shaped, and nuclear molding is prominent
(c) The mitotic count is high and often extensive Necrosis is present.
(d) Basophilic staining of vascular walls due to encrustation by DNA from necrotic
tumor cells (Azzopardi effect) is frequently present.
Electron (a) Reveal several Membrane bound electron dense Neurosecretory granules
Microscopic (b) Granules contain Hormones released by these tumors e.g., ACTH & ADH
Features:
(c) What do you understand by the term Pancoast tumors? (1)
• “Carcinoma that occurs in the apex of lung”
• Also called superior sulcus tumor
• It may cause Pancoast syndrome by invading/compressing local structures.
• It leads to Horner syndrome

2. A 52-year-old non-smoker woman presented with fever and cough for past few weeks. There are decreased breath
sounds over the right upper lung. Her chest X-ray now reveals a 3 cm peripheral mass in the right upper lobe. Biopsy
reveals tumor with glandular pattern. [Supple 2019 held in 2020]
(a) What is the most likely diagnosis? (1)
2. A 35-year-old female slowly gained weight over the past one and half year. She also complains of muscle weakness
and menstrual cycle irregularity. On examination, her face is swollen, there is truncal obesity, buffalo hump, and
abdominal cutaneous striae. Her BP is elevated. [Supple 2018 held in 2019]
(a) What is the clinical diagnosis?
Answer: “Cushing syndrome”
(b) How the laboratory work-up will confirm the diagnosis?
Lab tests include:
• Free cortisol on 24-hr urinalysis
• Late night salivary cortisol
• Suppression with overnight low-dose dexamethasone test.
• High-dose dexamethasone suppression test
• CRH stimulation test
Results of Screening Tests and Interpretation about Etiology:

Reference: First Aid for the USMLE STEP – 1(2023)

3. A female of 25 years age presented with hypertension and weight gain. She also developed truncal obesity and moon
face. [Supple 2017 held in 2018]
(a) What is most likely diagnosis? (1)
Answer: “Cushing syndrome”
(b) What are the endogenous causes of this disorder? (2)
(1) Adrenal-related causes:
• Primary adrenal adenoma
• Adrenal Hyperplasia
• Adrenal Gland carcinoma
(2) Pituitary-related causes:
• ACTH-secreting pituitary adenoma (Cushing disease)
(3) Paraneoplastic (Ectopic ACTH secretion) causes:
• Small cell lung cancer
• Bronchial carcinoids
NOTE: “Cushing disease is responsible for the majority of endogenous cases of Cushing syndrome”.
(c) How will you diagnose this disease in the laboratory? (2)
Answer: See Q#2 (b)
 UHS MCQS 2012--2023

Sr. Statement Answer

Blood Vessels
1 Vessel exhibiting onion skin lesion. Type of blood vessel lesion ? Hyperplastic arteriolosclerosis
2 Critical stenosis is defined as ____ % occlusion of vessel 70%
3 Tree barking appearance of aorta is seen in Syphilis
4 Most important cause of abdominal aortic aneurysm ? Atherosclerosis
5 Most important cause of thoracic aortic aneurysm ? Hypertension
6 Most important cause of aortic dissection ? Hypertension
7 Hereditary cause of aortic dissection ? A. Marfan Syndrome ✓
B. Ehler Danlos syndrome
8 A patient presents with stabbing chest pain radiating to the back . Most Aortic dissection
probable diagnosis ?
9 A patient presents with tearing chest pain and mediastinal widening . Aortic dissection
Most probable diagnosis ?
10 Most common cause of death in Aortic dissection ? Rupturing
11 A 45 year male presents with scalp pain, visual disturbance & weak pulses A. Temporal Arteritis
in upper limbs. Diagnosis ? B. Takayasu Arteritis ✓
12 A 3 year child presents with cervical lymph node enlargement, erythema Kawasaki disease
of palms and soles. Coronary artery was involved. Vessel disorder ?
13 An adult indian smoker presented with complain of foot pain induced by Buerger disease
excercise. Diagnosis ?
14 Prostatectomy may lead to Pulmonary embolism
15 Homan sign (calf pain at dorsiflexion ot foot) is indicative of DVT
16 Kaposi Sarcoma is which type of disorder ? Vascular (intermediate grade)
17 Major risk factor for Buerger thromboangitis obliterans ? Smoking
18 A 30 years old male was diagnosed as a case of wegner's granulomatosis. A. ANCA ✓
Which of the following Investigation has pathognomic importance to B. ANA
confirm: C. Complement level
19 Most common source of pulmonary thromboembolism ? A. Deep veins of calf ✓
B. Femoral vein ×
C. Popliteal vein ×
20 Where are Glomus tumor most commonly found ? Fingers & toes
21 A factor that stimulates proliferation of SMC & also relates to A. PDGF ✓ B. TGF-β
pathogenesis of arteriolosclerosis ? C. TNF D. Interleukin I
22 Vascular disorder characterized by Violaceous plaques ? Kaposi sarcoma
Heart
1 Feature exclusive to left heart failure ? A. Pleural Edema
B. Heart failure cells ✓
2 Chromosomal anamoly associated with Aortic Coarctation? Turner syndrome
3 Intermittent chest pain on exertion and relieved by rest ? Stable angina
 05. Complications of CSOM

Classification of Complications

Q#1. Enumerate complications of atticoantral type of suppurative otitis media. [Supple 2014 held in 2015]

Intratemporal Complications Intracranial Complications

Mastoiditis Extradural, Subdural and Brain abscess
Petrositis Meningitis-most common complication
Facial paralysis Sigmoid sinus thrombosis
Labyrinthitis Otitic hydrocephalus

Q#2. Enlist complications of chronic suppurative otitis media. [Annual 2011]

Answer: See Q#1

Acute Mastoiditis

Q#1. A 45-year-old diabetic patient complained of earache. Examination showed mastoiditis. After several courses of
antibiotic, she develops symptoms and signs of ear infection again and again. What is the best plan of management? [Annual
2010]

History Time of onset, Poor nutrition, Hearing problem, Ear discharge duration
Examination Examination of external ear & mastoid
Investigation • Culture and Sensitivity
• X ray mastoid/CT temporal bone
• ESR & CBC
Treatment • Hospitalization of patient
• Antibiotics guided by culture & sensitivity ± Myringotomy
• Cortical Mastoidectomy – TOC

Q#2. A seven-year-old child who had chronically discharging left ear developed otalgia, retro-auricular tender swelling
with pinna protruded outwards and forwards. How will you manage? [Annual 2007]
See Q#1

Bezold Abscess

Q#1. A 9-year-old boy is brought to ENT emergency room with complaints of sudden onset of fever and pain in neck.
Examination reveals torticollis and a tender swelling behind the mandible. He also has associated history of ear discharge
since childhood. [Annual 2016]
a) What is the most probably diagnosis?
Bezold Abscess
b) What will be your treatment plan?
 Atrophic Rhinitis

Q#1. A 40-year-old female presents with complains of loss of smell, nasal blockage and intermittent mild epistaxis on
cleaning nose. On examination, there was greenish crusting in both nostrils with extremely foul smell.
[Supple 2018 held in 2019]
a) What is the most likely diagnosis? (1)
Answer: Primary Atrophic Rhinitis.
b) What is differential diagnosis of this condition? (2)
Answer: 1) Rhinitis sicca 2) Rhinitis caseosa
c)How will you manage this case? (2)
1. History Gender (Female), Onset(start from puberty), Family history, Nutritional status.
2. Examination Examination of nose (Anterior rhinoscopy), Examination of larynx
3. Investigations X-ray (Paranasal sinuses appear opaque), Bacterial culture of nasal secretions.
4. Treatment ❖ Medical
➢ Nasal irrigation & Removal of crust by normal saline
➢ 25% glucose in glycerine → inhibit growth of proteolytic bacteria.
➢ Local antibiotics --.Kemicetine-Antiozaena solution
➢ Oestradiol spray & placental extract → To increase vascularity & regenerate
seromucus glands.
➢ Systemic antibiotics → Streptomycin 1g/day for 10 days.
➢ Oral Potassium iodide→ Liquifies nasal secretions
❖ Surgery
➢ Young’s operation→ Close both nostrils completely for 6 months by raising flaps.
➢ Modified Young’s operation → Partial closure of nostrils
➢ Narrowing the nasal cavity by:
✓ Submucosal injection of Teflon
✓ Insertion of fat, cartilage, bone or Teflon strips under mucoperiosteum of
floor & lateral wall of nose
✓ Section & medial displacement of lateral wall of nose

Q#2. A villager lady presented with history of nasal obstruction, nose bleeding and nasal discharge having black coloration
and blood-stained for the last one year. Nose examination showed no mass and rather both nostrils found roomy and
containing blackish crusts. [Supple 2013 held in 2014]
a) What is provisional diagnosis?
Answer: Primary Atrophic Rhinitis.
b) Name two other diseases which can be included in D/D in this case.
Answer: 1) Rhinitis sicca 2) Rhinitis caseosa
c) Mention one diagnostic step/test for each of the above three diseases.
✓ Atrophic rhinitis → PNS x ray and Serum ferritin level
✓ Rhinitis sicca → Endoscopy and Nasal swabs
✓ Rhinitis caseosa → Biopsy
d) How will you manage this lady?
See Q1c

Q#3. What are signs and symptoms of Atrophic Rhinitis and treatment options? [Supple 2006 held in 2007]
✓ Foul smell from nose
✓ Merciful anosmia
✓ Nasal obstruction due to large crusts filling nasal cavity.
✓ Epistaxis when crusts are removed.
✓ Greenish or grayish black crusts covering terbinates and nasal septum.
✓ Roomy nasal cavity.
✓ Septal perforation & saddle nose may be present.
✓ It may accompany atrophic pharangitis/larynghitis.
✓ Hearing impairment due to Eustachian tube obstruction.
 05. Head & Neck Space Infection

Ludwig’s Angina

Q#1. A girl 10 years of age presented with fever and swelling in submental and submandibular region for four days. On
examination, skin over the swelling is red and swelling is tender. First molar teeth right lower jaw is carious.
[Supple 2015]
(a) What is most likely diagnosis?
Ludwig’s Angina (Sub-Maxillary space Infection)
(b) What are causative organisms?
“Mixed infections involving both Aerobes and Anaerobes are common”.
Common Organisms: Alpha-hemolytic Streptococci, Staphylococci and Bacteroides.
Rare Organisms: Hemophilus influenzae, Escherichia coli and Pseudomonas.
(c) How will you manage it?
(a) History • History of high grade fever, red and tender swelling in sub-mental region
and Carious 1st molar tooth in right lower jaw.
(b) Examination • Throat reveals
(a) Red and tender swelling in sub-mental and sub-mandibular region
imparting a “Woody Hard Feel”
(b) Tongue – Pushed upwards and backward compromising airway.
(c) Investigations (1) Specific Investigations:
• Needle Aspiration of the abscess provides material for Culture and
Sensitivity of bacteria.
(2) General (Laboratory) Investigations:
• CBC, ESR , CRP (C-Reactive Protein)& Urinalysis
(d) Treatment Medical (Conservative)
• I/V Fluids to combat dehydration.
• Systemic (I/V – High doses) Antimicrobial therapy
• Analgesics (Aspirin OR paracetamol) – To relieve local pain and Fever
• Maintenance of Oral hygiene.
Surgery
• Incision and Drainage of Abscess
Extra-Oral Approach will be used as it is a submaxillary space infection. A
Transverse incision extending from one angle of mandible to the other is
made with vertical opening of midline musculature of tongue with a blunt
hemostat. “Very often it is serous fluid rather than frank pus that is
encountered”.
• Tracheostomy may become necessary.

2. Write a note on Ludwig’s angina. [Annual 2013]

Definition:
“Ludwig’s angina is Infection of submandibular space (consisting of Sub-lingual and Sub-maxillary Compartments”
Etiology:
 06. Cancer Larynx

Supraglottic Cancer

Q#1. A 60-year-old male patient came with complaints of neck swelling in level 2 for one month. This swelling is painless,
progressively increasing, tethered deeply with normal temperature overlying skin. The clinical impression showed to be
metastatic. This patient also has history of voice change and also developed stridor.
[Supple 2018 held in 2019]
(a) What should be the area of focus to find primary? (2.5)
“Supra-glottic cancers spread to Level 2 (Upper and middle Deep cervical nodes), Glottic cancers Does not Metastasize
and Sub-glottic cancers spread to Level 4 (Lower Deep cervical nodes)
So, Area of Focus should be “Supra-glottis
Site Subsite
Supraglottic o Suprahyoid epiglottis
o Infrahyoid epiglottis
o Aryepiglottic folds
o Arytenoids
o Ventricular bands

(b) What investigations you suggest with logic to make diagnosis? (2.5)
Investigation Logic
CLINICAL
IDL Reveals mass on voval cord with/without impaired mobility or fixation
Flexible Fiber-optic laryngoscopy For detailed examination
Microlaryngoscopy To visualize hidden areas of larynx
Voice test Reveals change in voice
RADIOGRAPHY
Chest x ray Mar reveals TB or pulmonary metastasis
CT scan To find extent and invasion of tumor
MRI For soft invasion
LABORATORY
Supravital staining & Biopsy Staining of laryngeal lesion with toluidine blue will help in selecting the site
for biopsy. Carcinoma take up the dye while leukoplakia does not

Glottic Cancer

Q#1. A 56 years old Male Smoker presented with complaints of change in voice for last 6 months. Indirect laryngoscopy
shows a mass on left vocal cord with impaired mobility. Other ENT examination is normal. [Annual 2022 held in 2023]
(a) What is your provisional diagnosis?
Answer: Carcinoma Larynx (Glottic Cancer)
(b) How will you investigate this patient to confirm your diagnosis?
 UHS MCQs 2012--2023

SECTION I – EAR
Sr Statement Answer
Chapter 1 – Anatomy
1 Diameter of tympanic membrane in infants ? 0.5 -- 1 cm
Same diameter in adults
2 TM developes from ____ All 3 germinal layers
3 External auditory canal has how many constrictions ? 2
4 Length of external auditory canal is 24 mm
5 Outer 1/3 (8mm) of external auditory canal contains ? Hair + Sebaceous glands
(No mucus glands)
6 Cone of light seen in anteroinferior quadrant of TM is formed by Umbo/Handle of malleus
____
7 In middle ear, tensor tympani muscle encircle which structure ? Processes Cochleariformis
8 Korner septum is a surgical landmark for ? Mastoid antrum
9 Prussack's space is situated in ? Epitympanum
10 Largest mastoid air cell is : Mastoid antrum
11 Nerve supply of tensor tympani ? Mandibular division of
Trigeminal nerve
12 Tympanic plexus is formed by which nerve ? Jacobson nerve (Branch of IX)
13 Endolymph has high concentration of ____ as compared to Perilymph K+ ions
14 Endolymph is produced by ? Stria vascularis + Dark utricle
cells
15 Promontory in the medial wall of middle ear cavity is formed by Basal coil of cochlea
which structure ?
16 Surface area of TM ? 70 m2
17 Utricle lies in which part of Bony labyrinth ? Elliptical recess in Vestibule
Chapter 2 – Peripheral Receptor and Physiology
1 Transduction of mechanical energy into electrical energy is done at ? Outer hair cells
2 Where does maculae located ? Otolith organ (utricle and
saccule)
3 Function of utricle and Saccule Linear acceleration and
deceleration
4 Superior nystagmus is produced by which semi-circular canal ? Posterior
Chapter 3 – Audiology and Acoustic
1 Normal hearing frequency range for humans ? A. 15--20,000 Hz ×
B. None ✓
Chapter 4 – Assessment of Hearing
1 Ideal tuning fork frequency for routine clinical practice ? 512 Hz
 Indicators of Health

1. Health care Indicators of Pakistan have shown considerable improvement during the last few decades. However,
Health care system stills lags behind many countries with the same socioeconomic profile. [Supple 2021 held in 2022]
(a) How will you define an indicator?
“These are Variables which help to measure changes (as an indication of a given situation)”
(b) Enlist different Mortality indicators?
• Crude death rate
• Perinatal, Neonatal & Post-neonatal mortality rates
• Infant mortality rate – Most universally accepted indicator of health of whole population.
• Maternal mortality rate
• Child mortality rate
• Under-5 Proportionate mortality rate
• Disease specific mortality rate
• Life expectancy

2. Teaching hospitals in big cities of Pakistan are overcrowded and overburdened due to lack of implementation of
proper referral in health care delivery system. This situation affects health care delivery and health care utilization rates
both. [Supple 2018 held in 2019]
(a) Differentiate between health care delivery and health care utilization indicators with examples. (4)
Points of Health Care Delivery Indicators Health care utilization Indicators
Difference
Definition “Indicators that reflect the equity of “Indicators that Express the Proportion of
distribution of health resources in people in need of service, who actually receive
different parts of country and provision it in a given period”.
of health care”.
Uses They help to determine whether the They help to determine the Extent of use of
requirements of community are being health services by the community.
met with the provided health care
services or not.
Examples • Doctor-Population Ratio • Proportion of Infants who are fully
• Doctor-Nurse Ratio immunized against 9 EPI disease
• Population-Bed Ratio • %age of Population using various methods
• Population-TBA Ratio of family planning
• Bed-Occupancy Rate
• %age of Pregnant women who receive
Ante-natal care services.

(b) Enumerate the most important mortality indicator used to compare health status of a country internationally.
Infant mortality rate (IMR)
“Case-Control (Retrospective) study”
(b) Make 2x2 contingency table. Calculate the strength of association and interpret the results.
2x2 Contingency Table:
History of Cases (With Hypertension) Controls (Without Hypertension) Total:
Obesity
Yes 20 (a) 10 (b) a + b = 30
No 30 (c) 90 (d) c + d = 120
Total: a + c = 50 b + d = 100 “150”

Strength of association Odd’s (Cross-product) Ratio:

𝐚𝐝 20 x 90
𝐎𝐝𝐝’𝐬 𝐑𝐚𝐭𝐢𝐨 = =
𝐛𝐜 10 x 30
18
= = "𝟔"
3
Interpretation:
“Adults who are obese are 6 Times more at risk of developing Hypertension than those who are non-obese”.

3. A research study was conducted in a population of 3000 above 40 years of age to know the effect of obesity in the
development of diabetes. There were 200 obese in that community. The population was followed for a period of 10
years. It was found that 40 among obese and 56 among non-obese subjects developed diabetes. [Supple 2020 held in
2021]
(a) How would you make 2x2 table?
History of Developed Diabetes Not Developed Diabetes Total:
Obesity
Yes 40 (a) 160 (b) a + b = 200
No 56 (c) 2744 (d) c + d = 2800
Total: a + c = 96 b + d = 2904 “3000”

(b) Calculate risk and strength of association in this study. Interpret your results.
Measure of strength of Association in cohort study → Relative Risk (Risk Ratio)
Incidence of disease among Exposed
Relative Risk (Risk Ratio) =
Incidence of disease among Non − Exposed
𝐚 𝐜
= ÷
𝐚+𝐛 𝐜+𝐝
40 56 40 2800
= ÷ = 𝑋
200 2800 200 56
560
= = "𝟏𝟎"
56
Interpretation: (As RR > 1, Positive Association)
“Adults who are obese are 10 Times more at risk of developing Diabetes than those who are non-obese”.

4. A research study was conducted in a community of 10,000. There were 2000 smokers. The population was followed
for a period of 10 years. It was found that 40 among smokers while 50 among non-smokers develop lung cancer. [Annual
2020 held in 2021]
(a) How would you make 2x2 table?
History of Developed Lung cancer Not Developed Lung cancer Total:
Smoking
Yes 40 (a) 1960 (b) a + b = 2000
No 50 (c) 7950 (d) c + d = 8000
Total: a + c = 90 b + d = 9910 “10000”

(b) Calculate risk and strength of association in this study. Interpret your results.
Measure of strength of Association in cohort study → Relative Risk (Risk Ratio)
 11. REPRODUCTIVE HEALTH

Maternal mortality & morbidity

1. Maternal mortality is very high in Pakistan due to complications of child birth. [Annual 2020 held in 2021]
(a) Write 3 well-established delays at different levels contributing High mortality in our country.

(b) Enumerate important preventive and social measures needed to achieve reductions in Infant mortality.
(1) Preventive Measures:
(a) Effective MCH services:
• Antenatal Care (ANC) including home visiting
• Intra-natal Care (INC) including availability of TBA at the time of delivery
• Postnatal Care (PNC) including Consultations & Follow-up
(b) Care of the Newborn / Infant: [Mnemonic = GOBI FFF]
• Growth monitoring
• ORS / ORT – To reduce mortality due to dehydration
• Breast Feeding
• Immunization (of both mother & Child)
• Family planning
• Female education
• Food supplementation
(2) Social Measures:
• Increase Literacy rate
• Promote and encourage the women for breast feeding
• Concern about Child care
• Legislation for child sex

2. A pregnant female in her third trimester presented in emergency with blood pressure of 170/100, swelling of feet,
puffiness of face, urine R/E contains ++ albumin. [Supple 2019 held in 2020]
(a) Would you like to treat the woman at primary health care facility or refer it? Justify your answer. (2.5)
Refer the patient to Secondary Level of health care (THQ & DHQ) Because the Patient is pregnant and is suffering from
Preeclampsia (Complicated / High risk Pregnancy)
Why not treat at Primary Health Care Facility?
• Due to Lack of Facilities, Treatment modalities and Necessary equipment for the management of Complicated
/ High risk pregnancy
(b) Enlist the common causes of maternal mortality in Pakistan. (2.5)
 Disaster

Disaster
Preparedness
Impact

Risk reduction
phase

Mitigation Response
Recovery phase

Reconstruction Rehabilitation

Q#2. The natural and man-made disasters in an area generally lead to loss of life andproperty of affected local population.
[Annual 2017]
a) Write 4 basic and essential items immediately required by affected people in relief phase right after
the disaster. (3)
Answer: See in Q2a of Section “During disaster phase”.
b) Name any four commonly faced disasters in various parts of Pakistan. (2)
Answer: 1) Earthquake 2) Flood 3)Accidents 4) Epidemics 5) Smog 6) Drought

Q#3. Floods affect large areas of our country causing scores of families to either stay in open or take shelter in camps.
Give five measures to counter likely hazards that they face in the shelter camps in the post-disaster period. (5)
[Supple 2016 held in 2017]
Answer: Cram post-disaster management with mnemonic NERVe
•Reasoning for incresed transmission of communicable diseases.
•Overcrowding, migration, poor sanitation, Contamination of water supply, damage to
sevage, Disruption of control programs, favorable breeding environment for vector.
Epidemological •Prevent these problems by implementing public health measures, investigate outbreaks,
Survilliance Organize a reliable disaster reporting system.

•cholera & Typhoid vaccines are given to camp officers, while measles is contraindicated.
•All vaccines are contraindicated in victims except measles wwich is given upto 3 days.
Nutrition & •Assess food supply, nutritional needs, calculate food ration, and monitor the nutritional
status of affected people.
Vaccination

•Safe water supply (chloeination 0.7mg/L)

•Ensure adecuate exreta disposal. Emergency latrines should be made.
•Food safety (Good hygiene is necessary)
Rehabilitation •Vector control (Control for vector born diseases should be intensified.
•Psychological treatment of affected people.

Q#4. Every year, on account of heavy rains during monsoon season, enormous areas of Pakistan become flooded.
 UHS MCQs 2012—2023
Sr. Statement Answer
Chapter 1 – Basic Definations
1 The science and art of preventing diseases, prolonging life and Public Health
promoting physical and mental health is known as
2 The science of prevention and treating STDs ? A. Social hygiene ✓
B. Social medicine
3 Disease near to eradicate in Pakistan ? Measles, Polio and Cyclop
4 In a country where there is no problem of environmental pollution, Primordial prevention
legislation is made to have efficient vehicle engines & to have
hydroelectricity power plants instead of coal power plants to prevent
air pollution. This is an example of
5 Imparting health and religious education to drug addicts is which type Rehabilitation
of intervention ?
6 In an area with fluoride rich water, the defluoridation of water is A. Primordial
which level of prevention ? B. Primary ✓
7 Study of man in his total environment which may be physical, A. Social hygiene
biological & socioeconomic is known as B. Social medicine ✓
8 The actions that include promotion of health, prevention of sickness A. Health protection ✓
and curative and restorative medicine in all aspects ? B. Public health
9 Scenario: _______ prevention against smog ? Secondary or Primary
10 Mammography is which type of prevention ? Secondary
11 Identification & quantification of health problems in a community in Community diagnosis
terms of mortality & morbidity rates ?
12 Wearing a respiratory mask in dusty atmosphere is which type of Specific protection
protection?
13 Giving Isoniazid to a newly born kid to a mother having TB is Primary prevention
14 Dracunculiasis (by Guinea worm) is an example of ____ in Pak Disease elimination
15 A researcher carried out a survey in an urban slum population. His A. diagnosis ✓
objective was to identify & quantify the main health problems in that B. assessment
community. This is known as community ____ C. requirement
15 Most cost efficient intervention of disease prevention and good health Health Promotion
16 A young student who was a good athlete lost his leg in accident. He A. Handicap ✓
recovered but very upset despite having artificial leg as he was unable B. Disability
to participate in his school annual athletics. His failure to participate
in athletics will be name as;
Chapter 2 – Concept of Health and Disease
1 Most acceptable indicator of health of whole population and of IMR
socioeconomic conditions ?
2 Pakistan spends how much of its GDP on health ? 1%
3 Millennium development goal directly related to health ? Goal number 4,5 & 6
4 Sustainable development goal directly related to health ? Goal number 3
5 Most universally acceptable indicator of health ? IMR
6 Tip of the iceberg represent ? Diagnosed cases
7 According to UNICEFF, the best single indicator of social A. IMR
development is B. Under-5 mortality rate ✓
Chapter 3 – Epidemiology
1 As a researcher you want to find out burden of malaria in a Discriptive study
community. Which type of study will you prefer ?
 Cataract

Q#1. A mother notes a white spot in center of black portion of her child’s right eye. [Annual 2019]
a) Write common causes of leukocoria. (3)
(1) Congenital cataract (2) Retinoblastoma (3) Retrolental fibroplasias (4) Coat’s disease
5) Anterior Persistent Hyperplastic Primary Vitreous (APHPV) 6) Endophthalmitis (7) Toxocarial granuloma
b) What investigations are required in this case? (2)
1. Clinical • In partial cataract → Fundus examination & Retinoscopy.
investigation • In complete cataract → B scan & A scan
2. Lab • Urinalysis
Investigations • Serum biochemistry
• Serological tests.

Q#2. A 5-year-old child is brought to you with developed of a white pupillary reflex. On examination, the pupillary light
reflex is brisk and B-scan ultrasound shows no shadows in the vitreous and the retina is flat. [Annual 2015]
a) What is the most probable diagnosis?
Answer: Cataract
b) What will happen if the surgery is delayed till 15 years of age?
Answer: Amblyopia & Squint
c) How will you treat him so that he completely recovers his vision?
1. Lens Aspiration 2. Pars Plana Lensectomy
• General Anesthesia. • Incision at pars plana.
• Corneoscleral incision. • It involves removal of whole lens & anterior
• Anterior capsulotomy. vitreous.
• Aspiration irrigation of soft lens matter. • It is indicated in special cases of cataract
• Posterior capsulotomy with limited secondary to chronic anterior uveitis, ectopic
anterior vitrectomy. lentis & subluxated lens.
• IOL implant in posterior chamber.

Q#3. A mother brings a 6 months old child complaining of right white pupil since birth.[Supple 2009 held in 2010]
 Keratitis

Q#1. [Supple 2011 held in 2012 + Supple 2010]

a) Classify keratitis.
1. Microbial or Infective keratitis
• Bacteria - Gram +ve and -ve
• Virus – HSV
• Fungi – Candida, Aspergillus
• Protozoa – Acanthamoeba
b) Describe the treatment of each type of keratitis.
Type of keratitis
• Bacterial
• Fungal
• Viral
• Acanthamoeba
2. Non microbial OR Non-Infective keratitis
• Hypersensitivity (allergic)
• Autoimmune
• Neurotrophic
• Exposure keratopathy
• Nutritional deficiency
• Chemical burn
• Eyelid abnormalities (Entropion, Trichiasis)
Treatment
Antibiotics, Atropine, Analgesic, Antiglaucoma
drugs, Amniotic membrane transplant, Limbal
stem transplant, Cauterization
Natamycin, Atropine, Antibiotics
Acyclovir, Atropine, Antibiotics
Chlorhexidine

Bacterial Corneal Ulcer

Q#1. A 30 year old female contact lens user , present with unilateral painful red eye after she wore it overnight. On
examination there is a central corneal haze that stains with fluorescein. (Supply 2021)
a) How will you investigate the case? (2)
1. Gram stain and Giemsa stain
2. Culture and Sensitivity
3. 10% KOH
(c) What investigation will you prescribe? Give their justifications.
1. TFT’s (T3, T4, TSH) and Radioactive iodine uptake – Graves’ disease
2. CT scan (investigation of choice) – Shows Enlargement of extraocular muscles
3. MRI – Compression of optic nerve

Q#2. A 30-year-old young lady presents with mild ocular pain and staring and frightened appearance of eyes. There is
history of profuse sweating, palpitations and weight loss. Visual acuity is 6/6 in both eyes and there is congestion of
conjunctiva. [Annual 2019]
(a) What is the most probable diagnosis? (1)
Answer: Thyroid (Grave's) eye disease
(b) How will you examine and investigate this case? (2)
Examination
• Proptosis, Lid lagging, Staring look, Stellwag sign
Investigation
Answer: See Q1c.
(c) What is management at this stage of the disease? (2)
1. Antithyroid drugs – Propyl-thiouracil (PTU), Carbimazole
2. Thyroidectomy
3. Artificial tears
4. Methylprednisolone
5. Tarsorrhaphy

Q#3. A 20 years old female with Grave’s disease presented with bilateral axial proptosis. [Supple 2017 held in 2018]
(a) Name ocular signs to look for in this case. (2)
Signs Description
Dalrymple sign Lid retraction
Kocher sign Staring and Frightening look
Stellwag sign Infrequent blinking
Von Graffe sign Lid lagging
Mobius sign Restricted eye movement
Joffroy sign Poor forehead wrinkling
Jellinek' sign Hyperpigmentation of lid

(b) Name two vision threatening complications of this condition. (1)

1.Diplopia –Due to restrictive myopathy by inflammation and fibrosis
2.Papilledema – Due to optic nerve compression
3.Exposure keratopathy – Due to proptosis
(c) Enlist treatment options. (2)
Answer: See in Q2c.

Q#4. A middle-aged lady reports in eye department with a history of protrusion of her right eye ball. In ten days duration,
she has swollen lids with incomplete closure of palpebra fissure along with decrease in vision. [Supple 2015 held in 2016]
(a) Write down differential diagnosis.
1. Orbital cellulitis
2. Grave's disease
3. Blow out fracture
4. Cavernous sinus thrombosis
(b) Write down investigations which you can do in order to reach diagnosis.
Answer: See Q1c.

Q#5. A 30 years old female presents with axial proptosis of the right eye. On examination, the Von Graefe sign is positive
and there is upper lid retraction on straight gaze. Extraocular movements are restricted in all directions of gaze. The
visual acuity is 6/18 in the affected eye. [Annual 2016 + Annual 2015]
(a) What is most probable diagnosis?
 INTRA
INTRA
VITREAL
VITREAL STEROID
ANTI- (TRIAMCINIL
VEGF: Decrease macular ONE
ACETONIDE)
edema by decreasing Useful to treat
capillary Macular edema
permeability.

Regress Can cause

neovascularizations Secondary
by Inhibiting
Endothelial cell GLAUCOMA and
proliferation. CATARACT.

(b) LASER TREATMENT:

(1) Focal treatment - For focal macular edema
(2) Grid pattern – For diffuse macular edema
(3) Pan-retinal Photocoagulation – Scatter Laser technique, used for Proliferative Diabetic retinopathy (PDR).
(c)SURGICAL TREATMENT:
Pars Plana Vitrectomy Combined with Pan-Retinal photocoagulation. PPV is indicated when there is:
• Dense persistent vitreous hemorrhage
• Tractional retinal detachment
• Pre-Macular OR Retro-hyaloid Hemorrhage
• Tractional macular edema

Q#4. Write a short note on cotton wool spots. [Supple 2018 held in 2019]
Also called soft exudates.
• Present an area of Nerve fiber layer Infarcts resulting from occlusion of Pre-capillary arterioles
• They are caused by Swelling of Nerve fibers (Actually Stagnant Axoplasm in retinal nerve fibers)
• They have white fluffy appearance with Indistinct margins.
• Present in many diseases, For example: Diabetic Retinopathy, Hypertensive Retinopathy, CRVO, BRVO.

Q#5. A 30-year-old non-insulin dependent diabetic presents with hard exudates in the posterior pole. His visual acuity is
6/60 in the right and 6/36 in the left eye. [Supple 2019]
(a)What is the pathogenesis of this finding? (1)

"PERSISTANT Loss of pericytes, Resulting into Breakdown of INNER Blood -Retinal

formation of micro-aneurysms And Barrier (iBRB) and formation of
HYPERGLYCEMIA" Microvascular Leakage Areas "HARD EXUDATES"

(b)Give two investigations with justification. (2)

• Slit Lamp Bio-microscopy with contact OR non-contact lens – For Fundus examination.
• Optical Coherence Tomography (OCT) – To assess the MACULA.
• Fundus Fluorescein Angiography (FFA) – For assessment of vascular dysfunctions.
(c)Give four treatment options for this patient. (2)
Answer: See in Q3c.

Q#6. A 65 years old poorly controlled diabetic patient presented with gradual painless reduction of vision in both eyes
which was not improved with glasses. His ocular examination revealed both eyes with proliferative diabetic retinopathy.
[Supple 2017 held in 2018]
 UHS MCQs 2012--2023

Eyelid
Sr# Statement Answer
1 Tarsal plate contains which glands? Meibomian glands
2 Painless progressively increasing swelling on lower eyelid? Chalazion
3 Treatment of choice for Chalazion Triamcinolone acetonide or
Surgery
4 Painful swelling on lid margin with pus around hair follicle? Stye
5 Burning sensation in eyes in which disease of eyelid? Posterior Blepharitis
6 Treatment of choice for Anterior blepharitis? Topical antibiotics (Bacitracin)
7 Cryotherapy for Trichiasis is done at? Gray line at -60°C to -80°C
8 Eyeball is moved outward and downward + Ptosis? 3rd nerve palsy
11 Small sized pupil + Elevation of lower eyelid? Horner syndrome
12 Normal marginal reflex distance is 4 mm
13
14 Paralytic Ectropion is due to paralysis of which muscle? Orbicularis oculi
15 Procedure for cicatricial entropion is Tarsal rotation surgery
16 Modified sebaceous glands of eye are? Meibomian glands
17 In normal Bell phenomenon, eyeball moves ----- when lids are closed upward and outward
18 One of the important Contraindication for performing Sling Operation is? Absence of Bell's phenomenon
19 Most common tumor of upper eyelid is? Sebaceous gland carcinoma
20 Most common tumor of lower eyelid is? BCC
21 Most common location for BCC is? Lower eyelid
22 Painless progressively increasing swelling on upper eyelid causing Mechanical ptosis (Ptosis due to
narrowing of palpebral fissure. Diagnosis? Chalazion)
23 Sebaceous gland carcinoma simulates with which eyelid pathology Chalazion
Lacrimal System
1 Length of Nasolacrimal duct? 12 mm
2 Length of Lacrimal sac? 15 mm
3 When does Tear production starts after delivery? 3-4th week
4 Treatment of choice for congenital Nasolacrimal duct obstruction at age Probing
of 2 year?
5 When does DCR performed? When probing failed. At age of ≈
5 years
6 In DCR, channel is created between which two structures? Lacrimal sac and Nasal cavity
7 Lacrimal glands are located in which bone? Frontal bone
8 Tear film has 3 layers. Thinnest layer is secreted by which glands? Conjunctival glands (Glands of
Henle and Manz)
9 Aqueous layer of tear film is secreted by which glands? Lacrimal glands and accessory
lacrimal glands
10 Cause of Lacrimal pump failure is? Facial nerve palsy (paralysis of
orbicularis oculi)
11 Painful swelling at medial canthus + Discharge ? Acute Dacrocystitis
12 Most common site of congenital obstruction in Lacrimal drainage Lower end of Nasolacrimal duct
pathway?
13 Cause of Lacrimal pathway obstruction is? Chronic dacryoadenitis
14 Painless swelling of upper eyelid causing ptosis + epiphora and Chronic dacryoadenitis
conjunctival chemosis. Diagnosis?
15 Painless swelling on eyelid causing downward and inward movement of Tumor of lacrimal gland