CHAPTER 4 © 5th Edition MODULE 24: COMMUNITY MEDICINE & FAMILY HEALTH-II

BLOCK-10
TOS
SUBJECT MCQs MARKS
COMMUNITY MEDICINE 25 25

FAMILY HEALTH 15 15

GIT & NUTRITION-II 35 + 5 40

EYE-I 30 30

ENT-I 30 30

140 140

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MODULE-24
COMMUNITY MEDICINE
& FAMILY HEATH-II

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CHAPTER 4 © 5th Edition MODULE 24: COMMUNITY MEDICINE & FAMILY HEALTH-II

COMMUNITY MEDICINE
CM001 – CM005
CM & FH

CM-001 ֍BIOSTATISTICS֍

01. Data & its Presentation

Collection of observation in a scientific way is called data. When data becomes meaningful, it is called information.

Graphs for Quantitative data Trend of event with passage of time is

 Histogram represented by line diagram
 Frequency polygon
 Line diagram Relationship between 2 variables is
represented by Scattered diagram
 Scattered diagram
Graphs for Qualitative data Data represented as % of the whole – Pie chart
 Bar graphs
 Pie charts Data presentation by pictures for illetrate
 Pictogram people – Pictogram

02. Measures of Central Tendency

1. Diastolic blood pressure of randomly selected 10 students from a medical college was 83, 77, 81, 79, 71, 95, 75, 77, 82, 90.
a) Calculate three measures of central tendency in the above data.
1. Mean = = = 81
2. Median = 71,75,77,77, 79,81 ,82,83,90,95 = 79+81/2 = 80
3. Mode = 77

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b) Name the type of distribution in this type of data.

Answer: Quantitative data
c) Name the type of skewedness in the above scenario.
Positive skewedness because mean > median > mode

03. Measures of Dispersion

Measures of dispersion
1. Mean deviation
2. Standard deviation
3. Range

1. 10 government employees came for their annual medical examination in a hospital laboratory. They also gave blood to check their
serum cholesterol levels. They were as follows: 185, 250, 220, 245, 220, 200, 220, 210, 230, 220 mg/100 ml. If standard deviation is
10, calculate the 95% of the population under study.
Con n lmt=X SD
Confidence limit = 220 ±2 × 10
Confidence limit = 220 ± 20
Confidence limit = 200 – 240
Interpretation: We can say that 95% of distribution lies between 200 mg/100ml and 240 mg/100ml

2. A study was conducted on 100 pregnant women to determine the prevalence of anemia in pregnancy. The mean hemoglobin level
was 12 gm/dL with standard deviation of 2. [Annual 2013]
a) What will be the variance in this sample?
Variance = (S.D)²
Variance = 2² = 4
b) Calculate the standard error.
S.E =

3. What is coefficient of variation and its uses. Suppose mean and standard deviation of Hb level of a group is 12.6 g percent & 1.5 g
percent respectively while mean & standard deviation of body weight of same group is 50 kg & 2.2 kg respectively. Calculate
coefficient of variation and interpret the result. [Annual 2022 held in 2023]
Coefficient of variation (CV)
 Standard deviation expressed as percentage of mean
 CV = S.D/Mean × 100%
Uses
 It helps to determine uniformity in data distribution
 It compares two quantities irrespective of units

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Calculation of Coefficient of variation

Standard deviation Mean value Coefficient of variation
S.D D 100%
Hb level 1.5 12.6 1.5/12.6 × 100 = 11.9
Weight 2.2 50 2.2/50 × 100 = 4.4
Interpretation: There is more dispersion around mean value of Hb level of a group than mean value of body weight of that group.

4. A survey was conducted in a rural area and Hb level of 100 women was obtained. Mean Hb level was 11g/dl with standard
deviation 2. Calculate 95% confidence level and interpret result?
Calculation
95 Con n l v l = X 1.96 S.E
First Calculate S.E from S.D (2) & n (sample size 100)
95% confidence level = 11 ± 1.96 × 0.2 = 7.08g/dl – 14.92 g/dl
Interpretation: We can say with 95% confidence level that 95% of the distribution lies between 7.08g/dl and 14.92g/dl

5. 10 government employee visited district headquarter hospital for annual checkup. Their blood sample was taken to check their
serum cholesterol level. The values of their serum cholesterol were as follows: 180, 250, 220, 240, 220, 200, 220, 210, 230 and
220mg/100ml. If standard deviation of data set is 10, then calculate range of cholesterol covering 95% of population under study.
R n =X

Range = 219 ± 1.96 = 219 ± 1.96 × 3.16

Range = 219 ± 6
Range = 213 – 225

04. Tests of Significance

1. Results from isoniazid trial after 6 months follow-up are given in the following table:

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Dead Alive Total

Placebo 21 110 131
Isoniazid 11 121 132
Total 32 231 263
a) Formulate null hypothesis.
There is no difference between effects of isoniazid and placebo
b) Is there any significant difference between placebo and isoniazid? (chi-square value for P value 0.05 is 3.84)
Dead Alive Total
Placebo 21 O1 110 O2 131 C1
Isoniazid 11 O3 121 O4 132 C2
Total 32 R1 231 R2 263
E1 = 131×32/263 = 15.94
E2 = 131×231/263 = 115.06
E3 = 132×32/263 = 16.06
E4 = 132×231/263 = 115.94
X² = (15.94 - 21) ²/15.94 + (115.06 - 110)²/115.06 + (16.06 - 11)²/16.06 + (115.94 -121)²/115.94
X² = 3.64
Interpretation: As X² value (3.64) is less than Chi-square value (3.84) so the Null hypothesis is True and there is no difference
between placebo & isoniazid

05. Testing Errors

Type I error (α) Stating that there is an effect or difference when none exists (H 0 n orr tly r j t n vor o H1). α s th
prob b l ty o m k n typ I rror (usu lly 0.05 s hos n). I P < α, th n ssum n H0 s tru , th prob b l ty
of obtaining the test results would be less than the probability of making a type I error. H 0 is therefore rejected
s ls . St t st l s n n ≠ ln ls n n .
Type II error (β) Stating that there is not an effect or difference when one exists (H 0 is not r j t wh n t s n t ls ). β s
th prob b l ty o m k n typ II rror. β s r l t to st t st l pow r (1 – β), wh h s th prob b l ty o
rejecting H0 when it is false.

06. Normal Distribution Curve

Features
 Right and left halves are equal
 Mean, median & mode coincide at center
 Total area = 1
 Curve never touches base line
 Unimodal
 Bell shaped
Distribution of observation around the mean in normal distribution curve
 Mean ± 1 S.D = covers an area of 68.3%
 Mean ± 2 S.D = covers an area of 95.4%
 Mean ± 3 S.D = covers an area of 99.9%

07. Sampling
Why do we need to study the sample rather than the whole population?
 We cannot involve the whole world in scientific study
 Studying sample is easier and economical
What are the uses of table of random numbers in sampling?
 To determine which units are to be included in the sample
 To eliminate personal selection of unconscious bias in taking out sample
 To make sure that each unit has an equal chance of being included in the sample

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Types of sampling techniques

Probability Sampling  every member of the population has an equal chance of being selected
 Simple random sampling
 Systematic random sample Cluster sampling is used for EPI coverage &
 Stratified random sample emergency situations (wars, natural disasters
& calamities)
 Cluster sampling
Advantages
 Minimal bias
 Results can be generalized to the whole population
Disadvantages:
 More expensive
 Time consuming
Stratified random sampling.
In the method, the population is divided into different strata (on the basis of one / more characteristics), then random / systematic
procedures are followed to take the sample from each stratum. Steps:
 Population is first divided into various strata (Sub-groups) on the basis of one / more characteristics (e.g., age, sex, economic
status and religion)
 Then random / systematic procedures are followed to take the sample.
 For example, if we want to study smokers in college, we divide them into 2 sub-groups, boarders and non-boarders and then
we pick sample from each group.
Non-probability Sampling  selection of members is based on non-random criteria
 Convenience sampling
Quota sampling  Population is divided into
 Judgement sampling
groups & sample is taken on proportionate
 Quota sampling basis
 Snowball (confidential) sampling Snowball sampling is used for a population
 Purposive sampling that is hard to reach like injection drug users
Errors of sampling techniques
1. Sampling errors: If we take repeated samples from same population or universe, the results obtained from one sample will
differ to some extent from results of another sample; this type of variation is sampling error.
Factors influencing the sampling error are:
 Size of sample
 Natural variability of individual readings
2. Non-sampling errors: They may occur due to inadequately calibrated instruments, due to observer variation, as well as due to
incomplete coverage achieved in examining the subjects selected and conceptual errors.

CM-002 ֍DEMOGRAPHY֍

01. Demographic Processes

Demography is the study of Population and mathematical knowledge of population changes such as size, structure, distribution and
growth / decline. Demography deals with five demographic processes:
1. Mortality
2. Fertility / Natality
3. Migration
4. Marriage
5. Social Factors

02. Population Pyramid

Age pyramid is a graphic representation of Population of an area OR a country in terms of its composition by age and sex at a point
in time. It provides following information:
 Population size
 Population structure (Distribution among age and sex groups)

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 Sex Ratio
 Population changes e.g., Growth rate
 Dependency Ratio
 Occurrence of Disaster / Epidemic in the population
Points Of Difference Developing country e.g., Pakistan Developed country e.g., United states
Shape Triangular – Broad-based and Tapering Rectangular – Almost equal size of bars
Top
Information Birth rate > Death rate i.e., Rapid Growth. Birth rate is approximately equal to Death rate
i.e., Slow Growth.
Population Structure Population of Children is more in Pakistan. Population of all age groups is almost same.
Dependency ratio High Comparatively Low

1. Comment on the population growth rate of country A, B and C based on Crude Birth Rate and Crude Death Rate as inferred from
pictures below.

1) Country A: Rapid Growth – As CBR > CDR.

2) Country B: Slow Growth – As CBR is Approximately equal to CDR.
3) Country C: Zero / Negative Growth – As CBR < CDR.

2. Define sex ratio. What are the main reasons for a low sex ratio in some developing countries?
It is the ratio of the number of Males per 1000 Females (Except in India where it is Number of Females per 1000 males)”
Causes of Low sex ratio:
 Male child preference
 Female Infanticide
 Female feticide
 High MMR
 Neglect of Girls
 Male Bias in population enumeration
 Male sperm reach and fertilize the egg more often due to its lighter nature.

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3. The hypothetical population of a country is as follows: [Annual 2014]

Population under 15 years of age: 11,245,500
Population above 65 years of age: 9,015,600
Population in age bracket 15-64 years: 38,232,800.
a) Calculate dependency ratio.

Interpretation: It means for every 100 persons in economically active ages, there are 53 dependents.
b) What does dependency ratio indicate?
It indicates out of 100 persons in economically active ages, how many persons are dependents. It is used to study the “Demographic
Burden” (Increase in total dependency ratio mostly due to increased old age dependency as the fertility in population declines).

4. In a village with 50,000 population, total annual births are recorded to be 3000, which total deaths are 1000. Total infant deaths are
200 in that year. No migration took place during this year. [Annual 2011]
(a) Calculate annual population growth rate % (taking migration as zero) and vital index.

(b) Interpret your results.

Interpretation of Growth rate:
 Population of the village is growing / increasing at the rate of per year.
Interpretation of Vital Index:
 As vital Index is > 100, it means Births are more than deaths and the population is increasing.

03. Determinants of Fertility

 Age at marriage – If marriages of females are postponed from the age of 16 years to 20-21 years, the number of births would
decrease by 20-30%.
 Duration of Married Life
 Spacing of children – At-least 1 year of gap between children.
 Education – has Inverse relationship with fertility
 Economic status – has Inverse relationship with fertility
 Caste and Religion
 Nutrition – has Inverse relationship with fertility
 Family Planning
 Others e.g., Physical, biological, social and Cultural factors such as Widow remarriage, Breast feeding, Industrialization,
Urbanization, Customs and Beliefs etc.
Infant Mortality affects the fertility in 3 ways:
1. Replacement effects  Parents produce more children to replace those who die at early age.

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2. Insurance effects  Parents produce more children because some of them die before reaching adulthood.
3. Biological effects  Curtailment of Breast feeding due to death of infant  Early start of ovulation  Early next pregnancy

04. Basic Fertility Measures

General Fertility Rate It is the number of live births per 1000 women in the reproductive age group (15-44 / 49 years) in
a given year

Total Fertility Rate It is the average number of children a women would have if she were to pass through her
reproductive years bearing children at the women now in each age group

Age-Specific Fertility Rate Number of live births in a year to 1000 women in any specified age-group
Crude birth Rate The number of live births per 1000 estimated mid-year population, in a given year
Gross Reproduction Rate Average number of girls that would be born to a woman if she experiences the current fertility
pattern throughout her reproductive span (15-44 or 49 years), assuming no mortality
Net Reproduction Rate It is defined as the number of daughters a newborn girl will bear during her lifetime assuming
fixed age-specific fertility and mortality rates. NRR of 1 is equivalent to attaining approximately
the 2—child norm. If the NRR is less than 1, then the reproductive performance of the population
is said to be below replacement level

05. Demographic Principles

Demographic
transition

1st Stage: (High stationary)

 CBR & CDR are both High, Cancel each other and Population remains stationary.
nd
2 Stage: (Early Expanding)
 CBR remains same while CDR Declines, so Population starts expanding.
3rd Stage: (Late Expanding)
 CBR starts declining & CDR also Declines, but still CBR > CDR, so Population continues to
expand.
4th stage: (Low stationary)
 CBR & CDR are both Low, Cancel each other and Population remains stationary.
5th stage: (Declining)
 CBR < CDR, so Growth rate comes down.
Note: Pakistan is falling in 3rd Stage

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Demographic trap It is a situation in country which is experiencing high fertility (birth rate high along with low mortality
(death rate) which results in periods of high population growth rates or stuck into a situation of
imbalance
Demographic window The Demographic Window is a specific period in a nation's history—usually lasting 30 to 40 years—
when the proportion of the working-age population is at its highest. It is characterized by a low Total
Dependency Ratio.
Demographic bonus Dependency ratio of a country declines due to decrease in fertility rates
Demographic dividend The Demographic Dividend is the actual economic benefit realized from the bonus.
Population Doubling PDT = 70/Growth rate
Time
Population Momentum Population momentum refers to population growth at the national level that would occur even if levels
of childbearing immediately declined to replacement level (NRR=1)‖.
Population Momentum of a Country = Population X Growth Rate
“It means Greater the Growth rate of a country, Greater will be its population and difficult would be to
stop population momentum”!
Example:
If Pakistan fertility declines to Replacement level, even then Population of Pakistan will continue to
grow for 40 years (Because Potential Mothers has already been born in population who will produce
more children (Including daughters and so on).

06. Census
A Census is the total process of collecting, compiling, evaluating, analyzing, and publishing demographic, economic, and social data
pertaining to all persons in a country (or a well-defined part of a country) at a specific time. De Facto Method: Individuals are
recorded where they are physically present on the census night. De Jure Method: Individuals are recorded at their permanent/usual
place of residence, regardless of where they are on the day of the count.

CM-003 ֍OCCUPATIONAL HEALTH֍

01. Pneumoconiosis

1. Occupational dust inhalation is very common. Enlist disease that occur due to inhalation of different types of mineral dust and their
related industries. Enumerate different preventive measures that should be adopted by the factory workers to decrease frequency of
pneumoconiosis.

Disease Chemical dust Related industry Specific Feature

Silicosis Silica Pottery, ceramic & glass industry Snow storm appearance
Asbestosis Asbestos Brick lining industry, gaskit industry Ground glass appearance
Anthracosis Coal Minig industry
Bagassosis Sugarcane dust Cardboard industry, Sugar factory
Bysinossis Cotton dust Textile industry
F rm r‘ lun s s Grain ________
The major cause of permanent disability and mortality among the occupational lung diseases is Silicosis

Medical measures  Preplacement examination

 Periodic examination
 Medical & healthcare services
 Notification of disease
 Supervision of working environment
Engineering measures  Proper building design
 Good house keeping
 Dust control
 Proper ventilation system
 Isolation of process

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 Protective devices
Legislative measures  Treatment of family
 Sickness benefit (18 days leave with full pay, 180 days
leave with half pay.
 Maternity leave (120 days with 75% salary)

02. Lead Poisoning

Features
Symptoms related to excess of lead in body
 Blue lines on gums
produced when level of lead is 70g/100ml
 Basophilic stippling of rbcs
 Wrist drop Most useful laboratory test for diagnosis of
 Abdominal colic/ constipation lead poisoning is Coproporphyrin in urine
Management
1. Removal from lead exposure
2. Chelation therapy with EDTA
3. Supportive care for abdominal colic & constipation
4. Monitoring of blood lead level
Preventive measures
 See in above topic

CM-004 ֍DISASTER MANAGEMENT֍

01. Types of Disasters

Type Example
Geophysical/telluric Earthquake, Volcano, Tsunami
Biological Epidemic, pandemic (Covid-19)
Climatologically Drought, forest fire
Meteorological Storm, Hurricane & Waves
Hydrological/Topological Flood, landslides, Rain, Avalaunches

02. Triage
Rapidly classifying the injured on the basis of the severity of their injury and the likelihood of their survival with prompt medical
intervention. Triage color coding is given below
 Red  High priority treatment
 Yellow  Signals medium priority
 Green  Indicates ambulatory patients
 Black  For dead or moribund patients

03. Pre-disaster management

(Mnemonic: POST-CoRB)
1) Planning
2) Organization
3) Staff
4) Training
5) Coordination
6) Reporting
7) Budgeting

04. During-disaster management

Disaster-relief phase
 Search injured people, rescue them and provide first aid

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 Establish field care centers

 Establish information centers
 Apply Triage
 Tagging
 Identification of dead bodies
 Transport
Personal protective measures which are to be taken in different types of disasters/emergencies.
 High risk areas should be known
 Keep family emergency kit ready
 hoose shelter before hand
 Don‘t us t l phon x pt or m r n y ll
 Listen broadcast by radio
 Carry out official instructions.
 Be prepared than be hurt.
 To get information be organized.
 Wait rather than act too hastily.

05. Post-disaster management

1. 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 NERVi

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06. Surveillance Cycle

1 . Floods play havoc every year in a country. In relation to floods, write down at least 10 components of surveillance cycle.
1. Rescue victims
2. First Aid provision
3. Evacuation of the population
4. Elimination of physical dangers
5. Provision of safe water
6. Provision of food, clothing and shelter
7. Disposal of excreta & waste.
8. Control of vector borne diseases.
9. Disposal of human bodies.
10. Vaccination

CM-005 ֍HEALTH PLANNING & MANAGEMENT֍

01. Health Planning & Cycle

The orderly process of defining community health problems, identifying unmet needs and surveying the resources to meet them,
establishing priority goals that are realistic and feasible and projecting administrative action to accomplish the purpose of the proposed
programme

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02. Management Methods & Techniques

1. Methods Based on Behavioural Sciences
Organizational Design Arranging the health service structure to fit the current needs of the community. It involves regular
reviews to adapt to new technology or changing health concepts.
Personnel Management The art of selecting, training, and motivating staff. The goal is to avoid "square pegs in round holes" by
matching the right person to the right job.
Communication Breaking down "roadblocks" between different levels (e.g., doctor and patient, or health ministry and
field workers) to prevent delays in supplies or reporting.
Information Systems A system to collect, process, and display data. This gives managers a "feedback loop" to see if
programmes are actually working
Management by Setting clear, short-term goals for different units. It helps staff understand exactly what they need to
Objectives (MBO) achieve, making results more predictable.
2. Quantitative Methods
Cost-Benefit Analysis Comp r n th mon y sp nt on pro r m to th mon y s v (or "b n ts" xpr ss n sh). It‘s
difficult in health because it's hard to put a price tag on a life saved.
Cost-Effective Analysis More practical for health. It measures the cost against a specific result, like "cost per case of polio
prevented" or "number of lives saved," rather than a monetary value.
Input-Output Analysis An economic model that shows exactly how much "input" (money, staff, time) is needed to produce
one unit of "output" (cases treated or vaccinations given)
Decision Making Described as the "differential diagnosis" of management. It involves investigating a problem, finding
alternatives, and choosing the best course of action.
Network Analysis This is a graphical way to plan and monitor complex projects. It uses Arrow Diagrams to show the
sequence of events.
PERT (Programme Evaluation and Review Technique): A tool to calculate the minimum time needed
to complete a project. It identifies potential problems early and provides a foundation for evaluation.
CPM (Critical Path Method): The "Critical Path" is the longest path through the network. If any
activity on this path is delayed, the entire project will be delayed.
Administrative & Systems Analysis: Viewing a hospital or clinic as a "system." It helps managers see how changing one
Budgeting Tools part (like the outpatient clinic) affects the rest of the system. PPBS (Planning-Programming-Budgeting
System): A method to allocate resources to the most effective programmes. It often uses a "Zero
Budget Approach," where every expense must be justified from scratch every year. Work Sampling:
Observing health workers at random intervals to see how they spend their time. This helps in
"standardizing" jobs and figuring out exactly how many staff members are actually needed.

֍PAST UHS MCQs & SAMPLE PAPER֍

Sr. Statement Answer

CM-001 Biostatistics
01 Data having categories like English, Urdu and Arabic. This type of data is known as Nominal data
02 Mean and standard deviation for height of 50 boys were 150 and 7cm respectively. Find
S.E = =1
standard error of mean?
03 Hospital data is considered a poor guide to the estimation of disease prevalence because Denominator is not known
04 Data presentation method for illiterate people? Pictogram
05 Data presentation method that shows malaria cases during year 1091 to 1978 throughout the Line diagram
world?
06 Test of significance for nominal data? Chi square test
07 Test of significance for comparing weight of 100 pregnant ladies at the start and end of Paired T test
pregnancy?
08 If researcher wants to be 99% confident in his findings, where should be fix his P value 0.01
09 If we take area covered by ± 2 S.D then probability of value to fall outside this area will be 0.05
95% will fall inside it

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10 A study was conducted on 100 pregnant women to determine the prevalence of anemia in S.D/X ×100%
pregnancy. The mean hemoglobin level was 10 g/dl with standard deviation of ± 2. What 2/10 ×100%
will be the coefficient of variation? 20 %
11 3 groups of subjects were followed over course of 5 year to compare treatment for F test (ANOVA test) also
sideroblastic anemia. Most statistical analysis to determine quantitative serological known as Analysis of variance
difference from these treatment? because groups are > 2
12 In descriptive study, the mean is 220 and S.E is 10. The 95% confidence limit would be ? x ± z S.E
220 ± 2 × 10
200----240
13 Counting pulse rate of class is an example of which data type? Continuous Quantitative
14 Best way to study relationship between two variables? Scattered diagram
15 The person is counted at the place of his or her own residence De Jure census
16 Mean weight of class is 3.3 with 0.5 S.D . If the child has 4.4 kg what is the probability of A. 50% B. 99% ✓
him residing in the confidence limit ? C. 64%. D. 95%
17 S.D is 5. Mean value is 176. 95% Confidence limit? 176 ± 2 S.D
176 ± 2×5
166 --- 186
18 Presentation method to show Blood groups distribution (%)? Pie chart
19 SD is 5 & mean value is 176. Find 95% confidence level? 166---186
20 Test of significance for comparing two vaccines? Chi square
21 Disease may be classified as mild, moderate & severe. This type of data is? Ordinal data
22 mean < median < mode. Type of skewedness? Negative
23 In medical statistics, P value is set at < 0.05
24 Type I or alpha error occurs when Null hypothesis is true &
researcher rejects null
hypothesis
25 Finding variable from another known variable is known as Regression coefficient
26 A researcher is interested to assess writing skills of post-graduate medical trainees working Stratified random sampling
in different hospitals of Lahore city. Total number of trainees is 8000, who are working in
different specialties and different years of training. If he is desirous to select a sample of
2000 trainees. What sampling technique would you recommend that is most appropriate in
the given situation?
27 Cholesterol level of 12 nurses of final year class was recorded and the values were as: 164, Quantitative data
168, 140, 168, 175, 123, 168, 135, 180, 185, 190, 124 mg/100 ml. Type of data?
28 The record of labor room from a hospital showed that in the month of April the total Negative skewedness because
deliveries were 150 and 15 newborns were low birth weight. Their weights were as follows: mean < median < mode
1.3, 1.7, 1.8, 1.8, 1.9, 2.0, 2.1, 2.1, 2.2, 2.2. 2.2, 2.2, 2.3, 2.3, 2.4, 2.4. Name the type of
skewness in data.
29 A study was conducted to determine the heights of 10 lady doctors working in the Quantitative
department of community medicine and pathology. The data obtained were 5.8, 5.6,5.6, 5.0,
4.11, 5.3, 5.7, 5.4, 5.6 & 5.2. Categorize the type of variable under study.
30 The standard deviation & mean of a data are 6.5 & 12.5 respectively. Calculate coefficient Coefficient of v r t on =
of variation? S.D X 100% = 6.5/12.5 x
100% = 52%
CM-002 Demography
31 Replacement fertility level is achieved if net reproduction rate is 1
32 NRR = 1 can be achieved if at least ____ of eligible couples effectively practicing family 60%
planning
33 Dependency ratio in Pakistan? 66%
34 Low birth rate and low death rate. Which demographic stage? Low stationary

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35 Which of following (mortality, morbidity, marriage, disability, migration) is not a Disability

demographic indicator ?
36 One of the characteristic of population pyramid ? Women on right side
37 Replacement fertility level for most of the countries ? 2.1
38 Pakistan is in which stage of demographic cycle ? Late expanding
39 Best fertility measure in Pakistan? TFR
40 Population growth rate is zero or negative in ______ Sweden
41 In population pyramid, each bar graph represents a ____ year age group apart from the top 5 years
most bars
42 Tendency of a population to grow continue even after the attainment of replacement fertility Population momentum
level ?
43 In a population pyramid, when each cohort is larger than the previous cohort produing a Rapid growth
pyramid shape, it indicates
44 Country X has population of 200 million; the growth rate of that country is 2%. What will 35 years
be the population doubling time of that country?
45 If 1% increase in population in one-year causes population to double in 70 years, what will 23.3 years
be doubling time if population increases at 3% per year?
46 Counting the person at the place where he or she is present at the time of census. This type De facto census
of census is known as
CM-003 Occupational Health
47 In a glass factory some workers have developed silicosis, you being medical officer Rigorous dust control
employed. What measures would you recommend to prevent this problem?
A. Pre-placement examination B. Rigorous dust control
C. Periodic x-ray D. Substitution
48 Person working in Textile industry is more likely to develop ? Byssinosis
49 Mesothelioma is related to which asbestos? Blue asbestos (Crocidolite)
50 Age for child labour according to International labour organization? Under 15 years
The child labour act bans employment in mines and hazardous employments for children
under
51 Symptoms related to excess of lead in body produced when level of lead is 70g/100ml
52 Most useful laboratory test for diagnosis of Lead poisoning? A. Basophilic stippling
B. Coproporphyrine in urine ✓
53 Risk of physical hazard is highest _______ A. At the end of working shift
✓
B. At the start ×
54 Welder flash contain ____ light and causes conjunctival xerosis UV
55 Dye worker are at greater risk of developing which cancer ? Bladder & Skin cancer
56 Hazard in foundry industry ? Heat stress/Noise
57 What is the cause of Nystagmus in coal miners? Poor illumination
58 Size of respirable dust ? < 5 microns
59 Benzidine is cause of ? Bladder cancer
60 Causative organism of Farmer's lung disease ? Micropolysporafaeni
61 The princple "designing a job to fit the worker so the work is safer and more efficient" is Ergonomic
known as
62 Scenario of child labour, low socioeconomic status & low education. What should be done Increase parental education
?
63 Person working in cardboard industry is at greater risk of ? Bagassosis
64 A person working in sandblasting industry presents with shortness of breath & x-ray shows Silicosis
egg shell calcification. What is the diagnosis ?

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65 A person working in storage battery factory presents with constipation, shortness of breath Lead poisoning
& black lines on gums. Most likely diagnosis ?
66 Type of pneumoconiosis that is predisposed to TB ? Silicosis
67 Invisible child labourers are those who are engaged in? A. Domestic services ✓
B. Garbage picking
68 Monday fever disease is caused by Bysinossis
69 Sickness absenteeism in industrial setting is useful index of A. Health status of workers✓
B. Working environment
C. Wages
70 According to Punjab Social Security rules, female workers are sanctioned maternity leaves 75% pay
with
71 A worker working in coal industry (dim light) having abnormal eye movement M n r‘ nyst mus
72 A twenty five years old man working in manufacturing factory came to OPD with history of Lead Poisoning
abdominal colic, persistent constipation, loss of appetite (OPD) & wrist drop since one
week. On examination, blue line on the gums was noticed. Blood report mentioned
stippling of red cells. What is your probable diagnosis?
CM-004 Disaster Management
72 Avalanches is a type of which disaster ? Topological
73 Earthquake is a type of which disaster ? Telluric & Tectonic
74 In Triage, red colour indicates Severe cases
75 Recently a violent storm struck Japan resulting in mass destruction of all types. Metrological storm.
What type of disaster was it?
76 About 3 years back, a vast population of Sindh province was struck by heavy rains and Topological disaster
floods. They were forced to leave their areas in search of safe shelter. Name the type of
disaster.
77 Due to heavy rains and floods last year, millions of people of Sindh province were displaced. Topological disaster
They were accommodated in camps in different areas. Name the type of disaster.
78 Due to climate change in the past few years, violent storms and hurricanes are hitting the Meteorological disaster.
different coastal areas of the world resulting in loss of life and damage to property. Name the
type of disaster?
79 The war against terror has displaced millions of people from Swat and Bunaer mainly in Man made disaster
2009. These people are adjusted in relief camps in different areas. Categorize the event?
A. Disaster
B. Accident
80 On account of heavy rain during monsoon season, enormous area in Southern Punjab had Topological disaster
been flooded. Numerous people became homeless and suffered infections. What is the type
of calamity?
81 Vast areas in Pakistan were stricken by floods this year, disrupting lives of many people. Topological disaster
Give type of disaster and health problems that occurred in those areas?
CM-005 Health Planning & Management
No past mcq from this section

֍PRACTICE MCQs֍

01. CM001 Biostatistics

1. Blood group classification (A, B, AB, O) represents:

A. Ordinal variable D. Discrete variable
B. Continuous variable E. Ratio variable
C. Nominal variable

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2. Height of an individual measured in centimeters is:

A. Nominal D. Continuous
B. Ordinal E. Dichotomous
C. Discrete
3. The mode of the data set (2, 3, 5, 2, 7, 2, 9, 4, 3) is:
A. 2 D. 5
B. 3 E. 7
C. 4
4. Which measure of central tendency is most affected by extreme values?
A. Mode D. Range
B. Median E. Standard deviation
C. Mean
5. In a normal distribution, approximately 95% of observations lie within:
A. ±1 SD of mean D. ±4 SD of mean
B. ±2 SD of mean E. ±5 SD of mean
C. ±3 SD of mean
6. In a normally distributed population, how many observations lie above mean + 1 SD?
A. 50% D. 5%
B. 32% E. 2.5%
C. 16%
7. Comparison of proportions between two independent groups requires:
A. Stu nt‘s t-test D. ANOVA
B. Paired t-test E. Correlation coefficient
C. Chi-square test
8. Stu nt‘s t-test is used to compare:
A. Two proportions D. Two correlations
B. Two means E. Two medians
C. Two variances
9. The P-value in medical statistics is usually considered significant when:
A. P > 0.5 D. P < 1.0
B. P > 0.1 E. P < 0.5
C. P < 0.05
10. Probability of committing Type I error is called:
A. Power of test D. Standard error
B. Confidence interval E. Odds ratio
C. Significance level
11. Sampling technique where population is divided into homogeneous groups first is:
A. Simple random sampling D. Cluster sampling
B. Systematic sampling E. Quota sampling
C. Stratified sampling
12. Snowball sampling is mainly used for:
A. General population surveys D. Census
B. Rare diseases E. Randomized trial
C. Hidden populations
13. Diastolic blood pressure of randomly selected 10 students from a medical college was 83, 77, 81, 79, 71, 95, 75, 77, 82, 90.
Calculate mean, median & mode.
A. 80, 81, 76 D. 84, 80, 71
B. 81, 80, 77 E. 83, 81, 77
C. 82, 81, 77
14. Cholesterol level of 12 nurses of final year class was recorded and the values were as: 164, 168, 140, 168, 175, 123, 168, 135, 180,
185, 190, 124 mg/100 ml. Calculate measures of central tendency.
A. 160, 168, 168 D. 140, 123, 175
B. 164, 175, 123 E. 160, 168, 175
C. 168, 140, 123

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15. Calculate standard deviation of means: 1, 2, 4, 7, 10, 12.

A. 4.1 D. 4.4
B. 4.2 E. 4.5
C. 4.3
16. A study was conducted on 100 pregnant women to determine the prevalence of anemia in pregnancy. The mean hemoglobin level
was 12 gm/dL with standard deviation of 2. Calculate Variance & Standard erroe.
A. 3, 0.1 D. 4, 0.1
B. 4, 0.5 E. 3, 0.5
C. 4, 0.2
17. The total number of students in a private school was 123. There were ten classes with different strength. A survey was conducted
to assess the number of students in each class. The data provided was 10, 10, 10, 10, 12, 12, 13, 14, 15, 17. Calculate measures of
central tendency in above data. Calculate mean
A. 11.3 D. 14.3
B. 12.3 E. 10.3
C. 13.3
18. What is coefficient of variation and its uses. Suppose mean and standard deviation of Hb level of a group is 12.6 g percent & 1.5 g
percent respectively while mean & standard deviation of body weight of same group is 50 kg & 2.2 kg respectively. Calculate
coefficient of variation.
A. 11.9, 4.4 D. 11. 5, 4.3
B. 11.2, 4.2 E. 11.7, 4.5
C. 11.8, 4.1
19. A survey was conducted in a rural area and Hb level of 100 women was obtained. Mean Hb level was 11g/dl with standard
deviation 2. Calculate 95% confidence level.
A. 7.09g/dl – 14.82 g/dl D. 8.08g/dl – 13.72 g/dl
B. 7.07g/dl – 14.72 g/dl E. 8.09g/dl – 13.92 g/dl
C. 7.08g/dl – 14.92 g/dl
20. 10 government employee visited district headquarter hospital for annual checkup. Their blood sample was taken to
check their serum cholesterol level. The values of their serum cholesterol were as follows: 180, 250, 220, 240, 220, 200,
220, 210, 230 and 220mg/100ml. If standard deviation of data set is 10, then calculate range of cholesterol covering 95%
of population under study.
A. 213-225 D. 212-224
B. 213-223 E. 212-228
C. 212-225
21. Mean and standard deviation for height of 50 boys were 150 and 7cm respectively. Find standard error of mean and 95%
confidence limits of heights from this data.
A. 148.05 – 151.86cm D. 148.02 – 151.76cm
B. 148.03 – 151.98cm E. 148.06 – 151.97cm
C. 148.04 – 151.96cm
22. Underweight–normal–overweight categories represent:
A. Nominal data D. Ratio data
B. Ordinal data E. Dichotomous data
C. Continuous data
23. A researcher is interested to assess writing skills of post-graduate medical trainees working in different hospitals of Lahore city.
Total number of trainees is 8000, who are working in different specialties and different years of training. If he is desirous to select a
sample of 2000 trainees. What sampling technique would you recommend that is most appropriate in the given situation?
A. Quota Sampling D. Stratified Sampling
B. Snowball Sampling E. Systemic Random Sampling
C. Random Sampling
24. To evaluate the teaching methodology, opinion of final year MBBS students is to be assessed. The total number of students in final
year class is 150. The desire sample size is 30. Write the most appropriate sampling technique.
A. Quota Sampling D. Stratified Sampling
B. Snowball Sampling E. Systemic Random Sampling
C. Simple Random Sampling

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25. To conduct a study in city, the population was first divided into different groups and sample was taken from each group on
proportionate basis. Name the sampling technique used in above study.
A. Quota Sampling D. Stratified Sampling
B. Snowball Sampling E. Systemic Random Sampling
C. Simple Random Sampling
26. Which of the following sampling is used for EPI coverage & emergency situations (wars, natural disasters & calamities)?
A. Quota Sampling D. Stratified Sampling
B. Snowball Sampling E. Cluster Sampling
C. Simple Random Sampling
27. Line diagrams are used to show:
A. Relationship between two variables D. Trend of events with passage of time
B. Most common value E. Measures of dispersion
C. Frequency distribution
28. Standard normal distribution curve — which is TRUE?
A. Area under curve = 10 D. Values lie between ±10 SD
B. It is asymmetrical E. It is skewed
C. Mean, median and mode coincide
29. Peak of a frequency curve represents:
A. Mean D. SD
B. Median E. SE
C. Mode
30. Frequency distribution means arrangement of data:
A. Individually D. By importance
B. In ascending order E. In pie chart
C. Into groups with frequencies
31. Probability lying outside 95% confidence interval on each side is:
A. 1% D. 10%
B. 2.5% E. 20%
C. 5%
32. Frequency polygon is constructed using:
A. Line diagram D. Component bar chart
B. Normal curve E. Histogram
C. Scatter diagram
33. Median of (1, 2, 4, 6, 8, 10, 11, 13) is:
A. 6 D. 9
B. 7 E. 10
C. 8
34. Line joining midpoints of histogram bars is called:
A. Bar diagram D. Pie chart
B. Frequency polygon E. Pictogram
C. Line graph
35. Which statement about Chi-square test is TRUE?
A. χ² = (O−E) E D. Used for descriptive studies
B. Used for 2×2 tables E. Measures incidence
C. Calculates odds ratio
36. Alph (α) rror m ns:
A. Type-I error D. Measurement error
B. Type-II error E. Bias
C. Sampling error
37. p-value of 0.05 means:
A. Event always occurs D. 100% certainty
B. 5% chance result is due to chance E. Study is invalid
C. 95% chance of disease

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38. Large sample size with nominal data — best test:

A. Wilcoxon D. ANOVA
B. Chi-square E. Correlation
C. t-test
39. Which test is used when expected frequency in a cell is <5?
A. Chi-square D. ANOVA
B. t-test E. Z-test
C. F sh r‘s x t t st
40. Better measure of central value when extremes exist:
A. Mean D. SD
B. Median E. Variance
C. Mode
41. If variance = 16, standard deviation is:
A. 2 D. 16
B. 4 E. 32
C. 8
42. Sum of squared deviations divided by N is:
A. SD D. Variance
B. Mean deviation E. CV
C. Standard error
43. Nominal data with small sample (<40) — best test:
A. Chi-square D. ANOVA
B. F sh r‘s x t t st E. Regression
C. t-test
44. Best diagram to show relationship between two variables:
A. Bar chart D. Scatter diagram
B. Histogram E. Line diagram
C. Pie chart
45. Standard error can be reduced by:
A. Decreasing sample size D. Longitudinal study
B. Increasing sample size E. Double blind study
C. Taking two samples
46. The temperature of a patient with typhoid is 100.2°F. What type of data is this?
A. Nominal D. Continuous
B. Ordinal E. Discrete
C. Categorical
47. Best indicator of central value when data are skewed:
A. Mean D. Standard deviation
B. Median E. Variance
C. Mode
48. Case–control study with nominal data — appropriate test:
A. ANOVA D. Pearson correlation
B. Chi-square E. t-test
C. Regression
49. Which measure of central tendency is most affected by extreme values?
A. Mean D. Range
B. Median E. Standard deviation
C. Mode
50. Estimating one variable from another requires:
A. Correlation D. Variance
B. Regression E. Mean deviation
C. Standard error

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51. Data with mean 50, median 40, mode 30 shows:

A. Symmetrical distribution D. Bimodal distribution
B. Negative skewness E. Kurtosis
C. Positive skewness
52. Which scale of measurement has a true zero?
A. Nominal D. Ratio
B. Ordinal E. Qualitative
C. Interval
53. Measure showing average dispersion around mean:
A. Range D. Mean
B. Standard deviation E. Median
C. Coefficient of variation
54. Cumulative frequency curve is called:
A. Scatter diagram D. Pie chart
B. Histogram E. Spot map
C. Ogive
55. To estimate population mean with 95% confidence, required calculation:
A. Variance D Standard error
B. Range E. CV
C. Standard deviation
56. Best diagram to represent age distribution of patients:
A. Pie chart D. Line graph
B. Bar chart E. Scatter diagram
C. Histogram
57. Weights of male and female newborns were compared. Which test of significance is appropriate?
A. Paired t-test D. Pearson correlation
B. Independent (unpaired) t-test E. ANOVA
C. Chi-square test
58. To test whether a new drug increases weight, 24 children were divided into two groups (12 each). Degree of freedom is:
A. 10 D. 18
B. 12 E. 22
C. 14
59. Which of the following is categorical data?
A. Weight D. Number of patients
B. Blood sugar level E. Gender
C. Blood pressure
60. Mean blood sugar of 100 students is 127 mg/dl. If SD = 6 and data is normal, how many will have >133 mg/dl?
A. 10 D. 68
B. 16 E. 95
C. 32
61. If data is normally distributed, approximately what percentage lies within ±3 SD?
A. 68% D. 90%
B. 95% E. 85%
C. 99.7%
62. Mean fasting blood sugar = 95 mg/dl, SD = 10, sample size = 100. Standard error is:
A. 0.5 D. 5
B. 1 E. 10
C. 2
63. Power of a study is the ability to:
A. Avoid Type I error D. Increase sample size
B. Avoid bias E. Reduce SD
C. Detect a true difference

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64. Mean cholesterol = 150, SD = 2. Range for central 10% lies approximately:
A. 130–160 D. 146–154
B. 120–160 E. 150–156
C. 148–152
65. Difference between mean weights of rural and urban children — appropriate test:
A. Pearson correlation D. Unpaired t-test
B. F sh r‘s x t E. Chi-square
C. ANOVA
66. To find statistically significant difference between two means, use:
A. Z-test D. Temporal association
B. t-test E. Regression
C. Pearson correlation
67. To represent 10% in a pie chart, angle required is:
A. 18° D. 60°
B. 36° E. 90°
C. 42°
68. Population shown on graph over years — type of graph:
A. Bar chart D. Frequency polygon
B. Line graph E. Stem-and-leaf
C. Histogram

ANSWER KEY
1. C 2. D 3. A 4. C 5. B 6. C 7. C 8. B 9.C 10. C
11. C 12. C 13. B 14. A 15. D 16. C 17. B 18. A 19. C 20. A
21. C 22. B 23. D 24. C 25. A 26. E 27. D 28. C 29. C 30. C
31. B 32. E 33. B 34. B 35. B 36. A 37. B 38. B 39. C 40. B
41. B 42. D 43. B 44. D 45. B 46. D 47. B 48. B 49. A 50. B
51. C 52. D 53. B 54. C 55. D 56. C 57. B 58. E 59. E 60. B
61. C 62. B 63. C 64. C 65. D 66. B 67. B 68. B 69. 70.

13. Mean = = = 81, Median = 71,75,77,77, 79,81 ,82,83,90,95 = 79+81/2 = 80, Mode = 77

14. Mean = = = 160, Median = 123,124,135,140,164, 168, 168,168,175,180,185,190 = 168+168/2 = 168, Mode
= 168

15. S.D = = 4.4

Mean (X) - ( - )² ( - )²
1 6 -5 25 98
2 6 -4 16 98
4 6 -2 4 98
7 6 1 1 98
10 6 4 16 98
12 6 6 36 98
16. Variance = (S.D)² ,Variance = 2² = 4, S.E =

17. Mean = = = 12.3

18. Calculation of Coefficient of variation

Standard deviation Mean value Coefficient of variation
S.D D 100%
Hb level 1.5 12.6 1.5/12.6 × 100 = 11.9
Weight 2.2 50 2.2/50 × 100 = 4.4

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19. 95 Con n l v l = X 1.96 S.E, First Calculate S.E from S.D (2) & n (sample size 100)
95% confidence level = 11 ± 1.96 × 0.2 = 7.08g/dl – 14.92 g/dl
20. R n =X , Range = 219 ± 1.96 , Range = 219 ± 1.96 × 3.16, Range = 219 ± 6, Range = 213-225

21. Standard error: S.E = = 0.99cm (Approx. 1)

95 on n m t: C. =X , C.L = 150cm ± 1.96 (1) = 148.04 – 151.96cm

31. 95% CI leaves 5% outside (2.5% on each side).
32. Frequency polygon is drawn from midpoints of histogram bars.
39. F sh r‘s x t t st s us or small samples.
40. Median is unaffected by extreme values.
42. V r n = Σ( ²) N.
43. F sh r‘s x t t st s us or sm ll s mpl s.
47. Median is least affected by extreme values.
51. Mean > median > mode indicates positive skewness.
56. Histogram represents continuous data.
58. For unpaired t-t st, = n₁ + n₂ − 2 = 22.
60. 133 = m n +1 SD = (68 ) → 32 w ll b str but roun m n, 16 on hs  So, 16% lie above +1 SD.
62. SE = SD √n = 10 10 = 1.
63. Pow r = 1 − β ( t ts tru t).
64. Central 10% lies close to mean within narrow SD range. So, Mean +/- 1SD.
67. 10% × 360° = (10/100) × 360° = 36°.
68. Line graph shows changes over time.

02. CM002 Demography

1. Infant Mortality Rate (IMR) includes deaths of children aged:
A. 0–7 days D. 0–1 year
B. 0–28 days E. 1–5 years
C. 28 days–1 year
2. Post-neonatal mortality rate includes deaths from:
A. 0–7 days D. 1–5 years
B. 0–28 days E. Birth–5 years
C. 28 days–1 year
3. Total Fertility Rate (TFR) refers to:
A. Births per year per population C. Number of live births per 1000 women
B. Average number of children a woman would bear during D. Number of pregnancies per woman
reproductive life E. Replacement level fertility
4. Replacement level fertility corresponds to a TFR of approximately:
A. 1.0 D. 2.1
B. 1.5 E. 3.0
C. 2.0
5. Net Reproductive Rate (NRR) of 1 indicates:
A. Declining population D. Negative growth
B. Stable population E. Zero fertility
C. Growing population
6. Population doubling time is calculated by:
A. Growth rate × 70 D. Growth rate ÷ 70
B. 70 ÷ Growth rate E. 100 × Growth rate
C. 100 ÷ Growth rate
7. If population growth rate is 2%, doubling time will be approximately:
A. 25 years D. 70 years
B. 35 years E. 100 years
C. 45 years

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8. A population pyramid with broad base indicates:

A. Zero population growth D. Rapid population growth
B. Declining population E. Stable population
C. Aging population
9. Rectangular population pyramid indicates:
A. High fertility D. Rapid growth
B. High mortality E. Population explosion
C. Slow or zero growth
10. Low birth rate and low death rate characterize which stage of demographic transition?
A. High stationary D. Low stationary
B. Early expanding E. Declining
C. Late expanding
11. Pakistan is currently in which stage of demographic transition?
A. High stationary D. Low stationary
B. Early expanding E. Declining
C. Late expanding
12. Vital index is defined as:
A. Birth rate × Death rate D. Births per population
B. Deaths ÷ Births × 100 E. Deaths per population
C. Births ÷ Deaths × 100
13. A country X in the year 2012 had a population of 150,000,000. During that year, the total births in that area were 15,500 and total
deaths were 12,800. The net migration rate in the same year was calculated to be 1350. With the help of the demographic equation,
calculate the change in the population that would be expected.
A. (4050) increased D. (-2580) decreased
B. (3990) increased E. (-4020) decreased
C. (3850) increased
14. If 1% increase in population in one-year causes population to double in 70 years, what will be doubling time if population
increases at 3% per year?
A. 21.3 D. 24.3
B. 22.2 E. 25.3
C. 23.3
15. A town had a population of 70,000. During the year of 2012, total births were 3000 and total deaths were 1200. 3000 people
migrated to Canada, while 250 displaced persons were received from Sindh and 50 came back from abroad to town for the year 2012.
Calculate the annual population growth rate of the town for the year 2012.
A. 1.29% D. -1.28%
B. -1.29% E. 1.27%
C. 1.28%
16. In a village with 50,000 population, total annual births are recorded to be 3000, which total deaths are 1000. Total infant deaths are
200 in that year. No migration took place during this year. Calculate Vital index.
A. 100 D. 400
B. 200 E. 500
C. 300
17. Best diagram to show age-sex composition:
A. Line diagram D. Map
B. Pie chart E. Population pyramid
C. Pictogram
18. Life expectancy in developed countries is:
A. Higher in males D. Declining
B. Higher in females E. Stationary
C. Equal
19. UN key strategy for population control is:
A. Abortion promotion D. Technological reduction
B. Decentralization E. Intersectoral rivalry
C. Women empowerment

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20. Demographic trap is a situiation in a country which is experiencing:

A. high fertility (birth rate) along with low mortality (death rate).
B. high fertility (birth rate) along with high mortality (death rate).
C. low fertility (birth rate) along with low mortality (death rate).
D. high fertility (birth rate) along with falling rapidly mortality (death rate).
E. Falling fertility (birth rate) along with falling rapidly mortality (death rate).
21. Best indicator for planning family welfare services:
A. Crude birth rate D Abortion rate
B. General fertility rate E. Infant mortality rate
C. Gross reproduction rate
22. In an age pyramid of a developed country, the female population is represented on the:
A. Base D. Top
B. Left side E. Center
C. Right side
23. Formula for General Fertility Rate (GFR) is:
A. Total births / total population D. Total births / females
B. Live births ×1000 / mid-year population E. Female population / total population
C. Live births ×1000 / women aged 15–49 years
24. One important cause of high fertility in developing countries is:
A. Late marriage D. Urbanization
B. High literacy rate E. Female employment
C. Low contraceptive use
25. According to 1998 census of Pakistan, the population growth rate was approximately:
A. 1.5% D. 3.5%
B. 2.0% E. 4.5%
C. 2.6%
26. In a town, birth rate = 20/1000 and death rate = 10/1000. Growth rate is:
A. 5% D. 10%
B. 1% E. 15%
C. 2%
27. Which statement regarding replacement level fertility is NOT true?
A. It is zero population growth D. It needs ~60% CPR
B. It requires ~2.1 births per woman E. Each couple has two children
C. Population will not increase
28. Time required for a population to double depends on:
A. Birth rate only D. Migration
B. Death rate only E. Fertility rate
C. Growth rate
29. Total number of children a woman bears during her lifetime is called:
A. Net reproduction rate D. Eligible couple rate
B. Gross reproduction rate E. Contraceptive prevalence
C. Total fertility rate
30. Literacy rate during census is calculated for people aged:
A. ≥4 y rs D. ≥10 y rs
B. ≥5 y rs E. Total population
C. ≥7 y rs
31. ―Numb r o u ht rs n wborn rl w ll b r ur n h r l t m ‖ n s:
A. General fertility rate D. Total fertility rate
B. Net reproduction rate E. Crude birth rate
C. Gross reproduction rate
32. Formula: Live births in age group / mid-year female population of same age represents:
A. Crude birth rate D. General fertility rate
B. Age-specific fertility rate E. Gross reproduction rate
C. Total fertility rate

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33. Continued population growth despite achieving replacement fertility is due to:
A. High mortality D. Low literacy
B. Migration E. Poor economy
C. Population momentum
34. Reproduction rate of 2.7 indicates:
A. Population decline D. Stable population
B. Replacement level E. No conclusion
C. Rapid population growth
35. Data required to calculate dependency ratio is:
A. Age-wise population distribution D. Per-capita income
B. Sex ratio E. Birth rate
C. Literacy rate

ANSWER KEY
1. D 2. C 3. B 4. D 5. B 6. B 7. C 8. D 9. C 10. D
11. C 12. C 13. A 14. C 15. D 16. C 17. E 18. B 19. C 20. A
21. B 22. C 23. C 24. C 25. C 26. B 27. E 28. C 29. C 30. C
31. C 32. B 33. C 34. C 35. A

7.
13. Pt1 = Pt0 + (B – D) + (IM – OM)
Pt1 = 150,000,000 + (15,500 – 12,800) + (1350)
Pt1 = 150,000,000 + (2700) + (1350)
Pt1 = 150,000,000 + 4050 = “150,004,050”
Change in POPULATION = Pt1 - Pt0, = 150,004,050 – 150,000,000 = “4050”; “ o, Population of country X has increased”.

14.

15.

16.

20. Demographic Trap is a situation in a country which is experiencing high fertility (birth rate) along with low mortality (death
rate) which results in periods of high population growth rates OR struck into a state of Imbalance.
27. Replacement fertility is slightly above two.
34. Value >1 indicates population growth.

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03. CM003 Occupational Health

1. Stippling of RBCs on blood smear is classically seen in poisoning by:

A. Mercury D. Cadmium
B. Arsenic E. Phosphorus
C. Lead
2. Maternity leave entitlement for a pregnant worker is:
A. 8 weeks D. 16 weeks
B. 10 weeks E. 20 weeks
C. 12 weeks
3. A 14-year-old wants employment in coal mine. Best advice:
A. Employ him D. Coal mine minimum age is 25
B. Employ after ruling out disease E. Ask him to join school
C. Reject due to age
4. M n r‘s lun s u to work n n:
A. Dusty atmosphere D. High atmospheric pressure
B. Poor illumination E. Allergy to coal
C. Hot conditions
5. Most effective preventive measure for silicosis is:
A. Periodic chest X-ray D. Dust control at workplace
B. Pre-placement examination E. Health education
C. Personal hygiene
6. A 45 year old Mason presented in pulmonology OPD with history of weakness, breathlessness, fatigue, and irritability for last few
weeks. On X-ray chest there was ground glass appearance in lower two third of the lungs. What is the most probable diagnosis?
A. Anthracosis D. Bagassosi
B. Asbestosis E. Byassinosis
C. Silicosis
7. A worker of 45 years of age who was engaged in building and construction work visited a tertiary care hospital with history of
cough, dyspnea on exertion and chest pain. On X-ray chest snow-storm appearance was shown with impairment of total lung capacity.
What is the most likely diagnosis?
A. Anthracosis D. Bagassosi
B. Asbestosis E. Byassinosis
C. Silicosis
8. Few cases of fibrotic lung disease reported in a tertiary care hospital. On history, it was revealed that the disease was progressive in
nature and patients were workingin a sugar factory. What is most likely diagnosis?
A. Anthracosis D. Bagassosi
B. Asbestosis E. Byassinosis
C. Silicosis
9. A medical officer in charge of social security health outlet attended about six patients with fibrotic lung disease. History revealed
that they were working in a gaskit industry for the last ten years. What is most likely diagnosis?
A. Anthracosis D. Bagassosi
B. Asbestosis E. Byassinosis
C. Silicosis
10. A worker from brick-lining industry reported to you with complains of chronic cough, dyspnea and clubbing of fingers. What is
most likely diagnosis?
A. Anthracosis D. Bagassosi
B. Asbestosis E. Byassinosis
C. Silicosis
11. A 40 years old pottery industry worker presented with complaints of fever & weight loss; he also complained about cough &
blood-stained sputum. X-ray confirmed fibrosis of lungs and hilar lymphadenopathy. Which factor in the particular trade has led to
development of this condition?
A. Anthracosis D. Bagassosi
B. Asbestosis E. Byassinosis
C. Silicosis

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12. A person aged 40 years who had been working in the grain market for the last 25 years presented with the history of repeated
attacks of respiratory infections from the last 1 year. X-ray showed pulmonary fibrosis. Give the likely diagnosis.
A. Anthracosis D. Bagassosi
B. Farmer lung disease E. Byassinosis
C. Silicosis
13. A 50 year old worker with history of working initially in printing and then in paint factory developed wrist drop, insomnia and
blu l n s on ums. On bloo x m n t on st ppl n o RBC‘s w s obs rv . Wh t s the most probably diagnosis?
A. Lead poisoning. D. Bagassosi
B. Farmer lung disease E. Byassinosis
C. Silicosis
14. A worker who is working in roof tiling industry for the last 15 years reports to you with the presenting complains of cough and
dyspnea. On examination, clubbing of fingers and cyanosis is observed. Chest X-ray shows ground-glass appearance in the lower 2/3
of the lung field. What is most likely diagnosis?
A. Anthracosis D. Bagassosi
B. Asbestosis E. Byassinosis
C. Silicosis
15. A laborer working in ship-building industry of Karachi since last 10 years presents to you with breathlessness. On examination, he
is cyanosed and has clubbing of fingers. X-ray chest showed diffuse fibrosis in lower two-thirds of lungs. What is most likely
diagnosis?
A. Anthracosis D. Bagassosi
B. Asbestosis E. Byassinosis
C. Silicosis
16. Pneumoconiosis is an important occupational health hazard. Which statement is TRUE?
A. History of chronic diarrhea is common D. Most dangerous type is by silica
B. Size of dust particles is usually 4–6 µm E. It is a fungal disease
C. Commonest type is anthracosis
17. In an industrial area with fertilizer manufacturing, refrigeration and oil refining, excessive release of which chemical is likely?
A. Asbestos D. Mercury
B. Phosgene E. Benzene
C. Ammonia
18. A 38 year old factory worker develops increasing weakness in his legs. Co-worker had noted episodes of transient confusion. The
patient has bilateral foot drop and atrophy, wrist weakness is also present. Hb is 9.6 g/dl, peripheral blood film shows basophilic
stippling. Which of the following is most likely diagnosis?
A. Amyotrophic lateral sclerosis D. Over use syndrome
B. Myasthenia gravis E. Lead poisoning
C. Alcoholism
19. Chance of accident in industry is highest:
A. At beginning of working shift
B. At middle of working shift
C. At end of working shift
D. Night shift
E. Day shift
20. Welding, agriculture, radiotherapy, painting — exposure to which causes SIDEROSIS?
A. Welding D. Painting
B. Agriculture E. Asbestos cement manufacturing
C. Radiotherapy
21. Byssinosis is common in which workers?
A. Cotton growers D. Cloth dyers
B. Cloth designers E. Cloth marketeers
C. Cloth weavers
22. Printing worker with abdominal colic, constipation, blue gum line and wrist drop. Best test?
A. Coproporphyrin in urine D. X-ray chest
B. Blood leukocyte count E. Kidney function test
C. Ultrasound abdomen

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23. Pneumoconiosis due to inhalation of finely divided particles — which is TRUE?

A. Particle size 1–3 µm D. Completely reversible
B. There is effective treatment E. Caused by infection
C. X-ray shows black spots
24. Ceramic industry worker with dyspnea, reduced lung capacity, chest X-ray shows eggshell calcification. Diagnosis?
A. Anthracosis D. Pulmonary tuberculosis
B. Asbestosis E. Bronchial asthma
C. Silicosis
25. Maximum recommended working hours per week in a factory:
A. 30 D. 48
B. 36 E. 60
C. 40
26. Prolonged exposure to sugarcane dust causes:
A. Siderosis D. Leptospirosis
B. Bagassosis E. Silicosis
C. Anthracosis
27. Which of the following is NOT an occupational disease?
A. Byssinosis D. Typhoid
B. Asthma E. Anthracosis
C. Brucellosis
28. Acceptable noise level for 8-hour work exposure is:
A. 10–20 dBA D. 80–100 dBA
B. 20–30 dBA E. 100–150 dBA
C. 40–60 dBA

ANSWER KEY
1. C 2. D 3. C 4. A 5. D 6. B 7. C 8. D 9. B 10. B
11. C 12. B 13. A 14. B 15. B 16. D 17. C 18. E 19. C 20. A
21. C 22. A 23. A 24. C 25. D 26. B 27. D 28. C 29. E 30.

11. Type of occupational settings lead to development of such medical condition (Pottery Industry, Iron and Steel industry, Gas
Industry, Sand blasting, building construction sites).
16. Silica causes the most severe and progressive pneumoconiosis.
20. Siderosis is caused by inhalation of iron dust during welding.
21. Weavers inhale cotton dust during processing.

04. CM004 Disaster Management

1. In major disasters, patients are managed based on severity and survival chances. This process is known as:
A. POSDCORB D. Relief phase
B. Triage E. Disaster cycle
C. Field care
2. ―R p l ss t on o su lt s n s st r b s on s v r ty o njury n l k l hoo o surv v l‖ s ll :
A. Golden hour D. Rapid intervention
B. Field care E. Scalar principle
C. Triage
3. A person is driving from Lahore to Multan. Considering fatigue, the risk of a road accident is highest:
A. At the beginning of the journey D. After a mid-journey stop
B. In the middle of the journey E. After tobacco smoking
C. Towards the end of the journey
4. The definition: ―An un xp t , unpl nn o urr n th t m y nvolv njury‖ r rs to:
A. Hazard D. Catastrophe
B. Accident E. Calamity
C. Disaster

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5. Which of the following is an example of a climatic (meteorological) disaster?

A. Heat wave D. Volcanic eruption
B. Earthquake E. Landslide
C. Tsunami
6. During earthquakes, safest place is:
A. Under strong table D. Near walls
B. Near windows E. Roof
C. Open ground
7. Vast areas in Pakistan were stricken by floods this year, disrupting lives of many people. Give type of disaster.
A. Meterological Disaster D. Climatological Disaster
B. Topological Disaster E. Geophysical Disater
C. Man made Disaster
8. The war against terror has displaced millions of people from Swat and Bunaer mainly in 2009. These people are adjusted in relief
camps in different areas. Categorize the event, is it an accident or a disaster?
A. Meterological Disaster D. Climatological Disaster
B. Topological Disaster E. Geophysical Disater
C. Man made Disaster
9. Due to climate change in the past few years, violent storms and hurricanes are hitting the different coastal areas of the world
resulting in loss of life and damage toproperty. Type of event:
A. Meterological Disaster D. Climatological Disaster
B. Topological Disaster E. Accident
C. Man made Disaster
10. Due to heavy rains and floods last year, millions of people of Sindh province were displaced. They were accommodated in camps in
different areas. Name the type of disaster.
A. Meterological Disaster C. Climatological Disaster
D. Topological Disaster E. Geophysical Disater
B. Man made Disaster

ANSWER KEY
1. B 2. C 3. C 4. B 5. A 6. C 7. B 8. C 9. A 10. D

05. CM005 Health Planning

1. Management in the health sector includes which of the following functions?

A. Planning D. Monitoring
B. Organizing E. All of the above
C. Communication
2. In cost–benefit analysis, the benefits of a health programme are expressed in
A. Health outcomes only D. Utility units
B. Number of lives saved E. Service coverage
C. Monetary terms
3. Which health management technique provides a graphic representation of all activities required to achieve an objective?
A. Input–output analysis D. Network analysis
B. Monitoring E. System analysis
C. Information system
4. Planning in its broadest sense includes
A. Planning and organizing D. Planning, implementation, monitoring and evaluation
B. Planning and implementation E. Planning and budgeting only
C. Planning and evaluation
5. High prevalence of diarrhoea in an urban slum should be controlled primarily by
A. Curative services D. Distribution of antibiotics
B. Health education alone E. Mass screening
C. Provision of safe water and sanitation

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6. Systematic observation and recording of activities at predetermined or random intervals is known as

A. Time–motion study D. Work sampling
B. Input–output analysis E. System analysis
C. Network analysis
7. A management approach based on behavioural sciences is
A. CPM D. Cost–benefit analysis
B. PERT E. PPBS
C. Management by Objectives
8. Estimating future vaccine requirements for a population is an example of
A. Budgeting D. Monitoring
B. Scheduling E. Evaluation
C. Forecasting
9. A health department prioritizes safe water supply over specialist services due to limited funds. This is an example of
A. Cost–benefit analysis D. Programme evaluation
B. Cost–effectiveness analysis E. PPBS
C. Input–output analysis
10. A housewife plans cooking so that all dishes are ready at the same time. Which technique does this represent?
A. PERT D. Work sampling
B. CPM E. Organizational design
C. PPBS
11. The critical path in CPM refers to
A. The longest path in the network D. The least important activities
B. The shortest path in the network E. The path with maximum manpower
C. The most expensive path
12. Health care differs from most goods and services because it
A. Is uncertain D. Requires professional dominance
B. Is a matter of life and death E. All of the above
C. Is considered a basic right
13. Which statement regarding preventive health care is most appropriate?
A. It always reduces health expenditure D. It increases health expenditure
B. It never reduces health expenditure E. It should not be undertaken
C. It seldom reduces expenditure but is cost-effective
14. Which of the following is a quantitative health management technique?
A. Communication D. Cost-effectiveness analysis
B. Organizational design E. Management by objectives
C. Personnel management
15. Planning Programming Budgeting System (PPBS) primarily helps in
A. Staff motivation D. Communication improvement
B. Resource allocation E. Leadership development
C. Organizational hierarchy
ANSWER KEY
1. E 2. C 3. D 4. D 5. C 6. D 7. C 8. C 9. B 10. B
11. A 12. E 13. C 14. B 15. B

2. Both costs and benefits are expressed in monetary terms to judge economic feasibility.
3. Network analysisA graphic representation showing sequence and inter-relationship of activities (PERT/CPM).
6. Work Sampling Random or fixed interval observation of activities to assess time utilization.
7. Management by objectivesGoal-oriented management approach based on behavioural sciences.
8. Forecasting Estimating future requirements such as vaccines, drugs, or manpower.
9. Cost effective analysis Used to prioritize interventions when funds are limited.
10. Critical Path MethodIdentifies activities that must be completed on time to avoid delay.
11. Critical PathThe longest path in the network; delay here slow down the whole project.
14. Quantitative management technique Uses numerical data for decision-making (e.g., cost-effectiveness).
15. PPBSLinks planning and budgeting to allocate resources efficiently.

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FH001 – FM008
CM & FH FAMILY HEALTH
֍PAST UHS MCQS & SAMPLE PAPER֍

1. A 40 years old man has developed recurrent headache which is limited to side & wakes him from sleep. It lasts for several hours &
his cheeks & nostrils feel congested. Most likely diagnosis in this patient?
a) Cluster headache d) Migraine without aura
b) Tension headache e) Subarachnoid headache
c) Migraine with aura
2. A 32 years old man complains of unilateral headache headache. Headaches start with stabbing pain just below the right eye. The
affected eye feels irritated (redness with increased lacrimation). Pain lasts for 60 to 90 minutes with discrete episode each day.
Neurological examination including cranial nerve is normal. What is best approach to treat?
a) Prescribe oral sumatriptan for use at time of headache d) Prednisolone 40-60 mg/day for 2-4 weeks
b) Begin propranolol 20 mg BID e) Obtain MRI scan of head with contrast
c) Refer to neuropsychiatric testing
3. 40 years old man has developed recurrent headache which is limited to left side & wakes him from sleep. It lasts for several hours
and his cheek and nostrils feel congested. Most likely diagnosis in this makes hir
a) Cluster headache d) Brain tumor
b) Migraine with aura c) Trigeminal neuralgia
c) Facioplegic migraine
4. An 18-year-old medical student presents with disabling recurrent attacks of migraneous headaches. The following not used for
prophylaxis of migraine:
a) Beta blockers d) Sumatriptan
b) Calcium channel blockers e) Sodium valproate
c) Amitriptyline
5. A 25-year-old lady one year history of episodic unilateral throbbing headache, associated with nausea, vomiting and photophobia.
There is a family history of similar headaches. On examination, BP 120/80 mm Hg, pulse 80/min, no neurological physical signs.
Fundoscopy is normal. On investigations: CBC: Hb 12.5 gm/dl, WBC 7x109, Platelets 235, ESR 20, contrast CT scan of head is
normal. The most likely diagnosis:
a) Cluster headache d) Brain tumor
b) Tension headache e) Subarachnoid headache
c) Migraine
6. A young lady presents with severe headache and vomiting for 2 hours. She says that she has been experiencing such episodes of
headache for past 3 years and each time she perceives flashing lights in her eyes before episode starts. The most likely diagnosis:
a) Cluster headache d) Migraine without aura
b) Tension headache e) Subarachnoid headache
c) Migraine with aura
7. Which of the following statements is true regarding acne vulgaris?
a) Acne should be treated with topical steroids d) All cases of acne should be treated with oral retinoids
b) Acne cyst may be treated with intralesional steroids e) Laser is first line treatment
c) Acne should not be treated at puberty
8. Following is not a feature of acute eczema:
a) Oozing d) Itching
b) Vesiculation e) Crusting
c) Lichenification
9. A 17 year old girl had Pruritic papulovesicular lesions involving flexor aspect of wrist, interdigital web spaces of hand & axillae.
Few of her family members also have pruritic skin lesion. What is most likely diagnosis?
a) Scabies d) Tinea corporis
b) Acne vulgaris e) Pediculosis
c) Atopic eczema

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10. A 28-year-old female seen in dermatology OPD with three months history of pruritogenic papular eruptions involving finger webs,
wrists, lower abdomen & antecubital fossae. The itching is usually worse at night. What is most likely diagnosis?
a) Scabies d) Tinea corporis
b) Acne vulgaris e) Pediculosis
c) Atopic eczema
11. An 18-year-old girl complains of itchy rash all over her body, mainly at night time. Her brother and sister also have same problem.
On examination, papular eruption with surrounding scratch marks noted in finger webs over wrist and buttocks. The first line
treatment:
a) Topical Minocycline d) Oral Doxycyline
b) Topical 5% Permethrin e) Oral Antihistamine
c) Topical 0.5% Permethrin
12. A 19-year-old boy presents with black heads, papules and pustules on his face. The most likely diagnosis:
a) Scabies d) Tinea corporis
b) Acne vulgaris e) Pediculosis
c) Atopic eczema
13. A 34-year-old female known case of bronchial asthma presents with seasonal variation of her skin disease. Her skin goes really
itchy and dry over her face and trunk in the spring season. On examination, widespread dryness and skin thickening with prominent
skin markings is noticeable. The most likely diagnosis:
a) Scabies d) Tinea corporis
b) Pmpholyx eczema e) Asteatotic eczema
c) Atopic eczema
14. A 30-year-old worker in flour mill presents to you with complaints of hyperpigmented itchy papular lesion in both popliteal fossae
of six months duration. There is past history of treatment of bronchial asthma. The most likely diagnosis:
a) Scabies d) Tinea corporis
b) Pmpholyx eczema e) Asteatotic eczema
c) Atopic eczema
15. A 6-year-old boy presented with recurrent, severely itchy lichenified plaques in both antecubital and popliteal fossae for the last
three years. His mother is asthmatic and has very dry skin. The most likely diagnosis:
a) Scabies d) Tinea corporis
b) Pmpholyx eczema e) Asteatotic eczema
c) Atopic eczema
16. A 23-year-old housewife presents with intense itching of her both hands dorsal aspect for three months. She has no comorbidities.
On examination, there are excoriation marks, few weeping lesions on an erythematous base. A strong suspicion of eczema is there.
The first line therapy:
a) Topical aqueous cream d) Oral Doxycyline
b) Systemic retinoids e) Oral Antihistamine
c) Phototherapy
17. A 9-year-old girl is brought to the pediatric clinic with complaints of severe itching of the scalp for 2 weeks, especially behind the
ears and at the nape of the neck. On examination, there are excoriations and small erythematous papules in these areas. Close
inspection reveals tiny white oval structures firmly attached to the hair shafts. What is the most likely diagnosis?
a) Seborrheic dermatitis d) Scabies
b) Tinea capitis e) Impetigo
c) Pediculosis capitis
18. A 10-year-old boy is diagnosed with pediculosis capitis. On examination, live lice and nits are seen firmly attached to the hair
shafts behind the ears. Which of the following is considered the first-line treatment?2
a) Oral ivermectin d) Shaving the scalp
b) Permethrin lotion e) Selenium sulfide shampoo
c) Malathion lotion
19. Xeroderma is a clinical finding seen in which condition?
a) Cne vulgaris d) Scabies
b) Tinea capitis e) Impetigo
c) Atopic eczema

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20. A twenty-year-old female presented with grouped vesicles on the angle of her mouth. There is a history of tingling sensations prior
to eruption in the involved area. She has similar eruptions in the past. The most likely causative organism:
a) HSV-1 d) Fungi
b) Itch mite e) Propionibacterium
c) HSV-II
21. Your diagnosis in a 30 year old promiscuous male with recurrent grouped vesicles on shaft of penis associated with burning and
discomfort would be:
a) Syphilis d) Gonorrhea
b) Candidiasis e) Herpes simplex
c) Genital warts
22. Fever in elderly due to infective causes include all except
a) Endocarditis d) Intra-abdominal sepsis
b) Thyrotoxicosis e) UTI
c) Tuberculosis
23. A 30 years old farmer presented with c/o high grade swinging temperature, rigors, sweating, lethargy, headache and Intense
backache. Physical signs show hepatosplenomegally and lymphadenopathy. CBC shows thrombocytopenia. What is most likely
diagnosis?
a) Lyme disease d) Tuberculosis
b) Dengue fever e) Brucellosis
c) Diphtheria
24. A 17-year-old man attends the local sexual health clinic. He has developed a large, keratinized genital wart on the shaft of his
penis. This has been present for around three months but he has been too embarrassed to present before now. What is the most
appropriate initial management?
a) Topical aciclovir d) Electrocautery
b) Cryotherapy e) Topical podophyllum
c) Topical salicylic acid
25. A young salesman who travels a lot has developed fever for the last seven days. Fever developed slowly but has not touched
baseline since onset. For the last two days he has pain abdomen and tenderness. His pulse rate is 95/min and temperature 102 F. His
laboratory results show TLC of 4000/mm3. The most likely diagnosis:
a) Typhoid fever d) Dengue fever
b) Malaria e) Infective endocarditis
c) Tuberculosis
26. A 25-year-old boy presented to the physician with 10 days history of fever. Initially fever was low grade and gradually progressed
to high grade. Fever was remittent and not associated with rigors/chills. Fever was associated with mild headache, myalgia, abdominal
distension. On examination, pulse 94/min, temperature 103 F and mild splenomegaly. The most likely diagnosis:
a) Typhoid fever d) Dengue fever
b) Malaria e) Infective endocarditis
c) Tuberculosis
27. A 32 years old male with 6 days history of fever, shaking chills and headache. Fever is paroxysmal (comes every 48-72 hours),
with rigors and sweating. No urinary symptoms. On examination temperature 103F, mild icterus, and small sized splenomegaly. What
is most likely clinical diagnosis?
a) Typhoid fever d) Dengue fever
b) Malaria e) Infective endocarditis
c) Tuberculosis
28. 24-year-old male presents with three days history of fever, headache, abdominal pain and diarrhea. On examination, temperature
40 C, pulse 80/min and diffused tenderness is present all over abdomen. Investigations Hb 3.5 g/dl, TLC 3000, Platelets 290000. You
suspect typhoid fever. What test would you like to do now to confirm your diagnosis?
a) Chest X-ray d) Widal test
b) Abdominal USG e) Blood culture
c) CBC
29. A 30-year-old female presented to you in OPD with complains of insidious onset malaise, headache, mild cough and high-grade
fever with rigors and chills. You are suspecting malaria. What investigation you will order to diagnose malaria?
a) Urine culture d) Abdominal USG

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b) CBC e) Blood culture

c) Immunochromatographic test (ICT)
30. A 28 year old married lady returns from honeymoon in gambia with a two day history of nausea, loin pain and painful micturition.
On examination she is flushed, mildly tender in the right loin with maximal tenderness in the suprapubic region. What is your
diagnosis?
a) Urinary tract infection d) Ureteric colic
b) Appendicitis e) Pelvic inflammatory disease
c) Infective diarrhea
31. A 28 year old married lady returns from honeymoon in gambia with a two day history of nausea, loin pain and painful micturition.
On examination she is flushed, mildly tender in the right loin with maximal tenderness in the suprapubic region. The drug of choice
for the most likely diagnosis in this case:
a) Ciprofloxacin d) Doxycycline
b) Augmentin e) Penicillin
c) Azithromycin
32. A 68 year old gentleman presents with painless haematuria and loss of weight of four months duration. He worked in the dye
industry before his retirement. What is most likely diagnosis?
a) Urinary tract infection d) Adenocarcinoma of kidney
b) Bladder carcinoma e) Angioma of renal artery
c) Infective diarrhea
33. A seven years old girl has high fever with generalized myalgias and headache for last two days. TLC is 4500/cmm, platelets
20,000/cmm. Most likely she is suffering from:
a) Aplastic anaemia d) Dengue fever
b) Malaria e) Typhoid fever
c) Tuberculosis
34. A 30-year-old farmer presents with a four-day history of fever, headache with retroorbital pain, severe musculoskeletal lumbar
pain and rash. The rash developed on his face before spreading over his trunks and extremities. He had temperature of 100 F with a
macular rash on trunk. Rest of physical examination is normal. Lab test shows normal liver and kidney function tests but leucopenia
and thrombocytopenia. Which investigation you will advise to confirm your most likely diagnosis?
a) CBC d) NS1 antigen
b) ICT e) Widal test
c) Blood culture
35. A 74 year old woman with progressive decline in recent memory and difficulty in naming objects and in performing dally
activities for last 10 years with no history of disturbance in movements or mood is like to suffer from:
a) Huntington's disease d) Creutzfeldt dementia
b) P rk nson‘s s s e) Wilson's disease
c) Alzheimer's disease
36. A woman visited dermatologist. She felt that her hands were always dirty and she used to wash her hands repeatedly. She most
probably suffering from which mental disorder?
a) Obsessive-compulsive disorder d) Anxiety
b) Paranoid disorder e) Phobia
c) Schizophrenia
37. A patient in the medical ward started complaining of hearing voices, seeing pictures and images, thoughts as if being controlled by
someone and feeling low. Which of the following describes one of his/her presenting symptoms?
a) Precognition d) Hallucinations
b) Depression e) Delusion
c) Illusions
38. A 39 year old male is brought by his family with the complaints that he has been unable to follow his daily routine and does not
take care of him-self. Sleep and appetite are also disturbed. He weeps a lot and wishes for death. Most likely diagnosis
a) Depressive disorder d) Phobic disorder
b) Schizophrenia e) Bipolar disorder
c) Manic episode

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39. Delusion can be best defined as:

a) Perceptual misrepresentation of a sensory image
b) Perceptual representation of a sound or an image not actually present
c) Fixed false belief which is keeping out of one's social, cultural and educational background
d) Pathological self preoccupation
e) Dissociative fugue
40. A 22 year old woman gave history of fearful apprehension associated with shortness of breath and pounding of heart. She feared
that she was going to die or would go crazy. Rest of her history and physical examination were normal. She is likely to suffer with:
a) Acute psychotic episode d) Panic attacks
b) Generalized anxiety disorder e) Conversion disorder
c) Major depressive disorder
41. A 52 year old man comes to a physician with the chief complaint of feeling sad for two months. He has lost 15 pounds of weight
in last 6 weeks, loss of energy and thought of committing suicide. The most probable diagnosis is:
a) Schizophrenia d) Anorexia nervosa
b) Generalized anxiety disorder e) Acute psychotic episode
c) Depressive illness
42. Somatic symptoms of depression include all EXCEPT:
a) Bowel disturbance d) Increased libido
b) Disturbed sleep e) Reduced appetite
c) Increased fatigue
43. Somatization disorder is:
a) Characterized by features of multiple personality
b) Related to heavy alcohol consumption
c) Usually treated successfully with surgery
d) Optimism
e) Characterized by recurrent multiple somatic complains without any organic basis
44. Auditory hallucinations are characteristics of which of the following?
a) Depression d) Fatigue syndrome
b) OCD (obsessive compulsive disorders) e) Anxiety
c) Schizophrenia
45. A 50 years old female has insomnia, excited mood, is talking excessively and wants everybody to listen to her because she's
messenger. She is taking antidepressants since last three months. What is most likely diagnosis?
a) Bipolar disorder currently maniac d) Anxiety
b) Schizophrenia e) Bipolar affective disorder currently depressed
c) Schizoaffective disorder
46. A 75 year old gentleman with chronic renal failure, suddenly starts to become Irritable refuses to recognize his family members,
and appears to be seeing things that aren't there. His daughter reports that he does not sleep at night and sleeps throughout the day
Instead. The most likely diagnosis is:
a) Dementia d) Depression with psychotic features
b) Delirium e) Anxiety
c) Schizophrenia
[Link] are appointed to give a lecture to medical students on Alzheimer's disease which is the most common symptom you will
discuss
a) Malnutrition d) Schizophrenia
b) Dementia e) Delirium
c) Anxiety disorder
48. A 30 year old man belives that his wife is trying to poison him. He also claims hearing multiple voices talking about him. There is
no evidence about his belief and voices he is hearing. The condition has been going on for several months. The most likely diagnosis:
a) Dementia d) Depression with psychotic features
b) Delirium e) Anxiety
c) Schizophrenia

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49. A patient aged 40 has been suffering from right sided hemicranial headaches for the last fifteen years. They are always on right
side of head. Occasionally there are visual symptoms. Which of the following possibilities is likely?
a) Migraine e) Cluster headaches
b) Intercranial vascular malformation c) Brain tumor
d) Tension headaches

ANSWER KEY
1. A 2. A 3. A 4. B 5. C 6. C 7. B 8. C 9. A 10. A
11. B 12. B 13. C 14. C 15. B 16. A 17. C 18. B 19. C 20. A
21. E 22. B 23. E 24. B 25. A 26. A 27. B 28. E 29. C 30. A
31. A 32. B 33. D 34. D 35. C 36. A 37. D 38. A 39. C 40. D
41. C 42. D 43. E 44. C 45. A 46. B 47. B 48. C 49. A

1-3. Cluster headache

Features Unilateral severe pain + Unilateral periorbital pain + Autonomic features (ipsilateral red watery eyes,
miosis & nasal congestion) + Recurrent attacks on same side with 30-90 mints duration + Patient is
agitated/restless ± Photophobia
Investigation Clinical diagnosis
Treatment 100% oxygen & Sumatriptan. Prophylaxis  Verapamil

4. Management of migraine
1. Find & avoid the precipitating factor + Rest in dark room
2. Simple Analgesic (paracetamol)
3. NSAID
4. Sumatriptan – DOC
5. Prophylaxis
 Beta blocker – DOC for prophylaxis
 Anti-epileptic drugs (Topiramate or Valproate)
 TCA (Amitriptyline)
6. The patient describes visual disturbances (flashing lights) that occur before the headache. This is a classic example of a migraine
aura.
7. Topical steroids can wors n n (―st ro n ‖). Acne cyst may be treated with intralesional steroid. Acne is common at puberty,
and appropriate treatment is recommended to prevent scarring. Oral retinoids (like isotretinoin) are reserved for severe or refractory
acne, not all cases. Laser therapy is adjunctive, not first-line. First-line is topical/oral medications.
9-11. Scabies Features
 Itchy papulo-pustular eruption & itching worse in night
 Found in web spaces between fingers, palm, sole, axilla, wrist, Genital region (penis) & Nipples
 Hx of same complain in other family members
Scabies Treatment
 Two applications one week apart of aqueous solution of 5% Permethrin or 0.5% Malathion on whole body
 Single oral dose of Ivermectin sometimes appropriate
12. Acne Vulgaris
 Onset at puberty
 Black heads (comedones) on face & trunk
13-16. Features of Atopic eczema
 Hx of allergic reaction (pollen, asthma, hay fever, food allergy)
 Itchy & scratchy marks
 Most common sites are anticubital fossa & popliteal fossa
 Lichenification (skin thickening)
 Xeroderma (widespread cutaneous dryness)

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Treatment of atopic eczema

Step I  Identification & avoidance of allergen
Step II  Emollients (white soft paraffin, aqueous cream) – Ist line treatment
 Topical glucocorticoid – 2nd line treatment
 Echthammol paste bandage & tar
 Antihistamine to break itchy/scratchy cycle
Step III  Phototherapy (Narrowband UVB > PUVA) if topical therapy fails
Step IV  Systemic immunosuppression & Systemic retinoids if above two options fail

18. Topical Dimeticone or Permethrin

20-21. HSV-1
 Recurrent grouped Vesicle eruption
 Prodromal hyperesthesia (Tingling sensations prior to vesicle eruption)
 Tx: Oral Acyclovir (in immunocompetent) while Foscarnet in immunocompromised
HSV-2
 Herpes genitalis (painful genital ulcers)
 Tx: Oral acylovir
23. The patient is a farmer, indicating a high-risk occupation for exposure to Brucella species (via contact with livestock like sheep,
goats, or cattle. "High grade swinging temperature" (undulant fever), rigors, sweating (often with a moldy smell), lethargy, headache,
and backache are classic symptoms of acute brucellosis. Hepatosplenomegaly and lymphadenopathy are common in brucellosis, as the
bacteria multiply within the reticuloendothelial system.
24. Genital wart 1st line treatment
 multiple, non-keratinised warts: topical podophyllum
 solitary, keratinised warts: cryotherapy
Genital wart 2nd line treatment
 Topical imiquimod cream
25-27. Fever types
 Typhoid  High grade continues, remittent fever (Temp always stays above baseline) Stepladder pattern fever
 Malaria  Intermittent fever (fever with normal temp between spikes) with rigors/chills
30-31. The combination of symptoms—nausea, loin pain, painful micturition, flushing (fever), and maximal tenderness in the
suprapubic region—is highly characteristic of a UTI. Ciprofloxacin is the drug of choice
32. Painless hematuria  suspect bladder carcinoma. Further hx of working in dye industry is a risk factor for bladder tumor
33. Features of dengue fever
 High grade fever, rigors, chills, malaise, Retro-orbital pain
 Rash
 Thrombocytopenia ± Leucocytopenia
34. The most likely diagnosis is Dengue and investigation to be done are NS1 antigen or Serologic test (IgM/IgG)
35. Alzheimer's disease is the most likely diagnosis due to the classic presentation of a slow, progressive decline in cognitive function
over a long period (10 years) in an elderly patient. Progressive decline in recent memory is the hallmark early symptom.
36. Recurrent intrusive thoughts (hands dirty) and compulsive actions (washing) = OCD.
37. Hearing voices and seeing images without external stimuli = hallucinations (perceptual disturbance).
38. Symptoms: low mood, weeping, loss of interest, poor sleep/appetite — classic major depression.
40. Panic attacks are characterized by a sudden, intense surge of fear or discomfort, often including symptoms like chest pain,
dizziness, palpitations, and intense fear of losing control or dying.
41-42. Features of Depression
 Loss of interest, Loss of enjoyment, Loss of appetite, Loss of libido
 Reduced self esteem & Guilt

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 Sleep disturbance
 Suicidal thinking indicates severe depression
 Atypical depression (eats a lot, sleep more)
44. Features of schizophrenia
 + Symptoms  Auditory hallucinations, Broadcasting, Controlled feelings & Delusional perception
 -ve Symptoms  Social isolation, Poor self care, Poverty of speech
45. Features of Bipolar disorder
 Symptoms of depression followed by mania
 Mania is characterized by over-activity, over-talkativeness, increased libido & appetite, racing thoughts & Pressure of speech
(rapid uninterrupted speech)
46. Features of delirium
 History of fever/medication, renal impairment, alcohol withdrawal
 Sudden onset
 Hallucination/illusion, Confusion & disorientation in time & place
 Often worse at night
 Sleep disturbance & Emotional disturbance (anxiety/depression)

NOTE: Don’t worry; these topics will be covered again in detail in next modules

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CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

MODULE-25
GIT & NUTRITION

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CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

Pa003 – Pa058
GIT & NUTRITION PATHOLOGY
֍PAST UHS MCQS & SAMPLE PAPER֍

Oral Cavity & GIT

01 Cause of lip ulcer? HSV
02 A 62 years old smoker male presented with left sided mass in parotid region. On Warthin tumor
microscopic examination cyst like spaces were seen lined by a double layer of
neoplastic epithelial cells resting on a dense lymphoid stroma. What is the most likey
diagnosis?
A. Warthin tumor
B. Pleomorphic adenoma
C. Mucoepidermoid carcinoma
D. Adenoid cystic carcinoma
E. Malignant mixed tumor
03 Most common predisposing factor to SCC of oral cavity in South Asia? Betel quid & Paan
04 Most common site of SCC of oral cavity? Ventral surface of tongue
05 Most common Benign tumor of salivary glands? Pleomorphic adenoma
06 Most common malignant tumor of salivary glands? Mucoepidermoid carcinoma
07 A male presented with swelling of salivary glands. Histology shows cyst lined by cells Warthin tumor (only salivary
with esoinophilic cytoplasm. Most likely Tumor? gland tumor common in males)
08 A 65-year-old writer with a history of smoking 45 pack years develops progressive SCC of esophagus
dysphagia to solids and liquids. An endoscopy reveals a 5 cm ulcerated mass in middle
of esophagus. The gastroesophageal junction is normal. What is the most likely
pathology?
A. Barrett esophagus
B. Adenocarcinoma of esophagus
C. SCC of esophagus
D. Achalasia
E. Plummer Vinson syndrome
09 Most common Congenital defect of GIT, 2 cm in length arising from ileocecal valve? Meckel diverticulum
10 What is the cause of Achalasia? No Myenteric plexus
11 Thin mucosal membrane projections into upper esophagus causing dysphagia? Esophageal web
12 A HIV patient developes grey-white membrane over the esophagus. Diagnosis? Candidiasis
13 Barrett Esophagus may lead to A. Adenocarcinoma ✓
B. SCC
14 A 45 years old male presents with dysphagia, weight loss, hoarseness & cough. SCC of esophagus
Endoscopy shows constriction in upper esophagus. What is most likely diagnosis?
15 From which part of stomach, biopsy should be taken for H. pylori associated gastritis? Antrum
16 Test to confirm that H. pylori has been eradicated after therapy? Urea breath test > Stool antigen
test
17 Complication of Autoimmune gastritis? A. Lymphoma
B. Peptic ulcer
C. Atrophic gastritis ✓
18 Most common cause of Peptic ulcer? H. pylori
19 Most common site of peptic ulcer? Proximal part of duodenum
20 Most common site of gastric ulcer? Lesser curvature of stomach
21 Thickeneng & carpeting of gastric mucosa. Diagnosis? Diffuse type adenocarcinoma

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22 What is " Sister Mary Joseph nodule "? Malignant metastatic

periumbilical nodule
23 Gastric adenocarcinoma metastasizes to which nodes? Virchow nodes
24 Most common site of Carcinoid tumor of GIT? Appendix
25 Most common mechanical cause of intestinal obstruction in children? Intessusception
26 Malignancy associated with Celiac disease? A. B-cell lymphoma
B. T-cell lymphoma ✓
27 What is the cause of toxic megacolon in Ulcerative colitis? Intestinal dysplasia
28 Multiple gastrointestinal hamartomatous polyps and mucocutaneous Peutz-Jeghers syndrome
hyperpigmentation?
29 Correct statement about FAP? 100% risk of carcinoma
30 Defect in FAP? APC gene mutation
31 Important Precursor lesion of Adenocarcinoma of colon? A. Peutz-Jegher syndrome
B. Villous adenoma ✓
32 A 51 years female presents with fatigue, weakness and pallor. Iron deficiency anemia is Colorectal carcinoma
suspected. What is the most likely cause?
33 Common cause of acute appendicitis? Fecolith obstruction followed by
Bacterial infection
34 Pain in periumbilical region radiating to right ilac fossa Acute appendicitis
35 Confirmatory sign of acute appendicitis on histology? Neutrophilic infiltration of
muscularis propria
36 Patient presented with fever & abdominal pain for last 4 days. Intestinal examination Typhoid enterocolitis
shows Longitudinal oval ulcer with black base. What can be the cause?
A. Tuberculosis
B. Typhoid enterocolitis
C. Celiac disease
D. Ulcerative colitis
E. Crohn's disease
37 Marker for evaluation of possible metastatic disease from his colon cancer? A. CEA ✓
B. AFP
38 Which salivary gland tumor is most common? Parotid gland
39 A 45 yeasr male presents with history of portal hypertension with blood vomiting. Dilated blood vessels in
During workup he dies suddenly. Expected histological finding of esophagus? submucosa
40 Cause of MALToma? H. pylori
41 Mutation associated with Diffuse gastric adenocarcinoma? CDH1
42 Pleomorphic adenoma of salivary glands arises from? A. Stem cells
B. CT
C. Myoepithelial cells ✓
43 A salivary gland tumor which histologicaly shows a double layer of epithelial cells A. Pleomorphic adenoma
based on reactive lymphoid stroma? B. Warthin tumor ✓
44 In which salivary gland tumor, histologicaly intermediate cells are present? Mucoepidermoid carcinoma
45 A mass with irregular margins presents at angle of jaw. Histologicaly composed of Pleomorphic adenoma
glands & cartilage. Tumor?
46 An HIV patient presents with painless lesion on lateral border of tongue. Most likely A. Hairy Leukoplakia ✓
diagnosis? B. Leukoplakia
47 What is the hallmark of Crohn's disease that distinguish it from Ulcerative colitis? Non caseating granuloma
48 Inflammatory lesion of rectum + bloody diarrhea with stringy mucoid material? Ulcerative colitis
49 Carcinoid tumor of appendix produces a solid bulbous swelling of ____ diameter 2 cm
50 An HIV Patient presents with White patch on tongue that can be scraped off. A. Hairy Leukoplakia ✓
Diagnosis? B. Leukoplakia

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51 A patient diagnosed with AIDs, presents with pseudomembranes in his mouth. What is Oral candidiasis
most likely diagnosis?
52 Histology report of gestor-esophageal junction in a patient, with a history of retrosternal Barret's esophagus
burning sensation, shows columnar epithelium and goblet cells. What is most likely
diagnosis?
53 A child presents with bilateral parotid swelling. What is most likely diagnosis? Mumps
54 A patient with history of smoking presents with swelling in right parotid. His histology Warthin tumor
report shows the double layer of lining cells; the upper layer consists of palisading
columnar cells with abundant, finely granular, eosinophilic cytoplasm, while the lower
layer is comprised of cuboidal to polygonal cells. What is most likely diagnosis?
55 Skip lesions are found in which of the following intestinal disease? Crohn disease
56 On colonoscopy of a patient, >100 tubular adenomatous polyps are found. What is most FAP
likely diagnosis?
57 A patient presents with severe pain on right iliac fossa. Tenderness and rebound Appendicitis
tenderness are found. Temperature was 101F. On CBC WBCs are increased, DLC
shows neutrophilia. What is most likely diagnosis?
58 A patient presented to surgical opd with swelling over right side of face near angle of Pleomorphic adenoma
mouth, biopsy was taken which shows myxoid stroma, what will be most likely
diagnosis?
59 Autoimmune gastritis can lead to deficiency of? Vitamin B12
60 Mutation in DNA repair proteins lead to HNPCC
61 Arborizing pattern is a hallmark of Peutz Jeghers polyp.
Liver & Gallbladder
62 Cells that produce collagen in liver cirrhosis? Stellate cells
63 What is the cause of gynecomastia in liver cirrhosis? Hyperestrogenemia
64 Spider angiomas of skin is indicative of Liver cirrhosis
65 A patient of liver cirrhosis developes ascites. What conc. of protein would you expect A. < 3 g/dL ✓
to find in aspirated ascetic fluid? B. 3-10 g/dL
C. > 20 g/dL
66 -ve HbsAg, -ve HbeAg, +ve Anti Hbs? Immunized
67 -ve HbeAg, +ve Anti HbeAb & normal aminotransferases? Inactive carrier
68 Portal inflammation disrupting limiting plate and surrounding hepatocytes is known as A. Piecemeal necrosis ✓
B. Confluent necrosis
69 Piecemeal necrosis is a characteristic finidng of? Chronic active hepatitis
70 In Chronic Hepatitis B, ground glass hepatocytes are swollen cells with? HbsAg
71 Schistosoma causes SCC
72 Hydatid cyst disease is caused by Echinococus granulosus
73 Hepatocellular steatosis begins in which region? Centrilobular region
74 Bronze skin + raised ferritin level? Hemochromatosis
75 Manifestation of Hemochromatosis? Bronze skin
76 Total bilirubin = 4mg/dL & Direct bilirubin = 0.8mg/dL. What is the cause? A. Dubin Johnson syndrome
B. Rotor syndrome
C. Gilbert syndrome ✓
D. Gallstones
77 Budd-Chiari syndrome is caused by thrombosis of which vessel? Hepatic vein
78 Resected specimen of liver showing Central gray-white, depressed stellate scar. Focal nodular hyperplasia
Diagnosis?
79 Tumor marker of hepatocellular carcinoma? Alpha fetoprotein
80 Colour of gallbladder stone infected with E. coli? Brown
81 Colour of bilirubin pigmented stone? Black

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CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

82 Marked hematemesis + Distended abdomen with a fluid wave + palpable spleen. A. Cirhosis ✓
Diagnosis? B. Acute Hepatitis
83 Three weeks after a meal at banquet dinner a 20 years male develops malaise, fatigue A. IgM Anti HAV antibody ✓
and loss of appetite. Mild icterus. Raised AST & ALT with the serum bilirubin 3.9 B. IgM Anti HDV antibody
mg/dl. Direct bilirubin is 2. Smptoms abate in 3 weeks. Serological test most likely to C. Anti Hbs antibody
be positive in the patient? D. Anti Hbc antibody
84 45 years female presents with ascites. Biopsy reveals diffuse portal tract bridging A. Alcoholic hepatitis
fibrosis and nodular regeneration of liver cells without hepatocyte necrosis and B. Viral hepatitis
cholestasis. Diagnosis? C. Chronic congestion
D. Cirhosis ✓
85 Organism causing liver abscess? Entameoba histolytica
86 A 65 years man presents with recent onset of jaundice, weight loss and anorexia. Gallbladder carcinoma
Abdominal examination reveals distended palpable gallbladder. Laboratory studies
reveal conj. hyperestrogenemia, +ve urine test for bilirubin & total absence of
urobilinogen in urine & stool. Diagnosis?
87 Viral Hepatitis causing Fulminant Liver failure in a pregnant lady? Hep E
88 Cause of Hepatocellular carcinoma Aflatoxin-B
89 Chances of Developing Chronic Liver disease in Hepatitis B? A. 5-10 % ✓ B. 1-2 %
C. 90% D. < 1%
90 Mallory Denk are the characteristic microscopic finding of? Alcohlic hepatitis
91 A patient presents with jaundice and right hypogastric pain. On GPE, corneal pigments Wilson disease
(kaiser-Fleisher ring) are found. What is most probably diagnosis?
92 Copper accumulation in tissue can be identified by Rhodamine stain
93 A primigravida presented to Obs clinic with complaint of generalized body itching and Cholestasis of pregnancy
yellow discoloration of sclera. Her labs show elevated ALP and GGT, What would be
diagnosis
94 Ampulla of Vater can be affected by infection of following parasite? Clonorchis
95 In chronic hepatitis which of the following is found Bridging necrosis
96 Serum serological studies of a patient with jaundice demonstrate the following: Acute phase Hepatitis B
1gG anti-HAV: Negative
IgM anti-HAV: Negative
IgM HBcAb Negative
HBcAb: Positive
HBsAg Positive
HBeAg Positive
HBV DNA: Positive
Anti-HCV: Negative
What is the most likely diagnosis of this patient?
A. Acute phase Hepatitis B
B. Chronic phase Hepatitis B
C. Window phase Hepatitis B
D. Recovery phase Hepatitis B
E. Immunized phase Hepatitis B
97 A 40-year-old female presented in the OPD of a tertiary care hospital with Jaundice, Primary Biliary Cholangitis
pruritus, and periocular and intra-digital xanthomas. On investigations alkaline
phosphatase is markedly elevated and she is positive for anti-mitochondrial antibodies.
What is the most likely diagnosis?
A. Primary Biliary Cholangitis
B. Primary Sclerosing Cholangitis
C. Autoimmune hepatitis
D. Hepatocellular carcinoma
E. Alcoholic hepatitis

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Pancreas
98 Which enzyme is mutated in Hereditary pancreatitis? A. Trypsin ✓
B. Lipase
99 Abdominal pain radiating to upper back. Elevated serum amylase. Diagnosis? Acute pancreatitis
100 Pancreatic adenocarcinoma is less likely/never originated from? A. Head
B. Body
C. Tail
D. Acinar ✓
101 Which cardiac pathology is associated with pancreatic carcinoma? Thrombotic Endocarditis
102 Tumor marker of pancreatic adenocarcinoma? CEA & CA 19-9
103 Which of the following enzyme raise in acute pancreatitis? Amylase & Lipase
104 A 38-year-old male is a smoker and sometimes takes alcohol after dinner. He got mild Acute pancreatitis
edema on his ankles and was prescribed thiazide diuretics by his doctor. At early
morning, after last nights heavy dinner, he got severe pain in his epigastrium
penetrating to his back. He got fever in the evening and got admitted in emergency.
There was marked leukocytosis and neutrophilia. The serum calcium was low. The
LFTs were normal and serum amylase was higher than normal. The BUN was 32 g/dL
and serum potassium was 3.2 mmol/L. What is your diagnosis?
A. Peptic ulcer disease
B. Acute pancreatitis
C. Perforated duodenum
D. GERD
E. Cholelithiasis

֍PRACTICE MCQs֍

01. Oral Cavity & GIT

1. Oesophageal varices are caused by which one of the following?

a) Enlarged liver pressing on the portal vein c) Pulmonary hypertension
b) Portal hypertension d) Systemic hypertension
e) Portal vein thrombosis
2. A patient presents to a physician complaining of recurrent episodic diarrhea triggered eating too much or drinking alcohol. He also
starts wheezing and is flushed during the episodes. Chest X-ray shows a lung mass. Biopsy of the mass would reveal
a) Adenocarcinoma c) Squamous cell carcinoma
b) Carcinoid tumour d) Primary tuberculosis
e) Small cell carcinoma
3. A 67 years old male has a tumour in parotid. It was removed surgically and showed glistening cut surface. Microscopically, it
showed multilayered eosinophilic cells lining cystic spaces. Underlying tissue showed numerous lymphocytes forming follicles. What
is the most likely diagnosis?
a) Adenoid cystic carcinoma c) Pleomorphic adenoma
b) Carcinoma ex-pleomorphic adenoma d) Warthin's tumor
e) Mucoepidermoid carcinoma
4. A 10 years old man with positive family history of colon cancer presented to his physician for genetic testing. His stool sample is
positive for occult blood. A colonoscopy is performed and showed multiple polyps in the colon. Which of the following genetic
mutation is likely to be seen in molecular analysis of this patient a blood?
a) APC c) K-RAS
b) P53 d) HNPCC
e) MLH1
5. What is the most likely complication of Barrett's esophagus?
a) Adenocarcinoma b) Lymphoma

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c) Reflux e) Varices
d) Squamous cell carcinoma
6. A healthy infant born at term shows no significant passage of meconium. The abdomen appears distended and tender. An
abdominal ultrasound shows marked colonic dilation above a narrow segment in the sigmoid region. Biopsy from narrow segment
shows absence of ganglion cells in muscle wall and submucosa. What is the likely diagnosis?
a) Colonic atresia c) Necrotizing enterocolitis
b) Hirschsprung disease d) Volvulus
e) Meconium ileus
7. A 57 years old woman with anemia is found to have a decreased Vitamin B12 level. Antibodies to intrinsic factor are identified
Levels of all other vitamins are within normal limits. Which of the following is most likely to be associated with this condition?
a) Angiodysplasia c) Dietary Vitamin B12 Deficiency
b) Atrophic gastritis d) Duodenal ulcer
e) leal resection
8. Stress ulcers of stomach are found in all but;
a) Shock c) Intracranial trauma or surgery
b) Sepsis d) Severe H. pylori infection
e) Burns
9. Barrett's oesophagus is characterized by
a) Presence of goblet cells c) Ulceration in oesophagus
b) Squamous cell carcinoma d) Pseudo-membrane formation
e) Neutrophilic abscess
10. H. Pylori associated gastritis is characterized by:
a) Predominantly body type inflammation c) Hypertrophy of gastric glands
b) Predominantly pyloric type inflammation d) Pyloric obstruction
e) Fundic sparing always
11. Coeliac disease is characterized by:
a) Atrophy of gastric mucosa c) Atrophy of duodenal mucosa
b) Hypertrophy of duodenal mucosa d) Granulomatous inflammation in duodenum
e) Caseation
12. Stage 'B1' of Dukes in carcinoma colon means:
a) Involvement of mucosa only c) Involvement of mucosa / sub-mucosa + muscularis externa
b) Involvement of mucosa and sub-mucosa d) Involvement of mucosa + submucosa + muscularis + serosa
e) Node positive
13. In cystic fibrosis:
a) Lungs and pancreas are predominantly involved c) Basic defect is in the high sweat Ca++ level
b) Exocrine secretions are abnormally thin d) Basic defect is mitochondria
e) Autoimmune
14. Preneoplastic conditions of the gastrointestinal tract include all of the following EXCEPT:
a) Barrett's esophagus c) Crohn's disease
b) Ulcerative colitis d) Diverticulitis
e) Adenoma
15. A 41 years old male with a history of chronic alcoholism has massive hematemesis following a bout of prolonged vomiting. This
is most typical for:
a) Hiatus hernia c) Esophageal carcinoma
b) Esophageal laceration (Mallory-Weiss syndrome) d) Barrett's esophagus (metaplasia with gastric mucosa)
e) Boerhaave
16. Causative organism of Whipple disease is:
a) Mycoplasma c) Triphorema
b) Rickettsia d) Actinomycetes
e) Nocardia
17. All of the following statements about gastric lymphoma are true, EXCEPT:
a) It is most form of extra-nodal lymphoma c) It has a worse prognosis than gastric carcinoma
b) It accounts for about 20% of all extra-nodal lymphomas d) Symptoms are indistinguishable from those of carcinoma
e) H. pylori related

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18. In Mallory - Weiss syndrome the site of tear is:

a) Proximal esophagus c) Oesophago-gastric junction
b) Distal esophagus d) Proximal stomach
e) Duodenum
19. Gastric carcinoma is most common in blood group:
a) AB c) A
b) B d) Equal in all groups
e) O
20. The complication of Meckel's diverticulum includes all of these EXCEPT:
a) Bleeding and ulceration c) Malignant transformation
b) Perforation d) Intussusceptions
e) Obstruction
21. The only polyp with malignant potential is:
a) Hyperplastic polyp c) Adenomatous polyps
b) Peutz-Jeghers syndrome d) Hamartomatous polyps
e) Inflammatory
22. Carcinoid of appendix most commonly arises from:
a) The base c) Tip
b) Middle d) Equally anywhere
e) Subserosa
23. Gastric polyps are usually:
a) Malignant c) Hamartomatous
b) Hyperplastic d) Large and pedunculated
e) Adenomatous mostly
24. Which of the following characterizes ulcerative colitis rather than Crohn's disease?
a) Discontinuous spread c) Fistula formation
b) Toxic megacolon d) Perianal abscess
e) Transmural
25. The following conditions may arise as complications of appendicitis EXCEPT:
a) Subphrenic abscess c) Carcinoma of appendix
b) Mucocele of the appendix d) Peritonitis
e) Pylephlebitis
26. A gastroenterologist performs a colonoscopy on a patient with a family history of gastric and colon cancer and discovers multiple
polyps. Biopsy of one lesion reveals benign hamartoma. On physical examination the patient is noted to have dark pigmentation of the
buccal mucosa and lips. What is the diagnosis?
a) Peutz-Jeghers syndrome c) Adenomatous polyposis coli
b) Gerdder's syndrome d) Turcot's syndrome
e) Lynch syndrome
27. The most common tumour of the appendix is:
a) Adenoma c) Carcinoid tumor
b) Mucinous adenocarcinoma d) Squamous cell carcinoma
e) Lymphoma
28. A 50 years old patient had chronic gastritis. His gastric biopsy showed abundant H. Pylori. If his disease persists for a long period,
which condition he is likely to develop;
a) Chronic duodenitis c) Gastric adenocarcinoma
b) Ischemic Heart Disease d) Gastric large B-cell lymphoma
e) GIST
29. A 56 years old female had gastric tumour which was 6.2 cm in diameter. The microscopy of the lesion showed spindle shaped
cells having tapering nuclei. Occasional mitoses were seen. Immunohistochemistry showed CD-117 (c-kit) Positive. Most likely
tumour is
a) Gastric polyp c) Leiomyoma
b) GIST d) Neuroendocrine tumour
e) Fibroma

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30. Pseudomembranous colitis is most likely caused by:

a) Actinomycosis after prolonged antibiotic use c) Clostridium Difficile after ischemic enterocolitis
b) Clostridium Perfringens after prolonged antibiotic use d) Clostridium Difficile after prolonged antibiotics use
e) Salmonella
31. A man with chronic history of heart burn recently diagnosed as lower esophageal carcinoma. What would be its underlying
pathology?
a) Anaplasia of the surface epithelium c) Metaplasia from columnar to squamous epithelium
b) Dysplasia from columnar to squamous d) Metaplasia from squamous to columnar epithelium
e) Hyperplasia
32. A 56 years old woman has adenocarcinoma of the colon that is surgically resected. Which of the following of growth of the
neoplasm suggests a poor prognosis?
a) Circumferential growth c) Polypoid growth
b) Extension to the muscular layer d) Extension to the serosa
e) Mucosal invasion
33. A 39 years old man presents with pharyngeal mass which on histology showed groups of cells penetrating deep, Keratin pearls
were seen. The most likely diagnosis is?
a) Diffuse large B cell lymphoma c) Squamous cell carcinoma
b) Hodgkin's lymphoma d) Squamous papilloma
e) Adenocarcinoma
34. The H. pylori can produce many pathogenetic changes in the stomach mucosa including gastric adenocarcinoma. Most common
location of such lesion is:
a) Cardia at greater curvature c) Any part of stomach at lesser curvature
b) Cardia at lesser curvature d) Pylorus and antrum at lesser curvature
e) Fundus
35. A 23-year-old primigravida gives birth at term to a boy infant. Ultrasound examination before delivery showed poly hydramnios.
A single umbilical artery is seen at the time of birth. The infant vomits all feedings, and then develops a fever and difficulty with
respirations within 2 days. A radiograph shows both lungs and the heart are of normal size, but there are pulmonary infiltrates and no
stomach bubble. What is the most likely diagnosis?
a) Achalasia c) Esophageal atresia
b) Diaphragmatic hernia d) Hiatal hernia
e) Pyloric stenosis
36. A 23-year-old woman, G2, P1, gave birth at term to a boy of normal weight and length following an uncomplicated pregnancy.
The infant initially did well, but at 6 weeks, he began feeding poorly for 1 week, and his mother noticed that much of the milk he
ingested was forcefully vomited within 1 hour. Now, on physical examination, the infant is afebrile, and there are no external
anomalies. A midabdominal mass is palpable. Bowel sounds are active. The medical history indicates that both the mother and her
first child had the same ill ness during infancy. Which of the following conditions is most likely to explain these findings?
a) Annular pancreas c) Duodenal atresia
b) Diaphragmatic hernia d) Pyloric stenosis
e) Tracheoesophageal fistula
37. A 24-year-old woman gives birth to term infant after an uncomplicated pregnancy. Apgar scores are 9 and 10 at 1 and 5 minutes
t r b rth. Th n nt‘s l n th n w ht r t th 55th p r nt l . Th r s no s n nt p ss o m on um. Three days after
birth, the infant vomits all oral feedings. On physical examination, the infant is afebrile, but the abdomen is distended and tender, and
bowel sounds are reduced. An abdominal ultrasound scan shows marked colonic dilation above a narrow segment in the distal sigmoid
region. A biopsy specimen from the narrowed region shows an absence of ganglion cells in the muscle wall and submucosa. Which of
the following is most likely to produce these findings?
a) Colonic atresia c) Intussusception
b) Hirschsprung disease d) Necrotizing enterocolitis
e) Trisomy 21
38. A 54-year-old, previously healthy man sustained an extensive thermal burn injury involving 70% of the total body surface area of
his skin. He was hospitalized in stable condition. Three weeks after the initial burn injury, he developed melanotic stools. His blood
pressure dropped to 80/40 mm Hg, and his hematocrit declined to 18%. Where are gastrointestinal ulcerations most likely to be found
in this man?
a) Colon b) Duodenum

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CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

c) Esophagus d) Ileum
e) Stomach
39. A 51-year-old woman has been feeling increasingly tired for the past 7 months. There are no remarkable findings on physical
x m n t on. bor tory stu s n lu h mo lob n, 9.5 ; h m to r t, 29.1 ; MCV, 124 μm3; pl t l t ount, 268,000 mm3; nd
WBC count, 8350/mm3. The reticulocyte index is low. Hyper-segmented polymorphonuclear leukocytes are found on a peripheral
blood smear. The serum gastrin is markedly increased. Antibodies to which of the following are most likely to be found in this
patient?
a) Gastric H+-K+-ATPase c) Helicobacter pylori
b) Gliadin d) Intrinsic factor receptor
e) Tropheryma whippelli
40. A 59-year-old man has had nausea and vomiting for 5 months. He has experienced no hematemesis. On physical examination,
there is no abdominal tenderness, and bowel sounds are present. Upper gastrointestinal endoscopy shows erythematous areas of
mucosa with thickening of the rugal folds in the gastric antrum. The microscopic appearance of a gastric biopsy specimen with a
Steiner silver stain is shown in the figure. Which of the following factors is most likely responsible for this gastric mucosal pathology?
a) Cysteine proteinase c) Heat-stable enterotoxin
b) Cytotoxin-associated gene A d) Shiga toxin
e) Verocytotoxin
41. A 35-year-old man has had epigastric pain for more than 1 year. The pain tends to occur 2 to 3 hours after a meal and is relieved if
he takes antacids or eats more food. He has noticed a 4-kg weight gain in the past year. He does not smoke and drinks 1 glass of
Johannisberg Riesling daily. The result of a urea breath test is positive, and a gastric biopsy specimen contains urease. He begins a 2-
week course of antibiotics, but on day 4, he feels better and discontinues treatment. Three weeks later, the epigastric pain recurs. If he
does not seek further treatment, which of the following complications is he most likely to develop?
a) Carcinoid syndrome c) Hematemesis
b) Fat malabsorption d) Migratory thrombophlebitis
e) Vitamin B12 deficiency
42. A 49-year-old woman has a history of peptic ulcer disease for which she has been treated with proton pump inhibitors. She has had
nausea with vomiting for the past 2 months. Upper GI endoscopy reveals three circumscribed, round, smooth lesions in the gastric
body from 1 to 2 cm in diameter. Biopsies are taken and microscopically show the lesions to consist of irregular glands that are
cystically dilated and lined by flattened parietal and chief cells. No inflammation, Helicobacter pylori, metaplasia, or dysplasia is
present. What is the most likely diagnosis?
a) Fundic gland polyps c) Hyperplastic polyps
b) Gastric adenomas d) Hypertrophic gastropathy
e) Gastric adenocarcinoma
43. A 67-year-old woman has experienced severe nausea, vomiting, early satiety, and a 9-kg weight loss over the past 4 months. On
physical examination, she has muscle wasting. Upper gastrointestinal endoscopy shows that the entire gastric mucosa is eroded and
has an erythematous, cobblestone appearance. An abdominal CT scan shows that the stomach is small and shrunken. Which of the
following is most likely to be found on histologic examination of a gastric biopsy specimen?
a) Chronic atrophic gastritis c) Gastrointestinal stromal tumor
b) Primary gastric lymphoma d) Granulomatous inflammation
e) Signet ring cell adenocarcinoma
44. A 26-year-old man is brought to the emergency department after sustaining abdominal gunshot injuries. At laparotomy, while
repairing the small intestine, the surgeon notices a 1-cm mass at the tip of the appendix. The yellow-tan submucosal mass is removed,
and the microscopic appearance of the mass is shown in the figure. Immunohistochemical staining is positive for chromogranin and
synaptophysin but negative for Ki-67. Which of the following is the most likely cell of origin of this lesion?
a) Lipoblast c) Goblet cell
b) Ganglion cell d) Neuroendocrine cell
e) Smooth muscle cell
45. A 61-year-old man has had severe abdominal pain and bloody diarrhea for the past day. On physical examination, his abdomen is
diffusely tender, and bowel sounds are absent. Abdominal plain films show no free air. Laboratory studies show a normal CBC and
normal levels of serum amylase, lipase, and bilirubin. His Hgb A1c is 10%. He develops shock. A year ago, he had an acute
myocardial infarction. Which of the following lesions is most likely to be found in this man?
a) Appendicitis c) Pancreatitis
b) Cholecystitis d) Intestinal infarction
e) Pseudomembranous colitis

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46. A 71-year-old woman with a history of rheumatic heart disease is hospitalized with severe congestive heart failure. Four days after
admission, she develops cramping lower abdominal pain. On physical examination, she is afebrile. The abdomen is distended and
tympanitic, without a fluid wave, and bowel sounds are absent. A stool sample is positive for occult blood. An abdominal plain film
shows no free air. Colonoscopy shows patchy areas of mucosal erythema with some overlying tan exudate in the ascending and
descending colon. No polyps or masses are found. What is the most likely diagnosis?
a) Ischemic colitis c) Shigellosis
b) Mesenteric vasculitis d) Ulcerative colitis
e) Volvulus
47. A 60-year-old man has had increasing fatigue for the past 8 months. On physical examination, he appears pale. On digital rectal
examination, no masses are palpable, but a stool sample is positive for occult blood. Auscultation of the abdomen shows active bowel
sounds, and on palpation there are no masses or areas of tenderness. Laboratory studies show hemoglobin, 8.3 g/dL; hematocrit,
24.6 ; MCV, 73 μm3; pl t l t ount, 226,000 mm3; n WBC ount, 7640 mm3. Colonos opy shows no nt bl sour o th
bleeding. Angiography shows a 1-cm focus of dilated and tortuous vascular channels in the mucosa and submucosa of the cecum.
What is the most likely diagnosis?
a) Angiodysplasia c) Diverticulosis
b) Collagenous colitis d) Internal hemorrhoids
e) Mesenteric vein thrombosis
48. An epidemiologic study of children with failure to thrive is undertaken in Guatemala. Some of these children with ages 1 to 3
years have repeated bouts of diarrhea, but do not improve with dietary supplements. Jejunal biopsies show blunted, atrophic villi with
crypt elongation and chronic inflammatory infiltrates. What is the most likely factor contributing to recurrent diarrhea in these
children?
a) Abetalipoproteinemia c) Chloride ion channel dysfunction
b) Bacterial infection d) Disaccharidase deficiency
e) NOD2 gene mutations
49. A 65-year-old woman is being treated in the hospital for pneumonia complicated by septicemia. She has required multiple
antibiotics and was intubated and mechanically ventilated earlier in the course. On day 20 of hospitalization, she has abdominal
distention. Bowel sounds are absent, and an abdominal radiograph shows dilated loops of small bowel suggestive of ileus. She has a
low volume of bloody stool that is positive for Clostridium difficile toxin. Laboratory studies show leukocytosis and
hypoalbuminemia. At laparotomy, a portion of distal ileum and cecum is resected. The gross appearance of the mucosal surface is
shown in the figure. What is the most likely diagnosis?
a) Gas gangrene with myonecrosis c) Ischemic bowel disease
b) Inflammatory bowel disease d) Pseudomembranous enterocolitis
e) Toxic megacolon
50. A 30-year-old woman has a 5-year history of recurrent episodes marked by days of abdominal bloating with alternat ing
constipation and diarrhea. She notes hard stools of narrow caliber, low volume mucous diarrhea, and pain in the left lower quadrant.
Her symptoms are relieved by defecation, which occurs more frequently now. On physical examination there are no abnormal
findings. Laboratory studies including stool for ova and parasites, bacterial pathogens, and fat show no abnormalities. An abdominal
CT scan is unremarkable. What is the most likely diagnosis?
a) Cystic fibrosis c) Inflammatory bowel disease
b) Diverticular disease d) Irritable bowel syndrome
e) Viral gastroenteritis
51. A clinical study of adult patients with chronic bloody diarrhea is performed. One group of these patients is found to have a
statistically increased likelihood for the following: antibodies to Saccharomyces cerevisiae but not anti–neutrophil cytoplasmic
autoantibodies, NOD2 gene polymorphisms, TH1 and TH17 immune cell activation, vitamin K deficiency, megaloblastic anemia, and
gallstones. Which of the following diseases is this group of patients most likely to have?
a) Angiodysplasia c) Diverticulitis
b) Crohn disease d) Ischemic enteritis
e) Ulcerative colitis

ANSWER KEY
1. B 2. B 3. D 4. A 5. A 6. B 7. B 8. D 9. A
10. B 11. C 12. B 13. A 14. D 15. B 16. C 17. C 18..C

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CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

19. C 20. C 21. C 22. C 23. B 24. B 25. C 26. A 27. C

28. C 29. B 30. D 31. D 32. D 33. C 34. C 35. C 36. D
37. B 38. E 39. A 40. B 41. C 42. A 43. E 44. D 45. D
46. A 47. A 48. B 49. D 50. D 51. B

1. Esophageal varices are caused by portal hypertension (option B), which leads to increased pressure in the portal venous system and
formation of portosystemic collaterals. Enlarged liver compressing the portal vein (A) is not the primary mechanism, pulmonary
hypertension (C) and systemic hypertension (D) do not affect portal circulation, while portal vein thrombosis (E) can cause portal
hypertension but is not the classical answer.
2. The clinical picture is typical of carcinoid syndrome (option B) due to serotonin secretion causing flushing, diarrhea, and wheeze.
Adenocarcinoma (A) and squamous cell carcinoma (C) do not produce such systemic hormonal symptoms, tuberculosis (D) is
infective, and small cell carcinoma (E) is neuroendocrine but usually lacks classic carcinoid syndrome presentation.
3. The parotid tumor with oncocytic epithelium and lymphoid follicles is Warthin tumor (option D). Adenoid cystic carcinoma (A)
shows perineural invasion, pleomorphic adenoma (C) is mixed without lymphoid stroma, carcinoma ex-pleomorphic adenoma (B) is
malignant transformation, and mucoepidermoid carcinoma (E) has mucous and epidermoid cells.
4. Multiple colonic polyps in a young patient suggest APC mutation (option A) seen in familial adenomatous polyposis. p53 (B) and
K-RAS (C) are later mutations in carcinoma progression, HNPCC (D) is mismatch repair gene-related, and BRAF (E) is associated
with serrated pathway lesions.
5. B rr tt‘s soph us most commonly progresses to adenocarcinoma (option A) due to intestinal metaplasia. Lymphoma (B) is
unrelated, reflux (C) is the cause rather than complication, squamous carcinoma (D) is linked to smoking/alcohol, and varices (E) are
unrelated to esophageal metaplasia.
6. The infant with absent ganglion cells has Hirschsprung disease (option B) due to failure of neural crest migration causing functional
obstruction. Atresia (A) is structural, NEC (C) is inflammatory necrosis, volvulus (D) is mechanical twisting, and meconium ileus (E)
is seen in cystic fibrosis.
7. Vitamin B12 deficiency with intrinsic factor antibodies indicates atrophic gastritis/pernicious anemia (option B). Angiodysplasia
(A) causes bleeding, dietary deficiency (C) is excluded by normal intake, duodenal ulcer (D) is acid-related, and ileal resection (E) can
cause B12 deficiency but lacks autoimmune mechanism.
8. Stress ulcers occur in shock, sepsis, burns, and CNS injury; hence H. pylori infection (option D) is the exception as it causes chronic
gastritis, not acute stress-related mucosal damage.
9. B rr tt‘s soph us s h r t r z by goblet cells (option A) indicating intestinal metaplasia. Squamous carcinoma (B) is a
complication but not defining, ulceration (C) is nonspecific, pseudomembrane formation (D) is infectious colitis, and eosinophils (E)
are not diagnostic.
10. H. pylori gastritis predominantly affects the antrum/pyloric region (option B) in early stages. Body involvement (A) is later or
autoimmune, gland hypertrophy (C) is not typical, obstruction (D) is a complication, and fundic sparing (E) is not absolute.
11. Celiac disease shows duodenal mucosal atrophy (option C) with villous flattening and malabsorption. Gastric changes (A, B) are
incorrect organ, granulomas (D) suggest Crohn disease, and caseation (E) indicates tuberculosis.
12. Dukes B1 corresponds to tumor invading muscularis externa (option B) without nodal involvement. Mucosal-only (A) is early
stage, serosal involvement (C) and beyond (D) are advanced, and node positivity (E) is Dukes C.
13. Cystic fibrosis primarily affects lungs and pancreas (option A) due to thick secretions from CFTR mutation. Thin secretions (B)
are incorrect, sweat Ca++ defect (C) is wrong ion, mitochondrial defect (D) is unrelated, and autoimmune mechanism (E) is not
involved.
14. Diverticulitis is not a premalignant condition (option D), unl k B rr tt‘s, ul r t v ol t s, Crohn s s , n nom tous
polyps which carry increased cancer risk.
15. Mallory-Weiss syndrome causes hematemesis due to mucosal tear at gastroesophageal junction (option B) after forceful vomiting.
H tus h rn (A) s r sk tor, r nom (C) us s hron bl n , B rr tt‘s (D) s m t pl s , n Bo rh v syn rome (E) is
full-thickness rupture.
16. Whipple disease is caused by Tropheryma whipplei (option C). Mycoplasma (A), rickettsia (B), actinomycetes (D), and other
bacteria (E) are not involved.
17. The incorrect statement is that gastric lymphoma has worse prognosis than carcinoma (option C); in fact, gastric lymphoma often
has a better prognosis. Other statements about extranodal frequency, symptoms, and H. pylori association are true.
18. Mallory-Weiss tears occur at the gastroesophageal junction (option C) due to sudden increase in intra-abdominal pressure.
Proximal or distal esophagus (A, B) and stomach (D) are less precise or incorrect.

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19. Gastric carcinoma is more common in blood group A (option C). Other blood groups (A, B, AB) do not show strong association.
20. Meckel diverticulum complications include bleeding, perforation, and obstruction; malignant transformation (option C) is very
rare and considered the exception.
21. Only adenomatous polyps (option C) have malignant potential via dysplasia–carcinoma sequence. Hyperplastic, hamartomatous,
and Peutz-Jeghers polyps are generally benign.
22. Appendiceal carcinoid tumors most commonly arise at the tip (option C) due to high concentration of neuroendocrine cells.
23. Gastric polyps are most commonly hyperplastic (option B), usually benign and associated with chronic gastritis.
24. Ulcerative colitis is characterized by toxic megacolon (option B), while Crohn disease shows skip lesions, fistulas, and perianal
disease.
25. Carcinoma of appendix is not a complication of appendicitis (option C) while abscess, peritonitis, and mucocele can occur.
26. Peutz-Jeghers syndrome presents with hamartomatous polyps and mucocutaneous pigmentation (option A), distinguishing it from
FAP, Turcot, and Lynch syndromes.
27. The most common tumor of appendix is carcinoid tumor (option C), arising from neuroendocrine cells.
28. Chronic H. pylori infection can lead to gastric adenocarcinoma (option C) and also MALT lymphoma, but adenocarcinoma is the
classic long-term outcome.
29. GIST is identified by CD117 (c-kit) positivity and spindle cells (option B). Leiomyoma lacks CD117, NETs have different
markers, and polyps are epithelial lesions.
30. Pseudomembranous colitis is caused by Clostridium difficile after antibiotic use (option D) producing toxin-mediated colonic
injury.
31. Lower esophageal carcinoma arises due to B rr tt m t pl s (squ mous → olumn r, opt on D) following chronic GERD. Other
options do not represent correct metaplastic pathway.
32. Serosal invasion (option D) indicates advanced colorectal cancer with poor prognosis compared to mucosal or muscular
involvement.
33. Keratin pearls are characteristic of squamous cell carcinoma (option C) due to keratinizing malignant squamous cells.
34. H. pylori–associated gastric adenocarcinoma most commonly occurs at the antrum and lesser curvature (option C) due to chronic
inflammation and atrophic changes.
35. Esophageal atresia is often associated with a tracheoesophageal fistula. Intrauterine GI obstruction can cause polyhydramnios. A
single umbilical artery suggests associated anomalies. Infant vomiting risks aspiration pneumonia. Achalasia (failure of LES
relaxation) is not present at birth. Diaphragmatic agenesis (usually left-sided) causes herniation of abdominal contents, but normal
lung size excludes this. Hiatal hernia predisposes to GERD, not obstruction. Pyloric stenosis causes gastric outlet obstruction, usually
in 2nd–3rd week of life. Zenker diverticulum occurs in adults.
36. Infant symptoms occur weeks after birth due to pyloric muscle hypertrophy. Pyloric stenosis shows multifactorial inheritance with
a threshold effect; more risk factors are needed in females (M:F ratio ~4:1). Annular pancreas can cause duodenal obstruction but
usually with no palpable mass. TEF, diaphragmatic hernia, and duodenal atresia present at birth with multiple anomalies. Pyloric
stenosis is typically isolated.
37. Hirschsprung disease (1/5000) causes functional obstruction due to aganglionic bowel segment with proximal dilation. Most cases
involve RET gene mutations affecting neural crest migration. Atresia is congenital luminal narrowing and associated with other
anomalies (e.g., Down syndrome with duodenal atresia). Intussusception is unrelated to aganglionosis. NEC is a prematurity
complication. Volvulus is twisting of bowel causing obstruction.
38. Stress (Curling) ulcers occur in burns; they are small, shallow, and may bleed. Cushing ulcers occur with CNS injury. Duodenal
ulcers are linked to H. pylori. Esophageal varices arise from portal hypertension (usually cirrhosis). Barrett esophagus is intestinal
metaplasia from GERD. Ileal/colonic ulcers may result from IBD or infections (e.g., shigellosis) or Crohn disease.
39. High MCV indicates megaloblastic anemia, most likely pernicious anemia due to autoimmune atrophic gastritis. Causes include
B12 deficiency from intrinsic factor loss. Anti-p r t l ll nt bo s t r t H⁺ K⁺-ATPase. Anti-gliadin antibodies occur in celiac
disease. H. pylori causes gastritis/ulcers but not parietal cell destruction. Whipple disease causes malabsorption with systemic
involvement.
40. H. pylori resides in gastric mucus and causes chronic gastritis, ulcers, and gastric cancer. CagA virulence gene increases
malignancy risk. Entamoeba histolytica uses cysteine proteases for invasion. ETEC produces heat-st bl tox n (tr v l r‘s rrh ).
Shigella produces Shiga toxin. E. coli verotoxin causes hemolytic uremic syndrome via endothelial injury.
41. Peptic ulcer disease is usually due to H. pylori. Urease test detects infection via labeled urea breath test or biopsy rapid urease test.
Untreated ulcers may cause bleeding. Carcinoid tumors are unrelated. Fat malabsorption is not present. Gastric cancer progression is
rare. Vitamin B12 deficiency occurs in autoimmune gastritis due to intrinsic factor loss.

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42. Fundic gland polyps are associated with proton pump inhibitor use and FAP due to gastrin-driven hyperplasia. Gastric adenomas
(antrum) show dysplasia and are premalignant. Hyperplastic polyps are linked to chronic H. pylori gastritis. Ménétrier disease
involves TGF-α ov rpro u t on us n nt ru l ol s n prot n loss.
43. n t s pl st (―l th r bottl ‖ stom h) r pr s nts us str r nom us n r th k n stom h w ll.
44. Tumor cells show neurosecretory granules, characteristic of neuroendocrine (carcinoid) tumors. These are often small, well-
differentiated, and incidental. Other listed cells lack neurosecretory granules.
45. MI history suggests severe atherosclerosis with diabetes (elevated HbA1c). Mesenteric vessel thrombosis causes bowel infarction.
Appendicitis rarely causes catastrophic disease unless perforated. Normal amylase/lipase excludes pancreatitis. Cholecystitis does not
usually cause bloody diarrhea. C. difficile colitis occurs after antibiotics.
46. Hypotension from heart failure causes ischemic bowel with patchy mucosal necrosis progressing to transmural infarction.
Mesenteric vasculitis is rare. Shigellosis causes colonic erosion and hemorrhage. Ulcerative colitis causes continuous mucosal
inflammation. Volvulus causes obstruction and ischemia via torsion.
47. Angiodysplasia is tortuous mucosal/submucosal vessels (usually cecum in elderly), causing intermittent lower GI bleeding. It
accounts for ~20% of lower GI bleeds. Diverticulosis may bleed but is visible on colonoscopy. Hemorrhoids cause bright red
bleeding. Mesenteric venous thrombosis is rare and severe.
48. Environmental enteropathy results from repeated infections causing chronic intestinal inflammation resembling celiac disease. No
single pathogen is responsible. Abetalipoproteinemia impairs lipoprotein transport. Cystic fibrosis causes malabsorption via pancreatic
insufficiency. Lactase deficiency causes milk intolerance. NOD2 mutations are linked to Crohn disease.
49. Pseudomembranous colitis shows fibrinopurulent plaques due to C. difficile after antibiotic use. C. septicum causes myonecrosis,
often with malignancy. IBD does not typically form pseudomembranes. Ischemic colitis may resemble it but lacks C. difficile. Toxic
megacolon is a complication of ulcerative colitis.
50. IBS has no structural or biochemical abnormalities. Behavioral therapy may help. Placebos may be effective. Lack of steatorrhea
excludes chronic pancreatitis/cystic fibrosis. Diverticular disease is age-related. IBD has identifiable pathological changes. Viral
gastroenteritis does not last years.
51. Crohn disease causes inflammatory bowel disease with ileal involvement leading to B12 and vitamin K deficiency and gallstones
due to bile salt disruption. It involves dysregulated innate immunity to gut flora. Angiodysplasia causes cecal bleeding in elderly.
Diverticular disease is mechanical, not immune-mediated. Ischemic bowel from atherosclerosis is acute.

02. Pancreas

52. An afebrile 62 years old man with a history of alcoholism and chronic pancreatitis presents with weight loss, a slow onset of
painless jaundice, and a normocytic anemia. Physical exam reveals a palpable gallbladder and a light-colored stool. The patient most
likely has:
a) Hepatocellular carcinoma c) A stone in the common bile duct
b) Carcinoma of gallbladder d) Carcinoma of the head of pancreas
e) Acute pancreatitis
53. After pancreatic adenocarcinoma, which one of the following is the most common tumour of pancreas?
a) Neuroendocrine tumour c) Liposarcoma
b) Lymphoma d) Angiosarcoma
e) Metastatic carcinoma
54. According to Courvoiser's law, a pancreatic cancer located in the head of the pancreas should be suspected in an individual with
which one of the following clinical signs?
a) Migratory thrombophlebitis c) Obstructive jaundice and a nonpalpable gall bladder
b) Obstructive jaundice and a dilated gallbladder d) Steatorrhea and a tender gallbladder
e) Fever + jaundice + pain (Charcot triad)
55. Which one of the following is the most common site of pancreatic cancer?
a) Head c) Tail
b) Body d) Uncinate process
e) Diffuse involvement
56. A 47 years old man presented to the emergency with sudden onset of severe upper abdominal pain with vomiting. Pain was in
epigastrium radiating to the back. Serum amylase level was 2000 u/l. Which of the following are predisposing factors for his
condition?
a) Helicobacter pylori infection & excess gastric acid secretion b) Hepatitis B infection and iron overload

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c) Obesity and high serum cholesterol and gallstones d) Alcohol use

e) NSAID use
57. A 45 years old presents with recurrent attacks of hypoglycemia that seems to follow fasting or strenuous exercise with relief of
symptoms following glucose ingestion. Which of the following disorder the patient most likely has?
a) Beta cell adenoma of pancreatic islets c) Diabetes insipidus
b) Carcinoma of tail of pancreas d) Hemochromatosis
e) Addison disease
58.. A 47 years old man presented to the emergency with sudden onset of severe upper abdominal pain with vomiting. Pain was in
epigastrium radiating to the back. Serum amylase level was 2000 u/l. Which of the following are predisposing factors for his
condition?
a) Helicobacter pylori infection & excess gastric acid secretion c) Obesity and high serum cholesterol
b) Hepatitis B infection and iron overload d) Alcohol use and gallstones
e) Hypercalcemia only
59. All predispose to pancreatic carcinoma except:
a) Smoking c) Fats and meat diet
b) Alcoholism d) Partial gastrectomy
e) Chronic pancreatitis
60. Severe damage to the pancreatic tissue can produce:
a) Chronic pancreatitis c) Traumatic fat necrosis
b) Enzymatic fat necrosis d) Hemorrhagic pancreatitis
e) Pancreatic pseudocyst only
61. A 33-year-old woman with Hodgkin lymphoma of cervical lymph nodes has an abdominal CT scan for staging. The scan reveals a
solitary 4-cm cyst in the body of the pancreas. A fine-needle aspirate is performed and yields clear serous fluid that microscopically
has low cuboidal cells with no atypia. What is this cyst most likely to be?
a) Adenocarcinoma c) Congenital malformation
b) Component of autosomal dominant PKD d) Cystadenoma, serous
e) Pseudocyst
62. A clinical study of patients with acute abdomen is per formed. Those patients with elevated serum lipase are identified. A decrease
in which of the following analytes is most likely to predict a worse prognosis?
a) Albumin c) Calcium
b) Bilirubin d) Fibrinogen
e) Haptoglobin
63. A 35-year-old man has a 1-year history of bouts of dull abdominal pain. Over the next 5 years he also develops steatorrhea and
mild glucose intolerance. He does not develop jaundice. An abdominal CT scan shows specks of calcification in the mid-abdomen,
particularly near the duodenum. One of his sisters has a similar clinical picture, but both parents are unaffected. Loss of inhibition of
which of the following is the most likely cause for the disease seen in these persons?
a) Amylase c) Lipase
b) Complement d) Transforming growth factor beta (TGF-β)
e) Trypsin
64. A 38-year-old woman with a long history of gallbladder disease has a sudden onset of severe midabdominal pain. On physical
examination, she has marked abdominal tenderness, particularly in the upper abdomen, and bowel sounds are reduced. An abdominal
radiograph shows no free air, but there is marked soft tissue edema. Abdominal CT scan shows de creased attenuation with fluid
density involving the pancreas. She is given intravenous fluids and nasogastric suction and recovers gradually. Which of the following
serum laboratory tests is most useful for diagnosis of her disease process?
a) Alanine aminotransferase c) Amylase
b) Ammonia d) Bilirubin
e) Glucose
65. A 63-year-old man who had worsening congestive heart failure with cardiac dysrhythmias for the past year of his life died of
pneumonia. At autopsy, his pancreas is grossly small and densely fibrotic. Microscopic examination shows extensive atrophy of the
acini with residual chronic inflammation, fibro sis, and inspissated protein plugs in small, obstructed pancreatic ducts. Some of the
protein plugs show calcification. The islets of Langerhans appear normal. The heart weighs 500 g, and all four chambers are dilated.
Which of the following conditions is most likely to account for his findings?
a) αl-Antitrypsin deficiency b) Blunt trauma to the abdomen

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c) Cholelithiasis d) Chronic alcoholism

e) Cystic fibrosis
66. A 65-year-old woman has had upper abdominal pain for the past month. On examination, the pain is localized to the epigastric
region on palpation. Abdominal CT scan shows a well-circumscribed, 8-cm mass in the tail of the pancreas that has many small fluid-
filled areas. At laparotomy, the mass is removed and on microscopic examination shows glycogen rich, low cuboidal cells surrounding
spaces filled with clear fluid. There is no recurrence of the lesion. What is the most likely diagnosis?
a) Serous cystadenoma c) Chronic pancreatitis
b) Adenocarcinoma d) Cystic fibrosis
e) Pseudocyst
67. A 46-year-old woman has severe abdominal pain for 2 days. On physical examination she has marked epigastric pain, and bowel
sounds are reduced. Laboratory studies show an elevated serum lipase. With supportive care, her acute condition subsides within 7
days. Which of the following complications is most likely to occur in this patient?
a) Gastric ulceration c) Hyperosmolar coma
b) Hemoperitoneum d) Ketoacidosis
e) Pseudocyst formation
68. A 73-year-old woman has noticed a 10-kg weight loss in the past 3 months. She is becoming increasingly icteric and has constant
vague epigastric pain, nausea, and episodes of bloating and diarrhea. On physical examination, she is afebrile. There is mild
tenderness to palpation in the upper abdomen, but bowel sounds are present. Her stool is negative for occult blood. Laboratory
findings include a total serum bilirubin con centration of 11.6 mg/dL and a direct bilirubin level of 10.5 mg/dL. Which of the
following conditions involving the pancreas is most likely to be present?
a) Adenocarcinoma c) Cystic fibrosis
b) Chronic pancreatitis d) Islet cell adenoma
e) Pseudocyst
69. A 68-year-old man notes dull but constant abdominal pain accompanied by nausea with vomiting for the past 8 months. On
physical examination he has tenderness to palpation of the upper abdomen. Abdominal CT imaging shows a 2-cm circumscribed mass
in the body of the pancreas. Pancreatectomy is performed and microscopic examination of this mass shows tall, columnar, mucinous
epithelial cells lining papillary excrescences within the main pancreatic duct. There is minimal atypia and no invasion. What is the
most likely future course for this man?
a) Additional gastrointestinal neoplasms c) Development of extra-abdominal malignancies
b) Complete remission d) Local recurrence
e) Pseudocyst formation
70. An 80-year-old man has increasing jaundice with abdominal pain for the past 2 weeks. He has lost 4 kg over the past 5 months. On
physical examination there is tenderness with palpable gallbladder in the right upper quadrant. An abdominal CT scan shows
gallbladder and common bile duct dilation, along with a 3-cm mass in the head of the pancreas. Which of the following lesions is the
most likely precursor to this mass?
a) Colonic neuroendocrine carcinoma c) Neuroendocrine tumor
b) Duodenal adenocarcinoma d) Pancreatic intraepithelial neoplasia
e) Serous cystadenoma

ANSWER KEY
52. D 53. A 54. B 55. A 56. D 57. A 58. D 59. D 60. B 61. C
62. C 63. E 64. C 65. D 66. A 67. E 68. A 69. B 70. D

52. The correct answer is carcinoma of the head of pancreas (D). Hepatocellular carcinoma (A) causes hepatic failure rather than
obstructive jaundice. Gallbladder carcinoma (B) can also cause jaundice but Courvoisier sign is less typical. Common bile duct stone
(C) usually causes painful jaundice with a non-palpable or fibrotic gallbladder. Acute pancreatitis (E) presents with pain and systemic
illness, not painless progressive jaundice with Courvoisier gallbladder.
53. The second most common pancreatic tumor is neuroendocrine tumor (A). Lymphoma (B), liposarcoma (C), and angiosarcoma (D)
are rare primary pancreatic tumors. Metastatic tumors (E) may involve pancreas but are not classified as primary pancreatic tumor.
54. Courvoisier law states that painless obstructive jaundice with a palpable, non-tender gallbladder suggests malignancy of the
pancreatic head (B). Migratory thrombophlebitis (A) is associated with Trousseau syndrome, not Courvoisier sign. Non-palpable
gallbladder (C) suggests gallstones due to fibrosis. Steatorrhea and tender gallbladder (D) suggest inflammatory disease, while
Charcot triad (E) indicates cholangitis.

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55. The most common site of pancreatic carcinoma is the head of pancreas (A). Body (B), tail (C), and uncinate process (D) are less
commonly involved, while diffuse involvement (E) is not typical of pancreatic ductal adenocarcinoma.
56. Acute pancreatitis is most commonly caused by alcohol use and gallstones (D). H. pylori infection and gastric acid excess (A) are
related to peptic ulcer disease, not pancreatitis. Hepatitis B and iron overload (B) affect the liver. Obesity and hyperlipidemia (C) are
risk factors but not the most classical paired cause in exams.
57. The presentation of fasting hypoglycemia relieved by glucose strongly suggests insulinoma (A), a beta cell tumor of pancreatic
islets. Carcinoma of pancreas (B) typically causes weight loss and pain. Diabetes insipidus (C) is a water balance disorder unrelated to
glucose levels. Hemochromatosis (D) causes endocrine dysfunction but not episodic hypoglycemia.
58. Acute pancreatitis is most commonly caused by alcohol use and gallstones (D). H. pylori infection with acid excess (A) is linked
to peptic ulcer disease. Hepatitis B and iron overload (B) are hepatic conditions. Obesity and hypercholesterolemia (C) are risk factors
but less specific than alcohol and gallstones in classical teaching.
59. Partial gastrectomy (D) is not a recognized risk factor for pancreatic carcinoma. Smoking (A) is the strongest risk factor.
Alcoholism (B) contributes indirectly via chronic pancreatitis. High-fat/meat diet (C) is associated with increased risk. Chronic
pancreatitis (E) is a well-established predisposing condition.
60. Severe pancreatic tissue injury leads to enzymatic fat necrosis (B) due to release of pancreatic lipase causing fat saponification and
chalky deposits. Chronic pancreatitis (A) is a long-term inflammatory outcome. Traumatic fat necrosis (C) is unrelated to pancreatic
enzyme activity. Hemorrhagic pancreatitis (D) is a severe form of acute pancreatitis, and pseudocyst formation (E) is a late
complication rather than direct tissue destruction pattern.
61. This is an incidentaloma with no clinical significance other than observation. Further testing often yields irrelevant findings.
―C t h n r l s ‖ ppro h ppl s. Poly yst s s shows mult pl b n n ysts th t m y h morrh or n t but r non-
neoplastic. Pseudocysts occur after pancreatitis and are lined by granulation tissue, not epithelium.
62. Acute pancreatitis causes fat necrosis with calcium precipitation, leading to hypocalcemia proportional to severity.
Hypoalbuminemia is seen in chronic pancreatitis with malabsorption. Hyperbilirubinemia may occur in gallstone pancreatitis but does
not reflect severity. Fibrinogen increases as an acute-phase reactant but is not severity-specific. Haptoglobin decreases in hemolysis,
not pancreatitis.
63. Hereditary pancreatitis (autosomal recessive) involves SPINK1 mutation, causing uncontrolled trypsin activation and pancreatic
injury. This activates Hageman factor, kallikrein, and complement, worsening inflammation. PRSS1 and SPINK1 mutations increase
pancreatic cancer risk. Amylase and lipase rise due to acinar injury. TGF-β ontr but s to bros s n hron p n r t t s.
64. Clinical and imaging findings suggest acute pancreatitis, often with gallstones. Serum amylase and lipase are rapidly elevated due
to acinar necrosis. Liver enzymes may be abnormal in gallstone disease, but ALT reflects hepatic injury. Hyperammonemia indicates
liver failure. Bilirubin may rise with bile duct obstruction but does not confirm pancreatitis. Islet function is usually preserved.
65. Chronic pancreatitis is commonly due to alcohol, which causes premature enzyme activation and protein-rich ductal plugs leading
to obstru t on n r urr nt njury. Th s r sults n bros s n xo r n lur . Al ohol m y lso us r omyop thy. α1-
antitrypsin deficiency causes liver disease. Cystic fibrosis causes ductal plugging and chronic pancreatitis. Severe hyperlipidemia and
gallstones can trigger acute pancreatitis.
66. Most pancreatic cysts are non-neoplastic (pseudocysts or ADPKD-related). ADPKD rarely involves pancreas without massive
kidney disease. A solitary cystic lesion suggests serous cystadenoma (benign). Adenocarcinomas are solid, infiltrative, and aggressive.
Chronic pancreatitis causes fibrosis; cystic fibrosis leads to pancreatic atrophy. Pseudocysts follow acute or chronic pancreatitis.
67. Severe acute pancreatitis may cause liquefaction necrosis forming a pseudocyst surrounded by granulation tissue (no epithelial
lining). Spread to stomach is uncommon. Hemorrhage remains localized to pancreas and surrounding tissue. Islets of Langerhans
usually remain functional. Pancreatitis does not typically cause systemic organ infarction or insulin deficiency.
68. Findings suggest pancreatic head carcinoma causing painless or painful obstructive jaundice (conjugated hyperbilirubinemia).
Weight loss and pain are typical. Tumor invasion may cause nerve pain. Islet cell adenoma is rare and usually non-obstructive.
Chronic pancreatitis rarely causes biliary obstruction. Pseudocysts are usually in body/tail and are non-neoplastic.
69. Intraductal papillary mucinous neoplasm (IPMN) is a cystic pancreatic tumor that may be noninvasive early and curable. It can
progress to dysplasia and adenocarcinoma. It is not syndromic and does not form pseudocysts after resection.
70. Pancreatic adenocarcinoma is most likely diagnosis. Early detection (PanIN) is rare. Courvoisier sign (palpable gallbladder +
jaundice) suggests malignant biliary obstruction. Prognosis is poor even when detected early. Metastasis, small intestinal carcinoma,
neuroendocrine tumors, and serous cystadenomas are less likely; neuroendocrine tumors are usually benign when small and do not
transform into adenocarcinoma.

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03. Hepatobiliary System

71. A 12 years old with sickle cell anemia presents with recurrent severe right upper quadrant colicky abdominal pain. At the time of
surgery, multiple dark black stones are found within the gallbladder. These stones will likely be composed of which one of the
following substances?
a) Bilirubin c) Cholesterol
b) Carbon d) Urate
e) Calcium oxalate
72. A 47 years old woman presents with a 3 months history of vague upper abdominal pain after meals, some abdominal distention,
and frequent indigestion. Physical examination shows an obese woman with right upper quadrant tenderness. An ultrasound
examination discloses multiple echogenic objects in the gall bladder. Which of the following metabolic change is most likely
associated with the formation of gall stones in this patient?
a) Decreased hepatic bilirubin conjugation c) Increased hepatic calcium secretion
b) Increased bilirubin uptake by the liver d) Increased hepatic cholesterol secretion
e) Decreased bile acid synthesis
73. The liver biopsy from a 41-year-old male with elevated transaminases demonstrates abundant Mallory's hyaline, neutrophils,
necrosis of hepatocytes, and fatty change. Which of the following is the probable etiology for these findings?
a) Acute hepatitis A infection c) Alcoholic hepatitis
b) Sclerosing cholangitis d) Acetaminophen toxicity
e) Viral hepatitis B
74. A 44 old man presents with the sudden onset of severe right upper quadrant abdominal pain, ascites, tender hepatomegaly, and
hematemesis. These symptoms are suggestive of Budd- Chiari syndrome. Which of the following is the most likely cause of this
disorder?
a) Obstruction of the intrahepatic sinusoids c) Thrombosis of hepatic vein
b) Thrombosis of the hepatic artery d) Thrombosis of the portal vein
e) IVC thrombosis
75. An oval lesion is found in the right lobe of the liver in an otherwise asymptomatic 24 year old woman. Surgical resection finds a
single well demarcated lesion that has a prominent, central, stellate white scar. Which of the following diagnoses is most consistent
with this gross appearance?
a) Focal nodular hyperplasia c) Hepatocellular carcinoma
b) Hemangioma d) Nodular regenerative hyperplasia
e) Hepatic adenoma
76. A patient with advanced cirrhosis is prone to show which of the following states?
a) Hypoalbuminemia c) Hypogammaglobulinemia
b) Thrombocytosis d) Hirsutism
e) Hypernatremia
77. Onion skin fibrosis of bile ducts is seen in which of the following conditions?
a) Primary biliary cirrhosis c) Extrahepatic biliary fibrosis
b) Primary sclerosing cholangitis d) Congenital hepatic fibrosis
e) Autoimmune hepatitis
78. Conjugated hyperbilirubinemia is seen in which of the following conditions?
a) Hemolytic anemia c) Crigler-Najjar syndrome
b) Physiologic jaundice of the newborn d) Dubin- Johnson syndrome
e) Gilbert syndrome
79. Which of the following type of cirrhosis is associated with features of obstructive jaundice?
a) Hepatitis B associated cirrhosis c) Primary biliary cirrhosis
b) Alcoholic cirrhosis d) Alpha-1 antitrypsin deficiency
e) Hemochromatosis
80. Oral contraceptives may produce which of the following hepatic neoplasm?
a) Adenoma d) Angiosarcoma
b) Hepatoma e) Focal nodular hyperplasia
c) Cholangioma

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81. A 50 years male patient is having chronic hepatitis B infection. What test will you order to determine active viral replication?
a) HBs antigen c) Anti HBc antibody
b) HBe antigen d) HBV DNA by PCR
e) Anti-HBs
82. Liver biopsy from a patient with chronic liver disease reveals parenchymal nodules surrounded by wide fibrous bands along with
disruption of vascular architecture. Which cells are involved in production of fibrous tissue?
a) Hepatocytes c) Stellate cells
b) Kupffer cells d) Sinusoidal endothelial cells
e) Portal fibroblasts
83. A 55-year-old male patient of chronic Hepatitis B infection is noted to have a right hepatic lobe spaceoccupying lesion on
abdominal ultrasound. Which tumor marker would you suggest to support the diagnosis of hepatocellular carcinoma?
a) Carcinoembryonic antigen c) CA 125
b) Beta HCG d) Alpha fetoprotein
e) LDH
84. Serum alkaline phosphatase is found to be characteristically high in cholestatic conditions. What is the mechanism underlying this
phenomenon?
a) Apoptosis of hepatocytes
b) Apoptosis of bile duct epithelial cells
c) Detergent action of bile salts on hepatocyte cell membrane
d) Retrograde release of enzyme due to biliary tract obstruction
e) Hepatocyte necrosis
85. An autopsy is performed on a 19 years old woman who died from an overdose of acetaminophen. Which of the following
histologic changes is most likely to be seen in a specimen taken from her liver?
a) Centrilobular necrosis c) Geographical necrosis
b) Focal scattered necrosis d) Midzonal necrosis
e) Portal necrosis
86. A family history of chronic liver disease beginning at an early age and a movement disorder developing later in life characterizes a
disease associated with which of the following?
a) A triplet repeat mutation c) Thiamine deficiency
b) Low ceruloplasmin levels d) Excess alcohol intake
e) Hemochromatosis
87. Which of the following worm can cause cholangio-carcinoma?
a) Ascaris lumbricoides c) Ancylostoma duodenale.
b) Clonorchis sinensis d) Schistosoma mansoni
e) Taenia solium
88. The incidence of pigment stones is increased in association with which of the following conditions?
a) Diabetes c) Hypercholesterolemia
b) Atherosclerosis. d) Sickle cell disease
e) Obesity
89. A 30 years old married woman presents to gynaecology OPD for routine checkup. She is taking Oral Contraceptive Pills for
contraception for the last 4 years. She reports slight discomfort in the right hypochrondrium. Ultrasound shows a space occupying
lesion. What can be this lesion?
a) Angiosarcoma c) Hepatocellular carcinoma
b) Hepatic adenoma d) Hydatid cyst
e) Hemangioma
90. Following is the characteristic of Hepatocellular carcinoma:
a) Multiple nodules in the liver c) Marked fibrosis in liver
b) Raised CEA level in blood d) Raised alpha-fetoprotein level in blood
e) Normal LFT
91. Which is not an etiologic agent for hepatocellular carcinoma
a) HBV c) Cirrhosis
b) HCV d) Oral contraceptives
e) Aflatoxin

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92. A female patient of a major depressive disorder ingests an entire bottle of a medication containing acetaminophen. She becomes
progressively obtunded over the next 8 hours. Which of the following microscopic findings is most likely to be present in her 3 days
following this ingestion?
a) Bridging fibrosis c) Portal chronic inflammation
b) Extensive necrosis d) Severe steatosis
e) Regenerative nodules
93. A 54-year-old woman has a long history of chronic hepatitis B infection and has had increasing malaise for the past year. She was
hospitalized 1 year ago because of upper gastrointestinal hemorrhage. Physical examination now shows a firm nodular liver.
Laboratory findings show a serum albumin level of 2.5 g/dL and prothrombin time of 28 seconds. Which of the following additional
physical examination findings is most likely to be present in this woman?
a) Caput medusae c) Distended jugular veins
b) Diminished deep tendon reflexes d) Papilledema
e) Splinter hemorrhage
94. A study of patients with ascites includes measurements of serum and ascitic fluid protein levels. The serum-ascites albumin
gradient (SAAG) is calculated. Some patients are found to have a high gradient, along with splenomegaly. They are found to have
serum albumin less than 2.5 g/dL Which of the following conditions is most likely to produce a SAAG greater than 1.1?
a) Budd-Chiari syndrome c) Nephrotic syndrome
b) Cirrhosis d) Pancreatitis
e) Peritonitis
95. A 65-year-old man with a history of alcohol abuse has had hematemesis for the past day. Physical examination reveals mild
jaundice, spider angiomas, and gynecomastia. He has mild pedal edema, normal jugular venous pulsation (JVP), and a massively
distended abdomen. Paracentesis is performed and the fluid obtained shows accumulation of protein-poor fluid that is free of
inflammatory cells. Which of the following factors is most likely to be responsible for the collection of abdominal fluid in this man?
a) Congestive heart failure c) Hyperbilirubinemia
b) Hepatopulmonary syndrome d) Portosystemic shunts
e) Splanchnic arterial vasodilation
96. A 59-year-old man has had increasing dyspnea on exertion for the past year. His dyspnea is worse in the upright position and
diminishes when he is recumbent. On physical examination he has clubbing of the fingers. Exercise induces a decrease in his Po2 that
improves when he stops and lies down. Which of the following liver abnormalities is he most likely to have?
a) Biliary obstruction c) Cirrhosis
b) Chronic inflammation d) Metastases
e) Steatosis
97. A 50-year-old man has a history of chronic alcoholism, but he stopped drinking alcohol 10 years ago. He has been tak ing no
medications. On physical examination, he is afebrile. The abdomen is not enlarged, and there is no tenderness. The liver span is
normal. Serologic test results for hepatitis A, B, and C are negative. The hematocrit is 35%. Which of the fol lowing morphologic
features is most likely to be present in his liver?
a) Con ntr ―on on-sk n‖ b l u t bros s c) Interface hepatitis
b) Hepatic venous thrombosis d) Massive hepatocellular necrosis
e) Portal fibrosis with regenerative nodules
98. In a clinical study, patients with infectious hepatitis, including viral hepatitis A, B, C, D, E, F, and G, are followed for 5 years.
During that time, prothrombin time, serum AST, ALT, alkaline phosphatase, total bilirubin, and ammonia are periodically measured.
A liver biopsy is performed each year, and the microscopic findings are recorded. Which of the following is most likely the best
predictor of whether a patient with viral hepatitis will develop chronic liver disease that progresses to cirrhosis?
a) Degree to which hepatic transaminases are elevated c) Presence of chronic inflammatory cells in the portal tract
b) Length of time that hepatic enzymes remain elevated d) Presence of inflammatory cells in the hepatic sinusoids
e) Specific form of hepatitis virus responsible for the infection
99. A 30-year-old man had a 2-week episode of malaise, fever, and jaundice 7 years ago. On physical examination, there were needle
tracks in the left antecubital fossa. Sero logic test results were positive for HBsAg, HBV DNA, and IgG anti-HBc. Two years later, he
was seen in the emergency department because of hematemesis and ascites. Serologic test results were similar to those reported
earlier. Five years after this episode, he now has a 5-kg weight loss, worsening abdominal pain, and rapid enlargement of the abdomen
over the past month. Physical examination shows an increased liver span. An increase in which of the following is most likely to be
diagnostic of this end stage of his disease?
a) Serum alanine aminotransferase (ALT) level b) Serum alkaline phosphatase level

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c) S rum α-fetoprotein level d) Serum ammonia level

e) Serum ferritin level
100. A 42-year-old man experiences malaise and increasing icterus for 2 weeks. Physical examination shows jaundice, but there are no
other significant findings. Serologic test results are positive for IgM anti-HAV and negative for anti-HCV, HBsAg, and IgM anti-HBc.
Which of the following outcomes is most likely to occur in this man?
a) Chronic active hepatitis c) Fulminant hepatitis
b) Complete recovery d) Hepatocellular carcinoma
e) Negative serologic test results
101. A 41-year-old woman who works as a tattoo artist has had increasing malaise and nausea for the past 2 weeks. On physical
examination, she has icterus and mild right upper quadrant tenderness. Laboratory studies show serum AST of 79 U/L, ALT of 85
U/L, total bilirubin of 3.3 mg/dL, and direct bilirubin of 2.5 mg/dL. She continues to have malaise for the next year. A liver biopsy is
done, and microscopic examination shows minimal hepatocyte necrosis, mild steatosis, and minimal portal bridging fibrosis. An
infection with which of the following viruses is most likely to produce these findings?
a) HAV c) HCV
b) HBV d) HDV
e) HEV
102. A 52-year-old woman has experienced worsening malaise during the past year. On physical examination, she has mild scleral
icterus. There is no ascites or splenomegaly. Sero logic test results are positive for IgG anti-HCV and HCV RNA and negative for
anti-HAV, HBsAg, ANA, and antimitochondrial antibody. The serum AST level is 88 U/L, and ALT is 94 U/L. Her condition remains
stable for months. Which of the following morpholo n n s s most l k ly to b pr s nt n th s p t nt‘s l v r?
a) Con ntr ―on on-sk n‖ b l u t bros s c) Granulomatous bile duct destruction
b) Copper deposition within hepatocytes d) Hepatic venous thrombosis
e) Interface hepatitis
103. A 31-year-old woman has experienced increasing malaise for the past 4 months. Physical examination yields no remark able
findings. Laboratory studies show total serum protein of 6.4 g/dL, albumin of 3.6 g/dL, total bilirubin of 1.4 mg/dL, AST of 67 U/L,
ALT of 91 U/L, and alkaline phosphatase of 99 U/L. Results of serologic testing for HAV, HBV, and HCV are negative. Test results
for ANA, anti-liver kidney microsome-1, and anti–smooth muscle antibody are positive. A liver biopsy is done; microscopically, there
are minimal portal mononuclear cell infiltrates with minimal interface hepatitis and mild portal fibrosis. What is the most likely
diagnosis?
a) α1-Antitrypsin deficiency c) Chronic alcoholism
b) Autoimmune hepatitis d) HDV infection
e) Isoniazid ingestion
104. A study of hepatic injury is undertaken. Patients with fulminant hepatic failure are found to have microscopic evidence in
biopsies for ballooning hepatocyte degeneration, canalicular bile plugs, bridging necrosis, and minimal inflammation. Which of the
following is most likely to cause this pattern of hepatic damage?
a) α1-Antitrypsin deficiency c) Hepatitis C virus infection
b) Chronic alcohol abuse d) Isoniazid toxicity
e) Wilson disease
105. A 28-year-old woman, G3, P2, is in the 35th week of a previously uncomplicated pregnancy when she develops increasing
lethargy with nausea, vomiting, and jaundice over a 10-day period. On physical examination, she has generalized jaundice and
scattered ecchymoses over the trunk and extremities. Laboratory studies show total serum bilirubin of 5.8 mg/dL, AST of 122 U/L,
ALT of 131 U/L, and alkaline phosphatase of 125 U/L. Which of the following histologic features is most likely to be found in a liver
biopsy specimen?
a) Concentric bile duct fibrosis c) Inflammation with loss of intrahepatic bile ducts
b) Extensive intrahepatic hemosiderin deposition d) Marked micro-vesicular steatosis
e) Multinucleated giant cells
106. A 41-year-old, previously healthy woman has noted abdominal discomfort for the past month. Laboratory studies show normal
serum total protein, albumin, AST, ALT, and bilirubin, but her alkaline phosphatase level is elevated. Serologic testing for hepatitis A,
B, and C viruses is negative. Abdominal CT scan shows a 9-cm right hepatic lobe mass with irregular borders. The lesion is resected,
and gross inspection reveals a central stellate scar with radiating fibrous septa that merge into surrounding hepatic parenchyma. On
microscopic examination, the mass has prominent arteries in dense connective tissue along with lymphocytic infiltrates and bile duct
proliferation. What is the most likely diagnosis?
a) Cholangiocarcinoma b) Focal nodular hyperplasia

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c) Hepatic adenoma d) Hepatocellular carcinoma

e) Macronodular cirrhosis
107. A 36-year-old woman is in the sixth month of her first pregnancy, but she is unsure of her dates because she was taking oral
contraceptives at the time she became pregnant. She experiences sudden onset of severe abdominal pain. On physical examination, she
is afebrile and normotensive. There is right upper quadrant tenderness on palpation. An ultra sound scan of the abdomen shows a well-
circumscribed, 7-cm subcapsular hepatic mass. Paracentesis yields bloody fluid. At laparotomy, the mass in the right hepatic lower
lobe, which has ruptured through the liver capsule, is removed. The remaining liver parenchyma appears to be of uniform consistency,
and the liver capsule is otherwise smooth. Which of the following is the most likely diagnosis?
a) Cholangiocarcinoma c) Choriocarcinoma
b) Choledochal cyst d) Focal nodular hyperplasia
e) Hepatic adenoma
108. A 36-year-old woman has become increasingly icteric for 1 month. She has had several bouts of colicky, mid abdominal pain for
3 years. On physical examination, she has generalized jaundice with scleral icterus. Her BMI is 32. There is tenderness in the right
upper quadrant, and the liver span is normal. A liver biopsy is obtained, and microscopic examination shows bile duct proliferation
and intracanalicular bile stasis, but no inflammation or hepatocyte necrosis. The level of which of the following is most likely to be
increased in the patient‘s s rum?
a) Alkaline phosphatase c) Antimitochondrial antibody
b) Ammonia d) Hepatitis C antibody
e) Indirect bilirubin level
109. A 34-year-old woman from Kobe, Japan, has experienced intermittent upper abdominal pain for 3 weeks. Physical examination
yields no remarkable findings. Laboratory findings show total serum protein of 7.3 g/dL, albumin of 5.2 g/dL, total bilirubin of 7.5
mg/dL, direct bilirubin of 6.8 mg/dL, AST of 35 U/L, ALT of 40 U/L, and alkaline phosphatase of 207 U/L. Representative
microscopic findings in her liver include intracanalicular cholestasis in the centrilobular regions, swollen liver cells, and portal tract
edema, but no necrosis and no fibrosis. Which of the following underlying conditions is she most likely to have?
a) Cardiomyopathy c) Hemoglobinopathy
b) Choledochal cyst d) Hepatitis B viral infection
e) Ulcerative colitis
110. A 55-year-old man has developed abdominal pain and jaundice over 5 weeks. On physical examination, there is right upper
quadrant pain, but no abdominal distention. Abdominal CT scan shows a markedly thickened gallbladder wall. A cholecystectomy is
performed, and sectioning shows an enlarged gallbladder containing a fungating, 4 × 7 cm firm, lobulated, tan mass. Which of the
following risk factors is most likely associated with this mass?
a) Alcohol abuse c) Clonorchis sinensis infection
b) Cholelithiasis d) Primary sclerosing cholangitis
e) Ulcerative colitis

ANSWER KEY
71. A 72. D 73. C 74. C 75. A 76. A 77. B 78. D 79. C 80. A
81. B 82. C 83. D 84. C 85. A 86. B 87. B 88. D 89. B 90. D
91. D 92. B 93. A 94. B 95. E 96. C 97. E 98. E 99. C 100. B
101. C 102. E 103. B 104. D 105. D 106. B 107. E 108. A 109. B 110. B

71. The correct answer is bilirubin (A). In sickle cell anemia, chronic hemolysis leads to excess unconjugated bilirubin, which
precipitates in the gallbladder forming black pigment stones. Cholesterol stones (C) are seen in metabolic conditions like obesity and
are yellow. Carbon (B) and urate (D) are not components of gallstones, while calcium oxalate (E) is associated with renal stones, not
biliary disease.
72. The correct mechanism is increased hepatic cholesterol secretion (D). In obese patients, hepatic hypersecretion of cholesterol leads
to bile supersaturation and cholesterol stone formation. Decreased bilirubin conjugation (A) and increased uptake (B) are related to
pigment stones. Increased calcium secretion (C) is not a primary mechanism, while decreased bile acid synthesis (E) contributes but is
secondary to cholesterol excess.
73. The findings are typical of alcoholic hepatitis (C). Mallory bodies, neutrophilic infiltration, hepatocyte necrosis, and fatty change
are classic histological features. Hepatitis A (A) causes acute viral hepatitis without Mallory hyaline. Sclerosing cholangitis (B) affects

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bile ducts, not hepatocytes. Acetaminophen toxicity (D) causes centrilobular necrosis without Mallory bodies, and hepatitis B (E)
shows viral cytopathic changes.
74. The most likely cause of Budd-Chiari syndrome is thrombosis of hepatic veins (C), leading to hepatic outflow obstruction,
hepatomegaly, ascites, and abdominal pain. Sinusoidal obstruction (A) is veno-occlusive disease. Hepatic artery thrombosis (B) causes
ischemia but not venous congestion. Portal vein thrombosis (D) causes portal hypertension but not Budd-Chiari syndrome.
75. The lesion is focal nodular hyperplasia (A), characterized by a well-circumscribed mass with a central stellate scar due to
abnormal vascular response. Hemangioma (B) is a vascular lesion without scar. Hepatocellular carcinoma (C) is malignant and lacks a
central scar. Nodular regenerative hyperplasia (D) shows diffuse nodularity without a dominant mass.
76. In advanced cirrhosis, hypoalbuminemia (A) is expected due to impaired hepatic synthetic function. Thrombocytosis (B) is
incorrect, as cirrhosis typically causes thrombocytopenia due to hypersplenism. Hypogammaglobulinemia (C) is false because
immunoglobulins are often elevated. Hirsutism (D) may occur due to hormonal imbalance but is not a primary feature.
77. Onion-skin fibrosis of bile ducts is characteristic of primary sclerosing cholangitis (B), which causes progressive obliteration of
intrahepatic and extrahepatic bile ducts. Primary biliary cirrhosis (A) shows florid duct lesions. Extrahepatic biliary fibrosis (C) is
nonspecific. Congenital hepatic fibrosis (D) is developmental, and autoimmune hepatitis (E) involves hepatocellular injury rather than
bile ducts.
78. Dubin-Johnson syndrome (D) causes conjugated hyperbilirubinemia due to defective canalicular excretion of conjugated bilirubin.
Hemolytic anemia (A), physiologic neonatal jaundice (B), Crigler-Najjar (C), and Gilbert syndrome (E) all cause unconjugated
hyperbilirubinemia.
79. Primary biliary cirrhosis (C) is associated with cholestatic features and obstructive-type jaundice due to autoimmune destruction of
intrahepatic bile ducts. Hepatitis B (A) and alcoholic cirrhosis (B) cause hepatocellular injury patterns. Alpha-1 antitrypsin deficiency
(D) and hemochromatosis (E) primarily cause parenchymal liver disease rather than cholestasis.
80. Oral contraceptive use is associated with hepatic adenoma (A), a benign hepatocellular tumor. Hepatocellular carcinoma (B) is
linked to viral hepatitis and cirrhosis. Cholangiocarcinoma (C) arises from bile ducts. Angiosarcoma (D) is linked to vinyl chloride
exposure, and focal nodular hyperplasia (E) is a benign vascular response, not a true neoplasm.
81. HBe antigen (B) indicates active viral replication and high infectivity in hepatitis B infection. HBsAg (A) indicates infection but
not replication status. Anti-HBc (C) reflects exposure. HBV DNA PCR (D) is the most sensitive marker of viral load but HBeAg is the
classical marker in exams. Anti-HBs (E) indicates immunity.
82. Hepatic stellate cells (C) are the primary source of collagen and fibrous tissue in cirrhosis after activation. Hepatocytes (A) do not
produce collagen. Kupffer cells (B) mediate inflammation but do not form fibrosis. Endothelial cells (D) are structural, and portal
fibroblasts (E) contribute but are less important than stellate cells.
83. Alpha-fetoprotein (D) is the most important tumor marker for hepatocellular carcinoma. CEA (A) is associated with colorectal
n r. β-hCG (B) is a marker for germ cell tumors. CA-125 (C) is used in ovarian cancer. LDH (E) is nonspecific and elevated in
many malignancies.
84. The increase in alkaline phosphatase in cholestasis is mainly due to increased synthesis in bile duct epithelial cells under
conditions of bile flow obstruction (C). Hepatocyte apoptosis (A) and bile duct apoptosis (B) are not primary mechanisms. Back
diffusion (D) is partial but not the main cause. Enzyme induction in biliary epithelium is the key mechanism.
85. Acetaminophen toxicity leads to centrilobular (zone 3) necrosis (A) due to accumulation of toxic metabolites via cytochrome P450
metabolism. Focal necrosis (B) is seen in viral hepatitis. Geographic necrosis (C) suggests ischemia. Midzonal necrosis (D) is typical
of yellow fever, and portal necrosis (E) is not characteristic.
86. Wilson disease (B), caused by defective copper metabolism and low ceruloplasmin levels, presents with liver disease and
neurological movement disorders. Huntington disease (A) is a trinucleotide repeat disorder affecting the brain. Thiamine deficiency
(C) causes Wernicke encephalopathy. Alcohol (D) causes toxic liver injury but not inherited movement disorders, while
hemochromatosis (E) causes iron overload.
87. Clonorchis sinensis (B) is strongly associated with cholangiocarcinoma due to chronic bile duct irritation and inflammation.
Ascaris (A) causes intestinal obstruction. Ancylostoma (C) causes anemia. Schistosoma mansoni (D) causes portal hypertension, and
Taenia solium (E) causes cysticercosis, not biliary malignancy.
88. Sickle cell disease (D) causes chronic hemolysis leading to increased bilirubin production and pigment gallstones. Diabetes (A),
atherosclerosis (B), and obesity (E) are associated with cholesterol stones. Hypercholesterolemia (C) also promotes cholesterol
gallstones rather than pigment stones.

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89. Hepatic adenoma (B) is associated with oral contraceptive use and presents as a solitary liver lesion in young women.
Angiosarcoma (A) is linked to toxins like vinyl chloride. Hepatocellular carcinoma (C) is associated with chronic hepatitis. Hydatid
cyst (D) is parasitic, and hemangioma (E) is a benign vascular malformation.
90. Alpha-fetoprotein (D) elevation is a characteristic finding in hepatocellular carcinoma. Multiple nodules (A) may occur but are
nonspecific. CEA (B) is related to colorectal malignancy. Marked fibrosis (C) reflects cirrhosis, not tumor itself. Normal LFTs (E)
may occur but are not diagnostic.
91. Oral contraceptive use (D) is not a recognized cause of hepatocellular carcinoma. Hepatitis B (A), hepatitis C (B), cirrhosis (C),
and aflatoxin exposure (E) are well-established etiological factors for hepatocellular carcinoma.
92. Acetaminophen overdose leads to extensive hepatic necrosis (B), typically centrilobular due to toxic metabolite accumulation.
Bridging fibrosis (A) is seen in chronic liver disease. Portal inflammation (C) is characteristic of viral hepatitis. Steatosis (D) occurs in
fatty liver disease, while regenerative nodules (E) appear in chronic liver injury rather than acute toxicity.
93. Cirrhosis with portal hypertension causes esophageal varices and caput medusae due to collateral circulation. Hepatic
encephalopathy may cause hyperreflexia, not reduced reflexes. Right heart failure causes hepatomegaly and jugular venous distension.
Hepatic coma may occur, but papilledema is uncommon. Coagulopathy causes purpura, whereas splinter hemorrhages suggest
infective endocarditis.
94. Serum- s t s lbum n r nt (SAAG) = s rum lbum n − s t lbum n; t r l ts port l pr ssur . C rrhos s us s port l
hyp rt ns on n tr nsu t v s t s (SAAG ≥ 1.1). Hypo lbum n m r sults rom r u h p t synth s s. ow SAAG (<1.1)
indicates exudative ascites (infection, malignancy, pancreatitis).
95. Alcoholic cirrhosis causes portal hypertension via sinusoidal distortion and increased splanchnic NO-mediated vasodilation,
leading to hyperdynamic circulation and ascites. Normal JVP excludes heart failure. Hyperbilirubinemia reflects liver failure.
Hepatopulmonary syndrome involves pulmonary vasodilation, not liver disease alone. Varices arise from portosystemic shunts.
96. Hepatopulmonary syndrome causes hypoxemia due to intrapulmonary vascular dilatation and V/Q mismatch. Other listed
conditions do not cause portal hypertension. Steatosis and inflammation alone do not explain hypoxemia. Metastases preserve liver
function. Biliary obstruction causes jaundice, not pulmonary vascular changes.
97. Cirrhosis shows bridging fibrosis and regenerative nodules. Regression may show thin fibrous septa and ductular reaction.
Variceal bleeding reflects portal hypertension. Alcohol abstinence does not reverse architecture. PSC causes concentric bile duct
fibrosis. Budd-Ch r us s h p tom ly n on st on. Int r h p t t s su sts v r l h p t t s. α1-antitrypsin deficiency is less
common cause.
98. HCV infection most commonly progresses to chronic hepatitis and cirrhosis. HAV, HEV, and HGV rarely become chronic. Viral
type, not enzyme level or histology, best predicts chronicity.
99. Chronic HBV infection is indicated by persistent HBsAg, HBV DNA, and anti-HBc IgG. IV drug users have high HBV/HCV risk.
Cirrhosis leads to variceal bleeding and ascit s. H p to llul r r nom s su st by w ht loss, s t s, n ↑AFP. A P
elevation indicates liver mass. Ammonia rises in liver failure.
100. IgM anti-HAV indicates acute hepatitis A. HAV does not become chronic. Transmission is fecal-oral (e.g., contaminated
shellfish). Viremia is short-lived, so blood transmission is rare.
101. HCV most commonly causes chronic hepatitis (>50%). Portal bridging fibrosis indicates chronic disease. Steatosis is common in
HCV. Lack of protective immunity allows persistence.
102. HCV causes chronic hepatitis with interface hepatitis and progression to cirrhosis via bridging fibrosis. PSC shows bile duct
fibrosis. Wilson disease causes copper deposition. PBC causes granulomatous bile duct destruction. Budd-Chiari causes hepatic
congestion and ascites.
103. Autoimmune hepatitis involves autoantibodies against hepatocytes, causing chronic inflammation and cirrhosis; responds to
st ro s. α1-antitrypsin deficiency and Wilson disease cause chronic hepatitis but are antibody-negative. Alcoholic liver disease is
non-autoimmune. PBC shows antimitochondrial antibodies with higher cholestatic enzymes.
104. Isoniazid can cause acute or massive hepatic necrosis. Toxicity may be silent until severe. Other listed conditions usually cause
chronic liver injury.
105. Acute fatty liver of pregnancy shows micro-vesicular steatosis due to mitochondrial fatty acid oxidation defect. PSC causes bile
duct fibrosis. Hemochromatosis causes iron overload in middle age. Biliary atresia is neonatal. PBC us s u t loss. α1-antitrypsin
deficiency shows PAS-positive globules.

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106. Focal nodular hyperplasia is a benign, well-circumscribed lesion with central scar. Adenoma is linked to OCP use. HCC and
cholangiocarcinoma are malignant and associated with hepatitis/cirrhosis. Metastases may be multiple or necrotic. Cirrhosis is diffuse,
not focal.
107. H p t nom o urs n youn wom n on OCPs n m y ruptur n pr n n y. M y nvolv HNF1α or β-catenin mutations.
HCC/cholangiocarcinoma are associated with chronic liver disease and occur in older patients. Choledochal cysts are congenital.
Hepatoblastoma occurs in children. Choriocarcinoma metastasis is unlikely as solitary liver lesion.
108. Obstructive jaundice causes elevated ALP due to cholestasis. Direct bilirubin increases in biliary obstruction. Hyperammonemia
occurs in liver failure with encephalopathy. PBC shows antimitochondrial antibodies but is less common. HCV causes chronic
inflammation. Only conjugated bilirubin rises in obstruction.
109. G llston s us nt rm tt nt RUQ p n n obstru t v j un w th ↑ onju t b l rub n n ↑A P. Chol o h l ysts r
rare (more in Japan). Hemolysis causes unconjugated bilirubin. Viral hepatitis causes hepatocellular injury. PSC is associated with
ulcerative colitis. Veno-occlusive disease is rare and not obstructive.
110. Gallbladder carcinoma is usually adenocarcinoma and strongly associated with gallstones. Alcohol is not a risk factor. Clonorchis
sinensis increases risk of cholangiocarcinoma, not gallbladder cancer. PSC increases cholangiocarcinoma risk. Ulcerative colitis is
linked to PSC.

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GIT & NUTRITION

MEDICINE
GE-013 ֍GERD֍

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Retrosternal burning sensation (Heart Burn)
 Regurgitation and waterbrash
 Epigastric pain (Provoked/Worsened by Bending, straining OR Lying Down)

1. A 55-year-old male presents with two months history of retrosternal pain and reflux of food contents sometimes reaching to the
pharynx whenever he bends forward during prayers. He also has night time attacks of cough and wheeze. The physical examination is
unremarkable. [Supple 2019 held in 2020]
a) What is the most likely diagnosis?
GERD
b) Enlist the treatment options.
1. Life style measures
 Weight Loss + Avoidance of late–night meals + Cessation of smoking
 Avoidance of dietary tems that worsen the symptoms e.g., Fatty, Spicy and Acidic Foods; also, Alcohol & Coffee.
 Elevation of ed head (By 6 Inches) in those experiencing nocturnal symptoms (Coughing, Regurgitation)
 Avoidance of provoking / exacerbating factors of Reflux i.e., straining, bending at waist OR Stooping
2. Medical treatment
 Antacids  Mg(OH)2, Al(OH)3
 PPIs  Therapy of Choice
 H2–Receptor Antagonists (Ranitidine, Famotidine)
3. Surgical treatment  Fundoplication
c) Write any four complications associated with GERD? Eosinophilic esophagitis
1. Reflux (erosive) Esophagitis  Young men with dysphagia
2. Benign Esophageal Stricture  Hx of eczema/asthma
3. Anemia (Iron Deficiency)  Tx: Dietary modification, 8 weeks PPI
4. B rr tt‘s Esoph us trial. If not responding then topical steroid
rd (fluticasone/budesonide)
5. Esophageal Adenocarcinoma in Lower 1/3

3. A middle-aged lady has presented with severe burning sensation behind the sternum along with regurgitation and feeling of
stickiness of food at the level of xiphisternum. On examination, she is an obese lady with normal physical examination. [Supple 2007
held in 2008]
a) What is the likely diagnosis?
GERD Risk factor for GERD  central obesity >>
smoking
b) Name at least three specific tests to confirm the diagnosis.
Aquaporin 4 positive serum antibody
1. Endoscopy  Investigation of choice
2. 24 Hour esophageal pH Monitoring (<4 pH) Gold standard
3. Esophageal impedance testing to detect alkaline reflux
4. Barium Swallow / Meal
Do You Know!
In case of GERD, investigations are done only if:
Aquaporin 4 positive serum antibody
 P t nt‘s s > 50–55 Years
 If atypical symptoms (cough, recurrent chest infection, hoarseness, weight loss)
 Any complication is suspected
Otherwise, it is Treated Empirically (With PPIs) Without Investigations!

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GE-014 ֍ACHALASIA֍

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Age < 50 years
 Dysphagia for both Solids & Liquids from the start
 Long duration (in years)
 Slight ease by taking Liquids with solid Food, Standing & moving around
after eating
 Regurgitation (chest pain) – Heart burn
 Weight Loss but no anorexia

1. A 35-year-old man presents with retrosternal discomfort after taking meal. The difficulty is more with eating solid foods and is less
for soft foods. Taking water with solid foods helps to some extent. More recently he has started having chest pain with food intake. He
also complains of 2-4 kg of weight loss. Examination is unremarkable. [Annual 2022]
a) What is your diagnosis?
Achalasia
b) Enlist investigations to confirm diagnosis? Always do endoscopy before Manometry to
1. Upper GI Endoscopy to rule out pseudo-achalasia rule out pseudoachalasia (cardia carcinoma)
2. Barium Swallow – Rat t l B r ‘s beak ± Retrocardiac air-fluid level b/c it can mimic clinical, barium swallow &
3. Esophageal Manometry is Gold Standard manometric features of Achalasia
c) List treatment options.
Treatment Modality Description / Comments
Medical  Nitrates or Calcium channel blockers such as Nifedipine
Endoscopic  Forceful endoscopic pneumatic dilatation of LES
 Endoscopically directed Injection of Botulinum Toxin (BOTOX)
Surgical  p ros op H ll r‘s Myotomy followed by Partial Fundoplication + PPIs to prevent GERD
(Treatment of choice)  Esophagectomy
Aquaporin 4 positive serum antibody

GE-016 ֍ESOPHAGEAL CARCINOMA֍

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Age > 50 years
 Progressive Dysphagia
 Smaller durations (months)
 Weight Loss + Anorexia
 Palpable Lymph nodes in the neck

1. A 55-year-old heavy smoker presents with progressive dysphagia to solids and a significant weight loss over the last three months.
On examination, he is pale and emaciated with no other detectable clinical abnormalities. [Supple 2012 held in 2013]
a) Give two most likely possibilities of this clinical condition.
Esophageal stricture
 Esophageal Carcinoma – most likely diagnosis
 Hx of GERD or Bisphosphonate
 Benign Esophageal Stricture  Intermitent dysphagia + Heart burn
 Achalasia  Tx: Endoscopic Dilatation
b) Write down three most useful investigations for this case.
1. For Diagnosis
 Upper GI endoscopy + Biopsy – diagnostic IOC
2. For Staging
 Endoscopic ultrasonography for local tumor
 CT chest & abdomen for metastatic tumor
3. Ro rule out achalasia
 Esophageal manometry to rule out achalasia
Aquaporin 4 positive serum antibody
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CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

c) Enumerate two most important steps in the management of this case.

1. Surgery – depends upon stage
2. Palliative care
Stage Treatment
CIS  Endoscopic Mucosal Resection (EMR) +/– Radiofrequency ablation
T1 – T3  Orringer Trans–hiatal Esophagectomy  Procedure of Choice
 Neoadjuvant Chemotherapy / Radiotherapy
 Local Lymphadenectomy (if N present)
T4, M1  Surgery is contraindicated
 Palliative measures

GE-024 ֍HEMATEMESIS֍

1. A 38-year-old barber presents to the emergency with hematemesis. On examination, he is pale with pulse rate 110/min and a BP of
90/60. [Annual 2012]
a) What are the four most likely causes of his condition?
Most Common cause of Bleeding in:
1. Peptic Ulcer Disease  Upper GI  Peptic Ulcer Disease
2. Erosive Gastritis / Esophagitis  Lower GI  Diverticular Disease
3. Esophageal Varices
4. Mallory Weiss Tear High urea levels can indicate an upper GI
5. AV malformations (Dieulafoy lesion) bleed versus lower GI bleed
6. Esophageal / Gastric Cancer
b) Enumerate the four most important procedures in the management of this patient.
Aquaporin 4 positive serum antibody
Source of Bleeding Procedures
Non–Variceal 1. Endoscopic Dual Therapy (Clipping & Adrenaline)
Aquaporin 4 positive serum antibody
2. Angiography with Trans–Catheter Embolization
Variceal 3. Endoscopic Band Ligation – Procedure of Choice
4. Ballon Tamponade
5. Transjugular Intrahepatic Portosystemic Stent Shunt (TIPSS)

2. A female presents with vomiting which contains blood clots. She has 6 episodes since morning and is now feeling very lethargic.
Her general physical examination is unremarkable except she is cold and looks pale. [Supple 2021 held in 2022]
a) What initial investigations must be performed in this Patient?
1. Full Blood Count (FBC)
2. Urea & Electrolytes
3. Liver Function Tests (LFTs)
4. Prothrombin Time
5. Cross-Matching
6. Upper GI Endoscopy
b) What are five basic steps of management irrespective of etiology?
1. Hospital admission and Gain IV Access using 2 Large-bore Canulae
2. Perform initial clinical assessment of the patient
 Check vitals
 Seek evidence of liver disease, CVS or renal disease
3. Perform basic investigations as described above
4. Resuscitation
 IV Crystalloids OR Blood Transfusion if HB < 7g/dl]
 Oxygen monitoring via Pulse oximetry; Target levels (94% - 98% saturation)
5. Urgent Endoscopy within 24 hours should be carried out to find out the cause of bleeding as well to treat it + Post Endoscopy
PPI's

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GE-025 ֍ABDOMINAL PAIN֍

1. A 35-year-old person presents with history of persistent pain in upper abdomen for the past two months. There is no history of
previous illness and he denies taking any medicines. His father died of a tumor in the abdomen in his mid-40. On examination, he is
pale and has tenderness in the epigastrium. [Annual 2007]
a) What are the differential diagnoses? Name at least four conditions.
 Chronic Pancreatitis
 Peptic Ulcer Disease
 Malignancies (Gastric / pancreatic Cancer)
 Functional cause e.g., Centrally mediated Abdominal Pain syndrome
b) Name at least three specific investigations to confirm the diagnosis.
1. Upper GI Endoscopy + Biopsy
2. Barium Meal
3. Endoscopic Ultrasound
4. Contrast Enhanced CT Abdomen – investigation of choice for chronic pancreatitis

GE-026 ֍PEPTIC ULCER DISEASE֍

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of NSAIDs Intake / H. Pylori Infection
 Epigastric abdominal Pain, that episodic & eating–associated
 Coffee colored Vomitus (Hematemesis) and / Black, tarry Stools (Melena)
indicates bleeding ulcer

1. A 55-year-old male presents with two days history of burning in epigastrium with nausea and vomiting. He had passed a black tarry
foul smelling stool this morning and is worried. He gives history of intake of some medication for his joint pain. The physical
examination is unremarkable. [Annual 2019]
a) What is the most likely diagnosis and what is the cause? Enumerate four other probable causative factors for such
presentation.
Peptic Ulcer Disease
Cause  Intake of Medications for Joint Pain (Most likely NSAIDs)
Other Causative Factors
1. H. Pylori Infection
2. Cigarette Smoking
3. Alcohol intake
4. Severe Physiological stress
5. Zollinger–Ellison Syndrome
b) What can be the two differentials?
1. NSAIDs induced–Acute erosive Gastritis
2. Gastric Cancer
3. Mallory–Weiss Tears Zollinger Ellison Syndrome
c) What investigations are available for diagnosis of a bacterial infection  Recurrent ulcers
causing these symptoms and what four drugs you will  Gastrinomas (duodenum > pancreas)
use for the treatment?  Ix  Secretin stimulation test (↑
Non-invasive gastrin after secretin administration)
1. Serology  H2 blockers – no role unlike in peptic
2. Urea breath test – highly sensitive & specific ulcer
3. Fecal antigen test – cheap & specific  Tx: Octreotide analogue
Invasive
Most appropriate test to ensure successful
1. Histology
eradication of H. pylori  C13 Urea Breath
2. Rapid urease test – cheap & specific test.
3. Culture on biopsy – Gold standard

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CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

Drugs
 PPIs (Omeprazole, Esomeprazole)
 Clarithromycin
 Penicillin (Amoxicillin)
 Metronidazole
 Bismuth salt

2. A 45-year-old obese male gave history of periodic epigastric pain radiating to the back particularly 2-4 hours after meals and
occasionally at bed time. There was no history of smoking or use of NSAIDs. However, he is fond of eating junk food. On
examination, there is no history of Diabetes Mellitus, Hypertension and Ischemic Heart Disease. His BP is 120/80 mm Hg, pulse is
80/min which is regular and there is no hepatomegaly. Lab investigations showed CBC 10x10^9/L, Hb 13.5 g/dL and platelets are
234x10^9/L. His liver function tests (LFTs) are: ALT 85 IU, AST 75 IU, ALP 140 IU. BUN and Serum Creatinine levels are normal.
[Annual 2016]
a) What is the most likely diagnosis? List two other possibilities.
Peptic Ulcer Disease Feature Gastric ulcer Duodenal ulcer
1. Gastric Cancer Site Antrum 1st part
2. Mallory–Weiss Tears Anterior Peritonitis Peritonitis
b) What further investigations are required to confirm diagnosis and etiology? wall
For Diagnosis Posterior Bleeding from Bleeding from
 Upper GI Endoscopy + Biopsy wall splenic artery gastroduodenal
artery
 Barium Meal
Relation ↑ After food Relieved by
For Etiology
e food food
 See Q1c
c) Outline the management of your most likely diagnosis.
Medical
1. H. pylori Eradication Triple Therapy:
o PPI (20mg omeprazole) + Clarithromycin (500mg) + Amoxicillin (1g)/ Metronidazole (500mg)
2. H. pylori Eradication Quadruple Therapy:
o PPIs + Tetracycline + Metronidazole + Bismuth Salt (Bismuth Salicylate)
3. Rescue Therapy
o PPIs + Clarithromycin + Levofloxacin Bismuth requires acidic environment; should
Surgical not be given with PPI at same time
For Duodenal ulcers
o Truncal Vagotomy + Gastric Drainage (Pyloroplasty)  Mainstay / Treatment of Choice
o Alternatives are; Gastrectomy in the Form of Billroth–I / Billroth–II and Gastrojejunostomy.
For Gastric ulcers:
o Billroth–I  Mainstay / Treatment of Choice

GE-035 & GE-043 ֍MALABSORPTION SYNDROMES֍

֍⸨Diagnostic Features by Team Medical Minds⸩֍

Aquaporin 4 positive serum antibody
Celiac Disease
1. Malabsorption
 Chronic Diarrhea (starts after weaning in infancy)
 NO blood / mucus in stools
 Steatorrhea (Bulky, Pale, offensive stools that float in toilet)
 Weight Loss, Edema, Iron / Folate deficiency anemia
2. Oral Ulceration
3. Growth & Pubertal Delay (Short Stature & Secondary Amenorrhea)
Malabsorption Syndrome: (Broad Term)
 All Symptoms of Malabsorption described Above
 Always Remember; Celiac Disease is one of the causes of Malabsorption!

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1. A 23 years old Female presents with abdominal discomfort, diarrhea 4–6 stools / day, nausea, weight loss for the last 4 months. On
further inquiry, she claims 11kgs weight loss. On examination, paler +, minimal pedal edema + but JVP not raised. Abdominal
examination is un–remarkable. On Labs, Hb is 8.7g/dl, MCV is Low, 61fl, Platelets and TLC is normal. [Annual 2023 held in 2024]
a) What is the Likely Diagnosis? (01)
Malabsorption Syndrome (Celiac Disease can also be Written; But better to write malabsorption syndrome, as symptoms are little bit
non–Specific)
DO NOT Con us th s s n r o w th th t o Crohn‘s D s s (CD); B us n CD, Chron Non–Bloody Diarrhea + Weight loss is
present, and also more common in Females BUT Abdominal Examination reveals Tenderness / Mass, and CBC Shows Leukocytosis +
Raised Platelets (Sign of chronic inflammation)
b) How will you investigate this Patient? (02)

Small bowel bacterial overgrowth

 Causes: Diabetic autonomic neuropathy,
Gastric atrophy, Gastric surgery &
Systemic sclerosis
 Ix: Hydrogen breath test – first line
 Tx: Rifaximin

Low Fecal Elastase – exocrine pancreatic

insufficiency

Bile Salt Malabsorption

 Causes: ileum resection – Crohn‘s s s
 Ix: SeHCAT
Aquaporin 4 positive serum antibody
 Tx: Colestyramine
c) How will you manage this Patient? (02)
 A Multidisciplinary Team should be made to ensure comprehensive care of this patient and investigate the patient to find the
Aquaporin 4 positive serum antibody
underlying cause of malabsorption.
 Dietary modifications should be considered
o Gluten & Lactose Free Diet should be used
o Also Avoid Fatty food specially if Pancreatic insufficiency is suspected
o Vitamins (A, D, E, K, Folate & B12) & Minerals Supplementation (Iron)
 Nutritional Support is essential; Oral / IV / Enter Tube Feeding whichever is possible.
Aquaporin 4 positive serum antibody
 Symptomatic Management includes
o Anti-Diarrheal
o Probiotics
o Pancreatic Enzyme Replacement Therapy in case of pancreatic Insufficiency
 Monitoring & Follow-up should be done to assess the patient's nutritional status, symptoms and response to treatment on
Regular basis. On each Visit, Routine Blood tests must be performed.

2. A 20-year-old girl has diarrhea for past 4 months. Stools are watery and difficult to flush. She has lost 5 kg weight in this duration.
On examination, she has marked pallor and slight pitting edema. Laboratory investigations reveal Hb 8g/dl microcytic hypochromic
blood smear. Serum calcium 7mg/dl. (Normal 8.5 to 10.5 mg/dl). Serum albumin 2.8 g/dl (normal 3.5 to 5.5 g/dl). [Annual 2021]
3. A 19-year-old boy has a long history of weight loss, abdominal distension, bloating, recurrent anemia and diarrhea, calcium is low.
A small bowel biopsy reveals blunting and flattening of villi. [Annual 2017]
a) What is the most likely diagnosis?
Celiac Disease

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CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

b) Enlist investigations along with expected findings.

Investigation Expected finding
Serology (Antibodies) Increased Levels of:
 IgA Anti–Tissue transglutaminase (tTG) Antibodies – 1st line
 IgA Anti–Endomysial Antibodies
 IgA/IgG Anti–Gliadin Antibodies
Small bowel biopsy  Subtotal Villous Atrophy (Blunting of Villi)
(gold standard)  Crypt Hyperplasia
 Intraepithelial lymphocytes
HLA–Typing  May reveal HLA–DQ2 / HLA–DQ8
Full Blood Count  Microcytic / Macrocytic Anemia
Biochemical Tests Decreased Levels of
 Calcium, Magnesium & Vitamin D
 Total Protein & Albumin
DEXA Bone Scan  Measures Bone density and show Osteopenia / Osteoporosis

c) Give her treatment plan.

 Life–long Gluten Free Diet with Strict Adherence [Treatment of Choice]
 Can not eat  Wheat, Oat, Barley & Rye
 Can Eat  Rice, Corn (maize), meat, Dairy Products, Vegetables & Fruits
 Avoid Alcohol
 Vitamin D, Folate, Iron, Calcium
 Corticosteroids +/– Immunosuppressive drugs in those who Fail to respond to Gluten–Free Diet
 Dapsone for dermatitis herpetiformis
 Pneumococcal vaccine in children  Once in every 5 years as Hyposplenism occurs

4. A 36-year-old female presents in medical OPD with history of occasional episodes of diarrhea, weight loss and fatigue. Your
clinical suspicion is celiac disease. [Annual 2016]
a) What antibody assays you will request to confirm your diagnosis?
See Q2
b) Enumerate any three disease conditions associated with celiac disease.
1. IgA Deficiency
2. Pernicious Anemia
3. Dermatitis Herpetiformis
4. Type–1 Diabetes Mellitus Tropical sprue
5. Thyroid Disease  Malabsorption with Villous atrophy
6. Primary Biliary Cholangitis  Tx: Tetracyline 250mg QID for 28 days
7. Sjogren Syndrome + 5mg Folic Acid
c) What are the other causes of villous atrophy apart from celiac disease?
 Tropical Sprue Whipple’s Disease
 Dermatitis Herpetiformis  Malabsorption, Arthralgia, Pigmentation
 Giardiasis  Lympadenopathy, Ophthalmoplegia
 Wh ppl ‘s D s s  Ix: Biopsy (PAS granules in macrophage)
 Tx: 2g IV Ceftriaxone (2 week) followed
 Hypogammaglobulinemia
by oral cotri-moxazole (1 year)
 Lymphoma

GE-036, GE-037 & GE-044 ֍INFLAMMATORY BOWEL

Aquaporin 4DISEASE֍
positive serum antibody

֍⸨Diagnostic Features by Team Medical Minds⸩֍

Crohn’s Disease
 Chronic watery diarrhea, NO blood / mucus in stools
 Weight loss, edema, Iron / Folate deficiency anemia
 Abdominal Pain + Tenderness / mass on Examination
Aquaporin 4 positive serum antibody

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CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

 Glossitis & Angular Stomatitis +/– Peri–Anal Disease

 Can Involve any part of GIT (From Mouth to Anus)
Ulcerative Colitis
 Bloody Diarrhea + Mucus + Abdominal Cramps/Tenesmus
 Cryptitis / Abscesses + Loss of Goblet cells
 Abdominal distension may indicate Toxic megacolon

1. A 28-year-old female 6 months history of chronic diarrhea associated with lower abdominal crampy pain & fever. The stool
contains mucus and blood. On examination, she is pale, mild tenderness all over the abdomen, no hepatosplenomegaly. Investigations:
Hb 9.5 mg/dL, TLC 15000, Platelets 550, ESR 75, Serum Albumin 2.5 g/dL, LFTs: Total Bilirubin 1 mg/dL, AST 70 IU/L, ALT 65
IU/L, ALP 240 IU/L. Ultrasound Abdomen was normal. [Annual 2018]
a) What is the most likely diagnosis?
Ulcerative Colitis
b) List the features of severe disease.

c) Name various groups of pharmacological drugs used and outline the management of this illness.
Non–Biologics Biologics
 5–ASA  Anti–TNF Inhibitors
 Glucocorticoids  Anti–α4ß7 Int r n
 Anti–Metabolites  Janus Kinase Inhibitors
 Calcineurin Inhibitors  Anti–p40 antibodies
 Antibiotics (Ciprofloxacin > Metronidazole)
Management
Patient is Suffering from Acute Severe UC & topical / oral 5–ASA has no role in acute severe UC
Remission induction
 Give IV methylprednisolone or hydrocortisone
 Infliximab/Ciclosporin in stable patients not responding to glucocorticoids
Remission maintennece
 Oral Thiopurine (azathioprine or mercaptopurine) – 1st line
Surgical
 Surgical Management  if Toxic Megacolon (> 6cm) or Failed Maximal Medical Therapy
 Laparoscopic Proctocolectomy with Ileal Pouch–Anal Canal Anastomosis

2. A 35-year-old female presented with 3 months history of bloody diarrhea with lower abdominal crampy pain. She also gives history
of fever, weight loss and occasional large joint pains. [Supple 2016 held in 2017]
a) Enlist four other diseases causing chronic diarrhea.
Main Diagnosis  Ulcerative Colitis
Infectious Causes Non-infectious Causes
1. Salmonella 5. Crohn‘s D s s
2. Shigella 6. Ischemic Colitis
3. [Link] 7. Colonic Carcinoma
4. Compylobacter jejuni 8. B h t‘s D s s

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CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

b) Outline the management of such patient.

Management in case of mild to moderate UC
Remission induction Proctitis
 Topical (rectal) aminosalicylate
 if remission is not achieved, add an oral aminosalicylate
 if remission still not achieved add oral corticosteroid
 if remission still not achieved, try biologic therapy
Left-sided or extensive ulcerative colitis
 Oral aminosalicylate
 if remission still not achieved add oral corticosteroid
 if remission still not achieved, try biologic therapy
Remission maintenance  Oral 5-ASA  1st line
 Oral Thiopurine +/- Infliximab  2nd line
Surgical if toxic megacolon Laproscopic proctocolectomy with ileal pouch anal canal anastomosis

3. A 55-year-old man presented with history of diarrhea containing blood and abdominal pain for three months. He also reports low
grade fever and weight loss. Examination revealed a temperature of 99 F and some abdominal tenderness. [Annual 2010]
a) Enumerate four differential diagnoses.
 Ulcerative Colitis Smok n wors ns Crohn‘s s s
 Crohn‘s D s s
 Shigellosis (Bacillary Dysentery) Appendectomy & Smoking protect against UC
 Amoebiasis (Amoebic Dysentery)
b) How will you investigate the case?
1. Blood Examination
 CBC, CRP, ESR
 Albumin  Crohn‘s s s – pANCA +
 Serology (p-ANCA, c-ASCA) Aquaporin
Ulcerative – cASCA
colitis serum
4 positive +
antibody
2. Stool Examination
 Fecal calprotectin Aquaporin 4 positive serum antibody
3. Radiology
 Barrium enema
 Abdominal x-ray
4. Endoscopy + Biopsy – Diagnostic investigation for US

4. A 22-year-old female presents with a history of blood and mucous in stools. Her first episode was 2 years back since then she has
off & on episodes of bloody diarrhea associated with weight loss, abdominal pain & occasional diarrhea. [Supple 2023 held in 2024]
a) What is the most probable diagnosis? Aquaporin 4 positive serum antibody
Ulcerative colitis
b) Write at least 4 systemic complications of this disease.
1. Conjunctivitis, Scleritis & Iritis
2. Pyoderma gangrenosum & Erythema nodosum
3. Primary sclerosing cholangitis and cholangiocarcinoma
4. Mesenteric or portal vein thrombosis

GE-045 ֍IRRITABLE BOWEL SYNDROME֍

֍⸨Diagnostic Features by Team Medical Minds⸩֍

Rome IV Criteria
 Recurrent Abdominal pain at least 1 day / week on average in the last 3
months. Asso t w th ≥2 o th Follow n :
 Related to Defecation
 Onset associated with change in Frequency of Stool
 Onset associated with change in form (Appearance) of Stool
Absence of  Blood / Mucus in Stools, Nocturnal symptoms, Weight Loss.

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CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

1. A 15-year-old girl presents with abdominal bloating and discomfort for 2 years. She is an orphan and lives with her mother who
works in a factory. She also has episodes of diarrhea with abdominal cramps but there is no weight loss. Abdominal discomfort
improves with defecation. [Supple 2022 held in 2023]
a) What is the most likely diagnosis?
Irritable Bowel Syndrome – Diarrhea Predominant
b) Give her treatment plan.

c) How will you diagnose this patient?

 Clinical diagnosis – Rome IV Criteria
 Labortory (FBC, CRP, Fecal Calprotectin) – should be normal

2. A 47-year-old female presents with recurrent abdominal pain and fullness associated with increased number of stools. Her pain
improves after defecation and the symptoms worsen whenever she has some issues with her husband. [Supple 2019 held in 2020]
a) What is the most likely diagnosis?
Irritable Bowel Syndrome – Diarrhea Predominant
b) What alarm features (any six) you must ask her before starting her treatment?
1. Age > 50 years
2. Unintentional Weight loss
3. Nocturnal Symptoms
4. Recent Change in Bowel Habit
5. Palpable Abdominal Mass / Lymphadenopathy
6. Family History of Colon Cancer / IBD
7. Anemia
8. Evidence of Over GI Bleeding i.e., melena / Hematochezia

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CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

GE-047 ֍CONSIPATION֍

Condition Treatment
Impacted Stool  Phosphate enema in peope with old age & comorbidities
 Glycerol in young & healthy people
Hard stool but not impacted Stool softners
Constipation with soft stool High fiber diet  Senna (stimulant laxative)  Lactulose (osmotic laxative)
Pregnancy Ispaghula (Psyllium) – Bulk forming laxative  Lactulose  Seena
Diarrhoea - biospy shows pigment laden macrophages = laxative abuse

GE-048 ֍INTESTINAL TUBERCULOSIS֍

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History / Clinical Features Suggestive of Pulmonary TB (PTB)
 Ulcerative Type  Diarrhea, Weight Loss & Deep transverse ulcers
 Hyperplastic Type  Abdominal Pain, Doughy Mass (usually in RIF)
 Sclerotic Type  Napkin Ring like Strictures

1. An 18-years old boy presented with aggravated pain abdomen and vomiting for last one day. He has been unwell for last 2 to 3
months and complained of postprandial generalized abdominal pain, and diarrhea, fever, anorexia and weight loss. O/E patient was
anemic with generalized doughy feeling and suspicion of mass in right iliac fossa. [Supple 2020 held in 2021]
a) What is the likely diagnosis?
Intestinal Tuberculosis (Hyperplastic Type)
b) What investigations you will carry out?
Investigations Description / Possible Findings
Blood Examination  FBC  Anemia, Lymphocytosis
 ESR  Raised
 Albumin  Reduced
Sputum Examination  Staining & Culture  To detect Mycobacterium TB
Endoscopy + Biopsy  Diagnostic Laparoscopy +/– Biopsy  Gold standard
 Colonoscopy
Radiology  Plain Chest X–ray
 Abdominal Ultrasonography
c) How will you manage the case?
Medical Treatment
 Anti–Tuberculous Drugs (ATT); HRZE for 2 months Followed by HR for the next 4 months
Surgical Treatment
 Strictureplasty (in case of Single Stricture)
 Ileo–colectomy (resection of segments) in case of Multiple Strictures
 If Adhesions; then Adhesiolysis should be done.

GE-060 ֍VIRAL HEPATITIS֍

֍⸨Diagnostic Features by Team Medical Minds⸩֍

Common Features of Acute Viral Hepatitis:
 Prodromal  Headache, Anorexia, Arthralgia, Vomiting, Abdominal pain
 Tender Hepatomegaly; mild splenomegaly
Acute Hepatitis A
 Travelling history / Outdoor eating (Feco–Oral Transmission)
 Usually NO Jaundice in children, but in adults it is present

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CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

Acute Hepatitis B
 Jaundice
 Serology for HBV (+)

1. A 15-year-old boy presented with 5 days history of anorexia, nausea, vomiting and pain in right hypochondrium. The symptoms
started after his return from a hill station. On examination, temperature is 99 F, mild icterus + and tender hepatomegaly. Investigations
revealed: CBC: TLC 3500 cells/mm3, Hb 13.5 g/dl, platelets 220x10^9/L, LFTs: Total Bilirubin 2.3 mg/dl, ALT 3000 IU/L, AST
2795 IU/L, ALP 195 IU/L. [Annual 2016]
a) What is the diagnosis and the most likely etiologic agent?
Acute Viral Hepatitis & most likely etiologic agent is Hepatitis A Virus
b) How can you prevent this disease?
1. Avoid Overcrowded places
2. Improve Sanitation
3. Eat Clean & Hygienic Food
4. Active Immunization  Hep–A Vaccination
5. Passive Immunization  Anti–HAV immune serum globulins (If given soon after exposure to the Virus)
c) How will you treat him and what is the outcome?
Treatment
1. Bed rest & adequate diet + hydration should be maintained
2. Symptomatic Treatment (Anti–Pyretics & Anti–emetics) can be given.
3. Monitoring of vitals, urine output, conscious level & electrolytes
4. PT – highest prognostic value – twice daily
5. Vitamin K should be given to ensure that prolonged PT is not due to Vit K deficiency but avoid FFP
6. Avoid certain medications which are metabolized by Liver
7. Identify & treat complications (Encephalopathy, cerebral edema, Infections); if any
8. Liver Transplantation (in cases of Acute Liver Failure)
Outcome
There is NO role of Anti–viral agents in
1. Infection is Self–Limiting
therapy of HAV infection.
2. Rare chance of acute liver failure (0.1%)
3. No chronic infection

2. A 20-year-old student presents in the emergency with history of vomiting for one day. He usually eats out and has felt a bad taste in
his mouth for a few days. He also lost desire to smoke. [Supple 2010 held in 2011]
a) What is likely diagnosis?
Acute Viral Hepatitis & most likely etiologic agent is Hepatitis A Virus
b) What investigations would you perform?
1. Liver Function Tests (Bilirubin, ALT, AST, ALP, GGT & Albumin)
2. Coagulation profile (PT / INR) Aquaporin 4 positive serum antibody
3. Viral Serology:
 Anti–HAV IgM  Diagnostic of Acute HAV Infection
 Anti–HAV IgG  Marker of Previous HAV infection with Resulting Immunity
4. FBC, urea & Electrolytes

3. A medical student gets a needle prick injury while drawing blood from a patient suffering cirrhosis of liver. Earlier patient had
received a full course of interferon for hepatitis C and was vaccinated for Hepatitis B. [Annual 2008]
a) What is the risk to the student?
HCV Infection (Patient received a full course of interferon, which significantly decrease the viral load, but does NOT completely
eliminate the Virus)
Risk of Hep C by needlestick injury – 3%
b) How would you manage the patient?
Management of Cirrhosis
1. Test for HBsAg, Anti-HCV & HCV RNA
2. If patient is positive for any infection, manage accordingly
3. Maintenance of Nutrition

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Aquaporin 4 positive serum antibody
CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

4. Screening & Treatment of Complications

 Endoscopy to screen for Esophageal Varices; Primary prophylaxis (Propranolol) should be Considered, if Present,
Band ligation should be done.
 Regular surveillance for HCC
 DEXA scan for Bone Density; Treat accordingly
5. Liver Transplantation; in case of decompensation (Definitive Treatment)

4. A 40-year-old dentist presented with a five months H/O weight loss. He had recently become jaundiced. Blood results show ALT
400 IU/L, ALP 165 IU/L, Bilirubin 80 µmol/L, albumin 3.2 g/L (3.4-4.2 g/L), alpha fetoprotein 4 ng/L, serum ferritin 150 ug/L, (15-
250), HBsAg positive, HBeAg positive. [Supple 2007 held in 2008]
a) What is the diagnosis?
Window Phase in HBV Infection: from
Acute Viral Hepatitis caused by HBV disappearance of HBsAg to the appearance of
b) Which three tests will you perform? Anti–HBs

Tests Components
1. Viral Markers  HBsAg & HBeAg
 Viral Load & Genotype (PCR)
2. Liver Markers  Bilirubin, ALT, AST, ALP, GGT & Albumin)
 Fibrosis Markers (Fibro–test)
3. Serological Tests  Anti–HBc IgM
 Anti–HBc IgG
only anti-HBs positive & all others negative  Immunization without prior infection i.e. vaccinated
anti-HBs & anti-HBc positive  Immunization due to priorAquaporin
infection 4 positive serum antibody
c) What is the management?
1. Full Spontaneous Recovery Occurs in > 95% of the cases; Acute Liver Failure occurs in < 1% cases
2. Supportive Treatment  See Q1b in “Acute Hepatitis/ Acute Liver Failure”
3. Anti–Viral agents (Tenofovir > Entecavir; i.e., Less chances of resistance with Tenofovir

GE-061 ֍NON-ALCOHOLIC FATTY LIVER DISEASE (NAFLD)֍

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 NO history of alcohol intake
 Hx of obesity (high BMI or obstructive sleep apnea)
 Hx of inulin resistance (Diabetes type II or PCOS)
 Fatty changes (ecogenicity) on USG / Dyslipidemia on Lipid Profile

1. A 40-year-old male seen in outpatient department with pain in right hypochondrium. On examination, hepatomegaly without any
other stigmata of chronic liver disease. Investigations: Total Bilirubin 1.5 mg/dL, ALT 175 IU/L, AST 185 IU/L, ALP 180 IU/L,
Fasting lipid profile: triglycerides 450 mg/dL, T. Cholesterol 240 mg/dL, HbsAg / Anti-HCV negative. [Annual 2018]
a) What is the most likely diagnosis, and two principal causes?
Non–Alcoholic Fatty liver Disease / Non–Alcoholic Steato–Hepatitis
Principle causes
1. Morbid Obesity
2. Type–2 DM
b) Write down the investigations to make definite diagnosis.
Categories Investigations
Biochemical Tests  LFTs (ALT, AST & GGT)
 Serum Ferritin
 Enhanced liver fibrosis blood test (triple test)
o Hyaluronic acid
o Metalloproteinase-1 inhibitor
o Procollagen peptide III

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Imaging  USG – 1st line

 CT scan/MRI
Transient Elastography (FibroScan)  To assess fibrosis
Liver Biopsy  May show any of the 3 lesions / Combination (Steatosis,
(Gold Standard) Hepatocellular inflammation + Injury) & Perisinusoidal Fibrosis.

c) List different options of treatment.

Treatment Options Description
Non–Pharmacological  Weight loss
 Dietary changes
Pharmacological  Statins (For dyslipidemias)
(only for the associated  Insulin sensitizing agents (pioglitazone)
comorbidities)  Anti–Hypertensives
 Obeticholic acid  Improves fibrosis in NASH
Surgical  Liver Transplantation; for end–stage Cirrhosis
Monitoring for advanced  Transient Elastography (FibroScan)
fibrosis  Enhanced liver fibrosis blood test (triple test)

GE-062 ֍CHRONIC LIVER DISEASE֍

֍⸨Diagnostic Features by Team Medical Minds⸩֍

Hepatic Encephalopathy
 Features of CLD / Cirrhosis  Palmer erythema, Ascites, Splenomegaly,
Spider Naevi, Jaundice, Dilated abdominal wall veins
 Constipation (risk factor)
 Altered level of consciousness
Variceal Bleeding
 Features of CLD / Cirrhosis  Palmer erythema, Ascites, Splenomegaly,
Spider Naevi, Jaundice, Dilated abdominal wall veins
 Blood in Vomitus (Hematemesis)
Spontaneous Bacterial Peritonitis
 Features of CLD / Cirrhosis  Palmer erythema, Ascites, Splenomegaly,
Spider Naevi, Jaundice, Dilated abdominal wall veins
 Fever + abdominal pain & distension
 Ascites (+ shifting dullness)
 Trigers HE (Gradual deterioration of consciousness + Flapping tremors)
Hepatorenal Syndrome
 History of CLD / Cirrhosis / Acute Liver Failure
 Reduction of Urine output & Raised Serum Creatinine
 No renal parenchymal changes

1. A 72 years old female who is known case of Chronic Liver disease presents in emergency with altered state of consciousness which
was gradual and has worsened, although she is compliant to the medications prescribed by a local doctor, she had constipation for past
few days due to decreased oral intake. [Annual 2023 held in 2024]
a) What is the most probable diagnosis? (01)
Hepatic Encephalopathy (HE) Grading of HE
b) Enumerate the Factors that can precipitate this condition. (02) Grade Description
1. Constipation I Poor concentration, Slurred speech
2. Hypokalemia 2 Drowsy; but easily arousable
3. TIPSS 3 Marked delirium & drowsy, but
4. SBP responds to pain & voice
5. Dehydration (including Diuretics) 4 Unconscious / coma, unresponsive
to voice & pain
6. Sedative drugs such as opiate/benzodiazepine

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7. Increased protein Load (including GI bleeding)

8. Anti–depressants
c) Write At least 4 signs that would you find in this patient. (02)
1. Asterixis (Flapping Tremors)
2. Fetor Hepaticus (sweet musty odour in breath)
3. Constructional Apraxia (inability to draw objects)
4. Hyperreflexia & Bilateral Extensor Planters
5. Focal Neurological Deficits (Weakness)
d) What are the principles of management?
1. Treat / Remove precipitating Causes
2. Suppress the production of Neurotoxins by bacteria in the bowel; via:
 Lactulose (1st line)  Decrease colonic pH; limits colonic NH3 absorption
 Rifaximin  Dcrease bacterial content of colon
 Phosphate Enema (in patients with refractory constipation or oral route compromised)
 LOLA (L–ornithine L–arginine)
3. Intubation required for airway protection in comatose patients
4. Chronic / refractory HE  Liver Transplantation

4. A 40 years old male, a known case of chronic liver disease due to hepatitis C having child class C has presented with the gradual
deterioration of consciousness over one day. He was having fever for last two days along with burning micturition. On examination,
temperature 100oF, BP 90/70, Pulse 104/min, Flapping tremors positive, TLC 14800 mm3, INR 2.3, Albumin 2.4g/dl. [Supple 2020
held in 2021]
a) What is the most likely diagnosis? Why did it develop? CHILD PUGH SCORE
Hepatic Encephalopathy with End stage liver disease Score 1 2 3
Child Pugh Class of this patient is C (score >9) HE None Mild Moderate
INR = P t nt‘ PT Norm l PT  P t nt‘ PT = 2.3 x 12 = 28 Ascites None Mild Marked
I have added it here just to grab the concept. Biliribin <2 2-3 >3
Causes Albumin >3.5 2.8-3.5 <2.8
 Chronic Liver Disease (cannot detoxify) PT <4 4-6 >6
 Infection (most likely UTI) Class A = <7, Class B = 7-9, Class C = >9

3. A 33-year-old female presents with blood in the vomitus. On examination, she is pale with palmar erythema and had positive fluid
thrill on abdominal examination. [Supple 2019 held in 2020]
a) What six emergency management steps you will do? Give reason for each.

b) After stabilization, what treatment you will advise to prevent recurrence of the same complication?
Medical
ß–blockers used as Both Primary & Secondary
 ß–blockers (Propranolol) prophylaxis in case of Variceal Bleeding

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Surgical
 After Variceal banding performed in ER, it is Repeated at every 2–4 weeks intervals; until all varices are obliterated
 TIPSS (after successful Endoscopic Therapy)

4. A 50 year old cirrhotic has presented with worsening abdominal distention, fever and pain all over abdomen for last 3 days. He also
complains of increasing drowsiness. There was no history of constipation. On examination, temperature 100 oF, BP 90/70 mm Hg,
Pulse 110/min, RR 16/min, flapping tremors positive abdomen was tender and distended, shifting dullness was positive, TLC 16800
mm3, INR 2.3, Albumin 2.4g/dl. [Annual 2020]
a) What is the most likely diagnosis? What has happened and how it is caused? SAAG = Serumalbumin - Asciticalbumin
Spontaneous bacterial peritonitis due to CLD  SAAG > 11 = Portal HTN (transudative)
Happened Now  SAAG < 11 = Exudative cause
 Hepatic Encephalopathy
Caused
 Chronic Liver Disease / Liver Cirrhosis  Portal hypertension  Ascites  Infection of ascitic Fluid by translocation of
bacteria from intestine  SBP  Along with Porto–systemic Shunting  leads to Hepatic Encephalopathy
b) How will you confirm your diagnosis?
 Diagnostic Paracentesis & ascites fluid analysis  reveals Leukocyte (Neutrophil) Count > 250 x 106 /L & culture yields E.
Coli (most commonly)
 Imaging  To rule out other abdominal causes of Peritonitis e.g., Perforated Viscus
 Blood Examination  FBC, CRP, Culture Aquaporin 4 positive serum antibody
c) What is the immediate management for this? How will you prevent recurrence?
Immediate management for SBP
SBP prophylaxis
 Antibiotic (Cefotaxime or Piperacillin-Tazobactam)
 To prevent recurrence
 IV Albumin  To prevent occurrence in CLD patients e
Prevention of Recurrence low ascitic protein < 15g/L
Prophylactic Antibiotics (Norfloxacin / Ciprofloxacin / Co–trimoxazole)

5. A 55-year old male was treated for HCV 10 years ago. He developed progressively increasing abdominal distention and swelling
feet for 3 months. He has passed few drops of urine in past 24 hour. He does not give any history of vomiting, diarrhea and denies
intake of any medication in last two weeks. His blood urea is 130mg/dl (normal 10 to 40). Serum creatine 2.5 mg/dl (normal 0.7 to
1.3). Serum K 5.8 mEq/L (normal 3.6 to 5.2). Abdominal USG shows massive ascites, small shrunken liver and normal kidneys.
[Annual 2021]
a) What is the most likely diagnosis?
Hepatorenal Syndrome
b) What further investigations will you perform to confirm? Aquaporin 4 positive serum antibody
1. Blood Examination
 FBC (Leukocytosis; in case of infection) + Culture
 FT‘s & El trolyt s
 Coagulation Profile (PT/ INR)
 ABG‘s
2. Urine Examination
 Urinary Na+ excretion
 For Proteinuria & RBCs
3. Endoscopy
 Check for Varices / variceal bleeding
4. Paracentesis & Ascitic Fluid Examination
c) How will you manage?
 Identify and treat precipitating factors
 Volume expansion by albumin
Terlipression is preferred until unless there is
 IV Terlipressin/Octreotide – constriction of splanchnic vessels
contraindication (coronary disease)
 Manage ascites
o Sodium restriction
o Water restriction if plasma sodium levels fall <125 mmol/L

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o Spironolactone ± Furosemide
o Therapeutic large volume paracentesis (if tense ascites) + albumin to support circulation
 Liver transplantation ± Hemodialysis (Definitive) OR TIPSS

GE-063 ֍METABOLIC/ GENERTIC DISORDERS OF LIVER֍

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 It affects most of the organs of Body
 In Liver  Hepatomegaly
 In Pancreas  Diabetes (Polyuria, Polydipsia)
 In Skin  Leaden–Gray Skin Pigmentation (Bronzed Diabetes)
 In Reproductive System  Impotence, Loss of Libido & Testicular atrophy
 In Joints  Osteroarthritis changes
 In Heart  Features of Heart Failure +/– Cardiomegaly

1. A 42-year-old male presents with H/O polyuria, polydipsia, swelling of feet, SOB, easy fatigue and joint pains. He has almost no
desire for sexual activity. O/E, liver is enlarged, pedal edema; his color of skin has darkened for four months. Blood sugar fasting 140
mg/dL, x-ray chest shows increased cardiothoracic ratio. [Supple 2022 held in 2023]
a) What is the most likely diagnosis?
Main cause of death in hemochromatosis is
Hemochromatosis
HCC
b) What investigations are required to confirm the diagnosis?
 Transferrin saturation >> serum ferritin  ↑ Ferritin only  Alcohol, NAFLD
 Genetic testing  C282Y / mutation in HFE gene  ↑Ferritin and Transferrin saturation 
 MRI Liver Hemochromatosis
 Liver Biopsy is gold standard
c) Write down the treatment plan.
1. Repeated Venesection / Phlebotomies (Weekly; 500ml Blood)  Continued till the Aim (to reduce the Serum ferritin &
Transferrin saturation below 50µg/L & 50% respectively) is achieved
2. Regular surveillance for HCC
3. Cardiomyopathy and skin pigmentation are reversible with treatment Aquaporin 4 positive serum antibody
4. Dietary Precautions
 Limit Iron Rich Foods e.g., red meat, liver, kidneys, sea–Foods
 Avoidance of iron supplements (such as multivitamins containing iron)Aquaporin 4 positive serum antibody
 Avoidance of Vitamin C supplements & alcohol
 Use of agents e.g., Calcium, Oxalates, Phosphates to limit dietary iron absorption
 Drink Tea / Coffee in moderation

GE-064 ֍HEPATOCELLULAR CARCINOMA/ HEPATOMA֍

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of chronic liver Disease (HCV) / Cirrhosis
 Pain Right Hypochondrium; radiating to right shoulder
 Significant Weight Loss

1. A 65-year-old farmer with no history of alcohol intake presents with pain in the right hypochondrium radiating to the right shoulder
along with weight loss of seven kgs over the past two months. He was treated with ribavirin tablets and injection interferon five years
ago for his hepatitis. [Annual 2012]
a) Give two most likely diagnoses in this case.
1. Hepatocellular Carcinoma Causes of HCC
2. Advanced Cirrhosis  Hepatitis B – most common Worldwide
b) Give four most appropriate investigations.  Hepatitis C – most common UK
1. LFTs  Alcohol & NAFLD
 Hemochromatosis
2. α–fetoprotein & USG – screening
 Primary biliary cirhosis

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3. Triphasic CT scan – diagnostic investigation for HCC

4. Transient Elastography
5. Liver Biopsy
c) Give two appropriate treatment options for him
1. Hepatic resection  Treatment of choice for non–cirrhotic patients
2. Liver transplantation  Treatment of choice for cirrhotic patients

֍UHS PAST MCQs & SAMPLE PAPER֍

01. GASTROINTESTINAL SYSTEM
Annual 2024 held in 2025
1 Traveller diarrhea is caused by [Link] (Norfloxacin is DOC)
2 Treatment for acute severe ulcerative colitis? IV steroid
3 Barrium swallow = dilated esophagus with tapering end Achalasia
4 A 28-year-old man with a background of asthma presents with a history of intermittent B
dysphagia to solids and liquids, in addition to chest pain. An endoscopy is performed (if failed then give topical steroid)
which shows longitudinal furrows and exudate in the oesophagus. Oesophageal biopsies
demonstrate 25 eosinophils/HPF. What is the most appropriate initial pharmacological
management?
A. Amitryptiline B. 8-week empirical trial of PPI
C. Swallowed fluticasone D. Oral budesonide
E. Inhaled salbutamol
5 MALT (gastric ulcer & lymphoma) involving only mucosa A
A. H. pylori eradication therapy
B. Chemotherapy
C. Gastrectomy
Annual 2023
6 A child presents with bloating & chronic diarrhea; stools are foul smelling & bulky. On Celiac disease
examination he is thin lean & pale.
7 Young age + Family history + Small Bowel polyps + Mucocutaneous Pigmentation Peutz–Jeghers syndrome
8 ROME IV criteria: Recurrent Abdominal pain (1 day
/ week) in the last 3 months
9 Which of the following Inhibit HCl secretion? Both can Inhibit HCl, but
A. Somatostatin B. VIP Somatostatin should be preferred
Annual 2022
10 Which one is not a feature of H. Pylori Infection? Culture on gastric Aspirate
(Because gold standard is culture
on Antral Biopsy)
11 Celiac Disease is Not associated with: D
A. Type I Diabetes B. Inflammatory bowel disease C. PBC
D. Diverticular disease of colon D. Dermatitis herpetiformis
12 Protein losing enteropathy (malabsorption syndrome) is not seen with? B
A. Crohn disease B. Chronic duodenal ulcer C. Tropical sprue
D. Celiac disease D. Lymphoma
13 Which of the following is a complication of Terminal Ileum Resection? Vitamin B12 Deficiency
14 Which of the Following is associated with inflammatory bowel Disease? Diverticular Disease
15 Which is unlikely in a patient with irritable bowel syndrome? Bleeding per Rectum
Annual 2021
16 Investigation in a patient with ulcerative colitis? Sigmoidoscopy revealing ulcers
17 A patient presented with history of chronic diarrhea, low grade fever & joint problems. Wh ppl ‘s D s s
On biopsy, Foam cells were present which were also PAS (+). Likely diagnosis is?
18 Rash Associated with celiac disease is? Dermatitis Herpetiformis

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19 A patient presents with history of Progressive dysphagia, more for liquids, occasional Achalasia
regurgitation for the last 3 years. Likely diagnosis is?
20 Which is a risk factor for esophageal adenocarcinoma? GERD
21 Enterocutaneous Fistulas are a complication of which disease? Crohn ‗s D s s
22 A patient presented with history of Abdominal Discomfort, & weight loss. Stool Ulcerative Colitis
examination is positive for occult Blood. Likely Diagnosis is?
23 Which of the following is a complication of Terminal Ileum Resection? Vitamin B12 Deficiency
24 Treatment for Tropical Sprue is? Tetracyline 250mg 4 times daily
for 28 days + 5mg Folic Acid
Supply 2020
25 A condition with no harmful sequela is? Irritable Bowel Syndrome
26 The Condition associated with pyoderma gangrenosum is? Ulcerative Colitis
Annual 2020
27 Treatment Given in Acute severe ulcerative colitis is: Steroids
28 Investigation of choice for a patient suffering from Diverticular disease? CT scan
29 A patient has history of recurrent Ulcers, but no use of NSAIDs & tests for H. Pylori Check Serum Gastrin levels (As
detection are also negative. What should be the next step? it can be Zollinger Ellison
Syndrome)
30 A patient presented with history of Oral ulcers, and diarrhea that is usually water along Crohn‘s D s s
with abdominal discomfort and weight loss. Diagnosis?
31 A child presents with history of Chronic Diarrhea, stools are bulky and Foul smelling, he Celiac Disease
is also anemic. Diagnosis?
Annual 2019
32 Young patient with chronic foul–smelling diarrhea and weight loss. Diagnosis? Celiac Disease
33 Drug given in case of finding trophozoites from bowel biopsy (Amoebiasis) Metronidazole
34 Drugs used for symptomatic relief of patients with diagnosed achalasia are? Sublingual Nifedipine / Nitrates
35 Which of the following is a complication of Terminal Ileum Resection? Vitamin B12 Deficiency
36 An old patient came with complaints of diarrhea, & flushing in face and neck region. Carcinoid Syndrome
Vitals are not stable. Diagnosis?
37 Drugs for H. Pylori eradication: Omeprazole, Clarithromycin,
Amoxicillin / metronidazole
38 Dos o C tr xon n Wh ppl ‘s D s s s? 2g IV daily for 2 weeks
Annual 2018
39 Wh h on s F tur o Crohn‘s D s s ? Transmural inflammation
40 Anti-Parietal cell antibody + Vitamin B12 deficiency, associated disease can be? Atrophic (Type A) gastritis
41 A patient presented with Acute Abdomen. He has past history of Atrial Fibrillation. Ischemic Colitis
Diagnosis?
42 Which one is the cause of columnar (glandular) metaplasia in esophagus? GERD
Supply 2017
43 An obese person, presented with complain of band around the neck. His Blood sugar Hemochromatosis
levels are also raised (Diabetic). Most likely diagnosis?
44 Mesalamine (5–ASA) is used in which disease? Ulcerative Colitis
45 Investigation to differentiate between Acute pancreatitis & Duodenal perforation Serum Amylase (remember that
these levels are only slightly
elevated in perforation, while 3–4
times normal in pancreatitis)
46 Which disease is associated with Vitamin B12 deficiency? Celiac Disease
47 A patient presented with retrosternal burning sensation often triggered by bending, PPIs
stooping. Occasionally he regurgitates undigested food. Treatment will be:
48 Common Peptic Ulcer associated with H. Pylori Infection is? Duodenal Ulcer
Annual 2016
49 Patient presented with chronic Diarrhea containing blood and mucus + Tenesmus Ulcerative colitis

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50 Wh h on s ompl t on o B rr tt ‘s Esoph us? Adenocarcinoma

51 Which of the following is not a feature of Irritable Bowel Syndrome? Nocturnal Symptoms
52 Peptic ulcer strongly Associated with H. Pylori infection is: Duodenal Ulcers (as it is more
common than gastric ulcers)
53 Patient who was taking PPI for GERD presented with complain of dysphagia to solids Benign Esophageal stricture
and liquids
54 D r n b tw n TB & Crohn‘s s s ? Caseation is present in
granulomas of TB, while absent
n Crohn‘s D s s
55 Biopsy specimen showed Infiltration of macrophages which stain positive for PAS: Wh ppl ‘s D s s
6
1. A 14 years old boy with persistent diarrhoea and iron deficiency has villous atrophy on distal duodenal biopsies and has a positive
anti-transglutaminase antibodies. His diagnosis is:
a) Tropical sprue d) Abdominal T.B.
b) Crohn's disease e) Coeliac disease
c) Blind loop syndrome
2. A 23-year-old university student presents with the fever and pain in lower abdomen for the last six weeks. The following is not a
feature of ulcerative colitis:
a) Positive rheumatoid factor d) Proctitis
b) Sacroiliitis e) Carcinogenesis
c) Blood and mucus in stool
3. A 60 years old taxi driver presents with dysphagia and weight loss. The following is not cause of dysphagia:
a) Achalasia cardia d) Gastric outflow obstruction
b) Carcinoma oesophagus e) Bulbar paralysis
c) Systemic sclerosis
4. A 50 years old presents to the emergency with haematemesis, he is taking oral corticosteroids for his arthritis. The following is not
indicated in this emergency:
a) Clotting profile d) IV proton pump inhibitors
b) Upper GI endoscopy e) Sucralfate
c) Barium swallow
5. A 17 year old boy presents in medical OPD with watery and foul smelling diarrhea since childhood. His is anaemic & has growth
retardation and edema. During admission, his diarrhea responded to gluten free diet. His jejunal biopsy is expected to show
a) Normal mucosa d) PAS positive macrophages
b) Large mucosal ulcerations e) Goblet cells in submucosa
c) Subtotal villous atrophy
6. A 30-year-old lady with many months history of dysphagia begins to develop recurrent pneumonias. Barium swallow shows a
massively dilated esophagus with a smooth pencil tip tapering at the lower end. The barium fails to enter the stomach in appreciable
quantity. She is likely to have;
a) Achalasia of cardia d) Esophageal varices (Massive)
b) Esophageal malignancy of lower end e) Plummer-Vinson syndrome
c) Pharyngeal pouch
7. Which of the following is the most important risk factor for colorectal carcinoma?
a) Family history d) High Fiber diet
b) Nitrosamines e) Smoking
c) Low Fiber diet
8. A previously fit and well 14 weeks primigravida in one of her bouts of severe vomiting and wretching vomits out about 20 cc of
bright red blood. She is most likely to have developed:
a) Bleeding disorder d) Carcinoma stomach
b) Mallory Weiss tear e) Duodenal ulcer
c) Gastric ulcer
9. A 40 years old mate with severe retrosternal burning sensation exacerbated by food is diagnosed to have gastro-esophageal reflux
disease. In the long run he is at risk of:
a) Myocardial infarction b) Mallory-Weiss tear

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c) Pharyngeal pouch e) Squamous cell carcinoma

d) Barrett's esophagus
10. A patient with diarrhoea with blood is diagnosed to have ulcerative colitis. He is at risk of developing:
a) Perianal abscess d) Fistula in ano
b) Ischiorectal abscess e) Anorectal fistula
c) Toxic megacolon
11. A 50 years old man has a history of alcohol and tobacco abuse. He complains difficulty in swallowing solid food for the past two
months. Most recently, swallowing fluid has also become a problem. He has noted black tarry stool on occasions. Patient has lost 10
pounds weight. Which of the following investigation is most important step in diagnosis?
a) CT scan abdomen d) X-ray abdomen
b) Chest X-ray PA view e) Ultrasound abdomen
c) Gastroscopy
12. A 60 years old complains of abdominal pain, absolute constipation and vomiting. Abdomen is distended. Percussion shows no
shifting dullness. Which of the following should be the first step in evaluation?
a) Passing nasogastric tube d) Sigmoidoscopy
b) Abdominal ultrasound e) CT scan abdomen
c) Plain x-ray abdomen
13. A women aged 30 years from a remote village in Punjab presented with frequent bowel movement and tenesmas. She has low
grade fever. Stool contains blood and mucus. Which of the following possibilities comes to your mind first?
a) Ulcerative colitis d) Malabsorption syndrome
b) Bacillary dysentery e) Carcinoma of rectum
c) Irritable bowel syndrome
14. Three medical students went out to a restaurant. Four hours later, they suffer from severe vomiting and diarrhea. Which is most
likely cause?
a) Salmonella enteritis d) Malabsorption syndrome
b) Amoebic dysentery e) Staphylococcal food poisoning
c) Shigellosis
15. An old man has a history of periodic upper abdominal pain and occasional blood in vomiting. On endoscopy he was found to have
a gastric ulcer which on histology showed H. pylori. Which of the following treatment regimens you would prescribe?
a) Metronidazole plus clarithromycin plus omeprazole d) Metronidazole plus clarithromycin
b) Metronidazole e) Omeprazole
c) Clarithromycin
16. An 11 years old girl presents with chronic ill health and growth retardation. She has been diagnosed to be sufferig from celiac
disease which does not have a known association with:
a) Type 1 diabetes mellitus d) Primary biliary cirrhosis
b) Inflammatory bowel disease e) Dermatitis herpetiformis
c) Diverticular disease of the colon
17. A 55 year old obese male presents for a routine annual physical examination. A review of systemic examination is insignificant
except for constipation, which has been present for several years. He does not have any major medical problems. He has smoked one-
and-a-half packs of cigarettes daily for 30 years and drinks socially. A routine colonoscopy shower multiple diverticuli at the sigmoid
colon. He is concerned about this finding. What would be the best advice?
a) Stop smoking d) Counsel for surgery
b) Stop drinking alcohol e) Use of prophylactic antibiotic
c) Increase dietary fiber intake
18. A 23 years old lady presents with chronic ill health, generalized oedema and small ascites. Protein losing enteropathy is not seen in
the following condition:
a) Crohn's disease d) Coellac disease
b) Tropical sprue e) Chronic duodenal ulcer
c) Lymphoma
19. The following treatment are recommended in inflammatory bowel disease EXCEPT?
a) Steroids d) Infliximab (TNF-a antibody)
b) Sulphasalazine e) Eradication of helicobacter pylori
c) Methotrexate

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20. A patient comes in emergency and reports to have consumed strong hydrochloric acid in a suicidal attempt. Which is the first step
in treatment?
a) Gastroscopy d) IV proton pump inhibitors
b) Broad spectrum antibiotics e) Barium meal examination
c) Use of oral liquid antacids
21. Which of the following is an indication of immediate surgery in ulcerative colitis:
a) Toxic dilatation d) Excessive steroid requirement
b) Sclerosing cholangitis e) Non compliance
c) Risk of carcinoma
22. Irritable bowel syndrome:
a) Usually require surgery at some stage d) It is a chronic disorder with no serious consequences
b) Respond to steroids e) Should always be investigated in detail
c) There is increased risk of malignancy
23. A 45 year old female presents with epigastric pain for the last two months. She states that the pain is aggravated by eating food
and it does not radiate to back. Her symptoms do not improve by Antacids. She also has mitral valve prolapse. Endoscopy is needed to
diagnose ulcer and know Helicobacter pylori status. She is allergic to amoxicillin. which one of the following is the best course of
action before doing endoscopy?
a) Prophylactic use of Ampicillin d) Prophylactic use of Ampicillin and Gentamicin
b) Prophylactic use of Amoxicillin e) No prophylaxis required
c) Prophylactic use of Clindamycin
24. A 45 year old male presents with a complaint of difficulty in swallowing of both liquids and solids which was mild initially but
has worsened gradually. He also complains of nocturnal cough and regurgitation of undigested food eaten several hours earlier.
Physical examination is unrevealing. Barium studies show dilated esophagus, loss of esophageal peristalsis and smooth tapering of the
distal esophagus. What will be the most appropriate next step in management of this patient?
a) Esophagoscopy d) Esophageal pH monitoring
b) Esophageal manometry e) Pneumatic dilatation
c) Botulinum toxin
25. A 55 years old male presented with complaint of constipation which alternates with diarrhea says that he is suffering from this
illness since childhood. There is no history of anorexia, weight loss or blood in stools. On examination, he is healthy looking middle
aged male his CBC: Hb 14 g/dl, TLC 6800/cmm, Platelets count 175000/cmm. TSH is 1 mu/I (0.2-4.5 mu/1). What is your
provisional diagnosis?
a) Colorectal Carcinoma d) Coeliac Disease
b) Hyperthyroidism e) Bacterial Overgrowth
c) Irritable Bowel Syndrome
26. Pyoderma gangrenosum is known manifestation of:
a) Coeliac disease d) Zollinger Ellison syndrome
b) Venous thrombosis e) Malignancy
c) Ulcerative colitis
27. Most common cardiac abnormality in patient with carcinoid tumors is:
a) Pulmonary stenosis d) VSD
b) Mitral stenosis e) Aortic regurgitation
c) Aortic stenosis
28. Which of the following is best investigation to diagnose celic disease?
a) Anti-gliadin antibodies d) Anti-nuclear antibodies
b) Anti-reticulin antibodies e) Absorption test
c) Anti-endomysial & tissue transglutaminase antibodies
29. A 25 year old man with long history of dysphagia is seen by his doctor. The patient has dysphagia for both solids and fiquids and
at time regurgitation of food takes place particularly at night. The food at time stuck up and patient has to drink large amount of water.
The most likely diagnosis in this patient would be:
a) Peptic ulcer d) Hiatus hernia
b) Esophageal reflux e) Achalasia
c) Esophageal carcinoma

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30. A 40 years old alcoholic is admitted in the emergency with severe retching followed by a small amount of blood in his vomit.
Most likely diagnosis in this patient would be:
a) Acute hepatitis d) Cirrhosis of liver
b) Mallory Weiss syndrome e) Reflux esophagitis
c) Peptic ulcer
31. A 55 year old male presents to his physician for routine annual physical examination. He has got complaint of constipation. As
part of routine screening, colonoscopy is done which shows multiple diverticuli at sigmoid colon. He is concerned about
diverticulosis. What would be next best step regarding diverticulosis?
a) Advise him to stop smoking d) Explain about surgical option
b) Advise him to stop taking alcohol e) Educate about prophylactic antibiotics
c) Increase dietary fiber intake
32. A 78 year old man with coronary artery disease presents with several months of postprandial generalized abdominal pain that
typically lasts 30-60 mins. He has become fearful of eating and has lost 15 lbs. of weight since then. What is most likely diagnosis?
a) Acute diverticulosis d) Intestinal obstruction
b) Acute pancreatitis e) Mesenteric obstruction
c) Acute cholecystitis
33. A 40 years old male presents with compliant of moderate to severe buring chest pain, which occurs after meals. The pain doesn't
radiate. It is relieved by taking antacids & is aggravated upon reclining. He also complain of bitter taste. He says that he has lost 10 lbs
over a period of 5 months. He has been smoking two packs of cigarettes per day for last 20 years, His vitals are stable. Chest X ray,
EKG and echocardiography are all normal. What will be next appropriate step in management of this patient?
a) Treatment with antacids d) Esophagoscopy
b) Treatment with famotidine e) Esophageal pH monitoring
c) Treatment with omeprazole
34. A 40 years old male presented with a complaint of diarrhea for 3 months. He has 5-6 episodes of diarrhea per day which contains
mucus and blood. He is anorexic & is losing weight. Which one of following investigations should be carried out to reach diagnosis?
a) lleocolonoscopy with biopsy for histopathology d) CT colonogram
b) Stool for culture sensitivity e) Therapeutic trial of ciprofloxacin and metronidazole
c) Barium enema
35. A 50 year old woman is referred by GP for upper GI endoscopy following a 4 month history of epigastric pain despite treatment
with antacids and proton pump inhibitors. Her endoscopy demonstrated a duodenal ulcer coupled with a positive H. [Link] was
given a 2 week course of drugs to eradicate H. pylori. How will you assess eradication of H. pylori by non invasive method:
a) Anti helicobacter antibody test d) Microbiological culture of gastric aspirate
b) Fecal antigen test e) Histology of gastric mucosa
c) Rapid urease test
36. A middle aged person is admitted with nausea, vomiting and upper abdominal distension for last 6 months. His vomiting is of
large quantities and contains food particles ingested 24 hours ago. He is having metabolic alkalosis with acidic urine. What is most
likely diagnosis?
a) Acute gastritis d) Addison's disease
b) Acid peptic disease e) Gastric outlet obstruction
c) Raised intracranial pressure
37. A 14 year old boy presents with loose motions and weight loss for last many year. His diarrhea improves with avoiding wheat
products. He is diagnosed as a case of celiac disease. Which of following features is not consistent with this disease?
a) Growth retardation d) Impaired glucose tolerance curve
b) Weight loss e) Night blindness
c) Osteomalacia
38. A 30 years old female presents with weight loss, abdominal pain and diarrhea. She also has vomiting and severe oral ulcers.
Barium follow through shows affected areas as ulcerated and narrowed along with normal areas in between them. What is most likely
diagnosis?
a) Ulcerative colitis d) Whipple diseasex
b) Tuberculosis of abdomen e) Crohn's disease
c) Celiac diseased
39. All of following facts are true regarding ulcerative colitis except:
a) Invariably involves rectum b) Spread proximally in continuous manner

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c) Inflammatory process is limited to mucosa e) Is associated with pseudo polyps

d) Is often associated with perianal fistulas
40. Which of following combinations is not seen in case of malabsorption:
a) Vitamin A deficiency: Night blindness d) Vitamin D deficiency: Muscle wasting
b) Vitamin B12 deficiency: Anemla e) Vitamin K deficiency: Bruises
c) Vitamin C deficiency: Bleeding gums

ANSWER KEYS
1. E 2. A 3. D 4. C 5. C 6. A 7. A 8. B 9. D 10. C
11. C 12. C 13. B 14. E 15. A 16. C 17. C 18. E 19. E 20. D
21. A 22. D 23. E 24. B 25. C 26. C 27. A 28. B 29. E 30. B
31. C 32. E 33. D 34. A 35. B 36. E 37. D 38. E 39. D 40. C

3. Dysphagia = difficulty swallowing (oropharyngeal or esophageal). A h l s , soph l n r, syst m s l ros s, bulb r p lsy →
all cause esophageal/oropharyngeal dysphagia. Gastric outflow obstruction affects the pylorus/duodenum, leading to post-prandial
vomiting and early satiety, not difficulty swallowing.
5. Infection (Tb) & malignancy causes exudative ascites
8. Severe vomiting is a strong risk factor for Mallory Weiss tear
11. The patient's symptoms and history are suggestive malignancy and esophago-gastroscopy should be peformed. CT/MRI/USG used
for staging.
12. Plain x-ray abdomen is the initial investigation to be performed in case of suspected obstruction
13. It can be UC but as she came from a remote village, it is more likely that she would be suffering from infectious disease
transmitted by contaminated food or water
14. Staphylococcal food poisoning developes within 1-6 hours
16. Table is given in Davidson for disease association of Celiac disease
17. Most common risk factor for diverticulosis is constipation that may occur due to absence of dietry fiber in diet. So, it is best
treated by intake of dietry fibers until unless it causes symptoms
18. Table is given in Davidson
20. 1st step is ABC mangement which is not given in option. 2nd step: urgent surgical repair if signs of perforation, otherwise give
PPI. 3rd step: Endoscopy (gastroscopy) to assess the extent and severity of corrosive injury to the esophagus and stomach. It is done
on urgent basis if ingestion is symptomatic (drooling, vomiting, dysphagia, odynophagia, chest pain). Oral antacid/sodium bicarbonate
contraindicated because neutralization can cause exothermic reaction & worse the condition. Barrium meal is contraindicated because
of risk of perforation. Gastric lavage is also contraindicated
23. Prophylactic antibiotic before endoscopy is given in case of variceal bleed to avoid SBP.
24. Although Bird beak appearance on Barrium swallow indicates Achalasia but it does not mean that it is 100% achalasia. It can be seen in
pseudoachalasia. Always do endoscopy before Manometry to rule out pseudoachalasia (cardia carcinoma) because pseudoachalasia can
mimic clinical, barium swallow & manometric features of Achalasia. So next appropriate step will be Endoscopy that will be followed by
Manometry & then start treatment on confirmation. Reference: Davidson 24th edition.
27. Carcinoid syndrome involves valves of right sided heart
30. Mallory Weiss tear = Hematemesis after forceful vomiting (Bulemia nervosa). Boerhaave syndrome (transmural esophageal
rupture) = Sudden severe chest pain with or without hematemesis
31. Most common risk factor for diverticulosis is constipation that may occur due to absence of dietry fiber in diet. So, it is best
treated by intake of dietry fibers until unless it causes symptoms.
32. Occurence of abdominal pain after MI or HF indicates Mesenteric ischemia or Ischemic colitis.
33. Previously patient had typical symptoms of GERD & was treating with antacids. Now patient has an alarming symptom (weight
loss) & this is an indication of performing esophagoscopy or endoscopy
34. Features are suggestive of IBD and ileocolonoscopy with biopsy is diagnostic
35. Most appropriate test to ensure successful eradication of H. pylori  C13 Urea Breath test (non-ivasive). 2nd best test  Faecal
antigen test (non-invasive)
38. Oral ulcers + Skip lesions  Crohn's disease.
40. It is a case of food poisoning & condition of patients is not severe i.e. no severe dehydration so it requires oral rehydration advice,
antiemetics & discharge.
41. Although Vit C deficiency may lead to bleeding gums but vitamin C deficiency is not typically associated with malabsorption.

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02. HEPATOBILIARY SYSTEM

Annual 2024 held in 2025
1 Patient with hepatic encephalopathy is drowsy but responding to pain Grade III
2 Oro-fecal route is the commonest mode of transmission in: Acute hepatitis A
3 FDA approved drug for NAFLD A
A. Vitamin E B. Statin C. Glitazone
4 Mr. X presented to your clinic with complaint of yellowish discoloration of eyes in the Gilbert syndrome
month of Ramadan. He has got no other complaint. He had similar problem last Ramadan
which resolved spontaneously. Physical exam is normal except for jaundice. LFTs are as:
direct bilirubin 0.6 mg/dl normal, indirect bilirubin 3.4mg/dl (raised), SGPT 34 IU/L,
SGOT 30 IU/L, ALP 123 IU/L, viral serology -ve, CBC and peripheral film normal.
What is possible cause?
5 Drug that increases level of gamma glutamyltransferase: Inducers of P450 = Phenytoin,
A. Barbiturate Ethanol, Barbiturate, Valproate,
B. Rifampicin Carbamazpepine, CCPs, Griseofulvin
Annual 2023 held in 2024
6 A 12 years old child complains of yellowness (jaundice) on fasting, Liver enzymes are Gilbert Syndrome
normal, no Bilirubinuria & normal peripheral blood film
7 A 36 years old woman presented Fatigue, Anorexia, Arthralgia. On examination, Autoimmune Hepatitis
Jaundice, Spider naevi, Hepatosplenomegaly is present, Lab report shows: ASMA (+)
8 Diagnostic test for Wilson Disease is: 24–hour urinary Cu excretion
09 Which type of hepatitis cannot be chronic: Hep–A
10 1st Line Emergency treatment for Variceal bleeding is: IV Terlipressin
11 Serology report of Patient: HBsAg (–), Anti–HBc IgM (–), but Anti–HBs (+) Immunization without Infection
12 A Patient presented with Choreiform Movements. On examination, Jaundice, Spider Wilsons Disease
naevi, Hepatosplenomegaly is present. What is the diagnosis?
13 Definitive Treatment for Variceal Bleeding is: Endoscopic Band Ligation
14 A Patient suffering from fever & Jaundice presented to OPD, Serology revealed Anti– Ribavirin (It is the only drug used
HEV (+). What treatment should be given to this patient? in treatment of HEV)
Annual 2022
15 Which of the following should not be given to a patient with Hepatic Encephalopathy Oral lactulose (Give Phosphate
(unconsciousness & constipation)? enema in such patients)
16 A Patient suffering from Hep–B, can have: Superinfection with HDV
17 Which of the following is Not Given in Hematemesis in Emergency: Barium Swallow
18 Which of the following condition is associated with clear ascitic Fluid (transudate) Cirrhosis
Annual 2021
20 A patient presented with Pain RUQ, and significant weight loss. On examination, Liver Hemochromatosis
was enlarged, lab reports showed raised serum Ferritin level & raised iron load?
21 A female with complaints of fatigue, anorexia and arthralgia. Lab reports showed LFTs (to check whether
Elevated ASMA levels, next investigation that should be done: cholestatic pattern is present,
because if present, then it will be
PBC rather than Autoimmune
Hepatitis)
Supply 2020
22 In order to control bleeding in case of Variceal bleeding, following intervention should Endoscopic Band Ligation
be done:
23 Which one is a common complication of NAFLD? Cirrhosis
24 Mechanism of Action of lactulose is: Decrease Colonic pH & decrease
the ammonia production
Annual 2020
25 A child presented with complains of yellowness (jaundice) on fasting, Liver enzymes are Gilbert Syndrome
normal, only Unconjugated bilirubin levels are raised. Diagnosis?

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26 A patient presented with abdominal distension; examination revealed positive shifting Cirrhosis (Transudative Ascites)
dullness. Paracentesis & ascitic fluid examination revealed protein content of 0.8 g/dl?
27 A patient presented with history of fever, Jaundice for last 2 days. Evidence of feco–oral IgM Anti–HEV
transmission is present. Investigation For diagnosis?
28 A Patient presented with complains Choreiform Movements, tremors and Dementia. On Wilsons Disease
examination, Jaundice, Spider naevi, Hepatosplenomegaly is present. LFTs are also
deranged What is the diagnosis?
Annual 2019
29 Diagnostic investigation for A patient of Autoimmune Hepatitis is? ASMA
30 HBeAg is associated with infectivity of which hepatitis virus? Hepatitis B virus
31 A Patient presented with complains of sudden onset of decreased urinary output. He is Hepatorenal Syndrome
known case of Cirrhosis. RFTs reveals raised Serum Creatinine. Diagnosis?
32 Ayoung patients presented with neurological deficits. His LFTs report showed raised Wilsons Disease
AST, what is the diagnosis?
Annual 2018
33 A person suffering from Active hepatitis C infection: Cannot Donate Blood
34 Best investigation in a patient who is alcoholic and has significant weight loss, ascites Liver Biopsy
and hepatomegaly?
35 Tests to be done in case of Hep–B? HBsAg, Anti-HBc, Anti-Hbs
36 A patient known case of cirrhosis, presented with ascites. Peritoneal fluid shows raised Spontaneous Bacterial peritonitis
neutrophils > 250 x 106/L, and increased proteins. Diagnosis?
Supply 2017
37 An obese person, presented with complain of band around the neck. His Blood sugar Hemochromatosis
levels are also raised (Diabetic). Most likely diagnosis?
38 Which of the following is a drug used for Hep C? Daclatasvir
39 Peritoneal fluid Findings of SBP due to liver cirhosis are: Low proteins & raised WBCs
40 Correct statement about Window Phase of Hep B infection is? During this Period individuals
may be infectious but may not
test positive for HBsAg / Anti-
Hbs
Annual 2016
41 Gold standard in a patient with suspected Liver disease is? Liver Biopsy
42 A child complains of yellowness (jaundice) on fasting, Liver enzymes are normal. Gilbert Syndrome
43 A patient with hematemesis, given terlipressin & IV fluids, now stabilized, what should Endoscopy / Band Ligation
be the next step?

1. A patient with known cirrhosis presents with haemetemesis. After initial resuscitation which one of the following drugs will be
useful?
a) Inj. vitamin K. d) Inj. omeprazole
b) Inj. terlipressin e) Inj. tranexemic acid
c) Inj. metronidazole
2. What is the most probable diagnosis of an apparently normal school boy of 12 years who has the following lab results: Hb 14.3
gm/dl; Bilirubin 3-8 mg/dl; conjugated 1.4 mg/dl; ALT 16 IU (N = less than 40); AST 12 (N = less than 40); Alkaline phosphatase
270 (N = less than 275):
a) Chronic hepatitis B d) Gaucher's disease
b) Excessive hemolysis e) Gilbert's syndrome
c) Hemochromatosis
3. A 54 years old man presents with a transudative ascites which is not a feature of:
a) Malabsorption d) Abdominal tuberculosis
b) Congestive cardiac failure e) Nephrotic syndrome
c) Protein losing enteropathy

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4. A 25 year pld pregnant female develops post-transfusion hepatitis. Which of the following viruses is not transmitted parenterally?
a) Hepatitis B d) Hepatitis D
b) Hepatitis C e) HIV
c) Hepatitis A
5. A 50 years old teacher who presents with drowsiness and urinary incontinence. In the emergency, he should be the treated with
following measures except for
a) Oral lactulose d) EEG is helpful
b) IV loop diuretics for cerebral oedema e) Sedation should be voided
c) Per rectal lactulose
6. In a case of obstructive jaundice, if the gall bladder is palpably enlarged. It is unlikely to be case of:
a) Carcinoma of gall bladder d) Ascaris obstructing the common bile duct
b) Stones in the common bite duct e) Cholangiocarcinoma
c) Carcinoma of head of pancreas
7. After a full three doses course of hepatitis B vaccine, which one of the following blood tests indicate successful uptake of the
vaccine:
a) HBsAg d) Anti-HBsAg
b) Anti-HBc IgM e) Anti-HBe
c) Anti-HBc IgG
8. Hepatitis A is the most common type of viral hepatitis in the world, which of the following measures can help prevent hepatitis A:
a) Screening of all blood donors d) Avoid meat intake
b) Avoid getting a shave from barbers e) Prevention of fecal contamination of food and water
c) Always using a disposable syringe
9. A 15 years old female presents with pruritis and jaundice. She has xanthelasmas bilaterally. Bilirubin 16 mg/dl, ALT 145 IU, AST
110 IU, Alkaline phosphatase 1116 IU. Anti-mitochondrial antibodies are present. She is suffering from:
a) Gall stones d) Hemochromatosis
b) Carcinoma head of pancreas e) Alcoholic cirrhosis
c) Primary biliary cirrhosis
10. A patient presents with severe epigastric pain, nausea and vomiting. There is upper abdominal tenderness. Serum amylase is 1025
IU. This condition has one of the following risk factors:
a) Gall stones d) Hyperthyroidism
b) Hypocalcaemia e) Diabetes mellitus
c) Colonic diverticulae
11. A 40 years old male has jaundice for the last six months, blood test shows bilirubin=6 mg/dl, ALT=200, alkaline phosphate=50,
test for hepatitis C is positive. Which of the following drug is likely to eradicate this viral infection?
a) Vitamin C d) Streptomycin
b) Ciprofloxacin e) Injection vitamin B complex
c) Interferon
12. Oro-fecal route is the commonest mode of transmission in:
a) Hepatitis A d) Hepatitis D
b) Hepatitis B e) Dengue fever
c) Hepatitis C
13. Non-alcoholic fatty liver disease is:
a) Harmless condition
b) Can lead to cirrhosis d) A consequence of starvation
c) Treated with anti-viral drugs e) Missed on routine abdominal ultrasound
14. Spontaneous bacterial peritonitis is known complication of:
a) Typhoid perforation d) Chronic liver disease
b) Abdominal tuberculosis e) Malignancy
c) Sepsis
15. Coarse flapping tremors are a feature of:
a) Parkinsonism d) Hepatic encephalopathy
b) Cerebellum disorder e) Anxiety
c) Chorea

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16. A pregnant lady in her last trimester presents with acute hepatic failure due to hepatitis E virus. The following is not a
complication of her condition:
a) Encephalopathy d) Hepatoma
b) Cerebral oedema e) Hypoglycemia
c) Renal failure
17. A 55 years old landlord with the 15 years history of alcohol intake presents with features of cirrhosis of liver. The following is not
an expected finding in him:
a) Spider telangiectasia d) Palmar erythema
b) Clubbing e) Deep vein thrombosis
c) Gynaecomastia
18. This is not a cause of portal hypertension:
a) Pancreatitis d) Chronic paracetamol intake
b) Cirrhesis of liver e) Umbilical sepsis
c) Budd-Chiari syndrome
19. A 68 years old man presents with jaundice which has developed over the last four weeks. There are scratch marks on his skin. He
has deep colored urine and clay colored feces. Abdominal examination reveals a mass in the right hypochondrium, which is globular
in shape and moves up and down with respiration. Which of the following is the most likely diagnosis?
a) Viral hepatitis d) Pancreatic carcinoma
b) Cholecystitis and gall stones e) Drug induced jaundice
c) Hemolytic anemia
20. A 40 years old man who is used to regular alcohol intake, presents with abdominal swelling which has increased over several
months. He has also history of gastrointestinal bleeding. Ultrasound shows liver cirrhosis. Which of the following physical sign points
out to its alcoholic etiology?
a) Ascites d) Dupuytren's contractures
b) Splenomegaly e) Pitting edema of feet
c) Caput medusae
21. A 45 year old male presents in Emergency Room with complaint of abdominal pain and fever for last 2 days. He is a known case
of chronic liver disease and has been treated for ascites and portal hypertension. Fluid thrill is positive. His CBC shows Hb 12.3 g/dl,
TLC 12,300/min, Platelets count 123,000/cmm. Diagnostic ascitic tap shows 2.3 g/dl protein, WBCs count 635/cmm and Neutrophil
count 390/cmm. Which one of the following is most likely cause of his present admission?
a) Spontaneous bacterial peritonitis d) Acute pancreatitis
b) Hepatorenal syndrome e) Enteritis
c) Secondary bacterial peritonitis
22. A 40 year old female presents with complains of high grade fever and pain in right quadrant of the liver. On examination, she has
an enlarged and tender liver. On Ultrasound, there is a 3 x 3 liver abscess in left lobe of liver. Which one of the following is the best
treatment option for this patient?
a) Empirical therapy with antibiotics d) Drainage of liver abscess
b) Serial monitoring of liver abscess with ultrasound Drainage e) Culture sensitivity of liver abscess
c) culture & sensitivity, empirical antibiotic therapy
23. A 42 years old female presents with pruritis for 4 months. She has noted progressive fatigue and 5 kg weight loss. She has
intermittent diarrhea and no vomiting and denies changes in her bowel habits. Her past medical history is significant only for
hypothyroidism for which she is taking levothyroxine. Her family history is unremarkable. She is mildly icteric, has spider angiomas
on her torso. You palpate a nodular liver edge 2 cm below the costal margin. The reminder of examination is unremarkable. A right
upper quadrant USG confirms your suspicion of cirrhosis. Which of following investigation findings is expected to be present in this
patient?
a) Hypercholesterolemia d) Hypercalcemia
b) Raised serum amylase e) Renal stones on USG abdomen
c) Urinary Bence Jones proteins
24. A 35 years old female with alcoholic cirrhosis is admitted with deteriorating confusion and deteriorating ascites. On examination
she is mildly jaundiced, temp 102°F, agitated and confused and has flapping tremor of outstretched hands. Abdominal exam reveals
ascites. Hb 12.2 g/dl, TLC 10200/cmm, Na 142 mmol/l, K 4.2 mmol/l, urea 42 mg/dl, creatinine 1.2 mg/dl and glucose 146 mg/dl.
Ascitic tap reveal cell count of 550/cmm, neutophils 330/cmm. How will you treat her?
a) IV cefotaxime b) IV metronidazole

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CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

c) IV octreotide e) Oral neomycin

d) IV ciprofloxacin
25. Mr. X presented to your clinic with complaint of yellowish discoloration of eyes in the month of Ramadan. He has got no other
complaint. He had similar problem last Ramadan which resolved spontaneously. Physical exam is normal except for jaundice. LFTs
are as: direct bilirubin 0.6 mg/dl normal, indirect bilirubin 3.4mg/dl (raised), SGPT 34 IU/L, SGOT 30 IU/L, ALP 123 IU/L, viral
serology -ve, CBC and peripheral film normal. What is possible cause?
a) Gilbert syndrome d) Choledocholithiasis
b) Criggler Najjar syndrome e) Cancer pancreas
c) Viral hepatitis
26. Lactulose is effective in treatment of hepatic encephalopathy as:
a) It reduces the colonic pH d) Reduces portal hypertension
b) It increases the colonic pH e) Correct serum sodium level
c) It increases ammonia absorption
27. Raised mitochondrial antibodies are a feature of:
a) Wilson's disease d) Alpha antitrypsin deficiency
b) Secondary biliary cirrhosis e) Primary billiary cirrhosis
c) Hereditary hemochromatosis
28. Which of the following features would be expected on lipid analysis in a 57 year old female with two year history of primary
biliary cirrhosis:
a) A lipaemic appearance of the serum would be expected.
b) Is treated with clofibrate therapy.
c) Is characteristically associated with tendon xanthomas.
d) Is characteristically associated with palmar xanthomas.
e) No evidence of a dysplipidaemia would be expected with this short duration of disease.
29. A known patient of HCV induced liver cirrhosis on regular diuretic therapy, develops diarrhea which is followed by oligouria. On
investigation his urinary sodium is low. Ultrasound abdomen reveals normal sized kidneys. Although renal functions are mildly
deranged, the renal histology is normal. The patient may be benefited by
a) Addition of beta-blockers d) Antidiarrheal drugs
b) Terlipressin e) Somatostatin
c) Renal transplantation
30. A 48 years old male who is a known case of HCV for last 15 years presented with complaint of haematemesis and melena in the
morning. There is no history of epigastric pain or NSAID intake. On examination, he has palmar erythema and spider naevi. His liver
is shrunken and spleen is palpable. Dullness is present, Endoscopy has been done and band ligation was carried out. Which one of the
following drugs should be prescribed for secondary prevention of esophageal variceal bleeding is first line?
a) Propranolol d) Lactulose
b) Diltiazem e) Furosemide
c) Spironolactone
31. A 40 year old woman presents with fatigue and pruritis for last many years. There is mild right upper quadrant discomfort but no
fever. She also complains of bone pains. On examination, she is mildly jaundiced with mildly enlarged tender liver. Her ALT is 50
U/L and AST 45 U/L and alkaline phosphatase 600 U/L. What is most likely diagnosis?
a) Chronic hepatitis d) Obstructive jaundice
b) Hemolytic anemia e) Primary sclerosing cholangitis
c) Primary biliary cirrhosis
32. Following are complications of portal hypertension except:
a) Variceal bleeding d) Prolonged PT and INR
b) Hypersplenism e) Hepatic encephalopathy
c) Iron deficiency anemia
33. A 60 years old man with alcoholic liver disease was admitted with an upper GI bleed secondary to esophageal varices. Patient
undergoes endoscopic variceal banding and is discharged after 2 weeks in hospital stay. Which of following medications will act as
prophylaxis in preventing a rebleed from his esophageal varices:
a) Furosemide d) Ramipril
b) Propranolol e) Irbesartan
c) Amlodipine

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34. A 67 year old man presents feeling unwell and complain of general malaise. He mentions a long history of alcohol abuse and his
past medical history shows deranged liver function tests. Which of following clinical signs will not form part of alcoholic liver
disease?
a) Finger clubbing d) Jaundice
b) Palmar erythema e) Koilonychia
c) Spider nevi
35. A patient in your ward is diagnosed as case of hepatocellular carcinoma. You are asked to perform tumor marker level on this
patient. Which of following tumor markers will be elevated in hepatocellular carcinoma:
a) Alpha fetoprotein d) CA15-3
b) Carcinoma antigen e) CA125
c) hCG
36. A 34 year old male, a diagnosed case of CLD, presented with complaints of 3 episodes of hematemesis and melena over last 12
hours. He is receiving Aldactone 100mg/day, Carvedilol 6.25mg/day. On endoscopy, there are esophageal varieces. Which one of
following is treatment of choice in this patient.
a) Sclerotherapy d) Hydro acryl gel therapy
b) Endoscopic band ligation e) Terlipressin
c) Propranolol
37. A 23 years old boy presented with complaint of involuntary, jerky, semi purposive movements of hands and legs. His elder sister
died of liver disease at age of 35 years. There is no focal neurological deficit. Which of following condition is complication of
disease?
a) Proximal renal tubular acidosis d) Berry aneurysm
b) Osteoporosis e) Premature atherosclerosis
c) Vitamin D deficiency
38. A 20 years old boy presents with fever, vomiting, loss of appetite and right upper quadrant pain. On examination, he is jaundiced
with palpable tender liver. His ALT and AST are raised 5 times the upper limits of the normal. His alkaline phosphatase is mildly
raised. What is most likely diagnosis?
a) Acute hepatitis d) Primary biliary cirrhosis
b) Obstructive jaundice e) Hemolytic anemia
c) Pyogenic liver abscess

ANSWER KEYS
1. B 2. E 3. D 4. C 5. B 6. B 7. D 8. E 9. C 10. A
11. C 12. A 13. B 14. D 15. D 16. D 17. E 18. A 19. D 20. D
21. A 22. C 23. A 24. A 25. A 26. A 27. E 28. D 29. B 30. A
31. C 32. D 33. B 34. E 35. A 36. B 37. A 38. A

2. Isolated raised unconjugated bilirubin – Gilbert syndrome

3. Transudative ascites occur either due to low plasma oncotic pressure (low plasma albumin) or high hydrostatic pressure. So causes
of transdutaive ascites include; protein losing enteropathy, nephrotic syndrome, malabsorption  low oncotic pressure, cardiac failure
 high hydrostatic pressure
5. Loop diuretics worsen the symptoms of hepatic encephalopathy (most likely diagnosis) by causing electrolyte imbalances
(hypokalemia) and dehydration.
6. If the gallbladder is palpable, the jaundice is unlikely to be caused by biliary obstruction due to gallstones, probably because a
chronically inflamed, stone- ont n n llbl r nnot r ly l t . Th s s Courvo s r‘s w, n suggests that jaundice is due
to a malignant biliary obstruction (e.g. pancreatic cancer).
7. A positive anti-HBs would imply immunity through either previous immunisation or disease. A positive HBsAg implies either acute
or chronic hepatitis B
10. Gall stone is a common risk factor for Acute pancreatitis
16. Acute hepatic failure (fulminant hepatitis) in pregnancy (commonly due to HEV) can lead to: Encephalopathy – due to
accumulation of toxins like ammonia, Cerebral edema – from severe liver dysfunction, Renal failure – hepatorenal syndrome may
develop & Hypoglycemia – due to impaired gluconeogenesis. Hepatoma (hepatocellular carcinoma) is a chronic complication, not an
acute one, and is not associated with acute HEV infection.
19. Patient has obstructive jaundice (deep colored urine & clay coloured feces) which is a common finding in pancreatic carcinoma

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20. Dupuytr n‘s ontr tur (p lm r s th k n n l n to l x on orm t s o n rs) s sp lly sso t w th chronic
alcohol use. Other listed findings—ascites, splenomegaly, caput medusae, pitting edema—are common in cirrhosis of any etiology,
not specifically alcoholic liver disease.
22. Surgical drainage is done for large abscess/not responding to antibiotic
23. This patient have PBC – intrahepatic cholestatic jaundice and will have Hypercholesterolemia (cholesterol accumulates due to
impaired bile excretion).
24. IV cefotaxime is the drug of choice for SBP
25. Isolated raised unconjugated bilirubin – Gilbert syndrome
29. Patient have HRS Type I and treatment of choice is IV terlipressin + Albumin
32. Reference: Davidson 24.33 (Complications of Portal HTN)
37. Wilson's disease can lead to premature osteoarthritis and increased urinary copper damages proximal convoluted tubules and
glomerulus leading to hematuria, Fanconi syndrome and aminoaciduria
38. Jaundice w th t n r, nl r l v r → h p to llul r nvolv m nt. A T n AST r s 5 U N → h p to llul r p tt rn o
injury. M l ly r s A P → hol st t ompon nt s m nor, ons st nt w th ut h p t t s. Obstru t v j un → pr om n ntly
high ALP, dark urine, pale stools. Pyo n l v r bs ss → usu lly v r + r ht upp r qu r nt p n but l bs show l uko ytos s, not
predominantly hepatocellular enzyme elevation. Pr m ry b l ry rrhos s → hron s s , mostly m l -aged women, ALP
elevated more than transaminases. H molyt n m → un onju t hyp rb l rub n m , norm l tr ns m n s s

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GIT & NUTRITION

SURGERY
S-051 ֍INTUSSUSCEPTION֍

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Common in Infants; present with episodes of screaming & drawing up legs in
a previously well child
 Bilious vomiting + Red Currant-jelly stools (Blood & mucus)
 Abdominal Examination shows:
 Sign of Dance; Feeling of emptiness in Right iliac fossa
 Sausage shaped lump in the umbilical area.

1. An infant was brought by his parents in surgical Emergency Room. Child has been well previously but has been recently suffering
from episodes of screaming and drawing up his legs and appear pale. In between screaming attacks, he has been lying listless.
Vomiting is bilious and stool has blood with mucus. On examination of abdomen, there is positive sign of Dance.
a) What is your clinical diagnosis?
Common types of Intussusceptions: ―Il o ol
Intussusception
> Ileo-ileal > Ileo-cecal > Colo- ol ‖
b) How would you confirm your diagnosis?
Modality Finding
Plain Abdominal X-ray  Soft-tissue opacity; Air-fluid levels & bowel dilation (Obstruction)
(Supine & Erect)  Absent cecal gas shadow in ileocolic cases
 Meniscus / Crescent Sign
Barium Enema  Claw Sign [Gold Standard]
Abdominal USG  Target / Bull-eye / Doughnut Sign (On Transverse View)
 Pseudo-kidney / Pitchfork Sign (On Longitudinal View)
CT scan  Target or sausage-shaped soft-tissue mass Aquaporin
with a 4layering
positive serum
effect antibody
+
mesenteric vessels within the bowel lumen.

c) What is the sign of Dance?

On abdominal examination, there is Feeling of emptiness in Right iliac fossa; known as Sign of Dance.
d) How would you manage this patient?
1. Initial Resuscitation of patient:
 NG decompression (For facilitating decompression + reducing risk of aspiration)
 IV Flu r pl m nt (H rtm nn‘s Solut on Normal Saline)
 Analgesics & Broad-spectrum antibiotics.
2. Relief of Obstruction:
 Non-operative:
 Hydrostatic reduction using an air or barium enema
 Operative:
 Surgical Reduction: ―A tr nsv rs r ht-sided abdominal incision followed by gently compressing the most distal
p rt o th ntussus pt on tow r s ts or n‖.
 Surgical Resection: ―R s t on n pr m ry n stomos s; rr u bl In r t ntussus pt on.

S-051a ֍APPENDICITIS֍

Clinical Features  Initially periumbilical pain (visceral pain – T10). Then shifts to right iliac fossa (RIF). Pain
migration is highly suggestive
 Anorexia
 Nausea and vomiting

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 Low-grade fever
Investigation  CBC → l uko ytos s w th n utroph lia
 CRP elevated
 Ultrasound
 CT scan abdomen (gold standard in adults)
Treatment Step 1: Admit patient. Nil per oral (NPO)
Step 2: IV fluids
Step 3: IV antibiotics (Ceftriaxone + Metronidazole)
St p 4: D n t v tr tm nt → App n tomy
 Open appendectomy
 Laparoscopic appendectomy (preferred)
Complications of delayed  Appendicular mass (Omentum walls off inflamed appendix)
treatment  Appendicular abscess
 P r or t on → n r l z p r ton t s
 Sepsis

S-051b ֍HERNIA & HYDROCELE֍

01. Hernia

Features Direct inguinal hernia Indirect Inguinal hernia

Congenital/Acquired Acquired in old age Congenital
Entry of hernial sac Through Hesselbach triangle Through deep inguinal ring into inguinal canal
Extent Pass through only superfical inguinal Pass through both deep & superficial inguinal
ring ring
Descent into scrotum No Yes
Relation with inferior epigastric artery Medial Lateral
Response on deep ring occlusion test Bulge appears No buldge appears

02. Hydrocele

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Painless, Scrotal-Inguinal swelling
 Upper limit reachable
 + Transillumination test

1. A 35-year-old male presented with a right sided painless inguinal scrotal swelling. It is relatively firm on palpation; upper limit is
reachable and transillumination test is positive. [Supple 2010 held in 2011]
a) What is probable diagnosis?
Answer: Hydrocele
b) Name different anatomical types of this condition.
1. Vaginal Hydrocele (very common)
2. Infantile Hydrocele
3. Congenital Hydrocele
4. Hydrocele of cord
c) Outline the treatment option for congenital type.
Herniotomy

S-051c ֍PHIMOSIS & PARAPHIMOSIS֍

Phimosis  Inability to retract prepuce over glans while Paraphimosis  For sk n on r tr t , n‘t b r pl b k to ts norm l
position, forms ring like constriction proximal to corona.
Complications
 Balanitis (inflammation of glans)

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 Posthitis (inflammation of foreskin)

 Balanoposthitis (both glans and foreskin inflamed)
 Painful erections
 Difficulty in urination
 Urinary retention
Management
 Circumcision

S-065 ֍CHOLECYSTECTOMY֍

1. A 46 years old female is undergoing Laparoscopic Cholecystectomy for gall stone disease. [Annual 2021 held in 2022]
a) Name the structures forming the Calot’s Triangle
C lot‘s (H p to-cystic) Triangle is bounded:
 Superiorly (Base) by Inferior surface of the Liver (Segment V of Right Hemi–Liver)
 Laterally by Cystic Duct and Medial border of Gall bladder
 Medially by Common Hepatic Duct
b) What is the Main Content of Calot’s Triangle?
Cystic Artery
c) Describe three steps of critical view of safety in cholecystectomy.
3 E‘s
 Ensure clearance of the Hepato-cystic triangle of all fibrofatty and soft areolar tissue.
 Ensure that only 2 Tubular structures enter the gallbladder (cystic artery and duct)
 Exposure of lower part of the cystic plate (This is done by separating the lower 1/3rd of gallbladder from its liver bed to
expose at least the medial third of the cystic plate).

2. Name four important structures in relation of Common Bile Duct. Location Structures
Anteriorly
 Liver
 1st Part of Duodenum
 Head of Pancreas
Posteriorly
 Portal Vein
 Inferior Vena cava
To the Left
 Common Hepatic Artery
 Gastroduodenal Artery

3. Write down steps of open cholecystectomy.

1. Induction and Maintenance of general anesthesia
2. An upper midline, short subcostal (Kocher) or right upper transverse incision is made, centered over the lateral border of the
rectus muscle.
3. The gallbladder is appropriately exposed and packs are placed on the hepatic flexure of the colon, the duodenum and the
lesser omentum to ensure a clear view of the anatomy of the porta hepatis.
4. R tr t on: (Th s xpos s th C lot‘s tr n l )
 Fundus is retracted towards the diaphragm.
 The neck of the gallbladder is then retracted towards the right iliac fossa.
5. S D ss t on o C lot‘s tr n l to h v Cr t l V w o S ty
6. Once the anatomy is clearly defined and the triangle of Calot has been laid wide open, the cystic duct and artery are tied and
divided. The gallbladder is then dissected away from its bed.
7. Closure of Abdominal wall: [Done in Reverse Order]
 Maintain Hemostasis
 Peritoneum and transversus abdominis are stitched together
 Then, approximate the rectus muscles and close the anterior rectus sheath
 Ko h r‘s (Sub ost l) In s on s los n two l y rs

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4. Write down steps of Laparoscopic Cholecystectomy.

1. The patient is placed supine on the operating table.
2. Induction and maintenance of General Anesthesia
3. Abdominal preparation & Establishing Pneumoperitoneum via open sub-umbilical OR closed technique (using a Verres
needle)
4. Insertion of Laparoscopic Ports
 A 10 mm port (inserted through umbilicus, will function as camera Port)
 Another 10 mm port is inserted in the subxiphoid area (Epigastrium)
 Two 5 mm ports, are inserted in the right subcostal area.
5. The patient is placed in a reverse Trendelenburg position slightly rotated to the left (to exposes the fundus of the gallbladder).
6. R tr t on to xpos s th C lot‘s tr n l
 Fundus is retracted towards the diaphragm.
 The neck of the gallbladder is then retracted towards the right iliac fossa.
7. S D ss t on o C lot‘s tr ngle to achieve Critical View of Safety
8. Once the anatomy is clearly defined and the triangle of Calot has been laid wide open, the cystic duct and artery are clipped
and divided.
9. The gallbladder is then removed from its bed by sharp or cautery dissection and, once free, removed via the umbilicus in a
retrieval bag.
10. Removal of Ports and Closure:
 Irrigation of RUQ is done and ports are removed under direct vision (Allow CO2 to escape completely)
 Suture the umbilical fascia to close it
 Closure of skin is done via subcuticular absorbable sutures and Local anesthetic is injected for post-operative pain.

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S-066a ֍PANCREATITIS֍

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Hx of gallstones (biliary colic) / Alcohol intake
 Sudden onset of severe epigastric pain radiating to the back, may be relieved
by sitting / leaning forwards
 Abdominal distension / mass / Guarding / Rigidity
 Signs of Shock  Tachypnea, Tachycardia & Hypotension
 Bleeding into the Fascial planes can produce:
 Bluish discoloration of th l nks (Gr y Turn r‘s s n)
 Blu sh s olor t on o Umb l us (Cull n‘s s n)
 Blu sh s olor t on n n u n l r on (Fox‘s S n)

1. A 35-year-old female is presented in emergency room with severe epigastric localized pain, vomiting and abdominal distension. On
examination, she is dehydrated with pulse 112/min & BP 90/70 mm Hg. RR is 35/min along with severe epigastric tenderness. Eight
months back she was diagnosed to be suffering from multiple tiny gallstones. [Annual 2013]
a) What is your most likely clinical diagnosis?
Acute (Gallstone / Biliary) Pancreatitis
b) What investigations you will advise in this patient?
 CBC
 Serum amylase & lipase
 Serum calcium
 Serum Triglycerides
 USG
 CT scan
c) Describe the role of surgery in the management of pancreatitis.
Usually acute pancreatitis is managed conservatively. Surgical intervention is required if;
 Pancreatic necrosis occurs
 Pancreatic abscess formation occurs
 Pancreatic pseudocyst form

S-066b ֍PERITONITIS֍

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Sudden onset of Abdominal pain (Diffuse spread), worse on movement,
coughing and deep respiration.
 Tachycardia & Hypotension
 Tenderness +/– guarding / rigidity with Absent or reduced bowel sounds

1. A 40-year-old male underwent primary repair of typhoid perforation involving the proximal ileum. On 4th post-operative day, he
complains of abdominal pain and has high grade fever. On examination, he looks toxic. His pulse is 120/min, BP 110/70 mm Hg,
temperature 39.4 C. abdomen is distended and bowel sounds are not audible. The abdominal drain reveals 1200 ml of greenish yellow
fluid. There is leakage of similar fluid from the wound.
a) What is the most likely diagnosis? And what could be the cause?
Diffuse (Generalized) Peritonitis
Cause: Anastomotic Leak causing leakage of intestinal contents into the peritoneal cavity, and this can further be due to:
 Inadequate surgical technique leading to poor anastomotic integrity
 Infection of surgical site
E. coli is the most common organism involved
 Ischemia / Compromised blood supply to anastomosis
in peritonitis
b) How will you manage this patient?
1. Initial Management
 Correction of fluid (IV Crystalloids) and electrolyte imbalances, if any.
 Insertion of nasogastric drainage tube and urinary catheter

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 Broad-spectrum antibiotic therapy (IV Piperacillin/Tazobactam OR, Carbapenem + Metronidazole combination)

 Analgesia
 Vital system support (Monitor vitals closely)
2. Definitive Management
 ―Sour ontrol‖ by r moval or exclusion of the cause (re-exploration of abdomen and repair of anastomotic site in this case]
 Peritoneal lavage +/– drainage

S-068 ֍SPLENECTOMY֍

01. Indications

Category Indications
Trauma  Accidental
 Iatrogenic
Hematological  Spherocytosis
 Idiopathic Thrombocytopenic Purpura (ITP)
 Hypersplenism
Oncological  Diagnostic
 Therapeutic
Portal Hypertension  Variceal Surgery

02. Pre-operative Considerations

Immunization against pneumococcus, meningococcus (both repeated every 5 years) and H. influenzae type b (Hib) (repeated every 10
years) should be done.

03. Post-operative complications

Category Complications
Immediate  Hemorrhage
 Pulmonary Complications  Atelectasis & Pleural Effusion
 Gastric dilatation, Pancreatitis, Fistula
 Subphrenic abscess
Late / Delayed  Thrombocytosis, increased risk of DVT and PE.
 Opportunist post-splenectomy infection (OPSI)  S. pneumoniae, Neisseria
meningitides, Hemophilus influenzae or Escherichia coli

S-075֍PERIOPERATIVE NUTRITIONAL MANAGEMENT֍

01. Nutritional Assessment

1. A 60 years old male patient is a kn own case of CA esophagus. He is in poor nutritional status. He is planned for esophagectomy.
How will you assess nutritional status of this patient?

Stage I History  History of dietry intake

(Clinical  History of infection
Assessment)  History of surgery
Clinical examination  Examination of skin, nail, hair, git, neurological & musculoskeletal
 Easily palpapted tendon indicate> 30% body protein loss

MUST score Score BMI (kg/m²) Weight loss Acute disease effect
0 > 20 < 5% Add 2 score if yes
1 18.5 - 20 5-10%
2 < 18.5 >10%

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Anthropometric  Mid-arm circumstance

measures  Tricep skin fold thickness
Stage II Laboratory  Serum albumin & pre-albumin
investigations  Serum transferrin
 CBC (lymphocytes)
 Blood indices
Stage III Advanced body  Hydrostatic weighting
composition analysis  Electrical impedance analysis
 DEXA scan
 Plethysmography
Functional assessment  Fist-grip dynamometry

02. Nutritional Requirement

1. A 20-year-old female had difficulty in swallowing after accidental ingestion of caustic soda six months ago. She lost about 20 kg
weight and needs corrective surgery. She is being admitted for surgery. What is average amount of energy, carbohydrate, fat and
protein requirement for 24 hours?

Food component Energy requirement for 24 hours

Carbohydrate 2 g/kg/day × 3.4 = 6.8 Kcal/kg/day
Protein 0.6-1g/kg/day × 4 = 2.4 - 4 Kcal/kg/day
Lipid 15-30 g/day × 9 = 135 - 270 Kcal/kg/day

Average amount of energy = 1300 - 1800 Kcal/day

Total energy requirement of a stable patient with a normal or moderately increased need is 20-30 Kcal/kg

03. Enteral Feeding

It is the method of provision of nutritional requirements by using GIT
Vvarious methods of enteral nutrition.
 Sip method
 Nasogastric tube (NG tube)
 Nasojejunal tube (NJ tube)
 Tube Gastrostomy (Endoscopic, Fluoroscopic & Surgical)
 Tube Jejunostomy (Endoscopic, Fluoroscopic & Surgical)
Indications
1. Dysphagia (esophageal carcinoma)
2. Unconscious patient
3. Low enterocutaneous fistula
4. Malnutrition

04. Parenteral Feeding

It is the method of provision of nutritional requirements without using GIT i.e. directly into bloodstream
Indications
1. Obstructed intestine
2. Paralytic ileus
3. High enterocutaneous fistula
4. Severe diarrhea
5. Acute Pancreatitis

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֍PAST UHS MCQS & SAMPLE PAPER֍

1. Overwhelming post splenectomy sepsis is commonly seen in patients:

a) Who has received pneumovax and Hib vaccine preoperative phon
b) Splenectomy performed in a patient with non-Hodgkin's lymphoma
c) Patients with massive splenomegaly
d) Splenectomy performed for hematological reasons in a young age group
e) The organisms involved are H. influenza, S. pneumoniae and C. tetani
2. Which of the following is not an indication for splenectomy?
a) Porphyria d) ITP
b) Heridetary spherocytosis e) Malignancy
c) Splenic trauma
3. A 50 years old woman has to undergo splenectomy for acquired autoimmune hemolytic anemia. Which organ is at maximum risk of
damage in this operation?
a) Stomach d) Left suprarenal gland
b) Left kidney e) Tail of pancreas
c) Splenic flexure of colon
4. Organism not involved in post-splenectomy infections:
a) Hemophilus influenza d) Neisseria meningitidis
b) Streptococcus pneumoniae e) [Link]
c) Streptococcus Pyogenes
5. Most common indication for splenectomy:
a) Splenic Trauma d) Portal hypertension
b) Hemolytic anemia e) Oncological purposes
c) Thalassemia
6. A lady presented with 3 years old child, previously well, now presented with episodes of screaming, having currant jelly stools.
What is the diagnosis?
a) Intussusception d) Hirushprung disease
b) Acute appendicitis e) Intestinal malrotation
c) Volvulus
7. A 6-month-old infant has history of acute onset of crampy abdominal pain and leg withdrawal of 12 hours duration. Rectal
examination shows stool positive for blood. Which of the following is most likely the diagnosis:
a) Intussusception d) Infected urachal cyst
b) Bleeding Meckel's diverticulum e) Acute appendicitis
c) Kidney stone
8. A 20 years old man notices a swelling in his right groin. It increases with coughing, but is easily reducible. Which of the following
hernias follows the path of spermatic cord within cremasteric muscle?
a) Femoral d) Interparietal
b) Spagelian e) Indirect inguinal
c) Direct inguinal
9. A 6 month old girl with a 24 hour history of distress, crying, abdominal distension, vomiting and dark blood per rectum. What is the
cause of bleeding in this case?
a) Anal fissure d) Meckel's diverticulum
b) Colonic carcinoma e) Intussusception
c) Hemorrhoids
10. A 44 year old boy with an easily reducible protuberance through the umbilicus has:
a) Umbilical hernia d) Incisional hernia
b) Lumbar hernia e) Indirect inguinal hernia
c) Direct inguinal hernia
11. A 17 years old boy presents with pain over the umbilicus 10 hours prior to admission. During transport to the hospital the pain was
mainly in the hypogastrium and right iliac fossa. He has tenderness on deep palpation in the right iliac fossa. The most likely
diagnosis
a) Mesenteric adenitis b) Acute appendicitis

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c) Torsion of the testis e) Sigmoid volvulus

d) Ureteric colic
12. A man presented with rapidly increasing painless mass in his right testis. Upper limit of testis was reachable. Transillumination
test was +. What is your diagnosis?
a) Hydrocele d) Varicocele
b) Direct inguinal hernia e) Spermatocele
c) Indirect inguinal
13. A patient presented with edema of glans penis. On examin t on sk n n‘t b r tr t b k to p n s. Wh t s your nos s?
a) Epispadias d) Phimosis
b) Direct inguinal hernia e) Paraphimosis
) P yron ‘s s s
14. A 35-year-old male presents with sudden severe pain in epigastrium associated with vomiting, on examination, he is markedly
tender in upper abdomen with some rigidity of muscles of upper abdomen. X-ray abdomen is normal. The most likely diagnosis:
a) Peptic ulcer d) Acute appendicitis
b) Intestinal perforation e) Peritonitis
c) Acute pancreatitis
15. A 35-year-old male having history of fever for last 10 days now presents in emergency with history of sudden onset of abdominal
pain spreading to whole of the abdomen. On examination, his pulse is 126/min and BP is 100/60 mm Hg. His respiratory rate is
22/min. He has slight distension with rigidity of abdomen and absent bowel sounds. The likely diagnosis:
a) Peptic ulcer d) Acute appendicitis
b) Primary eritonitis e) Secondary Peritonitis
c) Acute pancreatitis
16. Organism most commonly involved in peritonitis:
a) Hemophilus influenza d) Neisseria meningitidis
b) Staphylococcus aureus e) [Link]
c) Streptococcus Pyogenes
17. How much time it will take to deplete carbohydrates reserve in body?
a) 12 hours d) 6 hours
b) 18 hours e) 8 hours
c) 48 hours
18. A patient presents with history of corrosive intake and esophageal stricture formation. Which of the following is best method of
nutrition for him?
a) PEG (Percutaneous Endoscopic Gastrostomy) d) N/G tube feeding
b) PED (Percutaneous Endoscopic Deudenostomy) e) Fine needle catheter jejunostomy
c) PEJ (Percutaneous Endoscopic Jejunostomy)
19. An emaciated patient presented with 3rd degree of esophageal carcinoma. How much daily energy he requires?
a) 20kcal/kg d) 50kcal/kg
b) 30kcal/kg e) 80kal/kg
c) 40kcal/kg
20. A 67-year-old female is referred for consideration of total parenteral nutrition (TPN) following a total colostomy. Which of the
following biochemical and clinical markers are suggestive of malnutrition?
a) Albumin c) Weight loss
d) Urea e) Transferrin
b) Skin fold thickness
21. A patient with history of dysphgia gets admitted in a surgical unit for oesophagectomy. The best way to measure malnutrition is:
a) Total leukocyte count d) Serum ferritin level
b) Mid forearm circumference e) Candida skin test
c) Biceps fold thickness
22. You have been asked to assess nutritional status of a patient who is to undergo a major operation in few days. Your advice is based
mainly on:
a) Serum albumin estimation. d) Body mass index of 19%.
b) Immunity stakes evaluation by history. e) More than 10% weight loss in last six months
c) Body weight in kilogram.

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23. There is a patient scheduled for surgery on elective list. To assess his nutritional status one should know that it:
a) Does not include dynamometric studies d) Reveals positive candidal test
b) Is confirmed by a body mass index of 25 e) May include a leukocyte count
c) Includes serum transferrin assays
24. A 65 years old woman with advanced stage oesophageal carcinoma presents to OPD. You find that she has prominent tendons
which can be easily palpated as well as prominent bony prominences of scapula. At this point the patient has lost:
a) More than 30% of body protein stores d) 05-10% of body protein stores
b) 20-30% of body protein stores e) Less than 5% of body protein stores
c) 10-20% of body protein stores
25. A 42 year old obese woman presents to the emergency department with a 12 hour history of severe epigastric pain. The pain
started suddenly and and radiates to her back. It is relieved when sitting forward. She is nauseous and has vomited twice in since the
pains started. She drinks one and a half glasses of wine per day. She has no significant past medical history. She has a pulse rate of
110 beats/minute and is tender in the epigastric region. What is the SINGLE most appropriate investigation?
a) Chest X-ray d) Abdominal X-ray
b) Abdominal ultrasound e) Liver function test
c) Serum lipase
26. A 49 year old female presents with right hypochondrial pain. An ultrasound shows a large gallstone. Her BP is 120/85 mmHg;
respiratory rate 18/min; Heart rate 90 bpm; Temperature 37.6°C; WBC 15 x 109/L. What is the SINGLE most appropriate
management?
a) Laparoscopic cholecystectomy d) Ursodeoxycholic acid
b) Reassure e) Emergency laparotomy
c) Low fat diet

ANSWER KEY
1. D 2. A 3. E 4. C 5. A 6. A 7. A 8. E 9. E 10. A
11. B 12. A 13. E 14. C 15. E 16. E 17. B 18. C 19. B 20. C
21. B 22. E 23. C 24. A 25. C 26. A

4. The child's presentation suggests Thalassemia major (a genetic disorder requiring regular blood transfusions). Mass in the left upper
quadrant is likely splenomegaly (enlarged spleen) due to extramedullary hematopoiesis and sequestration of red blood cells and
platelet. Anemia and low platelet count are likely due to hypersplenism (sequestration of blood cells in the spleen). Splenectomy
(removal of the spleen) is often considered in patients with thalassemia major who develop hypersplenism. Blood transfusio may be
necessary to manage anemia, but does not address the underlying issue of hypersplenism. Platelet transfusion may be necessary to
manage thrombocytopenia, but does not address the underlying issue of hypersplenism.
5. Splenic trauma, either due to blunt or penetrating injury, is the most common indication for splenectomy, accounting for
approximately 70-80% of all splenectomies
15. Sudden onset severe abdominal pain spread n to whol b om n → l ss or p r or t on of hollow viscus. Primary peritonitis
occurs without perforation & usually seen in cirrhosis with ascites
17. 18-24 hrs
18. In cases of corrosive intake leading to esophageal stricture, nutritional management is critical. Jejunostomy (specifically PEJ) is
generally considered the best method because it provides a reliable route for long-term enteral nutrition while completely bypassing
the injured and potentially stenotic upper GI tract (esophagus and stomach). Fine needle catheter jejunostomy is typically
a surgical technique performed during a laparotomy (open surgery) rather than a primary bedside or endoscopic method for long-term
nutritional maintenance in a stable patient with a stricture.
19. Nutrient requirements may increase to 30 kcal/kg ideal body weight per day under conditions of severe stress. Ref: Baily & Love
28th edition
20. The best way of assessing nutritional supplementation is an estimation of weight loss. The Malnutrition Universal Screening Tool
(MUST) for adults is widely used and takes into consideration body mass index (BMI), recent weight loss and presence or absence of
acute disease. Anthropometric measures such as skin-fold thickness and midarm circumference are - are not helpful in an in-patient
setting. Albumin is prone to variation with dilutional state (e.g. IV fluids), liver disease etc. Further it has a long half-life of about 20
days and levels could still be normal despite nutritional inadequacy. Urea is also prone to dilutional effect, type of protein consumed
and presence of Gl bleed.
21. Anthropometric measures are best way of measuring malnutrition

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22. The best way of assessing nutritional supplementation is an estimation of weight loss. The Malnutrition Universal Screening Tool
(MUST) for adults is widely used and takes into consideration body mass index (BMI), recent weight loss and presence or absence of
acute disease. Albumin is prone to variation with dilutional state (e.g. IV fluids), liver disease etc. Further it has a long half-life of
about 20 days and levels could still be normal despite nutritional inadequacy.
24. Based on clinical findings of severe muscle wasting—indicated by "prominent tendons which can be easily palpated" and
"prominent bony prominences of scapula"—in a patient with advanced cancer, this represents a severe stage of protein-energy
malnutrition, often called cachexia. In such cases of advanced wasting, the loss of body protein stores exceeds 30%. This clinical
picture corresponds to severe cachexia and malnutrition, where significant muscle wasting is obvious and subcutaneous fat is lost
25. The likely diagnosis is acute pancreatitis. The most useful investigation is a serum lipase, looking for an elevation of more than 3
times the upper limit of normal. While abdominal x-rays are not useful in the diagnosis of pancreatitis, they are routinely ordered to
exclude other potential causes of abdominal pain such as perforation or bowel obstruction. Ultrasound is useful to detect the presence
of gallstones but it is not a good diagnostic test for acute pancreatitis. The pancreas is poorly visualised in 25-50% of cases. Urea and
electrolytes and liver function test do not directly aid the diagnosis of pancreatitis however, they are helpful in assessing the severity
of the disease (e.g. by showing the degree of leucocytosis or of hypovolaemia) or give clues of the aetiology of pancreatitis (e.g.
gallstone pancreatitis).
26. As she is symptomatic, reassurance is out of the question. The two remaining options are laparoscopic cholecystectomy or
emergency laparotomy. Laparoscopic cholecystectomy is the prefered option here as there are no signs of gallbladder perforation.
Laparotomy has higher risk as it is much more invasive

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GIT & NUTRITION

PHARMACOLOGY

֍PAST UHS MCQS & SAMPLE PAPER֍

1. A 65 years old lady who is a known patient of Parkinsonism is also on anti-cancer therapy; but to avoid their nauseating effects she
must be kept away from such a drug which may also cause extrapyramidal dysfunction e.g:
a) Dexamethasone d) Metoclopramide
b) Ondansetron e) Prochlorperazine
c) Dronabinol
2. Lactulose is effective in treatment of hepatic encephalopathy as:
a) It reduces the colonic pH d) Reduces portal hypertension
b) It increases the colonic pH e) Correct serum sodium level
c) It increases ammonia absorption
3. A 35 years old lady who is on anti-cancer therapy is now suffering from severe nausea and vomiting; which of the following drugs
is having most effective antiemetic actions in this case?
a) Dexamethasone d) Sucrulfate
b) Levodopa e) Omeprazole
c) Apomorphine
4. While prescribing a treatment to a young female patient suffering from peptic ulcer associated with H. Pylori the gastroenterologist
will neglect:
a) Tetracycline d) Metronidazole
b) Vancomycin e) Clarithromycin
c) Amoxicillin
5. The following pre-motility drug acts by inhibiting D2 receptors:
a) Bethancchol d) Erythromycin
b) Neostigmine e) Metoclopramide
c) Cisapride
6. In an old age debilitated patient who is having chronic constipation with severely reduced bowel tone may be benefited with:
a) Castor oil e) Magnesium hydroxide
b) Glycerine c) Phenolphthalein
d) Mineral oil

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CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

7. Which of the following drugs may be used in re eradication of H. pylori?

a) Clarithromycin d) Ciprofloxacin
b) Tobramycin e) Albendazole
c) Ticarcillin
8. While traveling by car to a hill-station, a child suffered from nausea and vomiting. In order to prevent these symptoms to occur
during return journey you would prescribe:
a) Atropine d) Diphenoxylate
b) Promethazine e) Chlorpromazine
c) Ondensatron
9. Acid rebound phenomenon is likely to occur with the use of:
a) Magnesium trisilicate d) Aluminum phosphate
b) Aluminum hydroxide e) Sucralfate
c) Sodium bicarbonate
10. A drug that causes purgation by local irritation of small intestine is:
a) Senna d) Castor oil
b) Bisacodyl e) Aloes
c) Sorbitol
11. A 70 years old male with gastritis is also having chronic constipation; which antacid may be useful for him:
a) Angnesium trisilicato d) Sodium bicarbonate
b) Magnesium hydroxide e) Aluminum hydroxide
c) Calcium carbonate
12. Which of the followings is an Irritant Purgative?
a) Lactulose d) Magnesium sulfate
b) Liquid poolfin e) Methylcellulose
c) Senna
13. Which of the following drug is used for diabetic gastroparisis?
a) Erythromycin d) Tetracycline
b) Ondanstron e) Diphenoxylate
c) Clarithromycin
14. Which of the purgative is used for managing constipation & blood ammonia level in hepatic encephalopathy?
a) Lactulose d) Linaclotide
b) Psyllium e) Senna
c) Castor oil
15. Which of the following laxatives acts by drawing water into the intestine along osmotic gradient?
a) Psyllium e) Magnesium hydroxide
b) Liquid paraffin c) Bisacodyl
d) Senna
16. A 27-year-old woman who is 34 weeks pregnant is on bed rest and visits her obstetrician. During the visit, she informs her
physician that she has been experiencing mild constipation. Which of the following medications will most likely be recommended to
her?
a) Castor oil d) Loperamide
b) Docusate e) Senna
c) Mineral oil

ANSWER KEY
1. D 2. A 3. A 4. B 5. E 6. A 7. A 8. B 9. C 10. D
11. B 12. C 13. A 14. A 15. E 16. B

2. Colonic bacteria ferment lactulose into lactic and acetic acids. This lowers the pH of the colon, converting diffusible ammonia
(NH3-) into non-diffusible ammonium ions (NH4+). This "ammonia trapping" prevents it from entering the bloodstream and reaching
the brain.
6. Castor oil is a stimulant

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CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

8. To prevent motion sickness (nausea and vomiting) in a child during a car journey, the most appropriate medication is a first-
generation antihistamine, with Promethazine being a highly effective option for preventing and treating symptoms
9. Sodium bicarbonate is a potent, systemic antacid that reacts rapidly with gastric hydrochloric acid to neutralize it. This sudden
increase in pH and the resulting antral alkalinization trigger the release of gastrin, which leads to a compensatory "rebound" of gastric
acid secretion.
11.
Antacid Side effect
Aluminium hydroxide Constipation, Hypophosphatemia
Magnessium hydroxide Diarrhea
Calcium carbonate Milk alkali syndrome
(triad of hypercalcemia, metabolic
alkalosis, and renal failure), rebound
acid phenomenon
Sodium bicarbonate Rebound acid phenomenon
13. The macrolide antibiotic erythromycin promotes motility by stimulating motilin receptors. It may have benefit in some patients
with gastroparesis.
15.

16. Although its effects are not immediate, docusate may be used for mild constipation and is generally considered safe in pregnancy.
Castor oil/Senna should not be used in pregnancy because of its ability to cause uterine contractions. Mineral oil should not be used in
bedridden patients due to the possibility of aspiration. Loperamide is used for diarrhea, not constipation.

֍PRACTICE MCQS֍

1. A 55-year-ol wom n w th typ 1 b t s o 40 y rs‘ ur t on ompl ns o s v r blo t n n b om n l str ss, sp lly

after meals. Evaluation is consistent with diabetic gastroparesis. Which of the following is a prokinetic drug that could be used in this
situation?
A) Alosetron D) Metoclopramide
B) Cimetidine E) Sucralfate
C) Loperamide
2. A patient who is taking verapamil for hypertension and angina has become constipated. Which of the following drugs is an osmotic
laxative that could be used to treat the p t nt‘s onst p t on?
A) Aluminum hydroxide D) Metoclopramide
B) Diphenoxylate E) Ranitidine
C) Magnesium hydroxide
3. A 40-year-old male CEO came to the emergency department with severe burning chest pain radiating into his neck. His
electrocardiogram was normal and test for troponin was negative. A diagnosis of GERD was made and he was sent home with a
prescription for a drug that inhibits stomach acid. Which of the following is a drug that irreversibly inhibits the H+/K+ATPase in the
parietal cells?
A) Cimetidine D) Metoclopramide
B) Diphenoxylate E) Sulfasalazine
C) Esomeprazole

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4. A 25-year-old college student went to student health care center for severe cramps, diarrhea, fever, and weight loss. She was
diagnosed with Crohn‘s s s . Wh h ru s most likely to be useful in the treatment of her inflammatory bowel disease?
A) Diphenhydramine D) Ondansetron
B) Diphenoxylate E) Ursodiol
C) Mesalamine
5. A 45-year-old man with a duodenal ulcer was treated with a combination of drugs intended to heal the mucosal damage and to
eradicate Helicobacter pylori. Which of the following antibacterial drugs is used commonly to eradicate intestinal H pylori?
A) Cefazolin D) Clindamycin
B) Ciprofloxacin E) Vancomycin
C) Clarithromycin
6. A patient is receiving highly emetogenic chemotherapy for metastatic carcinoma. To prevent chemotherapy-induced nausea and
vomiting, she is likely to be treated with which of the following?
A) Levodopa D) Ondansetron
B) Methotrexate E) Sucralfate
C) Misoprostol
7. Which of the following drug is a small molecule that polymerizes in stomach acid and coats the ulcer bed, resulting in accelerated
healing and reduction of symptoms?
A) Aluminum hydroxide D) Omeprazole
B) Balsalazide E) Sucralfate
C) Castor oil
8. A 48-year-old patient has been admitted with abdominal pain, and states that she has not had a bowel movement for 4 days. Her
abdomen is distended and slightly tender. Which laxative would be appropriate for this patient?
A) Milk of magnesia D) No laxative should be given at this time
B) A bulk-forming laxative E) Linaclotide
C) Mineral oil
9. Diarrhea is likely to occur with the use of:
A) Magnesium hydroxide D) Aluminum phosphate
B) Aluminum hydroxide E) Sucralfate
C) Sodium bicarbonate
10. Which drug stimulates chloride secretion into the gut lumen and is used for irritable bowel syndrome?
A) Milk of magnesia D) Docusate
B) Psyllium E) Linaclotide
C) Mineral oil
11. All of the following adverse effects are associated with the use of proton pump inhibitors except:
A) Community acquired pneumonia D) Hypothyroidism
B) Clostridium difficile infection E) Acute interstitial nephritis
C) Osteoporosis leading to hip fracture
12. A patient is taking famotidine, sucralfate and antacid tablets. This treatment is irrational because:
A) Sucralfate decreases the absorption of famotidine D) Sucralfate polymerizes only when gastric pH is less than 4
B) Sucralfate increases the toxicity of famotidine E) Sucralfate increases the absorption of antacids
C) Sucralfate decreases the absorption of antacids
13. Which of the following drugs is not an antiemetic?
A) Ondansetron D) Cinnarizine
B) Domperidone E) Scopolamine
C) Cimetidine
14. A 68-year-old patient with cardiac failure is diagnosed with ovarian cancer. She begins using cisplatin but becomes nauseous and
suffers from severe vomiting. Which of the following medications would be most effective to counteract the emesis in this patient
without exacerbating her cardiac problem?
A) Droperidol D) Dronabinol
B) Dolasetron E) Palonosetron
C) Prochlorperazine
15. Which of the following drugs has been known to cause discoloration of the tongue?
A) Amoxicillin B) Omeprazole

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CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

C) Bismuth compounds E) Clarithromycin

D) Lubiprostone
16. All of the following drugs are generally well tolerated for the treatment of constipation except:
A) Castor oil D) Docusate
B) Methylcellulose E) Glycerin
C) Polyethylene glycol
17. An elderly woman with a recent history of myocardial infarction is seeking a medication to help treat her occasional heartburn.
She is currently taking several medications, including aspirin, clopidogrel, simvastatin, metoprolol, and lisinopril. Which of the
following choices should be avoided in this patient?
A) Calcium citrate D) Ranitidine
B) Famotidine E) Calcium carbonate
C) Omeprazole
18. A 45-year-old woman complains of persistent heartburn and an unpleasant, acid-like taste in her mouth. The clinician suspects that
she has gastroesophageal reflux disease and advises her to raise the head of her bed 6 to 8 inches, not to eat for several hours before
retiring, and to eat smaller meals. Two weeks later, she returns and says the symptoms have subsided slightly but still are a concern.
The clinician will likely prescribe which one of the following drugs?
A) An antacid such as aluminum hydroxide D) Esomeprazole
B) Dicyclomine E) Metoclopramide
C) An antianxiety agent such as alprazolam
19. A 45-year-old man with a duodenal ulcer and laboratory evidence of Helicobacter pylori infection was treated with omeprazole,
clarithromycin, and amoxicillin. Endoscopy revealed rapid healing of the ulcer. Which of the following is the most accurate
description of the mechanism of omeprazol ‘s th r p ut t on?
A) Activation of prostaglandin E receptors D) Inhibition of H2 histamine receptors
B) Formation of protective coating over the ulcer bed E) Irreversible inactivation of H+/K+ ATPase
C) Inhibition of bacterial protein synthesis

ANSWER KEY
1. D 2. C 3. C 4. C 5. C 6. D 7. E 8. D 9. A 10. E
11. D 12. D 13. C 14. E 15. C 16. A 17. C 18. D 19. E

1. Of the drugs listed, only metoclopramide is considered a prokinetic agent (ie, one that increases propulsive motility in the gut). The
answer is D. Alosetron is a 5HT3 receptor blocker, cimetidine is a H2 receptor blocker, loperamide is an opioid, and sucralfate forms a
protective layer over an ulcer.
2. A laxative that mildly stimulates the gut would be most suitable in a patient taking a smooth muscle relaxant drug such as
verapamil. By holding water in the intestine, magnesium hydroxide provides additional bulk and stimulates increased contractions. A
helpful mnemonic is magnesium ―m n s‖ stool, lum num hALts the stool. The answer is C. Diphenoxylate is an opioid receptor
agonist, metoclopramide is a prokinetic agent, ranitidine is a H2 receptor blocker.
3. Esomeprazole, the (S) isomer of omeprazole, is a prodrug converting spontaneously in the parietal cell canaliculus to a sulfonamide
that irreversibly inactivates the proton pump. The answer is C
4. Mesalamine is a form of 5-aminosalicylic acid that is active in the large intestine and thereby provides a local antiinflammatory
effect that is use ul n Crohn‘s s s , orm of inflammatory bowel disease. The answer is C.
5. The macrolide antibiotic clarithromycin is commonly used in antibiotic regimens designed to treat duodenal ulcers caused by H
pylori. The other antibiotics that are used include amoxicillin, tetracycline, and metronidazole. Bismuth also has an antibacterial
action. The answer is C.
6. The 5-HT3 receptor antagonists are highly effective at preventing chemotherapy-induced nausea and vomiting, which can be a
dose-limiting toxicity of anticancer drugs. The answer is D
7. Sucralfate is a small molecule that polymerizes in stomach acid and forms a protective coat over the ulcer bed. The answer is E.
8. These laxatives are contraindicated in the presence of undiagnosed abdominal pain, as taking a laxative in cases of intestinal
obstruction could be very harmful to the patient. No laxatives should be given if the patient has undiagnosed abdominal pain.
9.
Antacid Side effect
Aluminium hydroxide Constipation, Hypophosphatemia
Magnessium hydroxide Diarrhea

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CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

Calcium carbonate Milk alkali syndrome

(triad of hypercalcemia, metabolic
alkalosis, and renal failure), rebound
acid phenomenon
Sodium bicarbonate Rebound acid phenomenon
10.

11. Increased risk of C difficile infection, pneumonia, acute interstitial nephritis. Vitamin B12 malabsorption; decreased serum
Mg2+/Ca2+ absorption (potentially leading to increased fracture risk in older adults).
12. Bismuth sucralfate requires acidic pH for its action while PPI raises the pH. Th t‘s why th s two ru s shoul b t k n
seperatly
14. Palonosetron is a 5-HT3 antagonist that is effective against drugs with high emetogenic activity, such as cisplatin. Although
dolasetron is also in this category, its propensity to affect the heart makes it a poor choice for this patient. Droperidol also affects the
heart and now is gener ally a second-line drug used in combination with opioids or benzodiazepines. The antiemetic effect of
prochlorpera zine, a phenothiazine, is most beneficial against anticancer drugs with moderate to low emetogenic properties.
15. Bismuth compounds may cause a black discoloration of the tongue. The other agents have not been associated with this
effect.
16. Castor oil can produce severe cramp ing, which makes it difficult to tolerate for many, including the elderly. The other three
choices are generally well tolerated.
17. Omeprazole may possibly decrease the efficacy of clopidogrel because it inhibits the conversion of clopidogrel to its active
form.
18. It is appropriate to treat this patient with a proton-pump inhibitor (PPI) to reduce acid produc tion and promote healing. An H2-
receptor antagonist might also be effective, but the PPIs are preferred. An antacid would decrease gastric acid, but its effects are short
lived compared to those of the PPIs and H2-receptor inhibitors. Dicyclomine is an antimuscarinic drug and would decrease acid
production, but it is not as effective as the PPIs or the H2-receptor inhibitors. An antianxiety agent might have antiemetic action but
would have no effect on the acid production.
19. Omeprazole, a proton pump inhibitor, very effec tively reduces gastric acid secretion. The drug is converted to an active
metabolite that irreversibly inhibits the parietal cell H+/K+ ATPase that is responsible for acid secretion. Misoprostol activates
prostaglandin E receptors. Sucralfate forms a protective coating over an ulcer bed, and cimetidine inhibits H2 histamine receptors.

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GIT & NUTRITION

COMMUNITY MEDICINE
CM-069 ֍NUTRITION & BALANCED DIED֍

01. Nutritional Requirement

1. A 25-year-old male sedentary person weighting 80 kg reports to you for dietary advice. On inquiry, it is estimated that he is taking
approximately 600g of carbohydrates, 140 g of fats and 100g of proteins per day.
a) What do you think is he taking required amount of energy?
No, He is taking ―mor ‖ than the required amount of energy.
b) How much calories should he take per day and what should be the proportion of macronutrients, as he is interested to
reduce weight to the reference level?
Reference level of weight for age between 18–29 years (Reference Man)  60 Kg. So, in order to reduce his weight to reference level
(60 Kg) + He is a Sedentary person. He should take  2320 kcal/day, OR 39 kcal/kg/day
Proportion of Macronutrients:
 Carbohydrates  Minimum 300 g/day Net Protein Utilization signifies protein quality
 Proteins  0.8 g/kg/day OR 50 g/day & it is highest for egg
 Fats  minimum 20% of total energy intake OR 52 g/day

02. Balanced Diet

WHO recommended various dietary goals (prudent diet)
Dietary Factor Goal (%age of total energy)
Fats  Total Fat  15–30%
 Saturated fats  <10% of total energy intake,
 Unsaturated oils should substitute for the
remaining fat requirements
 Cholesterol (< 300 mg/day)
Carbohydrates  Total carbohydrates 55–75%
 Free Sugars  < 10%
Proteins 10–15%
Sodium chloride (salt) < 5g/day
Fruits & Vegetables 400 g/day / greater
Dietary Fiber Up to 40g/day OR more for adults

CM-070 ֍MACRONUTRIENTS & MICRONUTRIENTS֍

01. Prevention & Control of Vitamin D deficiency

1. A mother brought her 3 years old child at a medical center with the complaints of difficulty in walking and generalized weakness.
On physical examination, the child had curved legs, knock knees and slightly pigeon shaped chest.
a) What is the most likely diagnosis?
Rickets due to Vitamin D deficiency
b) Give appropriate measures for the prevention and control of this health problem in the community.
Level of Prevention Interventions & Measures
Primary Health Promotion
 Health Education – Educating the Parents to expose their children
regularly to sunshine

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CHAPTER 4 © 5th Edition MODULE 25: GIT & NUTRITION

 Provision of adequate nutrition / Foods that are good source of Vitamin

D especially during early years of growth & development – e.g.,
Butter, Fish oil & Eggs
 Daily Vit D requirement in is 400 IU (10 mcg)
Specific Protection
 Periodic dosing (Prophylaxis) of young children with Vitamin D
 Vitamin D Fortification of the foods e.g., Milk, Margarine
Secondary Early Diagnosis & Prompt Treatment
 With orally supplemented Vitamin D supplements

02. Prevention & Control of Vit A Deficiency

Assessment of vitamin A deficiency
The formulation of an effective intervention programme for prevention of vitamin A deficiency (VAD) begins with the
characterization of the problem. This is done by population surveys employing both clinical and biochemical criteria. These surveys
(prevalence surveys) are done on preschool children (6 months to 6 years) who are at special risk. The criteria recommended by WHO
are as given in Table below. The presence of any one of the criteria should be considered as evidence of a xerophthalmia problem in
the community.

Reference: [Link]
Vitamin A prophylaxis programme
 Age 6–11 months: 100,000 IU once
 Age 12–59 months: 200,000 IU every 6 months

1. A mother brings her 2-year-old child to Paediatric OPD with complaints of inability to see in the evening & having dry eyes,
wrinkly eyes. He was diagnosed as a case of vitamin A deficiency.
a) Write down the ocular manifestations of vitamin A deficiency?
1. Night blindness
2. Xerophthalmia
3. Bitot spot
4. Keratomalacia
b) How would you treat this child?
Vitamin A Red capsule containing 2 Lac units (110 mg of retinol palmitate)
c) Enumerate ways to prevent this deficiency in the population?
1. Health promotion by
o Nutritional education  consumption of vitamin A-rich foods such as liver, eggs, dairy products, and colorful fruits
and vegetables)
o Supplementation programs  targeting high-risk groups like pregnant women and children in regions with known
deficiency
o Promotion of breastfeeding to ensure infants receive adequate vitamin A.
2. Specific protection
o Fortification of staple foods with vitamin A, such as fortified milk and cooking oils
o Implementation of public health interventions such as vitamin A supplementation campaigns and nutrition education
programs
3. Early detection and treatment of conditions that impair vitamin A absorption or utilization

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03. Prevention & Control of Iodine Deficiency

Iodine deficiency disorders refers to all the effects of Iodine deficiency on Human Growth and development which can be prevented
by the correction of Iodine deficiency.
Different forms of clinical presentation classified by WHO under the category of Iodine Deficiency Disorders.
 Goiter
Most sensitive indicator for monitoring
 Hypothyroidism
environmental iodine deficiency is Prevalence
 Retarded physical growth & mental retardation of neonatal hypothyroidism
 Increased rate of spontaneous abortion and stillbirth
 Neurological cretinism Daily iodine requirement for adult is 150 ug
 Nystagmus & Squint

Level of Prevention Interventions & Measures

Primary (a) Health Promotion
 ―Mass Communication‖ – Creation of Public awareness & Nutrition education
 Provision of adequate nutrition / Foods that are good source of Iodine especially
during early years of growth & development – e.g., Milk & Eggs
(b) Specific Protection
 Prophylactic supplementation of Iodine Fortified foods e.g.,
 Intake of Iodized Salt – Mass Prophylaxis
 I/M injection of Iodized Oil (Poppy–seed oil)
 Oral Iodized oil / Sodium iodate Tablets
Secondary (c) Early Diagnosis & Prompt Treatment
 Iodine Monitoring” – e.g., Urinary excretion of Iodine in order to screen the
Population for Iodine deficiency
 Iodized salt supplementation

04. Prevention & Control of Fluoride Deficiency

1. School children inspection revealed that most of students were having decaying teeth. On water analysis, fluoride level was found
to be 0.2 mg/dL. [Annual 2011]
a) Name the problem in children.
Dental Caries
b) What measures you will necessarily take to overcome this problem?
Level of Prevention Interventions & Measures
Primary  Mass Communication – Creation of Public awareness about drinking water containing
appropriate amount of fluoride
 Limit Food high in sugar and starches
 Use toothpaste containing fluoride daily
Secondary  Topical Application of Sodium Fluoride (NaF) to the enamel of Deciduous Teeth at
the age of 3 years and Permanent Teeth at the age of 7,10 & 13 years
c) Name what mode of prevention it will be.
Secondary Prevention – Early diagnosis & Prompt Treatment.

05. Prevention & Control of Iron Deficiency

1. A research was conducted in obstetric department regarding the effects of nutritional status of pregnant women on their deliveries
and outcomes. It was observed that 60% of women who presented during pregnancy with pallor, palpitations and dyspnea on exertion,
they developed complications at the time of delivery and their baby were below 2.5 kg of weight at birth.
a) Which nutritional condition is hinted in these women?
Iron Deficiency Anemia

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b) Suggest the measures to decrease the prevalence of this condition among pregnant women.
Level of Prevention Interventions & Measures
Primary a) Health Promotion
 Health Education – Creation of Public awareness & Nutrition education (that contain
adequate amounts of iron and folate e.g., Dairy products, beans, nuts & fruits)
 Provision of adequate Food supplements to pregnant & Lactating mothers
 Changing Dietary habits
 Family Planning
b) Specific Protection
 Prophylactic Supplementation of Fortified Foods e.g., Fortified salt with iron can be used
to control nutritional anemia.
 Control of Parasites – “To avoid Chronic Blood Loss”
Secondary c) Early Diagnosis & Prompt Treatment
 Periodic Surveillance & Screening
 Iron and Folic Acid Supplementation
 In Mothers, 1 Tablet of Iron (60 mg of elemental iron) and Folic acid (0.5 mg) daily,
continued for 2–3 months after Hb level returns to normal
 In Children, 1 Tablet of Iron (20 mg of elemental iron) and Folic acid (0.1 mg) daily,
Tertiary d) Disability Limitation (If any)
e) Rehabilitation
 Nutritional rehabilitation services
 Hospital treatment
 Follow-up care

06. Minerals

Mineral Biochemical Importance

Major Functions Deficiency disease/Symptoms
Iodine o Constituent of thyroxine hormone o Hypothyroidism (cretinism, myxedema)
Zinc o Cofactor for enzymes like alcohol dehydrogenase, Carbonic o Poor wound healing
anhydrase, Lactate dehydrogenase o Growth retardation
o Diarrhea
Selenium o Involved in antioxidant function along with vitamin E; o Muscular degeneration
constituent of glutathione peroxidase & selenocysteine o K sh n‘s s s (C r omyop thy)
Sodium o Chief cation of extracellular fluid o Almost unknown on normal diet
o Acid-Base balance
o Osmotic pressure
o Nerve & Muscle function
Potassium o Chief cation of intracellular fluid o Muscle weakness
o Acid-Base balance
o Osmotic pressure
o Muscle function

CM-071 ֍MALNUTRITION֍

1. Mother took her child of 2 years in a hospital. She gave history of generalized muscle wasting and Loss of subcutaneous fat. There
was no sign of edema and weight was below 60% of WHO standard. The mother also told that she is very poor and has a large family
so she is unable to give enough protein and other nutrients to her child after 6 months of age. [Supple 2021 held in 2022 + Annual
2007]
a) Name the likely condition and gives its causes.
Marasmus

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Main Etiological Factors  Nutritional Imbalance / Deficiency

 Bacterial / Parasitic Infection
 Non-Fulfilment of caloric requirements
 Deprivation of Child from Breast feeding
Contributory Etiological Factors  Delayed / Improper weaning by the Ignorant Mother
 Early weaning due to 2nd pregnancy
 Poor MCH care
 Poor environmental sanitation
 Gender discrimination
b) What is the primary prevention of above said condition.
Health Promotion
 “Health Education” – Creation of Public awareness & Nutrition education
 Provision of adequate Food supplements to pregnant & Lactating mothers
 Development of Low-cost Weaning Foods
 Home Economics
 Promotion of Breast feeding
 Family Planning
Specific Protection
 Prophylactic Supplementation of Fortified Foods
 Immunization of the child against major communicable diseases
 The diet should be balanced containing Recommended quantities of Macronutrients (Carbohydrates, Fats & Proteins) and
Micronutrients (Vitamins & Minerals)

2. A mother reports to you with her two-year-old child with the complains of skin pigmentation and cracks and changes in hair color.
Examination showed weight slightly below the standard for age but it was marked by generalized body edema.
(a) What will be your probable diagnosis?
Kwashiorkor
(b) What measures should be taken to overcome this problem in children?
Level of Prevention Interventions & Measures
Primary (a) Health Promotion
 Health Education – Creation of Public awareness & Nutrition education about balanced
diet
 Provision of adequate Food supplements to pregnant & Lactating mothers
 Development of Low-cost Weaning Foods
 Home Economics
 Promotion of Breast feeding
 Family Planning
(b) Specific Protection
 Prophylactic Supplementation of Fortified Foods
 Immunization of the child against major communicable diseases
 The diet should be balanced containing Recommended quantities of Macronutrients
(Carbohydrates, Fats & Proteins) and Micronutrients (Vitamins & Minerals)
Secondary (c) Early Diagnosis & Prompt Treatment
 Periodic Surveillance
 Development of Programs for early Rehydration of dehydrated children
 Deworming of heavily infested children
 Early diagnosis of any Lag in growth
Tertiary (d) Disability Limitation (If any)
(e) Rehabilitation
 Nutritional rehabilitation services
 Hospital treatment
 Follow-up care

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CM-072 ֍NUTRITIONAL REQUIREMENT֍

Extra allowance of Pregnancy Lactation

Calories 300-400 C/day 500-600 C/day
Protein 10 gm/day 20 gm/day
Iron 10 mg/day Not recomended
Folic acid 50-200 ug 50 ug
Calcium 500 mg/day 500 mg/day
Vitamin D 400 IU/day 600 IU/day
PRINCIPLES OF ARTIFICIAL FEEDING
In planning an artificial feed, the nutritional needs of infants should be kept in view. These include:
1. Infants require an average of 100 kcal of energy per kg of body weight per day, i.e., about 150 ml of milk per kg of body
weight each day.
2. The estimated protein requirement is about 2 g/kg of body weight during the first 6 months; it declines to about 1.5 g/kg by
the end of one year. This works out to 13-14 g protein daily during the first year of life. In terms of calories, 8 to 10 per cent
of calories are given as protein
3. The carbohydrate requirement is about 10 g/kg of body weight daily
4. After 4 months of age, undiluted boiled and cooled milk should be given
5. Infants need feeding at frequent intervals about 6-8 times a day; older babies 5 times a day
6. During illness (e.g., fevers) the calorie need is increased, and it should be met

CM-073 ֍PUBLIC HEALTH NUTRITION PROGRAMS֍

01. Food Fortification

Fortification of food is a public health measure aimed at reinforcing the usual dietary intake of nutrients with additional supplies to
prevent/control some nutritional disorders. WHO has defin ― oo ort t on‖ s ―th process whereby nutrients are added to foods
(in relatively small quantities) to maintain or improve the quality of the diet of a group, a community, or a popul t on.‖ Programmes
of demonstrated effectiveness of fortification of food or water are: fluoridation of water as a preventive of dental caries; iodization of
salt for combating the problem of endemic goitre, and food fortification (e.g., vanaspati, milk) with vitamins A and D. Technology has
also been developed for the twin fortification of salt with iodine and iron. In order to qualify as suitable for fortification, the vehicle
and the nutrient must fulfil certain criteria:
 the vehicle fortified must be consumed consistently as part of the regular daily diet by the relevant sections of the population
or total population;
 the amount of nutrient added must provide an effective supplement for low consumers of the vehicle, without contributing a
hazardous excess to high consumers;
 the addition of the nutrient should not cause it to undergo any noticeable change in taste, smell, appearance, or consistency;
 the cost of fortification must not raise the price of the food beyond the reach of the population in greatest need.
Finally, an adequate system of surveillance and control is indispensable for the effectiveness of food fortification. Food fortification is
a long-term measure for mitigating specific problems of malnutrition in the community.

02. Methods of Nutritional Assessment

Main Types of Methods Nutritional assessment

Direct Methods  Biophysical Assessment
 Biochemical Assessment
 Clinical Assessment
 Dietary method of Assessment
 Vital & Health Statistics
 Ecological Studies
Indirect Methods (a) Morbidity
 Diarrhea
 PEM

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 TB
(b) Mortality
 IMR
 MMR
 Prenatal Mortality
 Perinatal Mortality
 Neonatal & Post-neonatal mortality
(c) Life expectancy

Anthropometric Parameter Description

Weight for age (wt/age) Wt/age Nutrtional status
<60% Severe (3rd degree) Malnutrition
60-74% Moderate (2rd degree) Malnutrition
75-89% Mild (1rd degree) Malnutrition
90-110% Normal
Height for age (ht/age) According to water-low‘s l ss t on o PEM, rop n Ht A s <90 , th n rowth s s
to be stunted
Parameter Nutritional status
Drop in Weight for age (wt/age) < 80% Underweight
Drop in Weight for Height (wt/h) < 80% Wasted
Drop in Height for age (h/age) < 90% Stunted
Skin Fold thickness  Used to determine the Amount of body fat
Chest / Head circumference  Useful to diagnose Protein Energy Malnutrition (PEM) in early child hood
ratio  Chest & head circumferences are Equal at about 6 months of age
 After this, head grows slowly while chest grows rapidly
Upper (Mid) Arm  Useful to diagnose early Protein Energy Malnutrition when muscle mass is more
circumference reduced than body weight
Color of Tape Mid arm circumference (cm) Inference / Nutritional status
Red < 12.5 Gross Undernutrition
Yellow 12.5–13.5 Mild Undernutrition
Green > 13.5 Good Nutrition
Serum Albumin It is the best method for assessment of PEM. For example serum albumin < 3g/dl indicates
severe malnutrition
Note: wt/age is indicator of acute PEM while ht/age is indicator of chronic PEM

CM-074 ֍FOOD HYGIENE & SAFETY֍

01. Food Safety

Points of Difference Food Safety Food Security

Definition Food safety means preparation, handling Food security is the availability of food at
and storage of food in ways that are safe the right quantity, quality (safety) to meet
at the time of consumption their dietary and Nutritional requirements to
live an active & Healthy life
Elements /  Food Production  Food Availability
Components  Food Processing  Food Access
 Food Distribution  Food Utilization
 Food Surveillance  Food Stability
Purpose  Maintenance of Food Hygiene  Body Nourishment
 Prevention of Food-Borne  Unhindered Growth and
Illnesses development of the body

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02. Food Adulteration

It is a combination of various practices such as Mixing, Substitution, Abstraction, Concealing the quality, Putting Up decomposed
foods for sale, Misbranding OR Giving false tables and addition of Toxicants to the food that deteriorate the nutritional quality of the
Food. Examples of Adulteration:
Food Material Common Adulterants
Milk  Skimming
 Addition of Starch & water
Cereals e.g., rice  Mud
 Grits
Dals  Coal-tar dyes
 Khesari dal
Black pepper  Dried seeds of Papaya
Chilli Powder  Brick Powder
Coffee Powder  Date Husk
 Tamarind Husk
Edible Oils  Mineral Oils
 Argemone Oil
Ice cream  Cellulose
 Starch

03. Food Borne Diseases

Th t rm ― ood-borne diseas ‖ s n s: ―A s s , usually either infectious or toxic in nature, caused by agents that enter the
bo y throu h th n st on o oo .‖ W th th increase in urbanization, industrialization, tourism and mass catering systems, food-
borne diseases are on the increase throughout the world. Food-borne diseases may be classified as:
A. Food-borne intoxications
1. Due to naturally occurring toxins in some foods
 Lathyrism (beta oxalyl amino-alanine)
 Endemic ascitis (Pyrrolizidine alkaloids).
2. Due to toxins produced by certain bacteria
 Botulism
 Staphyloccus poisons
3. Due to toxins produced by some fungi
 Aflatoxin
 Ergot
 Fusarium toxins
4. Food-borne chemical poisoning
 Heavy metals, e.g., mercury (usually in fish), cadmium (in certain shellfish) and lead (in canned food)
 Oils, petroleum derivatives and solvents (e.g., Trycresyn phosphate or TCP)
 Migrant chemicals from package materials
 Asbestos
 Pesticide residues (DDT, BHC)
B. Food-borne infections
1. Bacterial diseases
 Typhoid fever, Paratyphoid fever, Salmonellosis, Staphylococcal intoxication, [Link] illness, Botulism, [Link]
Food Poisoning, [Link] diarrhoea, Non-cholera. vibrio illness, [Link] infection, Streptococcal infection,
Shigellosis & Brucellosis
2. Viral diseases
 Viral hepatitis, Gastroenteritis
3. Parasites
 Taeniasis Hydatidosis, Trichinosis, Ascariasis, Amoebiasis, Oxyuriasis

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04. Strategies to Prevent Food borne diseases

Personal Hygiene
 Hand washing before cooking/eating
 Wash hands after toilet use
 Keep nails short and clean
 Avoid cooking when ill
Safe Food Handling
 Wash fruits and vegetables
 Avoid cross-contamination
 Separate raw and cooked food
 Use clean utensils
Proper Cooking
 Educate the people about the importance of proper cooking of food. Most food poisoning organisms are killed at temperature
over 600 C
Safe Food Storage
 In the prevention of bacterial food poisoning, emphasis must be placed on proper temperature control. Food should not be left
in warm pantries; a few germs can multiply to millions by the next morning. Foods not eaten immediately should be kept in
cold storage to prevent bacterial multiplication and toxin production. "Cook and eat the same day" is a golden rule. When
foods are held between 10 deg. C (50 deg. F) and 49 deg. C (120 deg.F) they are in the danger zone for bacterial growth.
Cold is bacteriostatic at temperature below 4 deg. C (40 deg.F), and refrigeration temperature should not exceed this level
Safe Water and Raw Materials
 Use clean drinking water
 Avoid contaminated milk (use pasteurized milk)
 Avoid unsafe street food
 Wash vegetables with clean water
Environmental Sanitation
 Proper waste disposal
 Control flies and insects
 Clean kitchen surfaces
Public Health Measures
 Food inspection
 Health education
 Pasteurization of milk
 Surveillance of outbreaks

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֍PAST UHS MCQs & SAMPLE PAPER֍

1 1g dietary fibers give how much calories ? 2 Calories
2 1g Vitamin gives how much calories ? 0 Colaries
3 Additional calories required in lactating women ? 500 - 650 Kcal
4 Additional calories required in pregnant lady ? 300 - 450 Kcal
5 How much a 25 year old male should take calories ? 2960 Kcal
6 Protein we compare all other proteins against is known as reference protein. Which one is Egg protein
reference protein ?
7 Poor source of iron ? Refined floor
8 Nutritive value of Protein? 4 Kcal/g
9 Vegetable proteins are incomplete proteins. But an exception is Yeast
10 When Cereals & Pulses are given together they act as Complete protein
11 Cereals have all essential amino acids except Lysine
12 Horney papular rash (Phrenoderma) is caused by deficiency of Essential fatty acids in diet
13 Fast diarrhea is the feature of Stap aureus food poisoning
14 Why stap aureus cause diarrhea fastly ? Due to preformed toxins
15 Milk is deficient in Iron & Vit C
16 Pasteurization of milk by HTST (high temperature and short time) method is done by 72°C for 15 seconds
heating at
17 Most sensitive/early indicator of growth? Weight for age
18 Best measure to detect PEM? Serum [Albumin]
19 Serum albumin level is 3 g/dL. Interpretation ? Severe malnutrition
20 Indicator for chronic malnutrition? A. height for age ✓
B. weight for age
C. weight for height
21 WHO recommended protein % of total energy ? A.15-20 % ✓
B. 5-10%
(10-15% was not given)
22 Vit D requirement? 400 IU
23 Vit K requirement? 1000 IU
24 Which vit deficiency cause polyneuritis ? Vit B1
25 Angular stomatitis is caused by which vit deficiency ? Vit B2
26 Prolonged intake of Maize causes which vit deficiency ? Vit B3 (Niacin)
27 Most sensitive indicator for monitoring environmental iodine deficiency ? Prevalence of neonatal
hypothyroidism
28 For iron deficiency anemia, iron fortification is done with ___? Salt
.
29 Hidden hunger is referred as which nutrient deficiency ? Micronutrients (vitamins &
minerals)
30 Most widely used method for pasteurization of milk is High temperature & short time
method
31 Food related iron deficiency ? Tea decreases iron absorption
32 LBW babies, mental retardation. Nutrient deficiency ? Iodine
34 Nutrient that lowers incidence of colon cancer ? Dietary fibers
35 Daily requirement of dietary fibers ? 40 grams
36 Gomez classification "70%" . Interpret it ? Moderate PEM
37 Correct statement about PEM? Appetite is good in marasmus

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38 Feature of Kwashiorkor? Dyspigmentation

39 First step to investigate a case of food poisoning on a farm house ? History
40 Correct statement about Vit K ? It decreases by antibiotics
41 Tuberculosis + Peripheral neuropathy. Vit deficiency ? Vit B6
42 Mother presents with iron deficiency anemia. Amount of iron & folic acid 60mg Iron
supplementation? 0.5mg folate
43 Iron storing protein ? Ferritin
44 Bulging of tin food indicates putrification by Clostridium Botulism
45 Which one isn't a fat soluble vitamin ? Vit B complex
46 According to WHO If weight for age of a child is between Z score is -2 z and -3 z-score Moderate malnutrition
below median of WHO child growth standard then this condition is classified as?
47 Richest source of linoleic acid ? A. Safflower oil ✓
B. Soyabean oil
48 According to prudent diet recommendation by WHO, daily common salt intake should not 5g
exceed
49 Amount of calories per day recommended for 8 month old baby ? A. 105 Kcal
B. 108 Kcal✓
C. 118 Kcal
D. 100 Kcal
50 Deficiency of which vitamin causes numbess & tingling in foot in diabetic patient? Pyridoxine
51 This carbohydrate is a vital emergency fuel for heart: A
A. Sucrose B. Glycogen C. Fuctose D. Glucose
52 Daily iodine requirement for adult 150 micrograms
53 For an egg, the Net Protein Utilization which signifies biological value & digestibility 100
is
54 A 4 year child born normal, reports to you from Gilgit area. On examination his A
development is noted to be slow, hearing & speech defects, unilateral squint was present.
Muscular spasticity was also demonstrated. What is likely disorder?
A. Iodine deficiency disorder B. Any congenital defect
C. Zinc deficiency disorder D. Thiamine deficiency disorder
55. Egg does not contain Vitamin C
56 Canned food eating lead to diplopia & paralysis Botulism
57 Teeth discolouration caused by Tetracycline
58 Pr t l & b st m tho to m sur PEM n slums‘ h l r n? A
A. Albumin level B. Weight for height C. Weight for age

1. A nutritionist is counseling a patient on improving their gastrointestinal health, lowering cholesterol, and better controlling blood
sugar. The recommendation includes increasing the intake of non-digestible carbohydrates. What is the approximate recommended
daily intake of dietary fiber for a healthy adult?
A. 10 g D. 40 g
B. 20 g E. 50 g
C. 30 g
2. What is the minimum recommended daily intake of Vitamin D for infants and young children to prevent deficiency, as often cited
in historical public health guidelines?
A. 100 IU D. 400 IU
B. 200 IU E. 600 IU
C. 300 IU
3. Which of the following anthropometric measures is considered the most sensitive and earliest indicator of acute nutritional change
in a young child?
A. Weight for age B. Height for age

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C. BMI for age E. Head circumference

D. Mid-Upper Arm Circumference
4. Which trace mineral is often referred to as the "glucose tolerance factor" because it is believed to enhance the action of insulin by
facilitating glucose uptake and utilization by cells?
A. Chromium D. Copper
B. Magnesium E. Manganese
C. Zinc
5. A researcher is screening common micronutrients for their ability to scavenge free radicals. Which of the following compounds is
generally NOT classified as a natural, physiologically significant antioxidant?
A. Vitamin A D. Vitamin D
B. Vitamin E E. Selenium
C. Vitamin C
6. A child from an impoverished region is diagnosed with Kwashiorkor, presenting with edema, skin lesions, and apathy. A liver
biopsy is performed and shows severe fatty liver. The most likely cause of the severe fatty liver seen in Kwashiorkor disease is:
A. Fatty diet D. Iron overload
B. Vitamin A & D deficiency E. Severe protein deficiency
C. High carbohydrate intake
7. A 5-year old child presented in ophthalmology department with complaints of difficulty in vision during night times in dark room.
On examination, Bitot's spots and a corneal xerosis was observed. His condition may be resulted from a nutritional deficiency of
following vitamin:
A. Vitamin D D. Vitamin A
B. Vitamin E E. Vitamin K
C. Vitamin C
8. A two years old child presented in Paediatric emergency with oedema, wasting, liver enlargement, depigmentation of skin and hair.
He was diagnosed as a case of Kwashiorkor. Which type of malnutrition this child is suffering from?
A. Vitamin K deficiency D. Iodine deficiency
B. Essential fatty acid deficiency E. Vitamin E deficiency
C. Protein-energy deficiency
9. Knowledge about nutritional needs of infants is essential. The estimated protein requirement during first 6 months is about:
A. 1 gram/Kg body weight D. 5 gram/Kg body weight
B. 2 gram/Kg body weight E. 3 gram/kg body weight
C. 4 gram/Kg body weight
10. Food sanitation is an essential measure to prevent and control food poisoning. The dangerous range of temperature for bacterial
growth during food storage is:
A. 4-6 degree Centigrade D. 61-70 degree Centigrade
B. 10-49 degree Centigrade E. 71-80 degree Centigrade
C. 50-60 degree Centigrade
11. A field health worker is tasked with the early detection of Protein Energy Malnutrition (PEM) in children aged 0-5 years within a
remote village. The first and most practical indicator that can be easily and reliably measured by using growth charts to screen for
PEM is:
A. Low BMI for age D. Mid-Upper Arm Circumference
B. Under-weight for age E. Presence of bilateral pitting edema
C. Low height for age
12. A lactating woman visits her physician for guidance on nutritional needs. To support adequate milk production, the physician
advises an increase in daily caloric intake over the baseline requirement for non-lactating adults. Approximately how many extra
calories per day are typically recommended for a lactating woman?
A. 100–200 kcal/day D. 500–600 kcal/day
B. 200–300 kcal/day E. 600–800 kcal/day
C. 300–400 kcal/day
13. A community health worker is identifying children at high risk for developing Protein Energy Malnutrition (PEM) to prioritize
nutritional intervention and education. Which of the following is considered the single most significant risk factor for the development
of severe PEM in a child aged 6 to 24 months?
A. Vaccine hesitancy B. Lack of clean water

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C. Early weaning E. Early cessation of breastfeeding

D. Low birth weight
14. A public health survey identifies a community with a high prevalence of Rickets among children. Rickets is a bone disorder
primarily caused by Vitamin D deficiency, leading to impaired absorption of calcium and phosphate. To effectively combat this
deficiency, which staple food item is often chosen for national fortification programs but should not be prescribed to the community as
a preventative measure unless it is specifically fortified with Vitamin D?
A. Milk D. Spinach
B. Rice E. Orange
C. Eggs
15. Which measure is used to assess stunting on a growth chart?
A. Weight for age D. Mid-Upper Arm Circumference
B. Height for age E. Tricep skin fold thickness
C. BMI for age
16. The nutrients often called as "proximate principles" include the following:
A. Riboflavin D. Carbohydrates
B. Thiamine E. Iron
C. Dietary fibers
17. A mother has brought her 5 years old girl to BHU with complaints of poor appetite and diarrhea off and on. She has failure to
thrive. On examination she is irritable, moaning and apathetic. She has low weight for her height. There is edema both legs and skin is
dry and her hair are sparse and brittle. Her serum albumin is less than 3gm/dl of blood. The most likely diagnosis is:
A. Cretinism D. Marasmus
B. Growth retardation E. Mixed (Marasmic-Kwashiorkor)
C. Kwashiorkor
18. Which of the findings in the child would support a diagnosis of kwashiorkor?
A. Increased serum albumin D. Abdominal and peripheral edema
B. Good appetite E. Markedly decreased weight for height
C. Plump due to increased adipose tissue
19. A 4-year-old child living in a region with endemic malnutrition is brought to a clinic. The mother reports that the child has
difficulty seeing and navigating after sunset. The ocular symptom of night blindness (nyctalopia) is an early clinical sign caused by the
severe deficiency of which fat-soluble vitamin?
A. Vitamin E D. Vitamin D
B. Vitamin K E. Vitamin C
C. Vitamin A
20. During nutritional assessment of a surgical patient, the status of muscle of muscle protein is indicated by which one of the
following parameters:
A. Serum albumin D. Hb level
B. Triceps skinfold thickness E. Serum prealbumin
C. Mid-arm circumference
21. According to WHO, the largest proportion of a balanced diet should come from:
A. Fats D. Minerals
B. Proteins E. Vitamins
C. Carbohydrates
22. The public health practice of adding essential nutrients, such as vitamin D, to commonly consumed foods like milk & margarine to
prevent nutritional deficiencies such as rickets is called:
A. Supplementation D. Enrichment
B. Bioavailability E. Adulteration
C. Fortification

ANSWER KEY
1. D 2. D 3. A 4. A 5. B 6. E 7. D 8. C 9. B 10. B
11. B 12. D 13. E 14. A 15. B 16. D 17. C 18. D 19. C 20. C
21. C 22. B 23. 24. 25. 26. 27. 28. 29. 30.

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1.
Dietary Factor %age of total energy
Total Fat 25–35%
Saturated & Unsaturated fats  Saturated fats  <10% of total energy intake,
 Unsaturated oils should substitute for the remaining fat
requirements
Carbohydrates 45–65%
Proteins 10–35%
Dietary Fiber Up to 40g/day for adults
2. Daily Vit D requirement is 400 IU (10 mcg). Reference: [Link]
3. Weight for age – acute malnutrition while height for age – chronic malnutrition
4. Book line from [Link] & Lippinott
5. Hookworm larvae (filariform larvae) live in warm, moist soil contaminated with human faeces. The larvae typically penetrate the
host's body through the skin, most commonly when individuals walk barefoot on contaminated soil.
6. The fatty liver in Kwashiorkor is due to the severe deficiency of protein. This leads to a critical reduction in the synthesis of
Apolipoprotein (ApoB-100), which is required to form VLDL (Very-Low-Density Lipoproteins). Without sufficient ApoB, the liver
cannot package and export triglycerides, causing them to accumulate in the hepatocytes. This mcq is integrated with Biochemistry.
9. The estimated protein requirement is about 2 g/kg of body weight during the first 6 months; it declines to about 1.5 g/kg by the end
of one year. This works out to 13-14 g protein daily during the first year of life. In terms of calories, 8 to 10 per cent of calories are
given as protein
11. The first indicator of PEM is under-weight for age. The most practical method to detect this, which can be employed even by field
health workers, is to maintain growth charts. These charts indicate at a glance whether the child is gaining or losing weight. Reference:
[Link]
12. About 500-600 extra calories required for a lactating lady and 300-400 extra calories required for a pregnant lady.
Extra allowance of Pregnancy Lactation
Calories 300-400 C/day 500-600 C/day
Protein 10 gm/day 20 gm/day
Iron 10 mg/day Not recomended
Folic acid 50-200 ug 50 ug
Calcium 500 mg/day 500 mg/day
Vitamin D 400 IU/day 600 IU/day
Reference: Chatterjea, Excel & [Link]
13. Cholera is a severe waterborne illness; making water safe is the most immediate control action.
14. Milk is widely consumed and naturally low in vitamin D, so unfortified milk alone cannot prevent rickets. It is a common target
for national fortification programs to combat vitamin D deficiency. Rice, eggs, spinach, and orange either naturally contain little or no
vitamin D or are not practical as staple foods for fortification programs aimed at preventing rickets. Public health strategies focus on
foods that are widely consumed and suitable for fortification, making milk the ideal choice.
15. Weight for age – acute malnutrition while height for age – chronic malnutrition. Stunting reflects chronic malnutrition.
16. The term "proximate principles" historically refers to the large macronutrients that constitute the bulk of food and provide energy:
Carbohydrates, Proteins, and Fats.
17. The classic triad presented here—edema, apathy, and low serum albumin (indicating protein deficiency)—is diagnostic for
Kwashiorkor. This condition is primarily due to insufficient protein intake relative to energy, often leading to the retention of some
subcutaneous fat but characterized by generalized fluid retention.
18. Kwashiorkor is caused by inadequate protein intake in the presence of fair to good energy (calorie) intake. Typical findings in a
patient with Kwashiorkor include abdominal and peripheral edema caused largely by a decreased serum albumin concentration.
Anorexia is almost always present. Weight for height can be normal. Reference: Lippincott
20. Mid-arm circumference (MAC) is used to derive the mid-arm muscle circumference (MAMC), which is an indicator of muscle
protein stores (somatic protein mass). It provides a simple, inexpensive, and non-invasive measure of the body's lean body mass,
which is crucial for assessing muscle protein status in a surgical patient.
22. Fortification is the addition of nutrients to foods to prevent deficiencies in the population. For rickets prevention, vitamin D is
commonly added to milk, margarine, or cereals. Supplementation refers to giving nutrients directly as pills or drops. Enrichment

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restores nutrients lost during food processing. Adulteration mixing mixing, substitution, concealing the quality, putting up
decomposed foods for sale, misbranding or giving false labels and addition of toxicants.

֍PRACTICE MCQs֍

1. Important clinical sign that differentiates Kwashiorkor from Marasmus is:

a) Severe muscle wasting
b) Loss of subcutaneous fat d) Oedema
c) Good appetite e) Anaemia
2. Recommended daily protein intake in adult diet is:
a) 2–5% of total calories d) 25–35% of total calories
b) 5–10% of total calories e) 35–40% of total calories
c) 15–20% of total calories
3. Most important natural source of Vitamin D for humans is:
a) Wheat d) Sunlight
b) Citrus fruits e) Green leafy vegetables
c) Legumes
4. In a balanced adult diet, carbohydrates should provide:
a) 10–20% d) 75–80%
b) 30–40% e) 90%
c) 60–70%
5. During a community cholera outbreak, what is the most immediate public health measure?
a) Mass cholera vaccination d) Spray insecticides
b) Provision of safe water and ORS e) Distribute vitamin A
c) Antibiotic prophylaxis
6. Which of the following is the most effective method of preventing Hepatitis A outbreaks in school children?
a) Face mask d) Handwashing & sanitation
b) Mass vaccination e) Zn supplementation
c) Mass deworming
7. The critical measure for immediate prevention of Cholera outbreaks:
a) Mandatory quarantine of affected individuals d) Face mask
b) Oral antibiotics e) Insecticide spraying
c) Safe water chlorination/boiling
8. Vitamin A Deficiency (VAD) is a major public health concern globally due to its link with blindness and increased mortality from
infections. Which age group is the most critical target for formulation of an effective intervention programme for prevention of VAD?
a) Neonates (0–28) days d) Adolescents (13–19 years)
b) Infants and preschool children (6–59 months) e) Adults (>20 years)
c) School-aged children (6–12 years)
9. Food with highest Vitamin A content:
a) Potatoes d) Pulses
b) Banaspati ghee e) Rice
c) Cod liver oil
10. According to WHO, which dose of vitamin A is recommended for a 2-year-old child for prophylaxis?
a) 100,000 IU every 6 month d) 100,000 IU once
b) 200,000 IU every 6 months e) 200,000 IU once
c) 200,000 IU every month
11. Best group to assess prevalence of Vitamin A deficiency:
a) Adults d) Children 6 months–6 years
b) Teenagers e) Elderly
c) Pregnant women
12. Zinc deficiency may cause:
a) Growth failure d) Loss of taste
b) Delayed wound healing e) All of the above
c) Sexual infantilism

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13. Selenium deficiency with Vitamin E deficiency causes reduced:

a) Appetite d) Antibody production
b) RBC production e) Growth
c) WBC production
14. Indicator of chronic past nutritional status in children:
a) Weight d) Skinfold thickness
b) Height e) Chest circumference
c) MUAC
15. A 2-year-old child presents with skin pigmentation, cracks, and changes in hair color. Weight is slightly below normal, but there is
marked generalized edema. What is the most probable diagnosis?
a) Marasmus d) Pellagra
b) Nephrotic syndrome e) Hypothyroidism
c) Kwashiorkor
16. Main cause of high prevalence of anaemia in Pakistan:
a) Malaria d) Low iron intake
b) Hookworm e) Poor bioavailability of dietary iron
c) Roundworm
17. A 5-year-old child with night blindness will benefit from:
a) Antibiotics d) Surgery
b) Eye glasses e) Iron therapy
c) Vitamin A supplementation
18. Addition of iodine to salt is an example of:
a) Supplementation d) Food fortification
b) Adulteration e) Preservation
c) Mixing
19. A 2-year-old child presents with generalized muscle wasting and loss of subcutaneous fat. There is no edema, and weight is below
60% of WHO standard. The child comes from a poor family with inadequate nutrition after 6 months of age. What is the most likely
diagnosis?
a) Kwashiorkor d) Rickets
b) Underweight e) Failure to thrive
c) Marasmus
20. Indicator to assess PEM prevalence in urban children:
a) Plasma albumin d) Weight for age
b) Height for age e) Skinfold thickness
c) Weight for height
21. One-year-old child with bowed legs and pigeon chest has:
a) Marasmus d) Scurvy
b) Kwashiorkor e) Cretinism
c) Rickets
22. Water fluoride level causing mottled teeth:
a) 0.01 mg/L d) 3.5 mg/L
b) 0.5 mg/L e) 0.16 mg/L
c) 1.0 mg/L
23. Nutrient lost during polishing of rice:
a) Fat d) Carbohydrate
b) Protein e) Iodine
c) Thiamine
24. Best indicator for acute PEM in children:
a) Height for age d) Skinfold
b) Weight for height e) Head circumference
c) MUAC

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25. School health inspection revealed that most students had decaying teeth. Water analysis showed fluoride level of 0.2 mg/dL. What
is the most likely problem in these children?
a) Dental fluorosis d) Periodontitis
b) Gingivitis e) Enamel hypoplasia
c) Dental caries
26. Best practical method to assess protein quality:
a) NPU d) Protein efficiency ratio
b) Digestibility e) BV
c) Amino acid score
27. MUAC of 12 cm in a 3-year-old child indicates:
a) Normal
b) Mild malnutrition
c) Severe malnutrition
d) Overnutrition
e) Inconclusive
ANSWER KEY
1. D 2. C 3. D 4. C 5. B 6. B 7. C 8. B 9. C 10. B
11. D 12. E 13. D 14. B 15. C 16. E 17. C 18. D 19. C 20. D
21. C 22. D 23. C 24. B 25. C 26. D 27. C 28. 29. 30.

1. Oedema is characteristic of kwashiorkor.

5. WHO emphasizes rapid hydration and safe drinking water as first-line outbreak control
6. Hepatitis A is transmitted by the fecal–oral route, especially in school children, where outbreaks are common due to close contact
and poor hygiene. The most effective strategy for controlling Hepatitis A outbreaks is Mass vaccination of exposed or at-risk groups
While handwashing & sanitation (Option D) are very important and reduce transmission, they cannot stop outbreaks once transmission
begins. During outbreaks, vaccination provides rapid, strong, and lasting immunity, making it the most effective control measure.
7. Cholera is a severe waterborne illness; making water safe is the most immediate control action.
8. Assessment of vitamin A deficiency: The formulation of an effective intervention programme for prevention of vitamin A
deficiency (VAD) begins with the characterization of the problem. This is done by population surveys employing both clinical and
biochemical criteria. These surveys (prevalence surveys) are done on preschool children (6 months to 6 years) who are at special risk.
The criteria recommended by WHO are as given in Table below. The presence of any one of the criteria should be considered as
evidence of a xerophthalmia problem in the community.

Reference: [Link]
10. Vitamin A prophylaxis programme
 Age 6–11 months: 100,000 IU once
 Age 12–59 months: 200,000 IU every 6 months
11. Young children are most vulnerable.
27.
Color of Tape Mid arm circumference (cm) Inference / Nutritional status
Red < 12.5 “Gross Undernutrition”
Yellow 12.5–13.5 “Mild Undernutrition”
Green > 13.5 “Good Nutrition”

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CHAPTER 4 © 5th Edition MODULE 26: EYE & ENT-I

MODULE-26
EYE & ENT – 1

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Ear001 – Ear008
EYE & ENT-1 ENT-1
Following numbering of chapters is according to the UHS recommended book –Dhingra
Chapter 05 ֍HEARING LOSS֍

01. Presbycusis

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Old age + Progressive hearing loss
 No history of ear discharge / trauma / earache
 PTA reveals, downward sloping with preserved word recognition

1. An 85 years old male presents with history of pregressive hearing loss for last one year. There is no history of ear discharge. On
examination, both tympanic membranes are normal. PTA shows downward sloping pure tone threshold with preservation of word
recognition. [Annual 2021]
a) What is the diagnosis?
Answer: Presbycusis
b) How we can manage the patient?
History Onset of hearing loss, chronic noise exposure, vascular disorder
Examination Examination of ear by tuning fork
Investigation PTA, Speech audiometry
Treatment  Hearing aid
 Curtailment of smoking & tea/coffee

02. Noise Induced Hearing Loss (NIHL)

1. A 55 years old factory worker presents in ENT outpatient department with complaint of gradual decreased hearing from both ears
for last six months. He also complains of disturbing sounds in both ears especially at night. He is worried about lack of
communication in daily life due to this problem. [Annual 2024 held in 2025]
a) What type of hearing loss this patient is suffering from?
Answer: Noise Induced Hearing Loss
b) How will you confirm type and severity of hearing loss in this patient?
History and Physical  Detailed history of noise exposure at work, recreational activities, or other contributing factors.
Examination  Otoscopic examination to rule out external or middle ear pathology (e.g., cerumen impaction,
otitis media).
Audiological Tests Pure-Tone Audiometry (PTA)
 Gold standard for confirming sensorineural hearing loss.
 Typical findings in NIHL: A notch at 4 kHz on the audiogram (due to noise-induced damage
to cochlear hair cells).
Speech Audiometry:
 To evaluate speech recognition ability.
Tympanometry:
 To assess middle ear function and rule out conductive hearing loss.
Otoacoustic Emissions Confirms damage to outer hair cells in the cochlea, indicating NIHL.
Auditory Brainstem To assess retrocochlear pathology (e.g., acoustic neuroma) if asymmetry or additional symptoms like
Response dizziness are present.
Noise Exposure Occupational history to evaluate cumulative noise exposure levels (dB).
Assessment

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c) How will you manage this patient?

 Hearing aids
 Use of sound cancellation machine in noisy environment
 Limited exposure to loud noise
 Regular audiometry

Chapter 07 ֍DISORDERS OF VESTIBULAR SYSTEM֍

01. BPPV

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Multiple episodes of vertigo (of few seconds), occur when the head is placed in
certain critical position; associated with nausea.
 Positive Dix-Hallpike maoeuver / Positional test
 No history of tinnitus, otalgia, hearing loss / discharge.

1. A 49 years old lady presents with six weeks history of multiple episodes of vertigo of brief duration (few seconds) on turning
towards right in lying position associated with nausea. There is no history of tinnitus, hearing loss, Otalgia and ear discharge. [Supple
2022 held in 2023]
a) What is the most likely diagnosis?
Answer: Benign Paroxysmal Positional Vertigo (BPPV)
b) How will you investigate this case?
 Dix-Hallpike maneuver – Diagnostic
 Electronystagmography
 Videonystagmography
 MRI scan of brain.
c) How will you treat this patient?
Preventive measures Avoid head position & movements which trigger vertigo.
Medication Anti-histamine & Antiemetics
Epl y‘s m n uv r The principal of this maneuver is to reposition the otoconial debris (as shown below).

Chapter 08 ֍DISEASES OF EXTERNAL EAR֍

01. Trauma to Auricle

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of ear trauma (e.g., while playing)
 Unilateral Painless swelling (progressive in nature)
 Compressible swelling +/– deformity of auricle on examination
 If pain occurs alongwith swelling and deformity (Perichondritis)

1. A36 year old male presented with complain of painless swelling on right ear growing for last two days. He had no significant
previous medical history but there is history of trauma to ear while playing football. On examination slightly compressible swelling
affecting the concha limited to an area of approximately 10 x 5 mm was present. [Annual 2020]
a) What is the diagnosis?
Answ r: Aur ul r H m tom [Box r‘s r (C ul low r Pugilistic ear)]
b) Which ear deformity develops if not treated timely?
Perichondritis
(c) What is the treatment.
 Aspiration under strict aseptic precautions & a pressure dressing
 If aspiration fails, then incision & drainage should be done.
 Prophylactic antibiotics should be taken

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02. Furuncle/ Localized Otitis Externa

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Severe pain in ear (out of proportion to size of furuncle) + Painful movement of
pinna (Tragus) and Jaw
 Tender periauricular lymphadenopathy
 Usually no discharge (but sometimes some purulent discharge)

1. A 28-year-old male presented with progressively increasing persistent right earache for 2 days along with decreased hearing and
swelling around the ear and some purulent discharge from the ear. On examination, there is tragal tenderness and there is soft fluctuant
swelling along the floor of external auditory canal. Tympanic membrane could not be viewed due to inability to introduce the
speculum. [Supple 2014 held in 2015]
a) What is your diagnosis?
Answer: Furuncle
b) Give differential diagnosis.
1. Diffuse otitis externa
2. Acute mastoiditis
3. ASOM & SOM
c) How will you treat the patient?
1. Early cases without abscess  Systemic Antibiotics
formation  Analgesics
 Local Heat
 Ear pack of 10% ichthammol glycerine
2. If abscess is formed  Drain the abscess + Antibiotics
3. If recurrence  Rule out diabetes, Staph. skin infection, check Nasal vestibule (harbors
staphylococcus)

2. A young female presents in ENT clinic with complain of severe pain in left ear for for last one day. Movements of pinna and jaw as
on chewing are painful and there is obliteration of retroauricular groove. On examination, a swelling is noted in outer ear canal.
[Annual 2021]
a) What is most likely diagnosis?
Answer: Furuncle
b) What is the treatment?
Answer: See Q#1c

03. Otitis Externa Hemorrhagica

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of Influenza (Sneezing, rhinorrhea, nasal congestion)
 Severe pain in ear + Blood-stained ear discharge (if bullae rupture)
 Bluish-blebs on tympanic membrane on examination.

1. A16-year-old boy presented during winters with nasal obstruction, sneezing, rhinorrhea and left otalgia. There is blood-stained clear
discharge from the ear. Clinical examination revealed congested nose and after cleaning the external auditory meatus, bluish blebs are
seen on the tympanic membrane. [Annual 2015]
a) What is the clinical diagnosis?
Answer: Otitis Externa Hemorrhagica (Myringitis Bullosa)
b) What is the causative agent in this case?
 Most commonly caused by virus (influenza),
 Other causative agent is Mycoplasma pneumonia.

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c) How will you manage the disease?

History Time of onset, mode of onset, Hearing problem, History of throat infection, History
of ear discharge, Ear pain
Examination Examination of ear by otoscopy
Investigation Usually, no investigation required
Treatment  Analgesic
 Antibiotics to prevent secondary infection
 Keep ear dry

04. Malignant/ Necrotizing Otitis Externa

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of Diabetes / Immunocompromised persons
 Excruciating pain + Granulations in external ear canal (at junction of Bony &
cartilaginous parts) (Diagnostic)
 Ipsilateral Facial Palsy +/– other cranial nerve palsies

1. A male 60 years of age, diabetic has presented with pain in right ear for two months. He has not responded to usual treatment by
general practitioner. On examination, he has granulations at the junction of cartilaginous and bony meatuses.
a) What is your diagnosis? (2)
Answer: Malignant otitis externa
b) Give its pathogenesis
Pseudomonas infection of external ear  Cellulitis  Chondritis  Periostitis  Osteitis  Osteomyelitis  Multiple cranial nerve
palsies.
c) How will you manage it?
History Diabetes, Age of onset, Ear pain, Facial paralysis
Examination Ear examination with microscopy
Investigation  Gallium-67 is investigation of choice. Repeated every 3 weeks
 Technetium-99
 CT scan
 Culture & Sensitivity
Treatment  Control of diabetes
 Ear toilet
 Antibiotics (Ciprofloxacin/Gentamycin/Ceftriaxone)
 Local debridement of necrotic tissue

05. Otomycosis

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Intense itching +/– Pain & Aural fullness (Unilateral / bilateral)
 Watery discharge with musty odour
 Fungal mass on examination:
1. Black-headed growth  Aspergillus Niger Infection
2. Pale blue / green mass  Aspergillus Fumigatus Infection
3. White cheesy / creamy deposits  Candidal Infection

1. A 35-year- old male presents in ENT OPD with unilateral ear pain and fullness of ear. On examination, tympanic membrane is not
visible and masked by white cheesy material. [Annual 2018]
a) What is most likely diagnosis?
Answer: Otomycosis
b) How will you treat this case?
 Thorough ear toilet

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 Antifungal (Natamycin & Clotrimazole) and Povidone Iodine

 Keratolytic agent (20% salicylic acid in alcohol)
 Precaution (ear must be kept dry)

2. A 40 years old Swimmer comes with history of itching and watery discharge from right ear for the last 5 months. Ear examination
shows black spores with filamentous mass in the ear canal. What is your diagnosis?
Otomycosis (Due to Aspergillus Niger)

06. Impacted Wax

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Sense of blocked ear + Hearing impairment
 Hard wax in ear on examination, if impacted on tympanic membrane; cause
tinnitus, giddiness & coughing
 Long-standing wax impaction  Wax granuloma

1. A 50-year-old lady complained of blocked left ear. On otoscopy, she had hard wax in ear canal. When doctors tried to remove this
w x, sh st rt ou h n n pro ur w s b n on u to p t nt‘s non-cooperation. [Supple 2011 held in 2012]
a) Why she had cough during wax removal?
Answer: Due to stimulation of Auricular branch of Vagus (X) nerve.
b) How will you remove her wax?
 Softens the hard wax by:
 Drops of 5% sodium bicarbonate in equal parts with glycerine & water
 Hydrogen peroxide
 Liquefied paraffin
 Olive oil
 Syringing or Instrumental manipulation
c) List three contraindications for ear syringing.
 Presence of TM perforation
 Otitis externa or Otitis media
 Past history of ear discharge
 Only hearing ear
 Previous ear surgery

07. Foreign Bodies of Ear

1. [Annual 2007]
a) What are the various types of foreign bodies in ear?
a. Living – flying or crawling insects like mosquito, beetles, ant
b. Non-living – piece of paper & chalk, grain seeds, slate pencil
b) How will you treat maggots in ear?
Answer: First kill them by instilling chloroform water and then remove them by forceps

08. Traumatic Rupture of TM

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of trauma to ear
 Excruciating pain +/– Bloody discharge from external meatus; post-injury
 Hearing impairment / Loss

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1. A 25-year-old lady was slapped on face by her husband. She felt excruciating pain at time of injury and had few drops of blood
coming from external auditory meatus. [Annual 2012]
a) What is the expected diagnosis?
Answer: Traumatic Rupture of Tympanic membrane
b) List four other causes of bleeding from ear.
1. Fracture of temporal bone
2. Forceful syringing
3. Trauma due to hairpin or matchstick
4. Sudden change in air pressure such as kissing on ear or forceful valsalva
c) What is the treatment of this lady?
 Usually no treatment requires i.e., heals itself
 Splintage can be done
 Avoid putting ear drops and swimming

Chapter 10 ֍DISEASES OF MIDDLE EAR֍

01. Acute Suppurative Otitis Media (ASOM)

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of any Upper respiratory tract infection / sore throat / tonsillitis
 Severe earache + Hearing loss + Systemic features (Fever, Raised WBCs)
 Examination may show; Congested (Red), Bulged TM with loss of landmarks +/–
Yellow spot & Nipple-like protrusion on it.

1. An 8-year-old boy got an attack of acute coryza. After 2 years, he started having fever, pain and deafness in his left ear. On
examination, the tympanic membrane is badly congested and bulging outwards. Weber test is lateralized towards left ear. Temperature
is 103° F and WBC count is 18000. [Supple 2017 held in 2018]
a) What is the most probable diagnosis? (1)
Answer: Acute Suppurative Otitis Media (ASOM)
b) What are the various stages?
Stages Findings on TM
Stage of Tubal occlusion Retracted TM, Loss of light reflex
Stage of Pres-suppuration Congested TM, Cart-wheel appearance of TM
Stage of Suppuration Bulging of TM, Loss of landmarks, yellow spot on TM (Nipple sign)
Stage of Resolution Return of normal color & landmarks
Stage of complication Intra-temporal and intra-cranial complications
c) How will you treat this case? (4)
Medical  Antibiotics (ampicillin & amoxicillin or cotrimoxazole) for 10 days
 Nasal & Oral Decongestants
 Analgesics & Antipyretics
 Ear toilet
 Local heat
Surgical  Myringotomy usually done after 3 months (but can be done early if fever /
earache worsens after 2-3 days of antibiotic therapy)

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02. Otitis Media With Effusion

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of Adenoid hyperplasia / Chronic tonsillitis / Rhinitis / Allergy
 Mild earache + Hearing loss (Most common feature) & NO Systemic features
(Fever, Raised WBCs)
 Examination may show; dull & opaque TM with no light reflex [Colour may be
bluish  Blue Drum] with loss of landmarks.

1. A 5-year-old child brought to OPD with complains of watching television at a loud volume and lack of attention. She has a chronic
nasal obstruction. On examination, tympanic membrane is dull and bulging. [Supple 2015 held in 2016]
a) What is the most probable diagnosis?
Serous Otitis Media (SOM)
b) How will you confirm your diagnosis?
 Impedence audiometry – type B tympanogram
 Otoscopy – Dull tympanic membrane
 Appearance of bubbles in middle ear on Valsalva manoeuvre
 X ray mastoid show clouding of air cells
 Tuning fork & Audiometry shows conductive type hearing loss
c) What is the treatment of this condition?
Medical Antibiotics, Decongestants & Antihistamines
Surgical Myringotomy, Grommet tube insertion & Cortical mastoidectomy
Treatment of underlying cause like adenoidectomy or tonsillectomy

2. A 4-year-old girl comes to you with complaints of repeated episodes of earache, hearing loss, sore throat. On examination of the
ear, the ear drum is intact, dull looking and with loss of landmarks. [Supple 2016 held in 2017]
a) What is your diagnosis?
Answer: Serous otitis media (SOM)
b) Give one investigation to confirm the diagnosis.
Answer: Impedence audiometry – Gold standard
c) What are four types of Tympanograms?
Type Pathology
Type AS Otosclerosis or malleus fixation
Type AD Ossicular discontinuity or thin & lax TM
Type B SOM or thick TM
Type C Retracted TM

3. A 4-year-old boy is having problems in hearing for last three months. Mother says the child keeps mouth open at night. Medical
treatment has not helped. [Supple 2019 held in 2020]
a) What investigations are to be done? (2)
1. Lateral neck radiography for adenoid hyperplasia
2. Hearing tests
 Tuning fork
 Audiometry
 Impedance audiometry – Gold standard for SOM
 X-ray mastoids
b) What treatment may become necessary? (3)
 Myringotomy & Aspiration of fluid by giving incision in antero-inferior quadrant
 Grommet insertion – performed when myringotomy doesn't help or fluid recurs
 Adenoidectomy to correct the cause (adenoid hyperplasia)

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Chapter 11 ֍CHOLESTEATOMA & CHRONIC OTITIS MEDIA֍

01. Cholesteatoma

1. Define cholesteatoma. What are theories of origin of cholesteatoma? Give its complications (2.5) [Annual 2019]
It is a bag of stratified squamous epithelium containing keratin debris and desquamated epithelium
Theories
Wittmaack's theory Retraction pockets by invagination of TM
Ruedi's theory Basal cell hyperplasia under influence of infection
Habermann's theory Epithelial invasion through perforation
Sade's theory Metaplasia of middle ear mucosa due to repeated infection
Teed’s theory Congenital cell rests  Congenital cholesteatoma

Intratemporal Complications Intracranial Complications

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

02. Chronic Suppurative Otitis Media

֍⸨Diagnostic Features by Team Medical Minds⸩֍

Tubo-Tympanic (Safe) Type:
 History of ASOM / chronic tonsilltis, adenoids / allergy
 Profuse, mucoid and odourless discharge
 Pale Aural mass + Central perforation of TM
 Mild-moderate Conductive deafness
Attico-Antral (Unsafe) Type:
 History of Cholesteatoma
 Scanty, purulent and foul-smelling discharge
 Red, fleshy Aural mass + Attic / marginal perforation of TM
 Severe Conductive / Mixed deafness

1. A 25-year-old male presented with complains of unilateral ear blockage and intermittent ear discharge. On examination, there is
aural mass. There is history of ear surgery in the last six years. [Supple 2018 held in 2019]
a) What is the most likely diagnosis? (1)
Answer: Chronic Suppurative Otitis Media (Tubo-tympanic type)
b) What are the most common causes of recurrence? (2)
Answer: Spread of infection through
 Eustachian tube – from tonsils, adenoids and rhinosinusitis
 External auditory canal – via perforated TM
c) What is appropriate treatment of this patient? (2)
Wet Perforation Medical – Aural toilet, Antibiotics, Precautions (keep ear dry)
Surgical – Tympanoplasty ± Cortical mastoidectomy
Dry Perforation Tympanoplasty/Myringoplasty

2. A 25-year-old male patient presented with chronic foul-smelling ear discharge from right ear for last three years. On examination,
he had posterosuperior attic perforation. [Annual 2018]
a) What is your diagnosis? (1)
Answer: Chronic Suppurative Otitis Media (Atticoantral type)

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b) How will you investigate this patient? (2)

Investigations Justification
Examination Under  Shows presence of cholestetoma, its site & entent, evidence of bony destruction, granuloma,
Microscope condition of ossicles and discharge pockets.
Tuning Fork tests and  Essential for preoperative assessment to confirm the degree and type of hearing loss
Audiogram
X-ray mastoid / CT-scan  CT scan is preferred to X-ray, as it better reveals the extent of destruction and degree of
Temporal Bone mastoid pneumatization (also sclerotic mastoid); attic & antral area (Key-Area) destruction
caused by cholesteatoma.
Culture & Sensitivity of Ear  It helps in selecting proper antibiotics for local and systemic use.
Discharge
c) What are treatment options in this case? (2)
Conservative Treat the cause, Aural toilet & Antibiotics
Surgical Radical mastoidectomy or, Modified Radical Mastoidectomy is treatment of choice
Reconstructive Tympanoplasty usually done after 6 months

3. A middle-aged man presented with right sided ear discharge for the last three years along with impaired hearing. Sometimes he
experiences spells of vertigo which lasts for few minutes. Otoscopic examination revealed smooth surface mass in the external
auditory meatus. Pure tone audiometry (PTA) showed mixed type deafness. [Annual 2015]
a) What is the provisional diagnosis?
Answer: Chronic Suppurative Otitis Media (Atticoantral type)
b) What pathological process is going on in the ear?
Answer: Cholesteatoma, Osteitis & Granulations  Ossicular necrosis
c) What is your management plan?
Answer: See Q2

Chapter 12 ֍COMPLICATIONS OF SUPPURATIVE OTITIS MEDIA֍

01. Acute Mastoiditis

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of ASOM / CSOM, now presented with Severe Earache and Pulsatile ear
discharge (Light-house effect) + Systemic Features (Fever & tachycardia)
 Swelling behind ear (Tender mastoid); pinna pushed forward & downward
 Con u t v typ o h r n loss (R nn ‘s n t v )

1. A 3 years old child presented in ENT OPD with the complaints of earache and ear discharge associated with fever and swelling
b h n th r ht r s n , 2 ys. On x m n t on, R nn ‘s t st s n t v n th r ht r n w b r‘s t st s l t r l z towards the
right side. On otoscopy, there is a central perofration with pulsatile ear discharge. His pulse is 99 and temperature is 103oF. [Annual
2023 held in 2024]
a) What is the most likely diagnosis?
Answer: Acute Mastoiditis
b) How will you investigate this case?
 Culture and Sensitivity
 X ray mastoid/CT temporal bone
 ESR & CBC
c) How will you treat this case?
 Hospitalization of patient
 Antibiotics guided by culture & sensitivity ± Myringotomy
 Cortical Mastoidectomy – TOC

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2. A 35 years old non diabetic male presented to ENT emergency with complain of right sided earache, decreased hearing and high-
grade fever for last 3 days. On examination, there is redness and forward protrusion of the right pinna and external auditory canal is
narrowed due to the swelling. [Supple 2021]
a) What is the most likely diagnosis? 01
Answer: Acute mastoiditis
Why it CANNOT be Furunculosis
Furunculosis presents with:
• Intense localized pain
• Local furuncle near tragus
• No systemic fever
• No pinna protrusion
• No posterior canal wall bulging
• No major hearing loss
• No swelling behind the ear
b) What is the most common organism involved in this pathology? 02
Answer: Staph. aureus
c) How will you manage this patient? 02
See Q1

02. Bezold Abscess

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of ASOM / CSOM, now presented with sudden onset fever + Pain in neck
+ Torticollis
 Tender swelling behind the mandible in the neck on examination.

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?
 Cortical mastoidectomy
 Drainage of neck abscess
 I/V Antibiotics

03. Meningitis

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of ASOM / CSOM, now presented with High-grade Fever + Headache +
Neck rigidity + Nausea & Vomiting
 Photophobia and drowsiness (delirium / Coma) may be present.

1. A 40-year-old male long standing left sided ear discharge. For last 2 days, he complains of severe pain with vomiting. He cannot
bend his neck without pain. White cell count is 14000. [Annual 2009]
a) What is likely diagnosis?
Meningitis
b) Which tests you will do to confirm diagnosis?
Clinical  Positive Kernig's sign – extension of leg with thigh flexed on abdomen
 Positive Brudzinski's sign – flexion of neck causes flexion of hip & knee
Laboratory  CT scan or MRI
 Lumber puncture & CSF examination

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o Appearance – Turbid
o Cell count – Raised with predominance of polymorphs
o Protein level – Raised
o Sugar level – Reduced
o Chloride level – Diminshed
 CSF Culture and Sensitivity

c) How will you treat the patient?

 Medical – Antibiotics & Steroids
 Surgical – Radical mastoidectomy / modified radical mastoidectomy
d) Enumerate the complications of this primary ear problem.
 Intratemporal – Mastoiditis, Petrositis, Facial paralysis, Labyrinthitis
 Intracranial – Extradural, Subdural & Brain abscess, Sigmoid sinus thrombosis

Chapter 13 ֍OTOSCLEROSIS֍

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Usually females with Bilateral, slowly progressive painless hearing loss +/–
Tinnitus & vertigo
 Paracusis Willisii  Patient hears better in noisy > quiet surroundings
 Examination:
1) R nn ‘s test negative (Conductive deafness) & PTA shows dip in bone
on u t on urv t 2000 Hz (C rh rt‘s Not h)
2) Schwartz Sign [Reddish hue on promontory through TM]

1. A 27-year-old female developed hearing loss that was bilateral, slowly progressive and associated with tinnitus. Pure tone
audiometry (PTA) revealed bone conduction hearing loss at 2000 Hz. [Annual 2016]
a) What is your diagnosis?
Otosclerosis
b) Describe the differential diagnosis.
 Serous otitis media (SOM)  Ossicular discontinuity
 Adhesive otitis media  Congenital stapes fixation
 Tympanosclerosis  Attic fixation of malleus head
c) How will you investigate?
Investigation Findings
Pure tone audiometry Carhart's Notch at 2000 Hz
Tuning fork tests 1. Negative Rinne test (BC > AC)
2. Weber's test lateralized to ear with greater conductive loss
Impedence audiometry Type AS tympanogram
Otoscopy  Normal mobility of TM
 No perforation of TM
 Schwartz's sign
d) How will you treat this patient?
 NaF
 Stapedectomy – Treatment of choice
 Stapedotomy
 mp rt‘s n stration operation
 Hearing Aid

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2. A 25-year-old female presents with gradually increasing bilateral deafness. Clinical examination reveals bilateral normal, intact
tympanic membrane. PTA revealed a dip in hearing at 2000 Hz in bone conduction. Tuning fork test revealed conductive type of
deafness. [Annual 2015 + Supple 2020]
a) What is the most probably diagnosis?
Answer: Otosclerosis
b) Mention one audiological test which confirms your diagnosis.
Answer: Pure tone audiogram
c) Mention one tuning fork test which is also helpful in confirmation of the disease.
Answer: Rinne' test
d) What is the pattern of inheritance of this disease?
Answer: Autosomal dominant

Chapter 14 ֍FACIAL NERVE & ITS DISORDERS֍

01. Branches of Facial Nerve

1. Name the branches of facial nerve in the middle ear. (2) [Annual 2019]
1. Greater superficial petrosal nerve
2. Nerve to stapedius
3. Chorda tympani nerve
4. Communicating branch to vagus (X)

02. Complications Following Facial Nerve Palsy

֍⸨Diagnostic Features by Team Medical Minds⸩֍

Frey’s yndrome (Gustatory weating Bailarger yndrome):
 History of Facial mass / parotid surgery
 Sweating & flushing in pre-auricular area while eating (Mastication)

1. A 60 years old male presented with sweating and flushing in preauricular area in response to mastication. He gives history of facial
mass surgery 8 months ago. [Supple 2021]
a) What is your probable diagnosis?
Answer: Frey's Syndrome / Auriculotemporal nerve syndrome
b) What is underlying cause?
Injury to auriculotemporal nerve followed by inappropriate regeneration i.e., Parasympathetic fibers that supply parotid glands are
misdirected to the sweat glands causing gustatory sweating.
c) How will you treat this patient?
1. Tympanic neurectomy
2. Botulinum toxin
3. Reconstructive surgery

03. Herpes Zoster Oticus OR Ramsy Hunt Syndrome

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Excrutiating pain on face + Ipsilateral facial palsy (Weakness)
 Vesicular rash on pinna & external auditory canal +/– TM

1. A 30 years old male develops excruciating pain on left side of face and vesicles formation on auricle with ipsilateral facial
weakness for last three days. (2023 Supple)
a) What is the most probably diagnosis?
Answer; Herpes zoster Oticus/ Ramsay Hunt syndrome.

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b) What are the three differential diagnoses of the disease?

1. B ll‘s p lsy
2. Trigeminal Neuralgia
3. Herpes zoster infection
c) How will you treat this patient?
Conservative Maintain Ear hygiene to prevent any superimposed bacterial infection.
Medical Antivial Acyclovir [Drug of choice, ideally should be administered within 72 hours
onset of symptoms], Valacyclovir or Famciclovir
Analgesic NSAIDs or opioids
Anti-inflammatory Corticosteroids.

Chapter 15 ֍MENIERE’S DISEASE֍

֍⸨Diagnostic Features by Team Medical Minds⸩֍

Classic Tetrad of VAST:
 Vertigo (Episodic); +/– Nausea & Vomiting
 Aural Fullness / Pressure
 Sensorineural hearing loss
 Tinnitus

1. A 55-year-old male has episodic rotatory vertigo for the last 3 years. The attack of episodic vertigo lasts for 2-3 weeks, subsides
with treatment and recurs after 3-4 months. It is accompanied with nausea, vomiting with pallor and sweating. This attack of vertigo
follows, sense of fullness in the right ear, hearing loss and intermittent tinnitus again in the same ear. His pure tone audiometry reveals
50 dB hearing loss in right ear and normal hearing in left ear. [Supple 2017 held in 2018]
a) What is your diagnosis?
Answer: Meniere's disease
b) How will you manage the patient?
History Onset of vertigo, hearing loss, history of previous attacks, trauma history
Examination Examination of ear by otoscopy, Examination of Nystagmus
Investigation  PTA
 Electrocochleography + Glycerol test – Investigation of choice
 Speech audiometry
 Special audiometry tests (Recruitment test, SISI & Tone decay test)
Treatment Medical Surgical
For acute attack Conservative procedures
 Reassurance, Bed rest, IV fluid  Endolymphatic sac decompression
 Vestibular sedatives  Endolymphatic shunt operation
 Vasodilators (Carbogen)  Sacculotomy
For chronic attack  Sectioning of vestibular nerve
 Vestibular sedatives Destructive procedures
 Vasodilator – Betahistine is DOC  Labyrinthectomy
 Diuretics Intermittent low pulse pressure therapy
 Intralabyrinthine gentamicin injection (Meniett device)

2. A 50-year-old man while working in a factory got an attack of severe vertigo for which he had to stop his work. This attack was
associated with nausea and lasted for about one hour. There is history of three such attacks in the last one year. On examination, ear
looks normal. BP is 130/85 mm Hg; tuning fork tests show mild sensorineural deafness in left ear which is confirmed by audiometry.
[Annual 2017]
a) What is the most probable diagnosis?
Answer: Meniere's disease

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b) What instructions you will give to the patient during attack?

 Bed rest
 Avoid smoking
 Avoid stress
 Avoid excessive salt intake
 Take excess fluid to combat their loss due to vomiting
 Avoid over-indulgence in coffee, tea & alcohol

3. A 34 years old female have chief complaints of spontaneous, transient episodes of tinnitus, fullness in the ear and hearing loss all in
the left ear. Vertigo episodes lasted anywhere from several hours to a day and were preceded by the tinnitus. [Annual 2020]
(a) What is the likely diagnosis?
M n r ‘s s s
(b) Enumerate variants of this disease.
 Cochlear variant
 Vestibular variant
 Drop tt ks (Tum rk n‘s otol th r s s)
 Lermoyez syndrome

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֍PAST UHS MCQs & SAMPLE PAPER֍

Following numbering of chapters is according to the UHS recommended book – Dhingra
Sr Statement Answer
Chapter 4 – Assessment of Hearing
01 Ideal tuning fork frequency for routine clinical practice? 512 Hz
02 Rinne test is negative in right ear without ear masking but Weber test is louder in left Right sided Sensorineural hearing
ear. Diagnosis? loss
Hint: False -ve Rinne test
03 Speech discrimination score for conductive hearing loss? 90-100 %
04 Which type of tympanogram is obtained for serous otitis media? Type B
05 Which type of tympanogram is obtained for Otosclerosis? Type As
06 Graph obtained for axis (compliance and ambient pressure) is: Tympanogram
07 Flat or dome shaped tympanogram is obtained for which ear pathology? SOM
08 In which condition, tympanogram shows high compliance at ambient pressure? Ossicular discontinuity / thin or
laxed TM
09 Person non responding to PTA but responds to Stapedial reflex? Malingerer (NOHL)
10 Presence of Stapedial reflex at lower intensity i.e., 60 dB indicates? Cochlear pathology
11 Absence of Stapedial reflex when hearing is normal, indicates ____? Lesion of VII proximal to the
nerve to stapedius
12 Absence of OAEs indicates lesion of: Outer hair cells (cochlea)
13 A dull tympanic membrane with bubbles visible behind it suggests the presence of Type B
middle ear fluid, often due to otitis media with effusion. A --------- tympanogram is
typically observed in this condition
Chapter 5 – Hearing Loss
14 Hearing loss is greatest in which lesion of conductive apparatus? Closure of oval window (60 dB)
15 From where grafts are taken for myringoplasty? Temporalis fascia
16 Why graft is taken from Temporalis fascia for myringoplasty? Because it is superficial and easily
available
17 Ototoxic drugs cause which type of hearing loss? Sensorineural
18 Aminoglycosides cause Sensorineural hearing loss by destruction of? Outer hair cells
19 Diuretics cause Sensorineural hearing loss by causing ___? edema and cystic changes in stria
vascularis
20 Maximum permitted daily exposure for 90 dB: 8 hours
21 For NIHL, audiogram shows notch at what frequency? 4000 Hz
22 A 65 years old female comes with the complaint of severe hearing loss bilaterally. Presbyacusis
There is no pain, no otorrhoea. Tympanic membrane is intact and shows laxicity. This
condition corresponds with:
a) Ototoxicity
b) Tympanosclerosis
c) Otosclerosis
d) Presbyacusis
c) Noise induced hearing lass
Chapter 6 – Assessment of Vestibular Function
23 In darkness, nystagmus of peripheral origin is ____? Enhanced
24 Nystagmus when person look in the direction of slow component: 3rd degree nystagmus
25 Caloric test is performed to check the function of which semicircular canal? Lateral
26 While performing Caloric test, temperature of water used for irrigation? 37°C ± 7°C
Chapter 7 – Disorders of Vestibular System
27 BPPV can be distinguished from Meniere disease by _____? Absence of hearing loss
28 Manoeuvre perform to confirm when patient complains of BPPV? Dix Hallpike manoeuvre
A. Dix Hallpike manoeuvre
B. Epl y‘s m nouv r

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29 In which of the following peripheral vestibular disorders, hearing loss and vertigo are Labyrinthitis
seen?
A. BPPV
B. Labyrinthitis
C. Vestibular neuronitis
30 Fistula test is performed in which type of Labyrinthitis? Circumscribed Labyrinthitis
31 Treatment of positional vertigo? Epl y‘s m nouv r
32 A weight lifter presents with complain of episodes of vertigo, fluctuating sensory Perilymph fistula (Also known as
hearing neural loss and sense of fullness of ear for the last 1 month. There is no such Secondary Meniere's disease)
attack in past. Diagnosis?
33 When a person is exposed to a loud sound and he experiences vertigo, this particular Tullio phenomenon
situation is known as:
a) Tullio phenomenon
b) Benign paroxysmal positional vertigo
c) Fistula sign
d) Recruitment phenomenon
e) Meniere's syndrome
Chapter 8 – Diseases of External Ear
34 Treatment of Preauricular sinus? Surgical excision
35 Complication of Cauliflower ear is? Perichondritis
36 A rugby player had trauma to his pinna which got swollen after few hours. On Incision and drainage with
examination it was fluctuant swelling. What is the best treatment? pressure bandage
a) Aspiration
b) Repeated aspiration
c) Incision and drainage with pressure bandage
d) Otoplasty
37 Bacteria causing perichondritis? Pseudomonas > S. aureus >
Hemolytic strep > E. coli
(Pseudomonas option was not given)
38 Location of Preauricular sinus? In front of crus of helix or just
above the tragus
39 Fistula tract between external ear and neck just behind angle of mandible? Coll-aural fistula
40 Painful and tender pinna. Diagnosis? Furuncle
41 A 38 year diabetic male present with red and painful pinna. There is some purulent Furunculosis
discharge from the ear. Diagnosis?
42 An 18 year boy present with painful ear discharge after having upper respiratory tract A. Virus ✓
infection. Hemorrhagic blebs are seen on TM. Organism responsible for it? B. Bacteria
43 Most common/earliest presentation of otomycosis? Pruritus
44 Itching in ear, pain + wet tissue paper like material in external ear. Diagnosis? Otomycosis
45 Itching in ear, musty odor discharge + white cheesy material in auditory canal. Otomycosis (candidal)
Diagnosis?
46 Investigation of choice for Necrotizing otitis externa? Gallium-67
47 Wax composition: Sebaceous + Ceruminous +
Keratin + Desquamated epi.
48 Impacted wax causes reflex cough through stimulation of which nerve? Auricular branch of vagus nerve
49 Saline temperature used in Syringing should be equal to body temperature. Too cold or Vertigo through stimulation of
hot saline may cause _____ Labyrinth
50 Syringe during Syringing procedure should be directed along the: Posterosuperior wall of meatus
51 What procedure should be performed for removing wax if TM is perforated? Suction
Syringing is contraindicated
52 Treatment for traumatic TM rupture? Wait and watch or Splintage

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53 What should be the approach for removal of impacted foreign bodies in deep meatus, Post-aural approach
medial to the isthmus?
54 A patient presented in ENT clinic with irritation and bad smell discharge from right Aural toilet & Anti-fungal
ear, on examination a Black headed filamentous growth in ear canal, How will you
treat her?:
55 Malignant otitis externa is an invasive infection of the external canal usually seen in Pseudomonas
diabetic patients. Which microorganism is responsible:
A. Staph aureus
B. Pn um oœus
C. Hemophlus influnzae
D. Pseudomonas
E. Bacteroides
56 A patient developed severe vertigo during ear syringing. Which mistake has been A
committed by the doctor?
a) Too cold water has been used
b) Too much force has been used
c) Water at body temperature has been used
d) Poor technique has been used
e) Water has been directed on ear drum
57 A patient had common cold which was followed by severe bilateral otalgia with Otitis externa haemorrhagica
vertigo. Later there was blood stained watery discharge from both ears. What is the
likely cause:
a) Acute otitis media
b) Drum perforation
c) Chronic otitis media
d) Eczematous otitis externa
e) Otitis externa haemorrhagica
58 An old lady complains of severe earache for last three weeks. On examination she had Pseudomonas
granulation along floor of the ear canal. Her random blood sugar is 450 mg%. Which
organism is responsible for her condition?
a) Streptococci
b) Pseudomonas
c) E. coil
d) Klebsiella
e) Staphylococci
59 An old lady complains of blocked ear. On examination a whitish material was noted in Keratosis obturans
deep part of external auditory meatus which was very difficult to remove by suction
and it also became very painful. The likely diagnosis is:
a) Otomycosis
b) Maggot
c) Cholesteatoma
d) Keratosis obturans
e) Foreign body
60 Syringing the ear in an attempt to remove the wax in patient with heart disease can Cardiac arrest
result in'a serjous complication in the form of:
a) Cardiac arrest
b) Bleeding from ear
c) Total deafness
d) Vertigo
e) Tinnitus
61 A young adult male presents with severe pain in his right car and serosanguincous Myringitis bullosa haemorrhagica
discharge. Otoscopy shows crops of haemorrhagic Indlas on the surface of tympanic
membrane and deep in External Auditory Meatus (EAM). This clinical picture is

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consistent with:
a) Acute Otitis media
b) Acute Otitis externa
c) Ramsay Hunt syndrome
d) Herpes zoster oticus
e) Myringitis bullosa haemorrhagica
62 A female was slapped on left side of face by her husband. Ear examination shows C
central perforation. What instruction will you give to the patient?
a) Immediate pure tone audiometry.
b) Daily cleaning of ear canal with cotton bud
c) Do not instill any drops of medicine in the effected ear
d) Take bath daily
e) To have x-ray mastoid
Chapter 10 – Disorders of Middle Ear
63 A 12 years boy presents with her mother with complaint of severe earache and 103°F ASOM
fever. TM is badly congested. Diagnosis?
64 A school going child present with severe earache and throat pain Diagnosis? ASOM due to tonsillitis
65 A 35 years male presented with hearing problem and mild earache. Otoscopy on SOM
valsalva shows air bubbles on TM. Diagnosis?
66 A boy presents with his mother. Mother said that her child sleep with open mouth and SOM due to adenoid hyperplasia
watch TV with high volume. Diagnosis?
67 When does myringotomy is usually performed in case of ASOM? After 3 months
68 A six year old child is diagnosed suffering from acute otitis media. He is not Posteroinferior quadrant
improving inspite of adequate medical treatment. Where will you do the
Myringotomy?
a) Posteroinferior part
b) In the centre
c) Attic
d) Along the annulus
e) Anteroinferior part
69 Site of incision while performing myringotomy in SOM? Anteroinferior quadrant
70 What is the treatment of SOM due to adenoid hyperplasia? Adenoidectomy + Myringotomy ±
Grommet tube
71 Treatment of choice for SOM? Myringotomy
72 A 10 years old girl presented with complain of hearing loss. TM is pale. There is SOM
sickling of malleal folds of TM. Handle of malleus appears foreshortened. Diagnosis?
73 Antibiotics were prescribed for ASOM. Patient presents again after one week with no Wait for 3 months, if discharge
response to antibiotics. What is the appropriate action now? persists, myringotomy should be
done.
74 What is the treatment for perforation in ASOM? It spontaneously resolves
75 Gold standard test for SOM? Impedance audiometry
76 Site of perforation in Pars Tensa in ASOM? Anteroinferior Quadrant
77 Most common bacteria causing ASOM in infants? Streptococcus pneumoniae
78 A patient presents with earache. On examination Cartwheel appearance of tympanic Broad spectrum antibiotics
membrane is found how will you treat this
79 Which of the following is a common causative organism of ASOM? Strep. Pneumonae
80 A 20 years old boy had running nose followed by severe earache. One day later he had Acute suppurative otitis media
mucopuralent discharge from ear. Diagnosis is:
A. Malignant otitis externa
B. Acute suppurative otitis media
C. Myringitis Bullosa

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D. Eustachean catarrh
E. Barotrauma
81 A boy suffering from ASM. His symptoms are not settled inspite of adequate medical Myringotomy
treatment, T.M is bulging. Tretment is:
A. Mastoidectomy
B. Topical lignocaine drops
C. Analgesics
D. Myringotomy
E. Aspiration
82 Otitis Media with effusion (OME) is common problem encountered in children. Which Tympanometry
one is the objective test that helps in diagnosis:
A. Pure tone audiometry
B. Otoacoustic emission
C. Tympanometry
D. Otoscopy
E. EOM
Chapter 11 – Cholesteatoma and Chronic Otitis Media
83 A 25 year male presents with aural mass and ear discharge. He also complains of Atticoantral polyps
vertigo. Diagnosis?
84 Which bone/part of bone is most commonly eroded in CSOM? Long process of incus
85 Treatment of choice for Atticoantral polyp? Canal wall down procedure
(Radical mastoidectomy or Modified
radical mastoidectomy)
86 Most acceptable theory for cholesteatoma? Wittmaack's theory
87 Most commonly cholesteatoma arises as a retraction pocket from __? Pars Flacida (Attic)
88 Multiple perforations of TM + Painless foul smelly discharge. What is the diagnosis? Tubercular otitis media
89 Treatment of antrochonal polyp: Surgery
A. Surgery
B. Immunotherapy
C. Anti-histamine
D. Topical steroids
E. Systemic steroids
90 C.T. scan of a patient of CSOM shows extensive cholesteatomo with erosion of Radical mastoidectomy
ossicular chain. Which surgery should be planned:
A. Cortical Mastoidectomy
B. Atticotomy
C. Tympanoplasty
D. Radical mastoidectomy
E. Posterior tympanotomy
91 A young boy has developed Bezold's abscess as a complication of acute suppurative Posterior belly of digastric muscle
otitis media. The pus in this case accumulates along which muscle?
a) Posterior belly of digastric muscle
b) Zygomaticus major muscle
c) Anterior border of trapezeous muscle
d) Temporalis muscle
e) Sternormastoid muscle
Chapter 12 – Complications of Suppurative Otitis Media
92 Painful swelling behind the ear and pinna is moved forward and downward + Mucu- A. Mastoiditis ✓
purulent discharge? B. Frunculosis
93 Swelling behind ear and pinna is pushed forward with obliteration of retro-auricular Frunculosis
groove. Pinna is tender to touch. Diagnosis?
94 Treatment for mastoiditis? Antibiotics + Myringotomy

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95 A 14 years boy presented with earache and high-grade fever. Otoscopy showed TM Mastoiditis
perforation, nipple like protrusion and pulsatile ear discharge. Mastoid x ray showed
cloudiness. Diagnosis?
96 A 15 years boy presented with earache and high-grade fever. Otoscopy shows ASOM
anteroinferior perforation of TM and nipple like protrusion. TM is badly congested.
Diagnosis?
97 Most common site of Bezold abscess? Beneath Sternocleidomastoid
98 Most ommon s t o C t ll ‘s bs ss? Posterior belly of digastric
99 Gradinego syndrome is usually seen in ____? Petrositis
100 Which nerves are affected in Gradinego syndrome? V and VI
101 Swelling of posterior part of mastoid + CT scan showed delta sign. Diagnosis? Sigmoid sinus thrombosis
(Gresinger sign + Delta sign +
Malaria like picture)
102 Tobey Ayer test is performed in: Sigmoid sinus thrombosis
103 Chronic supporative otitis media mostly affects which of the following ear bone? Long process of incus
104 A patient is having ear discharge for 10 years. Now he has developed severe pain. CT scan
There is suspicious of intra cranial complication, investigation of choice is:
A. Blood CIP
B. X-ray mastoid
C. C.T scan
D. PTA
E. Lumbar puncture
105 A patient has discharging ear for last 06 years. Now he developed severe headache and Extradural abscess
vomiting. What is the commonest intracranial complications of CSOM:
A. Subdural abscess
B. Extradural abscess
C. Meningitis
D. Brain abscess
E. Lateral sinus thrombosis
Chapter 13 – Otosclerosis
106 Most common site of otosclerosis? Fissula ante fenestrum
107 Treatment of choice for otosclerosis? Stapedectomy
108 A dip at 2000 Hz on PTA is indicative of : Otosclerosis
109 A female presents with complain of progressively increasing conductive hearing loss. Otosclerosis
A reddish hue is seen on promontory through TM. What is the diagnosis?
110 The patient had stapedectomy operation for otosclerosis. She complains of fluctuating Long prosthesis
hearing loss and vertigo. The reason for this is:
a) Long prosthesis
b) Short prosthesis
c) Infection
d) Hematoma
e) Granuloma
111 Van der Hoeve Syndrome is a triad of _______? Blue sclera, Otosclerosis,
Osteogenesis imperfect
112 Paracusis Willisii is a characteristic of which disease? Otosclerosis
113 A patient who reports improved hearing in noisy environments may be experiencing Stapedectomy with prosthesis
conductive hearing loss due to stapes dysfunction. In such cases which treatment implant
option is recommended?,
114 C rh rt‘s not h n p t nt o otos l ros s s usu lly pr s nt t: 2 kHz
115 A 20 years old air hostess develops progressive hearing loss. PTA shows conductive D
hearing loss with dip at 2 KHz in bone conduction. Which option is best:
A. To wear hearing aid

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B. No treatment
C. To use neurotonics
D. To undergo stapedectomy
E. Tympanoplasty
116 A young married lady complains of hearing difficulty. She also told that her symptom Carhart's notch
got worse during pregnancy. Otoscopy revealed reddish hue on ear drums. What
finding on PTA will be diagnostic?
a) Conductive hearing loss
b) Mixed hearing loss
c) Carhart's notch
d) A dip at higher frequencies
e) Low frequency mixed hearing loss
Chapter 14 – Facial Nerve
117 Shortest segment of Intratemporal part of facial nerve? Labyrinthine segment
118 Which segment of Intratemporal part of facial nerve has vertical course? Mastoid segment
119 Which segment of Intratemporal part of facial nerve starts at level of 2nd genu? Mastoid segment
120 Loss of lacrimation + Loss of stapedial reflex + Loss of taste from anterior tongue. First genu
What is the site of VII nerve lesion?
121 Facial palsy on left side below the eye and area above eyes on left side is spared. What Right cortex
is the site of lesion?
122 Which nerve of facial nerve arise at level of 2nd genu? Nerve to stapedius
123 Risk of injury to which part of facial nerve in Cortical mastoidectomy? Mastoid/Vertical segment
124 Type of temporal bone fracture that leads to sensory neural hearing loss? Transverse fracture
125 Treatment of transverse temporal bone fracture? Nerve decompression
126 Fracture of temporal bone causes Sensorineural hearing loss. Which structure of ear Cochlea
damaged in such fracture?
127 Longitudinal fracture of temporal bone  Hemotympanum  conductive hearing loss No longer conductive hearing loss
 hemotympanum resolve ?
128 Facial nerve palsy along with vesicular rash in external auditory canal and pinna. Ramsay Hunt Operation
Diagnosis?
129 A diabetic patient presents with severe right-sided facial pain and facial weakness. B
What is the most appropriate initial treatment?
A. Oral antibiotics
B. Corticosteroids
C. Antiviral medication
D. Surgery
130 A patient presented with severe pain in the ear and facial nerve palsy. Examination Herpes zoster oticus
shows vesicles on pinna and in the ear canal. Diagnosis is:
Chapter 15 – Meniere's Disease
131 The first symptom of Meniere' disease? Vertigo
132 Noise induced vertigo is known as: Tullio phenomenon
133 A female teacher presented with complaint of multiple episodes of noise induced Meniere' disease
vertigo and distorted music sound. Diagnosis?
134 In which disease, recruitment phenomenon is positive? Meniere' disease (cochlear
pathology)
135 A 60 year old woman experiences recurrent episodes of vertigo, lasting for variables Electrocochleography
duration associated with tinnitus and hearing loss. To confirm it as a case of Meniere's
disease which of the following austiological test provide significantly reliable
information:
a) Electrocochleography
b) Auditory evoked response audiometery
c) Pure tone audiometery

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d) Tympanometery
c) Dekusy's audiometery
136 In Cochlear hydrops, what is the site of obstruction? Ductus reunion
137 Drop Attacks seen in which disease? Meniere' disease
138 Drug of choice for Meniere' disease? Betahistine
Chapter 17 – Tumors of Middle Ear and Mastoid
139 A 49 years male presented with slowly progressive hearing loss. Otoscopy showed Glomus tumor (Glomus
rising sun appearance with tumor arising from promontory of middle ear. Diagnosis? tympanicum)
140 Brown sign is indicative of _____? Glomus tumor

֍PRACTICE MCQs֍

01. Hearing Loss

1. An 85-year-old male presents with a history of progressive hearing loss for the last one year. There is no history of ear discharge.
On examination, both tympanic membranes appear normal. Pure tone audiometry (PTA) shows a downward-sloping hearing threshold
with preservation of word recognition. What is the most likely diagnosis?
A. Otosclerosis D. Chronic otitis media
B. Ménière disease E. Acoustic neuroma
C. Presbycusis
2. A 75-year-old teacher presents with progressive hearing loss. There is no history of earache, ear discharge, ototoxic drug intake, or
trauma to the ear. What is the most likely diagnosis?
A. Otosclerosis D. Acoustic neuroma
B. Presbycusis E. Ménière disease
C. Chronic suppurative otitis media
3. A 55-year-old factory worker presents to the ENT outpatient department with gradual decrease in hearing in both ears for the last
six months. He also complains of disturbing sounds in both ears, especially at night, and difficulty in communication during daily
activities. What type of hearing loss is this patient most likely suffering from?
A. Conductive hearing loss D. Presbycusis
B. Sudden sensorineural hearing loss E. Ménière disease
C. Noise-induced hearing loss
4. A 47 year old man has difficulty hearing on his right ear. Air conduction (AC) is better than bone conduction in both ears. The
soun w s lo l s tow r s th l t s on W b r‘s t st. Wh t s th SING E most l k ly nos s?
A. Right sensorineural deafness D. Left conductive deafness
B. Left sensorineural deafness E. Bilateral sensorineural deafness
C. Right conductive deafness
5. A 2 year old child is brought by his mother. The mother had hearing impairment in her early childhood and is now concerned about
the child having a similar condition. What is the SINGLE best investigation to be done for the child?
A. Conditioned response audiometry D. Tuning fork
B. Distraction testing E. Otoacoustic emissions
C. Scratch test
6. Which of the following drugs is well known to cause ototoxicity?
A. Amoxicillin D. Metformin
B. Gentamicin E. Propranolol
C. Paracetamol
7. Which of the following drugs is most commonly associated with reversible ototoxic hearing loss?
A. Quinine D. Tobramycin
B. Cisplatin E. Amikacin
C. Streptomycin
8. A 78-year-old man complains of difficultly following conversations. His wife says he has the TV turned up too loud. Audiometry
shows sensorineural hearing loss at the higher frequencies. What can be the diagnosis?
A. Presbycusis B. Acoustic Neuroma

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C. M n r ‘s s s E. Otosclerosis
D. Drug induced hearing loss

ANSWER KEY
1. C 2. B 3. C 4. A 5. E 6. B 7. A 8. A 9. 10.

6. Drugs that can lead to ototoxicity

1. Amino-glycosides (Streptomycin, Gentamycin)
2. Salicylates (Aspirin)
3. Anti-malarial (Quinine, Chloroquine)
4. Loop Diuretics (Ethacrynic acid, Furosemide)
7. Drugs which can cause reversible hearing loss
1. Quinine
2. Chloroquine
3. Furosemide
4. Ethacrynic acid
5. Salicylates

02. Disorders of Vestibular System

1. A 49-year-old woman presents with multiple episodes of brief vertigo lasting a few seconds when she turns toward the right side in
bed. The vertigo is associated with nausea, but there is no hearing loss, tinnitus, ear pain, or ear discharge. What is the most likely
diagnosis?
A. Ménière disease D. Labyrinthitis
B. Vestibular neuronitis E. Acoustic neuroma
C. Benign paroxysmal positional vertigo
2. A 59-year-old man presents with recurrent attacks of vertigo and dizziness. These attacks are often precipitated by a change in head
position and typically last around half a minute. Examination of the cranial nerves and ears is unremarkable. His blood pressure is
120/78 mmHg sitting and 116/76 mmHg standing. Given the likely underlying disorder, what is the most appropriate next step to help
confirm the diagnosis?
A. Rinne test D. Pure tone audiometry
B. Epl y‘s m n uv r E. Tympanometry
C. Dix–Hallpike maneuver
3. A 25 year old man presents with a four day history of anorexia, feverishness and vertigo. He has had intermittent difficulty
balancing and staying upright when walking and has had episodes of mild vertigo lasting 10-20 minutes at a time. His hearing is
unimpaired. On examination he has some cervical lymphadenopathy. Examination is otherwise unremarkable. What is the likely
diagnosis?
A. Mén èr ‘s s s D. Vestibular neuronitis
B. Benign Paroxysmal Positional Vertigo E. Viral labyrinthitis
C. Otitis media
4. A 30 year old woman presents with sudden onset of severe vertigo. She has a 4 week history of intermittent dizziness. These
episodes typically occur when she suddenly moves her head or roles in bed and are characterised by the sensation that the room is
'spinning'. Most attacks last a few seconds. Neurological examination is unremarkable. What is the SINGLE most likely diagnosis?
A. Benign paroxysmal positional vertigo D. Psychogenic vertigo
B. Meniere disease E. Viral labyrinthitis
C. Postural hypotension
5. A 45 year old woman presents with rotational vertigo, nausea and vomiting which is worst when moving her head. She also had a
similar episode 2 years ago. These episodes typically follow an event of runny nose, cough and fever. What is the SINGLE most likely
diagnosis?
A. Acoustic neuroma D. Benign paroxysmal positional vertigo
B. Meniere's disease E. Vestibular neuritis
C. Labyrinthitis

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6. A 52 year old patient is complaining of vertigo whenever she moves sideways on the bed while lying supine. She would feel as if
the room is spinning and she would feel nauseous. This goes away after a few minutes but returns when she moves her head. What is
the SINGLE most appropriate next step in management?
A. Hallpike's Manoeuvre D. Carotid Doppler
B. Reassure E. CT head
C. Advice on posture
7. A 33 year old tennis player has to stop playing tennis competitively because she has recurrent vertigo attacks every time she plays
tennis. The vertigo attacks started after a history of runny nose, cough and fever. Her hearing is not affected. What is the SINGLE
most likely diagnosis?
A. Acoustic neuroma C. Benign paroxysmal positional vertigo
D. Meniere's disease E. Vestibular neuritis
B. Labyrinthitis
8. A 25 years old male patient, presented to ENT OPD with vertigo which is sudden in onset & lasts for 20 to 30 seconds. Vertigo is
position related. What is your diagnosis?
A. Benign paroxysmal position vertigo D. Vertebrobasilar insufficiency
B. Perilymph fistula E. Vestibular neuritis
C. Meniere‘s s s
ANSWER KEY
1. C 2. C 3. D 4. A 5. E 6. A 7. E 8. A 9. 10.

3. Vestibular neuronitis may be preceded by viral symptoms. Vestibular neuronitis is associated with spontaneous onset vertigo and
imbalance often associated with nausea and vomiting. Unlike labyrinthitis it does not cause tinnitus or hearing loss.

03. Diseases of External Ear

1. A 36-year-old male presents with a painless swelling on the right ear for the last two days. He gives a history of trauma to the ear
while playing football. On examination, there is a slightly compressible swelling affecting the concha measuring about 10 × 5 mm.
What is the most likely diagnosis?
A. Perichondritis D. Otitis externa
B. Auricular hematoma E. Keloid of auricle
C. Sebaceous cyst of ear
2. If auricular hematoma is not treated in time, which of the following ear deformities may develop?
A. Bat ear deformity D. Lop ear deformity
B. Cauliflower ear E. Preauricular sinus
C. Microtia
3. A 28-year-old male presents with severe right earache for 2 days, associated with decreased hearing, swelling around the ear, and
purulent discharge. On examination, there is marked tragal tenderness and soft fluctuant swelling along the floor of the external
auditory canal. The tympanic membrane cannot be visualized. What is the most likely diagnosis?
A. Otomycosis D. Impacted ear wax
B. Furuncle of external auditory canal E. Acute mastoiditis
C. Acute otitis media
4. A 50-year-old diabetic male complains of severe ear pain. On examination, the pinna is protruding outward and is very
tender on pulling. Otoscopy cannot be performed due to severe pain. Which organism is most commonly responsible for
this condition?
A. Streptococcus pneumoniae D. Haemophilus influenzae
B. Staphylococcus aureus E. Proteus mirabilis
C. Pseudomonas aeruginosa
5. A young male presents with severe ear pain and decreased hearing in the right ear that worsens with movement of the jaw. He also
complains of a burning sensation in the ear and gives a history of swimming two days ago. Examination shows redness and swelling
of the external auditory canal with thick discharge. What is the most likely diagnosis?
A. Otomycosis D. Cholesteatoma
B. Acute localized otitis externa (furuncle) E. Impacted wax
C. Acute otitis media

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6. A 35-year-old male presents with unilateral ear pain and fullness in the ear. On examination, the tympanic membrane is not visible
and is masked by white cheesy material. What is the most likely diagnosis?
A. Cholesteatoma D. Ear wax impaction
B. Otomycosis E. Furuncle
C. Otitis media
7. A 40-year-old swimmer presents with itching and watery discharge from the ear for 5 months. Ear examination shows black spores
with filamentous masses in the ear canal. What is the most likely diagnosis?
A. Bacterial otitis externa D. Frunculosis
B. Otomycosis due to Aspergillus niger E. Impacted wax
C. Otomycosis due to Aspergillus fumigatus
8. A 16-year-old boy presents in winter with nasal obstruction, sneezing, rhinorrhea, and ear pain. There is blood-stained clear
discharge from the ear. After cleaning the ear canal, bluish blebs are seen on the tympanic membrane. What is the most likely
diagnosis?
A. Acute otitis media D. Otomycosis
B. Otitis externa E. Cholesteatoma
C. Bullous myringitis
9. Which of the following organisms is most commonly responsible for bullous myringitis?
A. Streptococcus pneumoniae D. Staphylococcus aureus
B. Influenza virus E. Klebsiella pneumoniae
C. Pseudomonas aeruginosa
10. A diabetic patient presents with severe ear pain and granulation tissue in the external auditory canal on examination. What is the
most likely diagnosis?
A. Furuncle D. Otomycosis
B. Acute otitis media E. Bullous myringitis
C. Malignant otitis externa
11. A 60-year-old diabetic female presents with rapidly worsening ear pain, swollen external auditory canal, conductive hearing loss,
and recent facial nerve palsy. What is the most probable diagnosis?
A. Acute otitis media D. Cholesteatoma
B. Otomycosis E. Mastoiditis
C. Malignant otitis externa
12. During ear wax removal, a patient suddenly develops cough and the procedure is stopped. Which nerve is responsible for this
reflex?
A. Facial nerve D. Trigeminal nerve
B. Glossopharyngeal nerve E. Hypoglossal nerve
C. Vagus nerve (auricular branch)
13. A 25-year-old woman was slapped on the face and immediately developed severe ear pain with a few drops of blood from the
external auditory canal. What is the most likely diagnosis?
A. Acute otitis media D. Mastoiditis
B. Rupture of tympanic membrane E. Bullous myringitis
C. Otitis externa
14. A 15 year old boy injured his right ear during a rugby match. He reports pain around the right pinna. On examination, the pinna of
the right ear is red and tender. The tympanic membrane was found to be normal. What is the SINGLE most appropriate next step?
A. Topical gentamicin D. Refer to ENT specialist
B. Oral flucloxacillin E. No further intervention needed
C. Intravenous flucloxacillin
15. A 33 year old man comes to the clinic complaining of hearing loss in one ear. There is no earache, fever, vertigo or tinnitus. On
inspection, a buildup of earwax is observed. What is the SINGLE most appropriate initial management?
A. Olive oil ear drops D. Advise to keep ear dry
B. ear irrigation E. Removal by cotton bud
C. Refer to an ENT specialist for removal of wax
16. An 8 year old boy who has recently returned from Spain complains of severe pain in one ear. On examination, pus is seen in the
auditory canal. The tympanic membrane looks normal. What is the SINGLE most appropriate treatment?
A. Topical gentamicin B. Amoxicillin PO

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C. Analgesia E. Microsuction
D. Amoxicillin IV
17. A 30 year old man was camping and an insect got stuck in his ear which he has been unable to remove. He complains that he can
still hear the buzzing in the ear. On inspection, the insect is clearly visible in the ear canal. What is the SINGLE most appropriate
initial management?
A. 2% lidocaine D. Reassure
B. Ear irrigation E. Removal by cotton bud
C. Refer to an ENT specialist
18. A mentally retarded 8 year old child puts a green pea in his ear while eating. Otoscopy shows a green coloured object in the ear
canal. What is the SINGLE most appropriate approach to remove the green pea?
A. By magnet D. By hook
B. Syringing E. By instilling olive oil
C. Removal under general anaesthesia
19. A 6 year old boy was was playing in the playground when he stuck a seed into his ear. He has been unable to remove it. On
inspection, the seed is clearly visible in the ear canal. What is the SINGLE most appropriate management?
A. 2% lidocaine D. Suction with a small catheter
B. Ear irrigation E. Removal by cotton bud
C. Refer to an ENT specialist
20. 6 year old boy was was playing at home alone when he stuck super glue into his ear. His mother has brought him to A&E and is
extremely concerned. On inspection, the adhesive is in contact with the tympanic membrane. What is the SINGLE most appropriate
management?
A. Reassure D. Suction with a small catheter
B. Ear irrigation E. Manual removal immediately
C. Refer to an ENT specialist
21. A 6 year old down syndrome boy was was playing at home alone when he stuck a small piece of toy into his ear. His mother has
brought him to a GP clinic and is extremely concerned. On inspection, a small foreign object is visible. The child is uncooperative and
does not understand why his mother has brought him here. What is the SINGLE most appropriate management?
A. Olive oil ear drops D. Suction with a small catheter
B. Ear irrigation E. Manual removal immediately using forceps
C. Refer to an ENT specialist
22. A 27 year old man had a fly enter his ear. He is anxious to get the fly removed. What is the SINGLE best method for removal of
the fly from his ear?
A. Removal with forceps D. Instill alcohol ear drops
B. Removal under general anaesthesia E. Syringe his ear with normal saline
C. Instill mineral oil into his ear
23. A 52 year old male with poorly controlled diabetes mellitus presents to his GP with severe pain in the ear and an intense headache.
On examination, his skin around the ear is black in colour and there is a foul smelling discharge coming from the ear. He is also noted
to have conductive hearing loss. What is the SINGLE most likely diagnosis?
A. Carbuncle D. Cholesteatoma
B. Folliculitis E. Furuncle
C. Malignant otitis externa
24. A 2-year-old child has inserted a piece of plastic into his ear and is irritable. What is the best management?
A. Removal under local anesthesia D. Removal by suction
B. Removal with metallic foreign body hook E. Removal under general anesthesia with microscope
C. Delay removal for one week
25. Malignant otitis externa is commonly seen in diabetics. Which organism is most commonly responsible?
A. Staphylococcus aureus D. Pseudomonas aeruginosa
B. Pneumococcus E. Bacteroides
C. Haemophilus influenzae
26. A female sustains trauma to the ear with central perforation of tympanic membrane. What advice should be given?
A. X-ray mastoid D. Do not instill any ear drops
B. Immediate audiometry E. Take bath daily
C. Clean ear with cotton buds daily

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27. A 15 year old boy injured his right ear during a rugby match. He reports pain around the right pinna. On examination, the pinna of
the right ear is red and tender. The tympanic membrane was found to be normal. What is the SINGLE most appropriate next step?
A. Topical gentamicin D. Refer to ENT specialist
B. Oral flucloxacillin E. No further intervention needed
C. Intravenous flucloxacillin

ANSWER KEY
1. B 2. B 3. B 4. B 5. B 6. B 7. B 8. C 9. B 10. C
11. C 12. C 13. B 14. E 15. A 16. A 17. A 18. D 19. D 20. C
21. C 22. C 23. C 24. E 25. D 26. D 27. E 28. 29. 30.
7. Otomycosis
 Black-headed growth  Aspergillus Niger Infection
 Pale blue / green mass  Aspergillus Fumigatus Infection
 White cheesy / creamy deposits  Candidal Infection
15. Ear wax softening drops are the first thing to try for a buildup of earwax. Prescribe ear drops for 3–5 days initially, to soften wax
and aid removal. Sodium bicarbonate 5%, sodium chloride 0.9%, olive oil, or almond oil drops can be used If symptoms persist,
consider ear irrigation
22. Always kill insect first before attempting removal to avoid trauma, after oil suck or remove with forceps.
27. No further intervention is needed as the tympanic membrane is normal. This is a transient inflammation of the pinna from an
injury during a hit in a rugby match. It is self limiting and of no worry.

04. Diseases of Middle Ear

1. An 8-year-old boy develops fever, ear pain, and deafness in the left ear following an episode of acute coryza. On examination, the
tympanic membrane is congested and bulging outward. Weber test lateralizes to the left ear. His temperature is 103°F and WBC count
is 18,000/mm³. What is the most probable diagnosis?
A. Serous otitis media D. Cholesteatoma
B. Acute suppurative otitis media E. Mastoiditis
C. Otitis externa
2. A 23-month-old female child presents with 2 days history of rhinorrhea and 1 day history of fever (101.5°F), irritability, and ear
tugging. On examination, the tympanic membrane is congested. What is the most likely diagnosis?
A. Otitis externa D. Mastoiditis
B. Acute suppurative otitis media E. Impacted wax
C. Serous otitis media
3. A 4-year-old girl presents with recurrent earache, hearing loss, and sore throat. Otoscopic examination reveals an intact but dull
tympanic membrane with loss of normal landmarks. What is the most likely diagnosis?
A. Acute otitis media D. Cholesteatoma
B. Otitis externa E. Mastoiditis
C. Serous otitis media
4. Which of the following investigations is considered the gold standard to confirm serous otitis media?
A. Pure tone audiometry D. X-ray mastoid
B. CT scan of temporal bone E. MRI temporal bone
C. Impedance audiometry (tympanometry)
5. A 6-year-old girl is brought for hearing evaluation. There is no ear pain or discharge, but she has mouth breathing and snoring at
night. Otoscopy shows a dull bluish tympanic membrane and Rinne test is negative bilaterally. What is the most likely diagnosis?
A. Otitis externa D. Cholesteatoma
B. Acute otitis media E. Impacted ear wax
C. SOM due to adenoid hypertrophy
6. Best investigation for Otitis Media with Effusion (OME):
A. Pure tone audiometry D. Otoscopy
B. Otoacoustic emission E. EOM
C. Tympanometry

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7. A patient develops ear pain followed by mucopurulent discharge after an upper respiratory infection. What is the diagnosis?
A. Malignant otitis externa D. Barotrauma
B. Acute suppurative otitis media E. Myringitis bullosa
C. Eustachian catarrh
8. A 9 year old girl has been referred for assessment of hearing as she is finding difficulty in hearing her teacher in the class. Her
hearing tests show that bone conduction is normal and symmetrical air conduction threshold is reduced bilaterally. Weber test does not
lateralize. What is the SINGLE most likely diagnosis?
A. Perforation of tympanic membrane D. Otosclerosis
B. Otitis media with effusion E. Presbycusis
C. Congenital sensorineural deficit
9. A 7 year old boy is brought to clinic by his mother. His mother complains that he has been getting in trouble in school because he is
inattentive in class. The mother also mentions that he sits close to the television at home. These problems have been going on for more
than 12 months. There is no pain or fever. A tympanogram highlights conductive hearing loss at 30-dB. What is the SINGLE most
appropriate management?
A. Grommet insertion D. Adenoidectomy
B. Reassure and review in 3 months E. Refer to child psychologist
C. Hearing aids
10. A 7 year old boy is brought to clinic by his mother. She says that he is always turning up the TV volume and she has to shout to
get his attention. There has been recurrent ear infections in the past which was resolved by medication. On examination: a bulging
drum is noticed. There is no pain or fever. What is the SINGLE most appropriate management?
A. Grommet insertion D. Adenoidectomy
B. Reassure and review in 3 months E. Antibiotics
C. Hearing aids
11. A 10 year old boy presents to clinic with poor grades in school and difficulty in hearing. There has been recurrent ear infections in
the past which was resolved by medication. On examination: bone conduction is normal, air conduction is reduced bilaterally, and
there is no lateralization in the Weber's test. There is no pain. What is the SINGLE most likely diagnosis?
A. Acute otitis media D. Congenital sensorineural deficit
B. Perforation of tympanic membrane E. Otosclerosis
C. Otitis media with effusion
12. A 5 year old girl has had an upper respiratory tract infection for 3 days and has been treated with paracetamol by her mother. In the
last 12 hours, she has been irritable and with severe pain in her right ear. She has a temperature of 38.3°C. What is the SINGLE most
likely diagnosis?
A. Herpes zoster infection D. Acute otitis media
B. Impacted ear wax E. Perforation of eardrum
C. Mumps
13. A 37 year old man presents to your clinic with otalgia. He was seen in the emergency department 2 days previously but was
discharged with advice only. He has now had otalgia for 5 days. On examination, he has a temperature of 38.5ºC, and he has a red
bulging ear drum on the right. How should you manage this gentleman?
A. Advise on regular paracetamol and return if no better D. Start amoxicillin
B. Start erythromycin E. Grommet insertion
C. Start penicillin V

ANSWER KEY
1. B 2. B 3. C 4. C 5. C 6. C 7. B 8. B 9. A 10. B
11. C 12. D 13. D 14. 15. 16. 17. 18. 19. 20.

8. Otitis media with effusion (OME), also known as glue ear. This is the most common cause of acquired conductive hearing loss in
school-aged children, often resulting in bilateral symmetrical hearing loss due to fluid accumulation in the middle ear without acute
pain.
9-10. 1st line treatment is wait for 3 months, if it is persistant for >3 months than insert grommet.
13. This is a case of otitis media. Although 50% of these cases are viral, and 60% improve without antibiotics, guidelines would
advocate treatment after a delay of 2-3 days if there is no improvement in symptoms. Especially in this case, where the gentleman has
a temperature and therefore evidence of systemic involvement. Therefore, advising regular paracetamol is not correct in this case.

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05. Cholesteatoma and Chronic Otitis Media

1. A patient with chronic ear discharge for 6 years develops severe headache and vomiting. What is the most common intracranial
complication of CSOM?
A. Subdural abscess D. Brain abscess
B. Extradural abscess E. Lateral sinus thrombosis
C. Meningitis
2. A 41 years old man presents with long standing foul smelling brown ear discharge and progressive hearing loss of his right ear. The
discharge has persisted despite three courses of antibiotic ear drops. Otoscopy shows perforation of the pars flaccida. A pearly white
soft matter is seen at the posterior margin of the perforation. What is the SINGLE most likely diagnosis?
A. ASOM D. Congenital cholesteatoma
B. CSOM E. Barotrauma
C. Acquired cholesteatoma
3. A 6 year old girl has a left earache for 4 days. The earache then subsided 2 hours ago with the onset of a purulent discharge which
relieved the pain. Her temperature is 39.2°C. What is the SINGLE most appropriate antibiotic to prescribe?
A. Amoxicillin D. Erythromycin
B. Ciprofloxacin E. Vancomycin
C. Clindamycin
4. A 40-year-old male with a long-standing history of left-sided ear discharge presents with severe headache, vomiting, and neck
stiffness for the last two days. His white blood cell count is 14,000/mm³, and he is unable to bend his neck without pain. What is the
most likely diagnosis?
A. Brain abscess D. Mastoiditis
B. Lateral sinus thrombosis E. Labyrinthitis
C. Meningitis
5. A 9-year-old boy is brought to the ENT emergency department with sudden onset fever and neck pain. Examination reveals
torticollis and a tender swelling behind the mandible. He also has a history of chronic ear discharge since childhood. What is the most
probable diagnosis?
A. Mastoiditis D. Parotid abscess
B. Bezold abscess E. Cervical lymphadenitis
C. Retropharyngeal abscess
6. A 25-year-old male presents with unilateral ear blockage and intermittent ear discharge. On examination, there is an aural mass, and
he gives a history of ear surgery six years ago. What is the most likely diagnosis?
A. Otomycosis D. Otitis externa
B. Acute otitis media E. Mastoiditis
C. CSOM (tubotympanic type)
7. A 25-year-old male presents with chronic foul-smelling ear discharge for three years. On examination, a posterosuperior attic
perforation is seen. What is the most likely diagnosis?
A. Acute otitis media D. Otitis externa
B. Serous otitis media E. CSOM (tubotympanic type)
C. CSOM (atticoantral type)
8. A middle-aged man presents with ear discharge and hearing impairment for three years. He occasionally experiences short episodes
of vertigo. Otoscopy reveals a smooth surface mass in the external auditory canal and pure tone audiometry shows mixed hearing loss.
What is the most likely provisional diagnosis?
A. Acute otitis media D. Otitis externa
B. Serous otitis media E. CSOM (tubotympanic type)
C. CSOM (atticoantral type)
9. A 9-year-old child presents with recurrent bilateral ear discharge for two years despite repeated antimicrobial therapy. Examination
shows profuse mucopurulent discharge with central perforation of tympanic membrane in both ears. What is the most likely
diagnosis?
A. Otitis externa D. Cholesteatoma
B. Acute otitis media E. CSOM (atticoantral type)
C. CSOM (tubotympanic type)

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10. A middle-aged man presents with chronic unilateral ear discharge for two years that has not responded to treatment. Otoscopic
examination reveals attic perforation with granulation tissue and foul-smelling scanty discharge. What pathology should be suspected?
A. Acute otitis media D. Cholesteatoma
B. Serous otitis media E. Impacted wax
C. Otomycosis
11. Picket fence fever is Characteristics of
A. Bezold abscess D. Lateral sinus thrombosis
B. Brain abscess E. Extra dural abscess
C. Meningitis
12. Characteristics of cholesteatoma is:
A. Very painful D. Rapidly progressive condition
B. Causes metastatic emboli E. Causes effusion
C. Erodes Bone
13. A 12 years old girl presented to ENT opd with complaints of pain and swelling behind the right ear having high grade fever, toxic
look and lethargy. O/E, there is right side postural tenderness. Otoscopic finding show sagging of posterior meatal wall. What is your
diagnosis?
A. Temporal abscess D. Petrositus
B. Bezold abscess E. Acute localized otitis externa
C. Acute mastoiditus

ANSWER KEY
1. B 2. C 3. C 4. C 5. B 6. C 7. C 8. C 9. C 10. D
11. D 12. C 13. C

2. The term cholesteatoma is a misnomer as it is actually neither cholesterol nor a tumour. Cholesteatoma is a destructive and
expanding growth consisting of keratinizing squamous epithelium in the middle ear and/or mastoid process. Think of cholesteatoma as
an uncommon abnormal collection of skin cells inside your ear that left untreated can continue to grow and damage the bones of the
middle ear (ossicles).
3. This is the picture of Acute Otitis Media which has led to tympanic membrane perforation.

06. Otosclerosis

1. A 27-year-old female presents with bilateral, slowly progressive hearing loss associated with tinnitus. Pure tone audiometry (PTA)
reveals a dip in bone conduction at 2000 Hz. What is the most likely diagnosis?
A. Ménière disease D. Presbycusis
B. Otosclerosis E. Acoustic neuroma
C. CSOM
2. A 28-year-old school teacher presents with progressive hearing loss for the last four years along with tinnitus. Otoscopic
examination is normal. R nn ‘s t st s n t v b l t r lly, and absolute bone conduction (ABC) is not reduced. What is the most
probable diagnosis?
A. Presbycusis D. Ménière disease
B. Otosclerosis E. Acoustic neuroma
C. Otitis externa
3. A 25-year-old female presents with gradually progressive bilateral deafness. Examination shows normal, intact tympanic
membranes. Pure tone audiometry reveals a dip at 2000 Hz in bone conduction, and tuning fork tests indicate conductive hearing loss.
What is the most likely diagnosis?
A. Otosclerosis D. Otitis externa
B. Presbycusis E. Labyrinthitis
C. Ménière disease
4. A 26 year old woman has become aware of an increasing right sided hearing loss since her last pregnancy. On otoscopy, her
eardrums look normal. Her hearing tests shows bone conduction (BC) is better than air conduction (AC) in the right ear. Weber‘s t st
lateralizes to the right ear. What is the SINGLE most likely diagnosis?
A. Encephalopathy B. Functional hearing loss

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C. Tympanosclerosis E. Sensorineural deafness

D. Otosclerosis
5. A 45 year old man has noticed difficulty hearing over the telephone. His hearing has been progressively getting worse over the last
few years. He is concerned because his father has had similar problems around his age. Rine's and Weber's test demonstrate
conductive hearing loss. An audiogram shows moderate hearing loss in both ears across all frequencies. What is the SINGLE most
likely diagnosis?
A. Acoustic neuroma D. Otosclerosis
B. Meniere's' disease E. Presbycusis
C. Glue ear
6. A 20-year-old air hostess has progressive conductive hearing loss with C rh rt‘s not h t 2 kHz. What is the best treatment?
A. Hearing aid D. Stapedectomy
B. No treatment E. Tympanoplasty
C. Neurotonics
7. C rh rt‘s not h s s n t wh h r qu n y?
A. 1 kHz D. 5 kHz
B. 3 kHz E. 6 kHz
C. 2 kHz
8. Which one of the following features is least consistent with a diagnosis of otosclerosis?
A. Tinnitus C. Normal tympanic membrane
B. Positive family history
D. Onset after the age of 50 years E. Conductive deafness
9. A 31-year-old man presents with bilateral hearing loss and tinnitus. There is a family history of similar problems. Examination of
the tympanic membranes is unremarkable. Audiometry shows bilateral conductive hearing loss. Diagnosis:
A. Acoustic Neuroma D. Vestibular neuronitis
B. M n r ‘s D s s E. Glomus tumor
C. Otosclerosis
10. A 30 years old female presented with bilateral conductive hearing loss, which is gradual, progressive and persistent. On
examination both tympanic membranes are intact. What is the most appropriate diagnosis?
A. Otosclerosis D. Chronic supperative otitis media
B. M n r ‘s s s E. Glomus tumor
C. Presbycusis

ANSWER KEY
1. B 2. B 3. A 4. D 5. D 6. D 7. C 8. D 9. C 10. A

4. W b r‘s t st l t r l z to th r ht n bon on u t on s b tter than air conduction on the right. This clearly shows a conductive
deafness on the right. There are no features of encephalopathy. Tympanosclerosis has characteristic chalky white patches seen on
inspection of the eardrum. Since the eardrum here was viewed as normal, it is unlikely to be tympanosclerosis. The only answer left
would be otosclerosis. Bone and air conduction must be tested and in otosclerosis it typically reveals a purely conductive,
predominantly low-tone loss.

06. Facial Nerve

1. A 60-year-old male presents with sweating and flushing in the preauricular area during mastication. He gives a history of facial
mass surgery 8 months ago. What is the most probable diagnosis?
A. Crocodile tear syndrome D. Temporomandibular joint disorder
B. Frey syndrome E. Glossopharyngeal neuralgia
C. B ll‘s p lsy
2. A 30-year-old male presents with severe pain on the left side of the face along with vesicular eruptions on the auricle and ipsilateral
facial weakness for the last three days. What is the most probable diagnosis?
A. B ll‘s p lsy D. Trigeminal neuralgia
B. Otitis externa E. Ménière disease
C. Ramsay Hunt syndrome

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3. Most common cause of facial nerve paralysis:

A. Mastoid surgery
B. Mumps
C. B ll‘s p lsy
D. Parotid surgery
E. Skull base fracture
4. A 28-year-old male is brought to the emergency department after a road traffic accident. He has bleeding from the right ear and
decreased hearing. On examination, there is B ttl ‘s s n ( hymos s ov r th m sto r on) and hemotympanum. What is the most
likely diagnosis?
A. Acute otitis media D. Mastoiditis
B. Temporal bone fracture E. Cholesteatoma
C. Otitis externa
5. A 30-year-old male presents after head trauma with bloody discharge from the ear and facial paralysis on the same side. Hearing
loss is also present. Which type of fracture is most commonly associated with facial nerve injury?
A. Longitudinal temporal bone fracture D. Comminuted fracture
B. Transverse temporal bone fracture E. Depressed skull fracture
C. Greenstick fracture
6. A 59-year-old man presents with a severe pain deep within his right ear. He feels dizzy and reports that the room 'is spinning'.
Clinical examination shows a partial facial nerve palsy on the right side and vesicular lesions on the anterior two-thirds of his tongue.
What is the most likely diagnosis?
A. Meniere's disease D. Acoustic neuroma
B. Herpes zoster ophthalmicus E. BPPV
C. Ramsay Hunt syndrome
ANSWER KEY
1. B 2. C 3. C 4. B 5. B 6. C 7. 8. 9. 10.

07. Meniere's Disease

1. A 55-year-old male presents with recurrent episodes of rotatory vertigo for the last three years. Each attack lasts 2–3 weeks and is
associated with nausea, vomiting, sweating, and pallor. The vertigo is preceded by ear fullness, hearing loss, and tinnitus in the right
ear. Pure tone audiometry shows 50 dB hearing loss in the right ear. What is the most likely diagnosis?
A. Benign paroxysmal positional vertigo D. Vestibular neuronitis
B. Ménière disease E. Acoustic neuroma
C. Labyrinthitis
2. Which of the following investigations is most useful for confirming Ménière disease?
A. Pure tone audiometry D. CT scan of temporal bone
B. Dix–Hallpike test E. Tympanometry
C. Electrocochleography
3. A 52 year old woman has intermittent vertigo, tinnitus and fluctuating hearing loss. She complains of a sensation of ear pressure.
The attacks can last for 2 to 3 hours. A MRI brain scan was reported as normal. What is the SINGLE most appropriate treatment?
A. Prochlorperazine D. Gentamicin drops
B. Fluphenazine E. Aspirin
C. Vitamin A
4. A 44 year old man presents with muffled hearing and tinnitus. He also complains of the feeling of pressure in ear and vertigo. He
has double vision when looking to the right. What is the SINGLE most likely diagnosis?
A. Meniere's disease D. Meningioma
B. Acoustic neuroma E. Otosclerosis
C. Acute labyrinthitis
5. A 28 year old woman complains of vertigo and nausea that last around 30 minutes several times a year. She has mild hearing loss in
the left ear. A diagnosis of Meniere's disease is made. What is the SINGLE most appropriate treatment?
A. Aspirin D. Clotrimazole
B. Metoclopramide E. Ondansetron
C. Cyclizine

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8. Wh h on o th ollow n s l st r o n s n p t nts w th Mén èr ‘s s s

A. Aural fullness D. Tinnitus
B. Symptoms triggered by sudden change in head position E. Episodic vertigo
C. Sensorineural hearing loss
9. A 40-year-old woman presents with recurrent episodes of vertigo associated with a feeling or 'fullness' and 'pressure' in her ears.
She thinks her hearing is worse during these attacks. Clinical examination is unremarkable. What is the most likely diagnosis?
A. Meniere's disease D. Cholesteatoma
B. Benign paroxysmal positional vertigo E. Labyrinthitis
C. Acoustic neuroma
10. A 45years old male patient presented to ENT OPD with vertigo, fluctuating hearing loss, tinnitus and aural fullness. On
examination, tympanic membranes are normal. What is your most appropriate diagnosis?
A. Otoclerosis D. M n r ‘s disease
B. Acute suppurative otitis media E. CP angle tumor
C. Seous otitis media

ANSWER KEY
1. B 2. C 3. A 4. A 5. C 6. C 7. C 8. B 9. A 10. D

08. Tumors of Middle Ear and Mastoid

1. A 45-year-old female presents with pulsatile tinnitus and progressive hearing loss in the right ear. Otoscopic examination shows a
reddish pulsatile mass behind the tympanic membrane. What is the most likely diagnosis?
A. Cholesteatoma D. Acute otitis media
B. Glomus tympanicum tumor E. Otosclerosis
C. Otomycosis
2. A 50-year-old woman complains of pulsatile tinnitus, hearing loss, and a reddish mass in the middle ear that blanches on pneumatic
otoscopy. This sign is known as:
A. Rinne sign D. Romberg sign
B. Schwartze sign E. Tullio phenomenon
C. Brown‘s s n
3. A female presents with pulsatile tinnitus and conductive hearing loss. Otoscopy reveals a vascular middle ear mass. Which
investigation is most useful to confirm the diagnosis and assess tumor extent?
A. Pure tone audiometry D. Tympanometry
B. CT scan temporal bone E. X-ray mastoid
C. MRI with contrast

ANSWER KEY
1. B 2. C 3. C 4. 5. 6. 7. 8. 9. 10.

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Eye001 – Ear006
EYE & ENT-1 EYE-1
֍EYELID֍

01. Anatomy & Physiology

Eyelid Muscles
Muscle Function Innervation
Orbicularis oculi  contract  eye close Facial nerve
Levator palpebrae superioris  contract  eye open Oculomotor nerve
Mull r‘s mus l  contract  eye open Sympathetic nervous system
Eyelid Glands
 Meibomion gland (oily secretion) in tarsal plate
 Glands of Zeis (modified sebaceous gland) at lid margin
 Glands of Moll (sweat gland) at base of eyelashes
Eyelid Lamella
 Anterior lamella  Skin, Subcutaneous tissue & Orbicularis oculi
 Posterior lamella  Tarsal plate & Conjunctiva

02. Chalazion

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Painless swelling on upper eyelid, non-tender & firm in consistency
 Size gradually increases, causing blurring of vision
 Conjunctiva is red or purple over the nodule or fleshy mass (if, Ruptured).

1. A 25 years old patient complains of painless swelling on his upper eyelid for the past three months. The size of the swelling is
increasing over few weeks and he has noticed blurring of vision in that eye. (2021 Supple)
a) What is the pathophysiology of the disease?
Answer: Obstruction of orifice of meibomian gland  Retention of lipid secretion  chronic granulomatous inflammation (large
number of giant cells and epithelioid cells surround acini of gland)  Retention of lipid secretion along with chronic granulomatous
inflammation appear as visible swelling on eyelid.
b) How will you manage it?

* Most common method (Vertical incision is given to prevent injury of surrounding healthy meibomian glands)

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2. A 20 years old university student is told by her friend that she has right upper eyelid small swelling. The swelling is located on the
outer part of the lid away from the lid margin. It is felt better than seen and is nontender and firm in consistency. Now that she is
aware and conscious of it, she wants proper management for the problem. [Supple 2014 held in 2015]
a) What is the diagnosis?
Answer: Chalazion
b) What refractive error it can cause if left untreated?
Answer: Astigmatism (Due to compression of Cornea by Chalazion)
c) What is the treatment of choice at this stage of the ailment? Give steps.
Answer: Surgery (Incision & Curettage method) Steps are given below:
1- Topical anesthesia with procaine OR Subconjunctival injection of lignocaine.
2- Lid is everted with Chalazion clamp.
3- A small Vertical incision is given with sharp blade.
4- The semifluid escaped & walls of cavity are scrapped with Chalazion scoop.
5- Cavity is cauterized with carbolic acid to avoid recurrence.
6- Topical Antibiotics & Steroids 3-4 times daily/1 week post operation

03. Hordeolum Externum (Stye)

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Painful upper eyelid swelling
 Tender, red and edematous eyelid
 Visible Pus points (Yellowish spots at outer lid margin)

1. A young girl is presented with progressive painful upper eyelid swelling with a pus points yellowish spot at the outer lid margin.
a) What do you think is the diagnosis?
Answer: Stye (Hordeolum Externum)
b) Enlist few D/D.
1. Hordeolum Internum
2. Secondary infected chalazion

04. Chalazion vs Stye

Features Stye Chalazion

1. Onset Acute Chronic
2. Gland involved s‘s & Moll l n Meibomian gland
3. Type of inflammation Suppurative Granulomatous
4. Symptoms Acute pain & swelling Painless disfigurement
5. Signs Localized hard and tender swelling near lid Hard swelling away from margin
margin
6. Treatment Hot fomentation + Antibiotics & removal of Incision & Curettage
eyelashes

05. Hordeolum Internum

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Inflammatory symptoms more violent than external stye (e.g., Pain) T
 The pus appears as a yellow spot; posterior to grey line, shining through the
conjunctiva when the lid is everted

1. A gentleman develops severe pain in lower lid. On eversion of lower lid, a yellowish focal area posterior to grey lid extending in a
streak downward on Conjunctival side, got better with treatment in 7 days.
a) What is the diagnosis?
Answer: Hordeolum Internum

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b) What is the common organism involved?

Staphylococcus Aureus
c) What is the cause of severe pain in this region?
Hordeolum Internum is suppurative inflammation of Meibomian Gland; and as this gland is larger and embedded in the deep fibrous
tissue, inflammatory symptoms such as pain is very severe in the affected region.
d) How would you treat this condition?
Medical
 Hot Compresses (3 – 4 Times daily)
 Topical Antibiotics
 Oral Antibiotics (if infection spreads to form pre-septal cellulitis)
Surgical
 Incision and Curettage (Via Vertical Incision)!

06. Blephritis

֍⸨Diagnostic Features by Team Medical Minds⸩֍

Ulcerative Blepharitis:
 Gluing of eyelashes + Crust formation around the bases of lashes,
 Eyelashes may be matted together by yellow crust; (when removed behind a tiny
bleeding ulcer visible).
Squamous Blepharitis:
 Deposition of whitish material at lid margin
 Shiny waxy appearance of eyelid margin + Dandruff like desquamation which
give rise to yellow greasy fine flakes & scales on lid margin

1 [Supple 2009 held in 2010]

a) What is blepharitis?
Answer. Subacute or chronic inflammation of eyelid margin.
b) How is it treated?

c) What are the complications?

Eyelid Trichiasis, Madorosis1, Poliosis2, Recurrence of Stye & Chalazion, Entropion, Ectropion, Epiphora
Conjunctiva Chronic conjunctivitis
Cornea Toxic punctuate keratitis, Catarrhal ulcer, Phlyctenular keratitis
1
loss of eyelashes, 2loss of color from hair

07. Trichiasis & Distichiasis

1. What are the causes of trichiasis? [Supple 2006]

1. Infective / Inflammatory:
 Stevens-Johnson Syndrome
 Keratoconjunctivitis Distichiasis  Additional row of eyelashes.

It is treated by freeze thaw freeze technique.

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2. Traumatic:
 Mechanical injuries
 Chemical Injuries
 Thermal Injuries
3. Autoimmune:
 Ocular cicatricial pemphigoid (OCP)

08. Entropion

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Inward rolling of lid margin (upper / lower)
 History of Trachoma / white band of sub-tarsal fibrosis on examination
(Cicatricial cause) OR old age (Senile cause).
 Trichiasis causing irritation + Blurring of vision

1. A 60 years old man comes with history of inward rolling of the upper lid margin. He has been diagnosed as case of trachoma since,
20 years. Now he has trichiasis causing irritation and blurring of vision. He comes to an ophthalmologist for treatment? (2022 Annual)
a) What is diagnosis?
Answer: Cicatricial entropion
b) Enumerate other cause of this condition?
1. Cicatrizing conjunctivitis (Trachoma, Stevens-Johnson syndrome, & ocular cicatricial pemphigoid)
2. Chemical injury (Face burn)
3. Trauma (Lacerating Injury)
c) What are the treatment options?
1. Resection of skin and muscle (simplest procedure)
2, Resection of tarsus, skin and muscle (Fox modification of Streatfield-Snellen procedure)
3. Tarsal hinge procedure (Tarsus is cut horizontally and everting suture is applied)
4. Mucous membrane graft.

09. Ectropion

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Outward rolling of lid margin (Lower lid)
 History of acid burn (Cicatricial cause) OR old age (Senile cause).
 Epiphora (watering of eyes)

1. A 30-year-old patient got acid burn on her right lower lid 5 months ago. Now she presents with epiphora and pulling of her lower
lid downward. [Annual 2017]
a) What is most probable diagnosis?
Answer: Cicatricial Ectropion.
b) Give the classification of this condition.
A. Congenital Ectropion
B. Acquired Ectropion
 Senile/ Involutional Ectropion.
 Paralytic Ectropion.
 Cicatricial Ectropion.
 Mechanical Ectropion.
 Spastic Ectropion.
c) How will you treat this patient?
 V-Y operation for mild ectropion
 Z-plasty for moderate ectropion
 Skin graft for severe ectropion

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d) What is the most important complication of this disease?

Answer: Exposure keratopathy that leads to Corneal ulceration.

2. A 60-year-old male presents with watering of his right eye. On examination, there is outward turning of the lower lid margin.
a) What is the most probable diagnosis?
Answer: Senile Ectropion
b) Give two reasons why this condition occurs.
1) Senile laxity of tissue of eyelid
2) Loss of tone of Palpebral part of orbicularis oculi.
Other causes of ectropion
1. Cicatricial Ectropion (Chemical injury/ Trauma/ Medical dermatitis)
2. Paralytic Ectropion (Fascial nerve palsy)
c) How will you treat this patient?
 Medial Conjuntivoplasty
 The horizontal Lid shortening
 Kuhnt-Szymanowski procedure

10. Ptosis

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Neurogenic cause:
1. Mild ptosis + smaller (constricted) pupil [Horner Syndrome]
2. History of Diabetes + eye deviated “Down & Out” + Pupil dilated and
non-reactive to light [3rd Nerve Palsy]
 Very Old age + Bilateral drooping of lids + High upper lid crease with intact
levator function [Senile / Involutional Cause]
 Gradual onset + Asymmetric (bilateral) ptosis + improves after icepacks +/–
Diplopia / weakness of other muscles in body [Myasthenia Gravis]

1. A 65 years old chain smoker presents with slight drooping of left upper eyelid for one week, on examination his visual acuity is
normal. He has mild ptosis and a smaller pupil on left side. (2021 Annual)
a) What is most probable diagnosis?
Answer: Neurogenic ptosis of left eyelid (Horner Syndrome)
b) What is the most probable cause?
Answer: Patient is smoker he must developed lung cancer (pan- o st tumor) n l t lun ‘s upp r lob wh h nvolv symp th t
trunk  Horner syndrome  paralysis of muller muscle  ptosis of upper eyelid.
c) What test will you perform to confirm the diagnosis?
 Phenylephrine test: Sympathomimetic agents, such as phenylephrine 2.5% (or 5%) drops are used to assess mild cases of
ptosis as in Horner's syndrome. The positive phenylephrine test suggests that the patient would respon d well to Muller's
muscle resection.
 Apraclonidine test: 0.5-1% apraclonidine drops are instilled in conjunctival sac pupil dilation confirms Horner syndrome.
c) How will you treat it?
Non-surgical
 In this case, underlying cause i.e., Diabetes is Controlled by Insulin (or other drugs) & lifestyle modifications.
 Amblyopia can be prevented by occlusion of better eye
 Occulsion or Prism for diplopia
Surgical
 Recti resection
 Neurosurgery to remove hematoma/aneurysm compressing the nerve
 If there is complete paralysis, Operation is usually contraindicated because of Intolerable Postoperative Diplopia

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2. A 5-year-old boy comes in the eye department with difficulty in lifting his right upper eyelid for the last three years. His pupils are
visible in primary gaze and he is emmetrope. [Supple 2018 held in 2019]
a) What is the clinical diagnosis? (1)
Answer: Ptosis
b) Write relevant clinical examinations. (3)
1. Tensilon test  it is performed when myasthenia gravis is suspected. To differentiate medical ptosis from
2. Ice Test  ptosis in myasthenia gravis patient improves with it. surgical ptosis
3. Phenylephrine Test  it is carried out patient suspected with Horner syndrome.
4. Neurological investigations.
5. Grade of ptosis.
6. Assessment of Levator (Palpebrae Superioris) muscle function.
7. Marginal reflex distance (Normal 4mm)
8. Other nv st t ons (O ul r mob l ty, Corn l s ns t v ty, M r us Gunn Pup l, B ll‘s ph nom non)
c) What are the indications for surgery in these cases?
 To prevent amblyopia (or Diplopia)
 For cosmetic purpose

3. A 2-year-old child is brought by her parents with a drooping upper eyelid on the right side. On examination, there is 3 mm levator
function and the upper eyelid is covering the central corneal light reflection. [Annual 2015]
a) Describe the classification of this disease.
A) Congenital ptosis B) Acquired Ptosis
1. Simple congenital ptosis. 1. Neurogenic ptosis (3rd nerve palsy, Horner syndrome)
2. Congenital Synkinetic Ptosis (Marcus 2. Myogenic ptosis (Myasthenia gravis)
Gunn Jaw Winking ptosis) 3. Aponeurotic/Involutional ptosis
3. Blepharophimosis Syndrome. 4. Mechanical ptosis (Trachoma, Tumor)
b) Enlist surgical treatment options to treat this condition.
Severity of Ptosis Surgical Options
1. Mild ptosis (In case of good levator function and  Fasanella Servat operation
Good Lid Fold) (Excision of tarsal plate + Conjunctiva + Muller muscle)
2. Moderate ptosis
 Levator Resection (excision of Levator muscle):
(a) When levator muscle is not completely paralyzed (a) Blaskovics Operation
(b) Everbusch Operation

(b) When levator muscle is completely paralyzed  Motais Operation

(Superior Rectus is used to elevate the lid)
3. Severe ptosis  Brow suspension/ Sling procedure
(When levator muscle is intact but its function is poor) (Attachment of lid with frontalis muscle)

c) What condition will develop if the problem is not corrected at this age and why?
Answer: Amblyopia will develop. Due to poor levator function, right eyelid partially covers pupil and hinder light rays to enter the
eye.

4. An 85-year-old patient reports with gradual onset of bilateral drooping of upper eyelids. On examination, there was high upper lid
crease in both the eyes with intact levator function. The gentleman was healthy otherwise. [Annual 2013]
a) What is your diagnosis?
Answer: Senile / Involutional (Aponeurotic) ptosis
b) Name three surgical procedures to correct this condition.
Answer:
 Reinsertion of Levator aponeurosis to the anterior surface of the Tarsus
 Levator Resection (excision of Levator muscle)
 Fasanella Servat operation (Excision of tarsal plate + Conjunctiva + Muller muscle) can also be done.

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c) What is the marginal reflex distance?

“It is measured from corneal light reflex to

the central position of upper eyelid, with eye
in primary position. Normal MRD is 4mm”.

֍LACRIMAL APPARATUS֍

01. Anatomy & Physiology

1. You put a drop of steroid placed in the conjunctival sac. [Annual 2018]
a) Name the structures through which you have passed before reaching the nose.
Conjunctival sac  Punctum  Superior & inferior Canaliculi  Common canaliculus Lacrimal sac  Nasolacrimal duct  Inferior
Nasal Meatus
b) Write down common indications and complications of using the steroid eye drops.
Complications
 Recurrence of Herpes simplex keratitis
 Glaucoma
 Posterior subcapsular Cataract
Indications
 Eyelid infection
 Conjunctivitis
 Keratitis
 Swelling/edema
Pre-Corneal Tear Film
Layer Thickness Glands
Mucus layer Innermost & thinnest layer (0.2 um) Conjunctival goblet cells, glands of Henle & glands of Manz
Aqueous layer Thickest intermediate layer Lacrimal glands, Accessory glands of Krause & Wolfring
Lipid layer Outermost layer Meibomian glands & Moll glands
Note: Tear secretion begins 4 weeks after birth & its average secretion rate is 1-2 microliter

02. Congenital Nasolacrimal duct Obstruction

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Watering & discharge from eye Since Birth
 Regurgitation test positive on examination
 If, Purulent discharge (complicated into acute dacryocystits)

1. A three months old baby is brought to Eye OPD by his parents with a chief complaint of watering and discharge from his left eye
since birth. On examination, regurgitation test was positive. [Supple 2019 held in 2020]
a) What is the most likely diagnosis?
Answer: Congenital Naso-lacrimal duct (NLD) obstruction.
b) What are its complications?
1) Mucocele
2) Fistula
3) Acute & Chronic dacrocystitis

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c) Outline its treatment plan.

Conservative  Wait for spontaneous resolution.
 Massage Lacrimal sac with little finger.
 Prophylactic topical Antibiotics.
Surgical  Probing (under general anesthesia) at age of 6 months – 1 year
 Syringing.
 Balloon catheter dilation.
 DCR (after 5-6 years)

03. Chronic Dacryocystitis

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Watering (Epiphora) + Medial canthal Swelling
 Positive regurgitation test on examination (There is No Regurgitation in acute
dacryocystitis, as canaliculi are blocked).

1. A 45-year-old female presents with a medial canthal swelling and epiphora. The regurgitation test is positive.
a) What is the diagnosis?
Answer: Chronic Dacrocystitis
b) What investigations can you perform?
 Radioactive sulphur
 X ray [e.g., Contrast Daryocystography (DCG)]
 Fluorescein dye disappearance test.
 Jones dye test 1 & 2.
 Macro-dacryo-cystography.
c) What complications can result if left untreated?
 Osteomyelitis of Lacrimal bone
 Hypopyon corneal Ulcer
 Orbital cellulitis
 Cavernous sinus thrombosis
 Panophthalmitis (Following intraocular surgery)

֍SCLERA֍
01. Anatomy & Physiology
Sclera
 Avascular
 Thickest (1 mm) on posterior pole where optic nerve leaves
 Intermediate (0.8 mm) at limbus
 Thinnest (0.3 mm) on equatorial pole where recti muscle attached
Episclera
 Vascular
 Topical 2.5% phenylephrine blanch episcleral vessels but not the deeper vessels (sclera)
02. Scleritis
1. Give clinical features of scleritis. [Annual 2006]
 Red nodule or diffused sclera with or without necrotic patch.
 Mild to moderate pain.
 Lid swelling and optic disc swelling (in posterior scleritis)
 Keratitis and anterior uveitis may be present. Secondary glaucoma may be present.
 Associated with systemic inflammatory conditions such as rheumatoid arthritis, SLE, PAN.

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֍CONJUNCTIVA֍

01. Anatomy & Physiology

Parts of Conjunctiva
o Palpebral part – covers inner surface of eyelid & contains Glands of Henle
o Forniceal conjunctiva – l s b tw n y l & y b ll, ont ns Mull r‘ mus l & l n s o Kr us
o Bulbar conjunctiva – covers anterior part of globe
Symblepharon  adhesion between palpebral
& bulbar conjunctiva
Structure of Conjunctiva
Layer Description
Epithelium Non-keratinized squamous epithelium consisting of goblet cells
Basement membrane consists of type IV collagen fibrils
Stroma Adenoid layer  consists of lymphocytes, macrophages & mast cells
Fibrous layer  consists of meshwork of collagenous & elastic tissue which contains blood vessels, nerves
Muller‘ mus l & ssory l r m l l n s (Gl n s o Kr us & Gl n s o Wol r n )

02. Viral Conjuntivitis

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Redness + burning sensation in both eyes +/– followed by upper respiratory tract
infection (viral)
 Watery discharge + follicular conjunctival reaction +/– painful preauricular
lymphadenopathy
 History of similar disease in family / surroundings

1. A 45-year-old male patient presented with burning and redness in both eyes for last three days. On examination, there is watery
discharge, follicular conjunctival reaction and painful preauricular lymphadenopathy. [Supple 2019 held in 2020]
a) What is the most likely diagnosis?
Answer: Epidemic Keratoconjunctivitis (Due to adenovirus)
b) How will you manage this case?
History Exposure within family or at a workplace
Ocular examination Conjunctival chemosis, Follicles, Pseudomembrane, Eyelid edema
Investigation Giemsa stain, PCR, ELISA
Treatment Spontaneous resolution, Application of cold water, Topical antibiotics, Topical Steroid, mast
cell stabilizers.
c) What complication can occur?
1. Follicles form and may persist
2. Corneal scarring
3. Conjunctival scarring
4. Keratitis

2. A 19 years old female presented with severe irritation, redness, watering and photophobia in both eyes after upper respiratory tract
infection. Her elder brother had similar episode 1 week earlier. [Supple 2017 held in 2018]
a) What is your diagnosis?
Answer: Epidemic Keratoconjunctivitis
b) Name other clinical signs to look for in this case.
1. Preauricular lymphadenopathy
2. Subepithelial corneal opacity
3. Subconjunctival hemorrhage
4. Chemosis
5. Pseudo-membrane formation
6. Eyelid edema

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c) How can you prevent this condition from spreading?

A patient can spread the disease by touching or rubbing their eyes and then touching another object. So, by staying at home, it can be
prevented

03. Pharyngoconjuntival Fever

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Triad of Fever + Pharyngitis + Conjunctivitis (Bilateral Pink eyes & follicles with
conjunctival congestion)
 Bilateral punctate keratitis may be present on examination of cornea

1. A 15-year-old boy presents with sudden onset of bilateral pink eye with fever and pharyngitis. On examination, his visual acuity is
6/6 and there are follicles present in the inferior fornix in association with diffuse conjunctival congestion. Corneal examination shows
punctate keratitis bilaterally. [Annual 2011]
a) What is most likely diagnosis?
Answer: Pharyngoconjunctival fever Epidemic keratoconjunctivitis is caused by
b) What organism causes this disease? adenovirus strain 8, 19 and 37
Answer: Adenovirus serotype 3, 4 and 7
c) Why should the child be advised to stay at home?
Answer: Because it spread through respiratory secretions.
d) What is the most appropriate treatment?
Answer: See Q 1b in Viral conjunctivitis section + Treatment of underlying causes (Tonsilitis / adenoids)

04. Trachoma

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Mild irritation + foreign body sensation +/– itching
 Pr s n o ≥ 2 s ns:
1. Follicles / Papilla on conjunctiva
2. Epithelial keratitis
3. Pannus formation
 Arlt‘s l n (Hor zont l wh t l n nvolv n onjun t v & tarsal plate) & Typical
Star-shaped scarring of conjunctiva

1. A 30 years old man of low socio-economic group presents within turned lashes of upper lid. Lid eversion shows a significant white
horizontal line involving the conjunctiva and tarsal plate. [Annual 2017]
a) What is the most probable diagnosis?
Answer: Trachoma
b) Write down the WHO classification of Trachoma.
WHO Classification:
 F – Follicles [5 / more (> 0.5mm)]
 I – Trachomatous Inflammation [obscuring 50% / more of normal deep tarsal vessels; papillae present]
 S – Conjunctival scarring [White tarsal bands]
 T – Trichiasis [At-least 1 lash touching the globe]
 O – Corneal opacity [sufficient to blue the details of at-least part of pupillary margin]
c) Enumerate the treatment strategies in this condition.
Treatment Strategy Description
Medical Topical
 1% erythromycin / 1% Tetracycline
 Ciprofloxacin – “For elimination of secondary infection of conjunctiva”
 Artificial tears

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Systemic
 Single dose of Azithromycin (Recommended now-a-days)
Combined Topical & Systemic:
 Used when infection is severe
 1% erythromycin / 1% Tetracycline (Ointment + Oral)
Surgical  For any sequalae i.e., Entropion, trichiasis & dry eyes, surgery should be done
Prophylaxis: [SAFE strategy]
S – Surgical treatment of complications associated with trachoma
A – Antibiotics (Azithromycin is DOC. Others are Tetracycline/Erythromycin)
F – Facial cleanliness
E – Environmental sanitation improvement

2. [Supple 2009]
a) Describe the clinical features of trachoma.
1. Subclinical stage Minimal signs and symptoms, small follicles
2. Clinical stage Follicles on bulbar conjunctiva, Corneal Pannus
3. Scarring stage Arlt‘s l n , H rb rt p ts
4. Cicatrization stage Inactive end stage without evidence of inflammation, Conjunctival cicatrization, Corneal opacity.
b) What are the complications of this disease?
1. Eyelid – Trichiasis, Entropion, Blepharitis
2. Conjunctiva – Dry eye due to destruction of goblet cells
3. Cornea – Scarring & neovascularization

05. Neonatal Conjunctivitis

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Watering & discharge from both eyes during 1 st week of life (as tears are seen 3 –
4 weeks after birth; N. Gonorrhea manifests within 1st 48 hours)
 Sticking of eyelids + conjunctival congestion + Pseudo-membrane + Intact cornea
on examination
 Eyelids may be swollen and tensed.

1. A 2-week-old baby girl has swelling and sticking of eye lids. On examination, there is mucopurulent discharge and conjunctival
congestion most marked in the fornix. [Annual 2014]
a) What is your diagnosis?
Answer: Neonatal Conjunctivitis
b) What organism is associated with this problem?
Answer: Chlamydia
c) How would you treat her?
1. Topical  10% Sulfacetamide, 1% Erythromycin, Tetracycline, Azithromycin – DOC
2. Systemic  Erythromycin 50mg/kg body weight.

2. A newborn child who is 48 hours old is brought to accident emergency with bilateral severe purulent discharge. On opening the eye
with retractor, ulceration of cornea is seen in the right eye. [Supple 2011]
a) What is most probable diagnosis?
Answer: Neonatal conjunctivitis
b) Which organism is most likely the cause of this condition?
Answer: N. Gonorrhea
c) What investigation would you perform?
1. Gram staining shows gram “negative” diplococci
2. Culture and sensitivity

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d) What is most appropriate treatment?

1. Topical  Benzyl penicillin, gentamicin, tobramycin
2. Systemic  Benzyl penicillin 5000 units/kg body weight, Cefotaxime 100mg/kg body weight.

06. Allergic Conjunctivitis

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of exposure to allergen e.g., Dust
 Itching (Most prominent Feature) + watering + redness of conjunctiva
 Eyelids swollen + red on examination

1. A young man presents with itchy, swollen red eyes with clear watery discharge following exposure to dust. [Annual 2010]
a) What is the most likely diagnosis?
Answer: Allergic Conjunctivitis
b) What drugs can be used to treat?
 Mast cell stabilizer (Lodoxamide is preferred)
 Antihistamine (Olopatadine)
 Combined Mast cell stabilizer & Anti-histamines
 Vasoconstrictor (Adrenaline)
 Steroids (Dexamethasone)
c) What complications can develop in cornea?
1. Corneal ulceration
2. Corneal scarring
3. Destruction of limbal stem cells
d) What is the natural course of disease if left untreated?
1. Allergic conjunctivitis  destruction of goblet cells  Dry eye  Corneal scarring + Limbal stem cell destruction
2. Allergic conjunctivitis  itching  rubbing of eyes and infection keratoconus

07. Vernal Keratoconjunctivitis (Spring Catarrh)

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Seasonal history of symptoms (Alleviate in winters while aggravate in summers)
 Itching (Most common complaint) + Thick, white, Ropy mucus discharge
 Palpebral Form:
 Large papillae + cobble stone appearance (on upper lid eversion)
 Bulbar Form:
 Multiple nodules / gelatinous thickening in limbal area (Diagnostic of Spring
Catarrh)

1. A 15 years old boy present with itching and swollen eyelids Since, one year. On examination there is diffuse congestion of bulbar
conjunctiva. Eversion of the upper eyelids on both sides shows large papillae with cobble stone. His skin examination is normal.
a) What is the probable diagnosis?
Spring Catarrh
b) What are the other clinical features seen in advanced disease?
1. Palpebral form Ropy secretion, Cobblestone/ Cauliflower appearance
2. Limbal form Gelatinous papillae, Trantas dots*
3. Mixed form Punctate epithelial erosion, Macroerosions, Plaque and shield ulcer,
Subepithelial scarring, Peripheral corneal vascularization
*Composed predominantly of eosinophils.
c) How will you treat this patient?
 Avoid Exposure to allergen in all cases!

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Topical
Mast cell stabilizers 2% Cromoglycate, Lodoxamide 4 times/day
Antihistamine Epinastine
NSAIDs Ketorolac, Diclofenac
Steroids Flouromethalone 0.1%, Prednisolone 0.5%
Mucolytic agent Acetylcystine 5%
Immunosuppressive Cyclosporin 0.05%
Subconjunctival Steroids Dexamethasone 4mg/ml, Prednisolone 40mg/ml
Systemic Azathrioprine, Antihistamines (For resistant cases)

2. A 15-year-old male presents with severe itching and burning of both eyes. The condition gets aggravated in summer. His eyes show
conjunctival redness, a gelatinous mass all around the cornea and flat-topped nodules on the upper tarsal conjunctiva. Visual acuity is
6/6 of both eyes. [Supple 2013]
a) What is the most likely diagnosis?
Answer: “Spring Catarrh”
b) What is the etiology of the disease?
Immune Reactions  (Type I and Type IV reaction) due to following causes:
1. Exogenous bacterial proteins such as in Hay fever
2. Endogenous bacterial protein such as Staph. aureus in nose
3. Chemicals and cosmetics
4. Drugs
b) What are the likely complications?
1. Punctate epithelial erosion
2. Macro-erosion
3. Plaque and shield ulcer
4. Subepithelial scarring
5. Peripheral corneal vascularization
6. Keratoconus

08. Occular Cicatricial Pemphigoid

1. A 65 years old lady has low grade itching in the eyes and whole body for last three years. She is a known case of ocular cicatricial
pemphigoid. [Supple 2018 held in 2019]
a) Write four clinical signs of the disease.
1. Bullae formation which may rupture and gray opacities formed
2. Dry eye due to destruction of goblet cells
3. Symblepharon and Ankyloblepharon
4. Keratinization of cornea
b) What are ocular complications of this disease?
1. Conjunctiva – Dry eye, Symblepharon, Grey opacities
2. Cornea – Keratinization, opacity
c) What is the ocular treatment of the disease?
1. Artificial tears – for dry eyes
2. Topical retinoic acid – to prevent or reduced corneal Keratinization
3. Antibiotics – to prevent bacterial infection
4. Steroids – slow progression of disease
5. Cyclosporine – Immunosuppressant

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09. Pterygium

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Bilateral redness of eyes
 Examination shows triangular (fleshy red) fibrovascular growth on medial sides of
both eyes encroaching onto cornea, reaching pupillary area
 Lesion is in interpalpebral area (exposed region)
1. A 60 years old farmer came to eye OPD with triangular growth on the medial side of both eyes in the inter-palpebral area. The
growth was encroaching the cornea and reaching the pupillary area. The eye was otherwise normal. [Annual 2018]
a) What is the most probable diagnosis?
Answer: Pterygium
b) What are the indications for treating this condition and how will you treat it?
Indications
 Cosmetic reason in grade I and II
 Vision problem due to astigmatism and diplopia in grade III
Treatment
 Simple excision (sclera bare) technique
 Conjunctival flap excision technique
 To prevent recurrence, Mitomycin C, Argon laser and Beta rays are used.
2. A 60 years old male, working as laborer in construction of housed, has presented with redness of both eyes on nasal side in
interpalpebral fissure, Examination revealed triangular fibrovascular subepithelial ingrowth of degenerative conjunctival tissue over
the limbus onto the cornea. [Annual 2023 held in 2024]
(a) What is the diagnosis?
Pterygium
(b) Name any two differential diagnoses?
1. Pseudo-pterygium
2. Pinguecula
(c) Name any three measures to reduce the recurrence of the condition when surgery is planned.
1. Mucus membrane autograft
2. Tr nspos t on m tho (M R ynol ‘s)
3. Lamellar corneal graft
4. Beta-radiation
5. Application of Mitomycin C
6. Amniotic membrane patch grafting
֍CORNEA֍
01. Anatomy & Physiology
Structure of Cornea
Layer Description
Epithelium Non-keratinized squamous epithelium like conjunctiva & have ability to regenerate
Impermeable to water due to presence of tight junction
Bowm n‘s m mbr n It has no power of regeneration after damage
Stroma It is the thickest layer (90%)
Composed of collagen fibrils that are regularly spaced thus maintain corneal transparency
Descemet membrane It is the basement membrane of endothelium
It ends at periphery as prominent l n ll S hw lb ‘ l n
It has no power of regeneration after damage
Endothelium It plays role in maintaining dehydration of cornea
It has no power of regeneration after damage
Its damage causes corneal edema
Active endothelial pump maintains corneal transparency

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Note: Cornea is avascular & supplied by anterior ciliary artery

02. Keratitis Classification

1. Microbial or Infective keratitis 2. Non-microbial or Non-Infective keratitis

 Bacteria – Gram +ve and -ve  Hypersensitivity (allergic)
 Virus – HSV  Autoimmune
 Fungi – Candida, Aspergillus  Neurotrophic
 Protozoa – Acanthamoeba  Exposure keratopathy
 Nutritional deficiency
 Chemical burns
 Eyelid abnormalities (Entropion, Trichiasis)

03. Bacterial Corneal Ulcer

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of wearing contact lenses (with onset 24 – 72 hours)
 Painful, red eye + Lacrimation & photophobia
 Central corneal haze / ulcer (or white patch) that stains positive with fluorescein dye.

1. A 30 years 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?
1. Gram stain and Giemsa stain
2. Culture and Sensitivity
3. 10% KOH
4. Blood test, Urine test
b) What complication can occur if the above condition remains untreated?
A. Acute uveitis
B. Secondary glaucoma
C. Descemetocele
D. Perforation
Iris prolapse, Subluxated lens, Cataract, Glaucoma, Endophthalmitis, Panophthalmitis, Intraocular Hemorrhage such as vitreous
hemorrhage, choroidal hemorrhage, Retinal detachment, Fistula, Anterior Synechiae
E. Corneal scarring
Nebula, Macula, Leucoma, Leucoma adherent, Pseudo-cornea, Ectatic cornea, Anterior staphyloma
d) Discuss treatment of corneal ulcer.
Control of infection Topical antibiotics (gentamycin, Tobramycin, Ciprofloxacin, moxifloxacin)
Subconjunctical antibiotics (0.5ml gentamycin).
Control of pain Analgesic, Atropine, Antiglaucoma drugs
Treatment of descemetocele Bed rest, Antiglaucoma drugs, Pressure bandage and Bandage contact lens, Conjunctival
flaps and Amniotic membrane transplant, Keratoplasty
Treatment of perforated Anti collagenase such as tetracycline, Conjunctival flaps and Amniotic membrane
corneal ulcer transplant, Keratoplasty
Treatment of non-healing Conjunctival flaps and Amniotic membrane transplant, Cauterization, Tarsorrhaphy, Limbal
corneal ulcer stem cell transplant

2. A 30-year-old man presents with metallic foreign body in his cornea during work. The foreign body is removed with a needle and
no medication is prescribed by mistake. The patient presented with reduced visual acuity and whiting around the foreign body bed.
a) What is the most likely diagnosis?
Answer: Corneal ulceration

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b) How will you perform investigations?

1. Slit lamp examination
2. Distant direct & Indirect Ophthalmoscopy
4. Culture and sensitivity of corneal scrapings
c) What is most important treatment?
1. Antibiotics + Analgesic
2. Keratoplasty
d) What is most serious complication?
Answer: Perforation

04. Hypopyon Ulcer

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of scratching with nail, followed by severe painful red eyes with visual
deterioration.
 Circumcorneal congestion + marked iritis (hypopyon) / cloudy aqueous on
examination

1. A young man sustained injury to the right cornea with finger nail followed by intense pain, irritation and visual deterioration in the
eye. Patient did some self-medication without consulting and presented with severe pain, intense redness and significant visual
deterioration. Examination revealed circumcorneal congestion, mild corneal edema and hypopyon along with pupil in the eye.
a) What is hypopyon?
Answer: Collection of sterile pus in anterior chamber of eye associated with the anterior uveitis
b) Name the bacteria capable of producing hypopyon.
1. Pneumococcus – most common cause
2. Staph. aureus
3. Pseudomonas
c) Describe the mechanism of hypopyon in intact corneal epithelium without perforation.
Iridocyclitis  Increase vascular permeability and release of leukocytes  Leukocyte enmesh with fibrin network  Pus collection.

05. Fungal Keratitis

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of farmer with injury due to vegetable matter (Onset 1 – 2 weeks)
 Painful redness of affected eye + Lacrimation / irritation
 Examination shows typical yellowish-white colored corneal ulcer with indistinct margins
+/– small satellite lesions with feathery, finger-like hyphate edges can also be seen

1. A 30-year-old farmer presents with redness in the right eye after a foreign body went in his eye one week ago. On examination,
there is intense redness around the cornea with 4 mm yellowish lesion in the center of the cornea. There is also loss of epithelium in
that area. [Annual 2015]
a) What other clinical features will be present with progression of the disease?
1. Satellite lesions
2. Hypopyon
3. Endothelial plaques with immune ring (Wesseley Lesion)
b) How will you investigate this case?
Corneal scraping used for
1. Gram, Giemsa & methenamine silver stains
2. Cultur n S bour u ‘s r n bloo r
3. 10% KOH
c) What will be the local treatment for his eye?
1. Topical Antifungal – Natamycin is DOC

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2. Topical 1% Atropine
3. Topical antibiotics
4. Debridement

2. An ol m n ntly ot h s r ht y njur w th broom‘s str w. H r port n y l n w th m l p n, photophob and

blurred vision after 3 weeks. Ocular examination revealed greyish white central corneal lesion surrounded by similar small satellite
feathery opacities. [Annual 2023 held in 2024]
a) What is your diagnosis and name the causative agent?
Diagnosis  Kerato-mycosis / mycotic hypopyon ulcer
Causative Organism  Aspergillus Fumigatus (Most common) [Candida Albicans in immunocompromised Hosts]
b) List the possible complications.
 Infection Spreading to sclera
 Corneal perforation
 Corneal opacification
 Endophthalmitis

06. Herpes Simplex Keratitis

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Immunocompromised host (e.g., on steroids)
 Redness, lacrimation + decreased vision
 Examination shows dendritic (Branching) corneal ulcer (Pathognomonic of HSK)
that stains positive with fluorescein OR, large geographical pattern (Confluent
ulcer).
1. A 40 years old female having rheumatoid arthritis on immune modulator presented with reduction in vision, irritation, redness and
photophobia in her right eye. Examination shows dendritic corneal ulcer stained with fluorescein. [Supple 2017 held in 2018]
a) What is the most common causative organism?
Answer: Herpes Simplex Virus (HSV)
b) Name treatment options for this case with reason.
Medicinal
 Topical antiviral – Acyclovir (DOC) to reduce viral load
 Oral antiviral drugs – reduce viral load
 Topical antibiotics – prevent bacterial superinfection
 1% Atropine – relive pain
 Steroids are contraindicated because they cause recurrence
Surgical
 Debridement – reduce viral load
c) What is mechanism of corneal involvement?
 Primary infection with HSV
 HSV settle into trigeminal ganglion
 Reactivation of virus and it travels along nerve axon into target tissue (cornea)
Dendritic ulcer
Geographical ulcer
Superficial punctate keratitis
Disciform keratitis

2. A 35-year-old laborer who recently had typhoid fever of 2 weeks starts complaining of pain, watering, redness, photophobia from
the right eye. His vision of right eye is 6/18. Fluorescein stain shows a branching type of area on the cornea. [Annual 2013]
a) What is the diagnosis? Also gives its differential diagnosis.
Diagnosis: Herpes simplex keratitis (Dendritic Ulcer)
DDs:
 Toxic drug induced keratopathy

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 Marginal ulcer
 Herpes zoster ophthalmicus
 Acanthamoeba keratitis
b) Which stain would be used to help the diagnosis?
Rose Bengal stain & Fluorescein stain
c) What are different morphological types of this ulcer?
1. Epithelial Dendritic ulcer, Geographical ulcer
2. Stromal Necrotizing stromal keratitis
3. Endothelial Disciform keratitis

07. Herpes Zoster Ophthalmicus

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of Zoster (Shingles) i.e., Pain & maculo-papular / pustular eruptions on
forehead, upper eyelid & nose (unilateral)
 Upper lid swelling with ptosis + conjunctival congestion & photophobia +/–
decreased vision

1. A 50 years old patient presents with pain on the right side of forehead since, 2 days. His visual acuity is 6/6 in both eyes. On
examination there is upper lid swelling with moderate ptosis. Vesicular eruptions are seen on right forehead going to the scalp.
Anterior segment shows mild conjunctival congestion. (Annual 2021)
a) What is the most likely diagnosis?
Answer: Herpes Zoster Ophthalmicus
b) Write the ocular manifestations of this disease?
Corneal  Acute epithelial keratitis
 Micro-dendritic ulcer
 Filamentary keratitis
 Numullar keratitis (anterior stromal keratitis)
 Disciform keratitis
 Reduced corneal sensitivity
Scleral Episcleritis
Conjunctiva Acute follicular Conjunctivitis
Uveal tract Anterior Uveitis

c) What will be the treatment plan?

A. Ocular treatment Antiviral – Acyclovir is DOC, Antibiotics, Steroids, Atropine, Cyclosporine
B. Systemic treatment Antiviral, Antibiotics, Steroids, Analgesic, Cyclosporine

2. An elderly lady has developed macular-papular-pustular eruptions on the forehead, upper eyelid and tip of the nose for the last two
weeks in the right side of the face. She has also developed severe lids swelling, conjunctival redness and photophobia of right eye; her
vision in the affected eye is 6/24 with no improvement with pinhole. [Supple 2018 held in 2019]
a) What is the diagnosis?
Answer: Herpes zoster ophthalmicus (HZO)

09. Exposure Keratopathy

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of diabetes with facial palsy (unilateral) & inability to close eyelid
 Later, opacification of cornea +/– Redness in eye

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1. A 30-year-old male diabetic presents with sudden onset deviation of the face to right side and inability to close he lids on the left
side. He later presents with a painful red eye and whitening of the inferior cornea. [Annual 2017]
a) What is the most probable diagnosis?
Answer: Exposure keratopathy
b) Enumerate the clinical features of the disease.
1. Severe itching that worse in the morning
2. Whitening involving inferior third of the cornea
3. Ulcer and perforation
4. Reduced corneal blinking reflex
c) How will you manage this condition?
1. History Eyelid trauma, surgery, take history of thyroid problem
2. Ocular examination P lp br l ssur w th, ↓bl nk n r qu n y, ry y , proptos s
3. Investigation Thyroid function tests
4. Treatment A. Artificial tears
B. Treat the cause
 Tarsorrhaphy for Ectropion
 Facial Nerve decompression for Bell palsy
 Antithyroid drugs such as Propylthiouracil and Carbimazole for Graves diseases

10. Keratoconus

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of wearing & frequently changing glasses
 History of allergic conjunctivitis in teenage
 On examination, decreased vision in both eyes, cone shaped cornea with positive
s ssor‘s r l x.

1. A 26-year-old patient wearing glasses comes to your OPD and complains of decreased vision in both eyes. He has a history of
frequent change of glasses. He also has a history of allergic conjunctivitis during his teenage. Retinoscopy shows scissors reflex.
a) What is the most likely diagnosis?
Answer: Keratoconus
b) Enumerate four sings of this disease.
1. Munson's sign
2. Placido disc / Keratoscopy – irregular rings
3. Retinoscopy – scissors reflex
4. Slit lamp – Vertical Vogt' lines, Fleisher ring
5. Ophthalmoscopy – Oil droplet reflex
c) What are the treatment options?
1. Spectacles/Contact lens to correct refractive error
2. INTACS to flatten the cornea and to restore original round shape
3. Increase collagen cross linking by exposure to UV light & application of riboflavin
4. Hypertonic saline solution to treat hydrops
5. Keratoplasty

2. A 20 years old patient came to eye OPD with history of frequent change of glasses over the last two years. On examination, you
found cone-shaped cornea. [Annual 2018]
a) What is your diagnosis?
Answer: Keratoconus
b) Which tests will help you in confirming the diagnosis?
1. Corneal topography – Investigation of choice
2. Keratometry – egg shaped mires
3. Keratoscopy / Placido disc

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4. Retinoscopy
c) What is the pathophysiology of this disease?
Primary – Decreased collagen cross linking
Secondary – Allergic conjunctivitis  itching  eye rubbing and infection  Keratoconus

֍ORBIT֍

01. Anatomy & Physiology

Orbital Bones In Each Wall
Roof Lateral wall Floor Medial wall
 Lesser wing of  Greater wing of  Zygomatic bone  Maxillary bone
sphenoid sphenoid  Maxillary bone  Lacrimal bone
 Frontal bone  Zygomatic bone  Palatine bone  Ethmoid bone
 Sphenoid bone
Surgical Spaces In Orbit
Space Significance
Central space  Retrobulbar injection is given in this space
 Tumor in this space causes axial proptosis
Peripheral space  Peribulbar anesthsia is given in this space
 Tumor in this space causes non-axial proptosis
Subperiosteal space  In orbital cellulitis, pus collect in thus space & need surgical intervention
Subt non‘s sp  In cataract surgery, anesthetic agent is given in this space

02. Proptosis

1. A 40-year-old lady presents in the outdoor clinic with bilateral proptosis.

(a) What is the differential diagnosis?
1. Grave's eye disease – most common cause of bilateral proptosis
2. Cavernous sinus disease
(b) What investigations would you like to do for this patient in order to confirm the diagnosis?
1. CBC, ESR
2. T3, T4, TSH & Radioactive iodine uptake Scan
3. CT scan and MRI
4. Lipid profile
4. Urine test
5. ANA

2. List four causes of proptosis. [Annual 2006]

1. Orbital cellulitis
2. Grave's eye disease
3. Blow out fracture
4. Cavernous sinus thrombosis.

03. Orbital Cellulitis

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of fall (trauma) / bacterial sinus infection or URTI
 Restricted & painful eyeball movements + Proptosis + lid swelling & conjunctival
chemosis
 Vision usually not affected, if reduced, indicates associated optic neuritis
 Systemic signs e.g., Fever.

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1. A 10 years old child present with swelling and redness if the right eyelids. He has history of a fall. On examination, he cannot move
his eye to right or left and there is pupillary dilation of the right eye on swinging light test. Forward protrusion of right eye is seen.
a) what is the most likely diagnosis?
Answer: Orbital cellulitis
b) Name at least 4 investigations along with justifications.
1. CBC to evaluate body infection
2. CT scan and MRI to detect subperiosteal abscess and intracranial extension
3. B scan to detect intra-orbital abscess
4. Conjunctival swabs for culture and sensitivity
c) Name 4 most important complications.
1. Cavernous sinus thrombosis
2. Exposure keratopathy
3. Cranial nerve palsy (III, IV, V, VI)
4. Subperiosteal abscess
d) How will you manage this case?
 Medical  IV Antibiotics (Cefotazidime, Ciprofloxacin, Vancomycin), Analgesic and Anti-Inflammatory drugs
 Surgery  Incision and Drainage of abscess
n and Drainage of abscess
2. A 19 years old boy presents with painful protrusion of left eyeball. There is a recent history of acute sinusitis. On examination,
ocular motility is restricted and painful. There is conjunctival chemosis & vision is also reduced. Fundus examination reveals disc
edema. What is the most likely diagnosis?
(a) What is the most likely diagnosis?
03. Thyroid Eye Disease (Graves Ophthalmopathy)

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 Signs of thyrotoxicosis; profuse sweating, palpitations & weight loss
 Exophthalmos (proptosis) + Restricted eyeball movements (often bilateral)
 Upper lid retraction + staring, frightening look + conjunctival congestion

1. A 30 years old female presents with 3mm axial proptosis of the left eye. On examination, there is 3mm Upper lid retraction on
primary gaze and lid lag on down gaze. Extraocular movements are restricted in up gaze. Visual acuity is 6/6 in the affected eye.
[Annual 2021 held in 2022]
a) What is the most probable diagnosis?
Answer: Grave's eye disease
b) What investigation will you prescribe? Give their justifications.
1. T3, T4, TSH and Radioactive iodine uptake – Gr v ‘s s s
2. CT scan (investigation of choice) – enlargement of extraocular muscles
3. MRI – compression of optic nerve
c) Name ocular signs to look for in this case.
Sign Description
Dalrymple sign Lid retraction
Kocher sign Staring and Frightening look
Stellwag sign Infrequent blinking
Von Graffe sign Lid lagging
Mobius sign Restricted convergence movement
Joffroy sign Poor forehead wrinkling
Jellinek' sign Hyperpigmentation of lid
d) What is management at this stage of the disease?
1. Antithyroid drugs – Propyl-thiouracil, Carbimazole
2. Thyroidectomy
3. Artificial tears

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4. Methylprednisolone
5. Tarsorrhaphy

2. A 30-year-old female presents with painless axial proptosis of the right side. Her visual acuity is 6/6 unaided both sides. There is
upper lid retraction and lid lag on down gaze. She is not complaining of sudden onset diplopia. [Supple 2011 held in 2012]
(a) What is the most likely diagnosis?
Answer: Grave's eye disease
(b) What are the findings on CT scan of this orbit?
Answer: Thickening of extraocular muscles
(c) What is the cause of diplopia?
Answer; Restrictive myopathy by inflammation and fibrosis

04. Blowout Fracture

֍⸨Diagnostic Features by Team Medical Minds⸩֍

 History of RTA / blunt trauma on eye, followed by diplopia on upward gaze.
 Impaired sensations on cheeks + surgical emphysema (crepitus) of eyelids

1. A young motorcycle driver had a fight with a car driver after a road traffic accident, after a few hours the motorcycle driver feels
double vision in the up-gaze along with impaired sensations in the right cheek along with surgical emphysema in the lids of right eye.
a) Write relevant investigation; give details for investigations for diplopia.
For Fracture
 Plain X-Rays (W t r‘s V w) – Shows Tear Drop Sign.
 CT Scan and MRI
For Diplopia
 Hess Chart Testing – Useful in Recording Restriction of Ocular Movement and also to monitor the Response to Treatment
 Force Duction Test (Traction Test) – will show restriction of passive movements of the eye.
b) What is the diagnosis?
Blow-Out Fracture
c) What is the initial treatment?
 Observation
 Avoiding Nose Blowing
 Systemic Antibiotics – To prevent secondary infection from maxillary sinus
 Analgesics and Anti-Inflammatory – For pain and swelling relief
 Systemic Steroids – Required for severe orbital edema surrounding the optic nerve
d) What happens if condition is left untreated?
 Diplopia (Double) – In both UP and DOWN gaze
 Hemorrhage
 Orbital Cellulitis
 Enophthalmos
 Ptosis

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֍ PAST UHS MCQs & SAMPLE PAPER֍

01. Orbit

Sr# Statement Answer

1 Cause of axial proptosis is? Optic glioma
2 Eyeball moves forward, downward and laterally in? Frontal mucocele
3 A 16 years boy presented with fever, proptosis, painful eye and restriction of eyeball Orbital cellulitis
movement to right and left direction. RAPD was positive. Diagnosis?
4 Which bones form floor of orbit? Zygomatic + Maxillary + Palatine
bone
5 Lid lagging is sign of? Thyroid eye disease
6 What is the finding on CT scan in Grave's eye disease shows? Thickening of extraocular muscles
7 Cause of pulsatile proptosis is? AV fistula
8 Most serious complication of Orbital cellulitis is? Cavernous sinus thrombosis
9 A 20 years boy presented with complete paralysis of extraocular muscles, proptosis and Cavernous sinus thrombosis
swelling behind the ear. Diagnosis?
10 A 21 years man presents with grossly swollen eyelid. A few days before he had a Pre-septal cellulitis
pimple that his girlfriend popped with finger nail clippers. Since then, his eyelid is
swollen. Diagnosis?
11 Which antibodies are formed in Graves eye disease? IgG
12 What is the cause of Dalrymple sign in Grave's eye disease? Sympathetic overstimulation of
Muller muscle
13 Most common cause of bilateral proptosis is? Graves eye disease
14 Wh h o th ollow n s r sk tor or r v s‘ y s s ? Smoking
15 Management of patient suffering from orbital cellulitis includes? Hospitalization, CT scan & IV
Antibiotics
16 Most common cause of unilateral Proptosis in young adult is: D
a) Capillary Haemangioma
b) Lymphoma
c) Meningioma
d) Thyroid eye disease
e) Tuberculosis
17 A 40 years old female presented in OPD with feeling of grittiness, heaviness and pain E
behind the globe. She had palpitations and tremors in her hand too. Ocular examination
revealed mild restriction of up gaze and on down gaze her eyelid lacks behind the
globe. What is name of this sign?
a) Dalrymple sign
b) Kocher sign
c) Jaffrey sign
d) Munson sign
e) Von Graefe sign

02. Lacrimal Apparatus

18 Length of Nasolacrimal duct? 12 mm

19 Length of Lacrimal sac? 15 mm
20 When does the Tears production starts after delivery? 3rd – 4th week
21 Treatment of choice for congenital Nasolacrimal duct obstruction at age of 2 year? Probing
22 When does DCR performed? Wh n prob n l . At o ≈5
years
23 In DCR, channel is created between which two structures? Lacrimal sac and Nasal cavity

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24 Lacrimal glands are located in which bone? Frontal bone

25 Tear film has 3 layers. Thinnest layer is secreted by which glands? Conjunctival glands (Glands of
Henle and Manz)
26 Aqueous layer of tear film is secreted by which glands? Lacrimal glands and accessory
lacrimal glands
27 Cause of Lacrimal pump failure is? Facial nerve palsy (paralysis of
orbicularis oculi)
28 Painful swelling at medial canthus + Discharge? Acute Dacrocystitis
29 Most common site of congenital obstruction in Lacrimal drainage pathway? Lower end of Nasolacrimal duct
30 Cause of Lacrimal pathway obstruction is? Chronic dacryocystitis
31 Painless swelling of upper eyelid causing ptosis + epiphora and conjunctival chemosis, Chronic dacryoadenitis
Diagnosis?
32 Painless swelling on eyelid causing downward and inward movement of eyeball? Tumor of lacrimal gland
33 Most common cause of congenital NLD obstruction? Incomplete canalization
34 An 18 months old baby presented with congenital NLD obstruction. Treatment Probing and syringing
includes?
35 Thickness of mucus layer in tear film is? 0.2 µm
36 A woman presented with constant epiphora which is aggravated by exposure to wind, Repeated syringing with
with conjunctiva congestion and positive regurgitation test, a diagnosis of chronic instillation of antibiotics
dacryocystitis is made. Treatment? (DCR is done; if recurrence
occurs)
37 A 50 years old female presented in OPD with complaint of watering and pain in her A
right eye. On examination there was a tender swelling below the medial canthus of right
eye. What will be initial management of her condition?
a) Application of warm compresses and Oral Antibiotics
b) Incision and drainage
c) Probing and syringing
d) Dacryocystorhinostomy
e) Dacrycystectomy
38 A 50 years old patient presented in OPD with complaint of dryness, grittiness and A
redness which worsen towards the end of the day. To confirm the diagnosis of dry eye
tear film breakup time was noted. What is the minimum amount of time for the dry spot
appearance?
a) BUT less than 5 second
b) BUT less than 10 second
c) BUT less than 15 second
d) BUT less than 20 second
e) But less than 25 second

03. Eyelid

39 Tarsal plate contains which glands? Meibomian glands

40 Painless progressively increasing swelling on lower eyelid? Chalazion
41 Treatment of choice for Chalazion Triamcinolone acetonide or
Surgery
42 Painful swelling on lid margin with pus around hair follicle? Stye
43 Burning sensation in eyes in which disease of eyelid? Posterior Blepharitis
44 Treatment of choice for Anterior blepharitis? Topical antibiotics (Bacitracin)
45 Cryotherapy for Trichiasis is done at? Gray line at -60°C to -80°C
46 Eyeball is moved outward and downward + Ptosis? 3rd nerve palsy
47 Small sized pupil + Elevation of lower eyelid? Horner syndrome

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48 Normal marginal reflex distance is 4 mm

49 Treatment for 3rd nerve ptosis is? Treat cause + Wait for nerve
regeneration
50 Paralytic Ectropion is due to paralysis of which muscle? Orbicularis oculi
51 Procedure for cicatricial entropion is Tarsal rotation surgery
52 Modified sebaceous glands of eye are? Meibomian glands
53 In normal Bell phenomenon, eyeball moves ----- when lids are closed upward and outward
54 One of the important contra-indications for performing Sling Operation is? Absence of Bell's phenomenon
55 Most common tumor of upper eyelid is? Sebaceous gland carcinoma
56 Most common tumor of lower eyelid is? BCC
57 Most common location for BCC is? Lower eyelid
58 Painless progressively increasing swelling on upper eyelid causing narrowing of Mechanical ptosis (Ptosis due to
palpebral fissure. Diagnosis? Chalazion)
59 Sebaceous gland carcinoma simulates with which eyelid pathology? Chalazion
60 Lagophthalmos is seen in which of the following condition? 7th nerve palsy
61 A patient presented with Bilateral ptosis, with associated symptoms of difficulty in Myasthenia Gravis
speech and swallowing too. Diagnosis?
62 A 60 years old man comes with history of inward rolling of the upper lid margin. Involutional Entropion
Diagnosis?
63 A 65 years old lady comes to OPD with the complaint of very thick and disturbing eye D
lashes for a couple of years, which drugs do you suspect she has been using?
a) Levobunolol
b) Brimonidine
c) Dorzolamide
d) Latanoprost
e) Pilocarpine
64 A 30 years old male patient presented with complaint of mild drooping of right eyelid C
with decreasing vision. On history he complains about loss of sweating on one side of
the face too. His eye colors were also different in both eyes. What pharmacological test
can be done to confirm the final diagnosis?
a) Adrenaline 0.1%
b) Apraclonidine 4%
c) Cocaine 4%
d) Hydroxy amphetamine 1%
e) Phenylephrine 1%
65 A 25-year-old patient presents to the eye OPD with a painless, slowly enlarging lump A
on the upper eyelid for the past 3 weeks. There is no history of acute redness, fever, or
discharge. The patient reports mild heaviness of the lid but no significant pain. On
examination, there is a firm, non-tender, localized nodule away from the lid margin,
with overlying skin normal and no signs of acute inflammation.
a) Chalazion
d) Molluscum Contagiosum
b) keratocanthoma
e) Xanthelesma
c) Stye

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04. Conjunctiva

66 Follicles on bulbar conjunctiva are pathognomonic for? Trachoma

67 Drug of choice for Chlamydia (ophthalmia neonatorum) Azithromycin
68 Drug of choice for Gonorrhea (ophthalmia neonatorum) Cefotaxime
69 A newborn baby presented with mucopurulent discharge on day 4. Diagnosis? Gonorrhea
70 Triangular fibrovascular growth extending from conjunctiva to cornea in interpalpebral Pterygium
region?
71 Correct statement about Pinguecula? It is avascular
72 Treatment of choice for Xerophthalmia? Oral Vit A
73 Jaundice like symptoms + Joint pain + Papilledema? Hypervitaminosis A
74 A 14 years boy presented with redness of white eye, 6/6 vision and pertussis. Treatment This condition is Subconjunctival
for this patient? hemorrhage. So, Treat only
etiological factor (pertussis cough)
75 Treatment for Acquired melanosis? Excision
76 Treatment for malignant melanoma? Enucleation
77 Position of phlyctenule in Phlyctenular Keratoconjunctivitis is? 9 O' clock
78 A 10 years old patient presented in start of summer with giant papilla on palpebral Vernal Catarrh
conjunctiva and ropy secretions. Diagnosis?
79 Most important cause of keratoconus is? Vernal Catarrh
80 SAFE strategy treatment is recommended by WHO for? Trachoma
81 Where does corneal pannus forms? Between Epi and Bowman's
membrane (Subepithelial)
82 A poor man presented with vision problem. On eye examination there was a white line Trachoma
on Tarsal conjunctiva and a few depressions at limbus. Diagnosis? (Arlt‘s l n n H rb rt p ts)
83 A newborn baby presented with conjunctival chemosis, watering and discharge. Viral conjunctivitis
Diagnosis?
84 Adhesion between eyelid and globe is known as Symblepharon
85 Adhesion between palpebral and bulbar conjunctiva is known as Symblepharon
86 Adhesion between eyelids is known as Ankyloblepharon
87 Treatment of pterygium is Excision with conjunctival graft
88 Which of the following characteristics is true for pterygium? High recurrence
89 A child, physically weak, known case of malabsorption, presented with complains of Vitamin A deficiency
impaired vision, occasional lacrimation and photophobia. Diagnosis? (Xerophthalmia)
90 Best Preventive Measure for vernal catarrh is? Avoidance of allergens
91 A 12 years old boy presented in OPD with complaint of severe itching, watering, E
photophobia and foreign body sensation. The symptoms worsen in spring and summer.
On examination conjunctiva was red and velvety appearance. There were white dots
near limbus with some whitish opacity near upper cornea too. What is the most
probable diagnosis?
a) Acute Allergic conjunctivitis
b) Atopic conjunctivitis
c) Seasonal allergic conjunctivitis
d) Perennial Allergic conjunctivitis
e) Vernal kerato-conjunctivitis
92 A 30 years old male patient presented in OPD with complaint of sudden onset of E
redness, watering, sensitivity to light and grittiness in both eyes. There was nasal pain,
shortness of breath, cough and pain on eating and drinking too. On examination his he
has hemorrhagic crusting of lip margin and papillary conjunctivitis. There were blisters
around mouth, on tongue and oropharynx too. What Type of allergic reaction is present
in this disease?

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a) Type 1 hypersensitivity reaction

b) Type 2 hypersensitivity reactions
c) Type 3 hypersensitivity reaction
d) Type 4 hypersensitivity reactions
e) Both a and d both
93. A 20 years old poor boy presented in OPD with complaint of decreasing night vision, E
discomfort and irritation in his both eyes. On examination his vision was 6/36 and 6/24
in right and left eye. Ocular examination showed white foamy lesions on inter-palpabral
conjunctiva. What is the most likely diagnosis?
a) Band keratopathy
b) Exposure keratopathy
c) Keratomalacia
d) Lipid keratopathy
e) Xerophthalmia

05. Sclera

94 Most common type of scleritis is? Diffuse type (anterior scleritis)

95 Most common etiological factor for scleritis? Rheumatoid arthritis
96 2.5% Phenylephrine blanches which vessels? superficial episcleral vessels
97 Thickness of sclera is 0.3 --- 1 mm
98 Sclera is weakest and thinnest at? Just behind the equator (0.3 mm)
99 Thickness of sclera at limbus is 0.8 mm
100 B scan shows T sign in which type of scleritis? Posterior scleritis
101 Treatment for Anterior scleritis is? Steroids, Immunosuppressive
therapy
102 A patient presented with joint pain, temporal pain, redness of white eye and no Scleritis
blanching of vessels with phenylephrine. What is the diagnosis?
103 Sclera is relatively? Avascular

06. Cornea

104 Thickest layer of cornea is? Stroma

105 Layer of cornea that determines dehydration? Endothelium
106 Layer of cornea responsible for maintaining corneal transparency? Endothelium
107 Most of the eye diopter power is provided by? Cornea (43 Diopters)
108 Basement membrane of Corneal Endothelium is D s m t‘s m mbr n
109 Which bacteria invade cornea through intact epithelium? Neisseria gonorrhea, Neisseria
meningitidis and Corynebacterium
Diphtheriae
110 Line of demarcation around lesion is formed in which stage of bacterial corneal Regressive stage
ulcer?
111 How to distinguish between corneal ulcer and corneal opacity/corneal abscess? Fluorescein stain
(Corneal ulcer takes up stain)
112 Most serious complication of bacterial corneal ulcer is? Perforation
113 Adhesion between cornea and iris is which complication of bacterial corneal ulcer? Leucoma adherent
114 Ectatic cornea anteriorly lined by the iris is known as? Anterior staphyloma
115 Treatment for corneal fistula is? Full thickness Keratoplasty
116 Treatment for Leucoma is? Full thickness keratoplasty
117 Treatment for Bullous keratopathy? Endothelial keratoplasty
118 Which layer of cornea is damaged in Bullous keratopathy? Endothelium

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119 Drug of choice for Acanthamoeba keratitis? Chlorhexidine or Poly-

hexamethylene biguanide
120 History of contact lens wearing + peripheral neuritis? Acanthamoeba keratitis
121 A former presented after ocular injury. Examination shows yellow stellate lesion. Fungal keratitis
Diagnosis?
122 A 20 years boy presented with complain of painful vesicles on forehead and Herpes zoster ophthalmicus
punctate epithelial keratitis. Diagnosis?
123 In which corneal pathology, corneal blinking reflex is absent? Herpes zoster ophthalmicus
124 A 19 years boy presented with palpitations, heat intolerance and slight eye Exposure keratopathy due to Graves
protrusion. On eye examination, there is whitening involving the inferior third of eye disease
the cornea. Diagnosis?
125 A female presented with complain of saliva dribbling, deviation of angle of mouth Exposure keratopathy due to Facial
on left side. She told about itching in her eyes which worse in the morning. palsy
Diagnosis?
126 Drug of choice for Herpes simplex keratitis? Acyclovir
127 Which drug is contraindicated for Herpes simplex keratitis treatment? Steroid because it causes recurrence
128 Three main principles of treatment for Fungal keratitis? Antifungal + 1% Atropine +
Debridement
129 Schwalbe' line is the anterior limit of Descemet
membrane
130 Most prominent sign of Disciform keratitis? Stromal edema
131 Chronic painful marginal corneal ulcer + Advancing raised edges. Diagnosis? Mooren' ulcer
132 Munson sign is seen in? Keratoconus
133 Vogt' line on slit lamp examination are seen in which disease? Keratoconus
134 Band shaped keratopathy is due to ____ degeneration Calcareous
135 Blood supply of cornea? Anterior ciliary artery
136 Investigation of choice for Keratoconus? Corneal topography
137 Drug of choice for Fungal keratitis? Natamycin
138 A 20 years old patient presents with decreased vision in both eyes. Examination A
shows bilateral interstitial keratitis with Salmon Patch appearance. What is the
diagnosis?
A. Syphilis
B. Herpes Zoster
C. Herpes Simplex
139 A 20 years old girl whose right eye was injured by a tree branch. Now complains of B
pain in the eye. Examination shows a 4mm circular yellow lesion in the center of
her cornea. What is the Investigation of choice?
A. Biopsy
B. Scraping
C. Swabs
140 A comatose patient lying on bed with open eyes. Complication that can arise? Exposure keratopathy
141 A female, contact lens wearer presented with bacterial corneal ulcer. What should Antibiotic + Discontinue contact
be the treatment? lens wearing
142 Number of Corneal Endothelial cells in young adults are? 3000
143 One of the slit-lamp examination finding of keratoconus is? Acute Hydrops (Aqueous in cornea)
144 A young male who recently had flu starts complaining of pain, watering, redness, HSV Keratitis
photophobia from the right eye. His vision of right eye is 6/18. Fluorescein stain
shows branching type of area on cornea. Diagnosis?
145 Best treatment for keratoconus is? Keratoplasty
146 A 20 years old boy presented in OPD with complaint of repeated changes in B
glasses. On Examination his vision was 6/24 in right eye and 6/36 in left eye. On

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extra ocular movements his lower eyelid bulges out on down gaze. On Anterior
segment examination his cornea showed some striations with thinning. What could
be the most probable diagnosis?
a) Keratoglobus
b) Keratoconus
c) Keratomalasia
d) Magalocornea
e) Micronea
147 A 20 years old female patient presented in OPD with complaint of pain, C
photophobia, and purulent discharge since last 1 day. Her symptoms start after
removing the contact lens and worsening since then. On examination there was a
there was corneal ulcer with hypopyon and Plaque like keratic precipitate. What
could be the most probable organism responsible for her condition?
a) Acanthamoeba
b) Candida
c) Pseudomonas
d) Staphylococci
e) Streptococci

֍ PRACTICE MCQs֍

01. Orbit

1. A 40-year-old female patient with bilateral mild proptosis complains of diplopia and foreign body sensation. She has mild tremors
with tachycardia. Visual acuity is normal. Most probable diagnosis is?
a) Cavernous sinus thrombosis c) Optic nerve tumor
b) Orbital cellulitis d) Inflammatory orbital disease
e) Thyroid eye disease
2. A 40-year-old male sustained a head injury after a motorcycle accident. Which feature is highly suggestive of a fracture of the floor
of the orbit?
a) Conjunctival chemosis c) Proptosis
b) Infraorbital hypoesthesia d) Periorbital lid edema
e) Limited horizontal movement
3. An 8-year-old boy presented with unilateral swelling of the right eye for the last three days. He had a high-grade fever with
vomiting. Visual acuity was normal but color vision was slightly reduced. The most probable diagnosis is?
a) Capillary Hemangioma c) Optic Nerve Glioma
b) Orbital Cellulitis d) Stye
e) Pre-septal Cellulitis
4. ENT department has sent a consultation to ophthalmology for a 6 years old child who has bacterial sinus infection. Examination
findings include marked pyrexia, and unilateral reduced vision, tender and worm eyelids, chemosis and proptosis and painful,
restricted eye movements. What is your diagnosis?
a) Endophthalmitis d) Grave's ophthalmopathy
b) Panophthalmitis e) Cavernous sinus disease
c) Orbital cellulitis
5. Which of the following sequelae of a carotid cavernous sinus fistula is the most common cause of visual disability?
a) Strabismus c) Orbital compression
b) Proptosis with corneal exposure d) Spontaneous choroidal detachment
e) Elevated intraocular pressure with progressive optic nerve damage
6. During a consultation in the emergency room, you are asked to see a patient with non-infected second-degree burns to the eyelids.
The emergency room physicians ask what topical medicine should be placed on the burns to prevent scarring. What would the most
appropriate response be?
a) Gentamicin in a water-miscible base b) Hydrocortisone 1% ointment

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c) Silver sulfadiazine 1% cream d) None of the above

e) No topical medications
7. What are the 2 most commonly affected rectus muscles in thyroid eye disease?
a) Superior and inferior c) Superior and medial
b) Medial and lateral d) Inferior and medial
e) None of these
8. A 42-year-old man presented with watering and redness of the right eye for the last 6 months. On examination, there was restricted
extraocular movements with lid lag and scleral show. The patient was found to have proptosis. What is the best way to measure the
amount of his proptosis?
a) B-scan ultrasonography c) Magnetic Resonance Imaging (MRI)
b) Computed Tomography (CT) d) Exophthalmometry
e) Corneal topography
9. A 7-year-old boy developed pain and swelling of the right orbital region for 3 days. He has a history of sinusitis for 1 week. On
examination, he has right proptosis with reduced ocular motility and conjunctival chemosis. His vision is 6/36 in the right eye. What is
the most appropriate treatment in this patient?
a) Systemic antibiotics c) Topical antibiotics
b) Systemic steroids d) Topical steroids
e) Topical cycloplegics
10. A young boy having history of head injury presents with bilateral protrusion of eye balls. Conjunctiva is chemosed. There is bruit
on the globe and he complains of tinnitus. The most probable cause can be:
a) Subdural haematoma c) Carotid-cavernous fistula
b) Bleed in 3rd ventricle d) Tolosa-Hunt syndrome
e) Carotid artery aneurysm
11. All of the following can cause proptosis except:
a) Optic nerve tumor c) Orbital varix
b) Orbital cellulitis d) Orbital blowout fracture
e) Rhabdomyosarcoma
12. A 13 years old boy is brought to an ophthalmologist with pain and diffuse swelling of right upper lid. On examination the boy is
febrile and the upper lid area is red, swollen and tender. What is the most likely diagnosis?
a) Amyloidosis of the lids c) Posterior Blepharitis
b) Pre-septal Cellulitis d) Seborrheic Blepharitis
e) Ulcerative Blepharitis
13. Axial Proptosis occurs in:
a) Frontal mucocele c) Maxillary carcinoma
b) Lacrimal gland tumors d) Orbital floor fracture
e) Thyroid ophthalmopathy
14. A 40 years old female comes to the eye OPD with prominent eyes, grittiness and foreign body sensations in her both eyes for the
last 6 months. On examination, there is bilateral asymmetrical axial proptosis with lid retraction and lid lag. CT-Scan shows
enlargement of recti muscles. Which is the most probable diagnosis?
a) Cavernous haemangioma c) Orbital cellulitis.
b) Orbital pseudotumour d) Optic nerve meningioma
e) Thyroid eye disease.
15. Orbital Cellulitis:
a) Does not cause motility disturbance c) Gentamycin is an appropriate antibiotic
b) Frequently causes intracranial infection in children d) Is most frequently caused sinus infection
e) Is usually not accompanied by fever
16. Pulsating proptosis is seen in
a) Orbital varicose vein c) Cavernous sinus thrombosis
b) Arteriovenous aneurysm d) Thyrotoxicosis
e) CNS Tumor
17. Ultrasonography is helpful in confirming the diagnosis of:
a) Central retinal artery occlusion b) Central retinal vein occlusion

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c) Retinitis pigmentosa d) Subluxated clear crystalline lens

e) Thyroid Ophthalmopathy
18. A patient presented with unilateral proptosis which was compressible and increases on bending forward. No thrill or bruit was
present. MRI shows a retro-orbital mass with enhancement. The likely diagnosis is:
a) AV malformations c) Neurofibromatosis
b) Fracture roof the orbit d) Orbital varix
e) Orbital encephalococle
19. 70 years old hypertensive lady is brought by her relatives to casualty medical officer with increasing confusion and severe
headache. Her pulse is 90/min and her BP is 240/120mmHg. She knows her name but does not recognise that she is in the hospital. On
examination she has slight Neck rigidity but her temperature is 98.6 F. Her right pupil is semi dilated but ocular movements are
normal. She is admitted for control of her blood pressure. After 1 hour she develops right ptosis and on lifting the eye lid the right eye
is abducted. After an another 1 hour she drifts into coma and uncomplicated repeated lumbar punctures reveals numerous RBCs in
CSF. The likely diagnosis is an expanding and leaking aneurysm in:
a) Frontal lobe c) Occipital lobe
b) Inter-penduncular fossa d) Parietal lobe
e) Temporal lobe
20. A 45 year old diabetic patient with a HbAlc of 14.5% develops a boil on left side of nose. 2 days later he presents with pain,
chemosis and decreased vision in the left eye, he also had severe headache, nausea and vomiting. On examination his Visual acuities
are 6/6 right and counting fingers Left. The left eye movements are restricted in all gazes and there is numbness in the upper divisions
of the 5th nerve. His left pupil is mid dilated and also has a left relative afferent pupillary defect. On fundoscopy the left optic nerve is
swollen. His body temperature is 101F. After 24 hours the right eye develops similar features. The likely diagnosis is:
a) Pharyngoconjunctival fever c) Orbital Cellulitis
b) Cavernous sinus Thrombosis d) Pre-septal Cellulitis
e) Tolosa Hunt Syndrome
21. A child has had recurrent episodes of right earache and discharge along with fever for the last 1 year. For last 2 days he has
developed ipsilateral periorbital pain, ipsilateral failure of abduction of right eye and ipsilateral weakness of facial muscles. The most
likely site of infection is:
a) Cavernous sinus infection c) Orbital Cellulitis
b) Frontal Sinusitis d) Petrous part of Temporal bone
e) Sphenoidal sinusitis
22. The most common cause of proptosis is:
a) Orbital hemorrhage c) Orbital tumor
b) Orbital infection d) Orbital pseudo-tumor
e) Thyroid ophthalmopathy
23. In children the common association of orbital cellulitis is with:
a) Meningitis c) Measles
b) Paranasal sinusitis d) Septicemia
e) Retinoblastoma
24. Swelling behind the ear is diagnostic of
a) Cavernous sinus thrombosis c) Unilateral proptosis
b) Orbital cellulitis d) Bilateral proptosis
e) CNS Tumor
25. The most dangerous complication of orbital cellulitis is
a) Abscess formation c) Diplopia
b) Proptosis d) Cerebral involvement
e) Malignant transformation

ANSWER KEY
1. E 2. B 3. B 4. C 5. E 6. E 7. A 8. D 9. A 10. C
11. B 12. B 13. E 14. E 15. D 16. B 17. D 18. D 19. B 20. B
21. D 22. E 23. B 24. A 25. D

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1. A 40-year-old female with bilateral mild proptosis, diplopia, foreign body sensation and systemic features (tremors, tachycardia)
su sts Gr v s‘ s s w th thyro y nvolv m nt. Thyro y s s s n uto mmune condition causing inflammation and
enlargement of extraocular muscles and orbital fat. This leads to bilateral or asymmetric proptosis, restrictive diplopia, lid retraction
and exposure symptoms. Visual acuity is usually normal in early disease. Other options like orbital cellulitis or tumors are usually
unilateral, painful or associated with neurological deficits.
2. Orbital floor (blow-out) fracture commonly injures the infraorbital nerve running in the infraorbital canal. This produces numbness
over the cheek, upper lip and upper gingiva. It is the most specific clinical sign of orbital floor fracture. Other findings like periorbital
edema, chemosis and proptosis are nonspecific trauma-related features, while motility restriction is variable depending on muscle
entrapment.
3. An 8-year-old child with fever, painful unilateral orbital swelling, proptosis, restricted ocular movements and reduced color vision
suggests orbital cellulitis. It is usually secondary to sinusitis. Key features include pain on eye movement, proptosis, chemosis and
possible optic nerve involvement. Preseptal cellulitis does not affect vision or ocular movements. Tumors are chronic and not febrile.
5. In carotid-cavernous fistula, arterial blood enters the cavernous sinus causing raised episcleral venous pressure. This leads to
secondary open-angle glaucoma. Chronic raised intraocular pressure causes optic nerve damage, which is the main cause of visual
loss. Proptosis and chemosis are early findings but vision loss occurs due to glaucoma.
6. Non-infected second-degree eyelid burns are managed conservatively with lubrication, cleaning and protection. The eyelid skin is
delicate, so topical agents like silver sulfadiazine or antibiotics may be harmful or delay healing. Steroids are not indicated in acute
burns. Supportive care is preferred.
7. The most commonly involved extraocular muscles in thyroid eye disease are inferior rectus and medial rectus. Inferior rectus
involvement causes limitation of elevation and vertical diplopia. Muscle enlargement is due to autoimmune inflammation and
glycosaminoglycan deposition. Lateral rectus is least commonly involved.
8. Exophthalmometry is the gold standard for measuring proptosis. It quantifies anterior globe displacement relative to the lateral
orbital rim. CT and MRI identify causes but do not provide standardized measurements of proptosis.
9. Orbital cellulitis requires immediate intravenous broad-spectrum antibiotics. It is a medical emergency due to risk of vision loss and
intracranial spread. Common pathogens include Staphylococcus and Streptococcus species. Steroids are considered only after
infection control.
10. Carotid-cavernous fistula occurs due to abnormal communication between carotid artery and cavernous sinus, usually after trauma.
It causes pulsatile proptosis, chemosis, ocular bruit, raised intraocular pressure and tinnitus due to venous arterialization.
11. Orbital cellulitis causes inflammatory swelling with proptosis but is not a true space-occupying lesion. Tumors, varix, fractures
and rhabdomyosarcoma are structural causes of proptosis. The question is inconsistently framed but cellulitis is not a typical mass
lesion cause.
12. Preseptal cellulitis is an infection anterior to the orbital septum causing eyelid swelling, redness, pain and fever. Eye movements,
vision and globe position are normal. Orbital cellulitis would show proptosis, pain on movement and motility restriction.
13. Axial proptosis occurs when a lesion is within the muscle cone pushing the globe straight forward. Thyroid eye disease is the most
common cause due to symmetrical enlargement of extraocular muscles.
14. CT s n shows nl r m nt o xtr o ul r mus l s w th t n on sp r n , wh h s typ l o Gr v s‘ orb top thy. Cl n l tures
include lid lag, lid retraction, proptosis and diplopia due to restrictive myopathy.
15. Orbital cellulitis most commonly results from paranasal sinus infection, especially ethmoidal sinusitis. It presents with fever,
painful ophthalmoplegia, proptosis and possible intracranial complications. It requires urgent intravenous antibiotics.
16. Pulsating proptosis is seen in high-flow vascular lesions such as arteriovenous malformations or fistulas. These conditions transmit
arterial pulsations to the orbit. Orbital varix causes compressible proptosis but not true pulsation.
17. B-scan ultrasonography helps in identifying intraocular structural abnormalities such as subluxated lens. It is especially useful
when ocular media is opaque and direct visualization is not possible.
18. Orbital varix is a venous malformation that is compressible and increases in size on bending forward or Valsalva maneuver due to
venous filling. It is non-pulsatile and does not have bruit.
19. Posterior communicating artery aneurysm compress s th o ulomotor n rv l n to ptos s, pup ll ry l t t on n ― own n
out‖ y pos t on. Ruptur l s to sub r hno h morrh w th RBCs n CSF n n urolo l t r or t on.
20. Cavernous sinus thrombosis occurs due to spread of infection from facial region, especially in uncontrolled diabetes. It causes
bilateral orbital signs, cranial nerve palsies, optic nerve involvement, fever and systemic toxicity.
21. Petrous apex infection causes triad of otitis media, abducens nerve palsy and trigeminal nerve pain. It localizes infection to petrous
temporal bone.
22. Thyroid eye disease is the most common cause of proptosis worldwide. It is autoimmune in nature and causes bilateral
enlargement of extraocular muscles and orbital fat.

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23. Ethmoidal sinusitis is the most common cause of orbital cellulitis in children due to thin orbital walls allowing spread of infection.
24. It may present with venous congestion signs including postauricular swelling due to venous drainage pathways. It is associated
with cranial nerve palsies and severe systemic illness.
25. The most dangerous complication of orbital cellulitis is intracranial spread leading to meningitis, brain abscess or cavernous sinus
thrombosis, which significantly increases mortality.

02. Lacrimal Apparatus

1. In Dacryocystorhinostomy (DCR) operation the window is made in the lateral nasal wall is at the:
a) Ethmoidal sinus c) Superior meatus
b) Middle meatus d) Inferior meatus
e) Lacrimal fossa
2. A patient of 45 years old presented with facial palsy. The epiphora in this patient was due to:
a) Ectropion c) Entropion
b) Lacrimal pump failure d) Lagophthalmos
e) Hypersecretion of tears
3. What is the most common organism implicated in dacryocystitis?
a) Non-septate fungi c) Gram-positive bacteria
b) Gram-negative bacteria d) Anaerobes
e) Septate fungi
4. A 40-year-old woman with rheumatoid arthritis takes oral steroids. She presents with watering of both eyes associated with
intermittent blurred vision when using a computer. What is the most likely diagnosis?
a) Cataract c) Dry eyes
b) Diabetic retinopathy d) Glaucoma
e) Transient ischaemic attack
5. The sequela of chronic dacryocystitis includes
a) Lacrimal abscess c) Panophthalmitis
b) Atonic sac d) Lacrimal fistula formation
e) All of the above
6. Dacryocystorhinostomy is done for:
a) Cataract c) Chronic dacryocystitis
b) Ectropion d) Acute dactyoscnitis
e) Acute orbital cellulitis
7. All the following are serous acinous glands EXCEPT
a) Lacrimal gland c) Meibomian gland
b) Glands of Krause d) Salivary gland
e) Glands of Wolfring
8. Nasolacrimal duct opens in:
a) Inferior meatus c) Middle meatus
b) Inferior turbinate d) Middle turbinate
e) Superior meatus
9. Epiphora occurs in
a) Iritis c) Chronic dacryocystitis
b) Trachoma d) Acute congestive glaucoma
e) Corneal foreign body
10. A patient of 45 years old presented with facial palsy. The epiphora in this patient was due to:
a) Ectropion c) Hyper secretion of tears
b) Entropion d) Lacrimal pump failure
e) Lagophthalmos
11. A 54-year-old woman presents with a persistent watery left eye for the past 4 days. On examination there is erythema and swelling
of the inner canthus of the left eye. What is the most likely diagnosis?
a) Blepharitis b) Meibomian cyst
b) Acute angle closure glaucoma d) Dacryocystitis
e) Pinguecula

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12. A 6-month-old baby presents with swelling at the left medial canthal area for two days. On palpation, the swelling is soft and
tender. What should be the treatment of this patient?
a) Topical antibiotics c) Local massage
b) Topical steroids d) Probing under GA
e) Intubation of canaliculi

ANSWER KEY
1. B 2. B 3. C 4. C 5. E 6. C 7. C 8. A 9. E 10. D
11. D 12. C

1. In Dacryocystorhinostomy (DCR), the surgical window is created in the lateral nasal wall at the level of the middle meatus. This
area provides direct access to the lacrimal sac region and allows drainage of tears into the nasal cavity. The inferior meatus is where
the nasolacrimal duct normally opens, but DCR bypasses this obstruction by creating a new drainage pathway into the middle meatus.
2. In facial palsy, epiphora occurs mainly due to lacrimal pump failure. Normally, blinking helps pump tears through the canaliculi
into the lacrimal sac, but facial nerve palsy disrupts orbicularis oculi function. This leads to poor tear drainage and watering. Ectropion
and lagophthalmos may contribute, but the primary mechanism is pump failure.
3. The most common organisms causing dacryocystitis are Gram-positive bacteria, especially Staphylococcus species and
Streptococcus pneumoniae. These organisms colonize the stagnant infected lacrimal sac due to nasolacrimal duct obstruction. Gram-
negative and fungal infections are less common and usually occur in immunocompromised states.
41. A rheumatoid arthritis patient on steroids with watering and intermittent blurred vision on computer use most likely has dry eye
disease. Autoimmune disease and prolonged screen use reduce tear film stability, leading to evaporative dryness. This causes reflex
tearing (paradoxical epiphora) and intermittent visual blur.
5. Chronic dacryocystitis can lead to multiple complications including lacrimal abscess formation, atonic lacrimal sac due to chronic
distension, panophthalmitis due to spread of infection, and formation of lacrimal fistula. Therefore, all listed options are recognized
sequelae of untreated chronic infection.
6. Dacryocystorhinostomy is performed in cases of chronic dacryocystitis due to nasolacrimal duct obstruction. It creates a bypass
drainage pathway from lacrimal sac to nasal cavity. It is not indicated for cataract, ectropion, acute dacryocystitis, or orbital cellulitis.
7. Meibomian glands are sebaceous (holocrine) glands, not serous acinous glands. Lacrimal gland, glands of Krause, Wolfring, and
salivary glands are serous in nature. Therefore, Meibomian gland is the exception.
8. The nasolacrimal duct opens into the inferior meatus of the nasal cavity. It drains tears from the lacrimal sac into the nasal cavity
beneath the inferior turbinate. This explains why tears drain into the nose and cause nasal irritation during crying.
9. Epiphora occurs when there is either obstruction of tear drainage or reflex hypersecretion. Conditions like chronic dacryocystitis,
trachoma (causing cicatricial changes), acute congestive glaucoma (reflex tearing), and corneal foreign body can all lead to excessive
tearing. Iritis is less commonly associated compared to others.
10. In facial palsy, epiphora is mainly due to lacrimal pump failure. Loss of orbicularis oculi function prevents normal pumping of
tears through the canaliculi, leading to tear stagnation and overflow. Ectropion and lagophthalmos may contribute but are secondary
mechanisms.
11. A 54-year-old woman with watery eye and swelling at the inner canthus most likely has acute dacryocystitis. It presents with pain,
erythema, swelling over the lacrimal sac area and epiphora due to nasolacrimal duct obstruction with secondary infection. Blepharitis
and meibomian cyst involve eyelids, not medial canthus swelling.
12. A 6-month-old infant with soft, tender swelling over the medial canthus most likely has congenital nasolacrimal duct obstruction.
Initial treatment is conservative with Crigler lacrimal sac massage, which helps open the membranous obstruction at the distal duct.
Probing is usually reserved for persistent cases after 1 year of age.

03. Eyelid

1. A 26-year-old patient presents with watery eyes, a foreign body sensation, and intolerance to light. On examination, lid margins are
swollen with whitish dandruff-like material on the lash margins. What is the other systemic association with this disorder?
a) Rashes on face c) Photosensitivity
b) Varicose veins d) Scalp dandruff
e) Hair discoloration

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2. A 20 years old university student is told by her friend that she has right upper eyelid small swelling. The swelling is located on the
outer part of the lid away from the lid margin. It is felt better than seen and is nontender and firm in consistency. Now that she is
aware and conscious of it, she wants proper management for the problem. What is the diagnosis?
a) Chalazion c) Dacryocystitis
b) Stye d) Hordeolum internum
e) Blepharitis
3. A 15-year-old boy presents to the eye OPD with severe ptosis and poor levato function the best treatment option is?
a) Inferior tarsal muscle surgery c) Sling/Frontalis surgery
b) Levator muscle resection d) Levator aponeurosis surgery
e) Muller muscle surgery
4. A 60-year-old woman with leprosy came to the ophthalmology department for a routine eye checkup. On examination, you notice
the presence of madarosis. What does this term mean?
a) Thickening of lashes c) Loss of eyelashes
b) Whitening of lashes d) Broken lashes
e) Thinning of eyelashes
5. A gentleman develops severe pain in lower lid. On eversion of lower lid, a yellowish focal area posterior to grey lid extending in a
streak downward on Conjunctival side, got better with treatment in 7 days. What is the diagnosis?
a) Chalazion c) Dacryocystitis
b) Stye d) Hordeolum internum
e) Blepharitis
6. Eyelid margin anatomy distortion and loss of eyelashes should alert one to the possibility of why following?
a) Facial nerve (VII) palsy c) Involutional ectropion
b) Chronic eyelid webbing d) Malignancy
e) Senile changes
7. A 2 Years old male child is brought to you with complaint of drooping of right eyelid since birth that his eye is half open during
sleep as well there is absent lid crease amblyopia and poor elevator further what is the most likely diagnoses.
a) Congenital Ptosis c) Aponeurotic Ptosis
b) Jaw winking ptosis d) Traumatic Ptosis
e) Myasthenia Gravis
8. A young lady with blepharitis presents with a swelling on the right upper lid for the last one month commonest painless lid swelling
is:
a) Chalazion c) Cellulitis
b) Stye d) Zeiss Cyst
e) Moll Cyst
9. The operation of plication of inferior lid retractors is indicated in:
a) Senile ectropion c) Cicatricial entropion.
b) Senile entropion d) Paralytic entropion
e) Congenital entropion
10. 25 Years old female had a trauma to the right lower lid. Now she is unable to close the right eye fully the lower eyelid margin is
rotated outward and there is scar mark 2mm below the lower eyelid. What's the likely diagnosis?
a) Congenital ectropion c) Paralytic ectropion
b) Cicatricial ectropion d) Senile ectropion
e) Traumatic entropion
11. Fasanella Servat operation is specifically indicated in:
a) Congenital ptosis c) Myasthenia gravis
b) Steroid induced ptosis d) Horner's syndrome
e) Aponeurotic (involutional) severe ptosis with poor levator function
12. A 25-year-old male comes to the clinic with a 3-day history of painful swelling on his right upper lid margin. On examination,
there is blepharitis with a red, tender upper eyelid and an infected eyelash. What is your most probable diagnosis?
a) Chalazion c) Dermoid Cyst
b) Haemangioma d) Papilloma
e) Stye

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13. A 13-year-old boy is brought to an ophthalmologist with pain and diffuse swelling of the right upper lid. The boy is febrile and the
upper lid area is red, swollen, and tender. The eye is white. What is the most likely diagnosis?
a) Amyloidosis of the lids c) Preseptal cellulitis
b Seborrheic blepharitis d) Ulcerative blepharitis
e) Posterior Blepharitis
14. Distichiasis is:
a) An extra row of eyelashes c) Central fusion of eyelid
b) Absence of lashes d) Distorted lid margin
e) White coloured lashes
15. The neurogenic cause of ptosis is?
a) Myasthenia gravis c) Third nerve palsy
b) Blepharophimosis d) Fourth nerve palsy
e) Sixth nerve palsy
16. Which of the following surgical instruments is used in Chalazion surgery?
a) Scoop c) Vanna scissor
b) Wire vectus d) Artery forceps
e) Punch
17. Which of the following sutures is not routinely used in ophthalmology?
a) Vicryl c) Silk
b) Catgut d) Nylon
e) Punch
18. A 30-year-old man presents to the Eye OPD with diplopia and bilateral droopy eyelids which worsen in the evening. There is also
a history of fatigability. On examination, his visual acuity is 6/6 in both eyes. Anterior and posterior segment examination is
unremarkable. There is bilateral ptosis partially obstructing the visual axis and 20 prism diopter esotropia. Which of the following
tests would you perform next?
a) Chest X-ray c) Ice pack test
b) CT head d) MRI brain
e) Serum antibodies
19. A 50-year-old man presented to you with watering and redness in both eyes for the last year. He had a previous history of
cicatricial conjunctivitis. On examination, you found inward rotation of the lower eyelids. What is your diagnosis?
a) Lower lid ectropion c) Lower lid epiblepharon
b) Lower lid entropion d) Lower lid ptosis
e) Lower lid trichiasis
20. A 70-year-old man presents to you with a mass on the left lower eyelid for 10 years. On examination, there is a well-circumscribed
mass on the lower eyelid with rolled edges and central ulceration. You are suspecting basal cell carcinoma (BCC). What is the most
common complication that can be expected in this patient?
a) Hematogenous metastasis to the brain c) Hematogenous metastasis to the lungs
b) Hematogenous metastasis to the liver d) Local invasion of skull and CNS
e) Lymphatic metastasis
21. A 19-year-old boy presents to your clinic with droopy eyelids on the right side. Visual acuities are 6/5 in the right eye and 6/6 in
the left eye. On examination, there is mild right ptosis. On slit lamp examination, you notice that the iris is slightly lighter in color on
the right side. What is your diagnosis?
a) Aponeurotic ptosis c) Congenital Horner syndrome
b) Blepharophimosis syndrome d) Congenital myogenic ptosis
e) Neurogenic ptosis
22. A 20 years old male presented with painful swelling on the upper eyelid margin for the last two days. Lesion is red and edematous
and tender to touch. What is the most likely diagnosis?
a) Chalazion c) Stye
b) Lipoma d) Dermoid cyst
e) Cyst of Zeiss
23. In case of entropion all are true except:
a) Cicatricial pemphigoid b) Congenital

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CHAPTER 4 © 5th Edition MODULE 26: EYE & ENT-I

c) Acute spastic d) Conjunctival scarring

e) Facial nerve palsy
24. Tarsorrhaphy is indicated in which of the following nerve palsy:
a) Second c) Fourth
b) Third d) Sixth
e) Seventh
25. Ectropion can be treated by all of the following procedures EXCEPT:
a) V-Y operation c) Kuhnt-Szymanowski operation
b) Skin muscle resection d) Skin graft
e) Fasanella-Servat operation
26. Distichiasis is:
a) Absent eyelashes c) Long eyelashes
b) Accessory row of lashes d) Misdirected eye lashes
e) Thick eyelashes
27. Surgery of choice in cases where multiple ptosis operations have failed and levator action is poor
a) Fascia lata sling surgery c) Levator resection
b) Skin muscle resection d) Fasanella-Servat operation
e) Mull r‘s mus l onjun t v l r s t on
28. Internal hordeolum is an acute suppurative inflammation of:
a) Zeis's gland c) Moll's gland
b) Meibomian gland d) Sweat glands
e) None of these
29. Exophthalmos associated with thyroid ophthalmopathy have following clinical signs except:
a) Proptosis c) Lid retraction
b) Ptosis d) Conjunctival chemosis
e) Extraocular muscle thickening
30. A 60-year-old man presents with a 1-week history of painless diplopia which he first noticed when reading. The images are
constantly horizontally and vertically separated, although he comments that the degree of separation varies. On examination the visual
acuities are 6/6 in both eyes. There is no pupil abnormality. There is a left ptosis, partially covering the pupil, and reduced abduction
and depression of the left eye occurs, both in abduction and adduction; other ocular movements appear normal. There are no other
abnormalities on examination. Which one of the following is the most likely diagnosis?
a) Orbital apex syndrome c) Third nerve palsy
b) Sixth nerve palsy d) Fourth nerve palsy
e) Ocular myasthenia gravis
31. A young lady with blepharitis presents with a swelling on the right upper lid for the last one month; the commonest painless lid
swelling is:
a) Chalazion c) Cyst of zeis
b) Cyst of mol d) Internal hordeolum
e) Stye
32. A young lady of 20 presents with chronic irritation, burning, grittiness and photophobia in both eyes. On slit lamp examination the
eye lashes are matted together with yellow crusts. One of these crusts was removed with forceps and the area started bleeding. What is
the most likely diagnosis?
a) Amyloidosis of the lids c) Posterior Blepharitis
b) Preseptal Cellulitis d) Seborrheic Blepharitis
e) Ulcerative Blepharitis
33. A 54-year-old man with a history of Type 1 diabetes and multiple microvascular complications comes to the Emergency
Department for review. He is complaining of diplopia which is making it impossible for him to drive. There are no other neurological
symptoms. On examination he has an outward deviating right eye and a ptosis; the pupil does not look particularly dilated. Which of
the following is the most likely cause?
a) Diabetes mellitus c) Idiopathic
b) Giant cell arteritis d) Posterior communicating artery aneurysm
e) Raised intracranial pressure

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Book Name Topic-1 – Pathology

34. A 25 years old male comes to the clinic with a 3 months history of painless swelling on his right upper lid. On examination there is
posterior blepharitis and a smooth rounded nodule slightly away from the lid margin. What is your most probable diagnosis?
a) Chalazion. c) Haemangioma
b) Dermoid d) Papilloma
e) Sebaceous cyst
35. Sling surgery should be avoided in cases of ptosis with:
a) Very poor levator action c) Weak Muller's muscle
b) Poor Bell's phenomenon d) Multiple failed surgery
e) Severe dry eye / exposure keratopathy
36. A recurrent chalazion should he subjected to histopathologic evaluation to exclude the possibility of:
a) Actinic Keratosis c) Malignant melanoma
b) Basal cell carcinoma d) Sebaceous cell carcinoma
e) Squamous cell carcinoma
37. A 64-year-old woman presents with bilateral sore eyelids. She also complains of her eyes being dry all the time. On examination
her eyelid margins are erythematous at the margins but are not swollen, Of the given options. what is the most appropriate initial
management?
a) Topical chloramphenicol mechanical removal of lid debris c) Topical chloramphenicol topical steroids
b) Hot compresses + topical steroids d) Hot compresses + mechanical removal of lid debris
e) Topical chloramphenicol hot compresses.
38. A 40-year-old man presents with bilateral dry, gritty eyes. A diagnosis of blepharitis is considered. Which one of the following is
least likely to be associated with blepharitis?
a) Meibomian gland dysfunction. c) Staphylococcal infection
b) Seborrhoeic dermatitis d) Acne rosacea
e) Viral upper respiratory tract infection

ANSWER KEY
1. D 2. A 3. C 4. C 5. D 6. D 7. A 8. A 9. B 10. B
11. D 12. E 13. C 14. A 15. C 16. A 17. E 18. C 19. B 20. D
21. C 22. C 23. E 24. E 25. E 26. B 27. A 28. B 29. B 30. B
31. A 32. E 33. A 34. A 35. E 36. D 37. D 38. E 39. 40.

1. Blepharitis with swollen lid margins and dandruff-like scales on the eyelashes is most consistent with anterior seborrheic
blepharitis. This condition is strongly associated with seborrheic dermatitis, particularly scalp dandruff. Patients commonly have
chronic irritation, foreign body sensation, watering and photophobia. Facial rash may occur in rosacea but scalp dandruff is the
classic association.
2. A chalazion is a firm, non-tender (painless) nodule or swelling in the eyelid caused by a blocked meibomian gland, often located
away from the lid margin
3. Severe ptosis with poor levator function is best treated with frontalis sling surgery. In this procedure, the eyelid is attached to the
frontalis muscle so brow elevation helps lift the eyelid. Levator resection is ineffective when levator function is markedly poor.
4. Madarosis refers to loss of eyelashes or eyebrows. It is seen in conditions such as leprosy, chronic blepharitis, hypothyroidism
and lid malignancies. It is an important sign indicating lash follicle damage.
5. An internal hordeolum is an acute, painful infection of the Meibomian gland. When the lower lid is everted, an internal
hordeolum presents as a yellow, abscess-like spot on the conjunctival side of the tarsal plate. Streak downward on Conjunctival
side refers to the pus extending from the infected gland downwards behind the tarsus. Internal hordeolum often rupture on the
conjunctival side and resolve within a week, particularly with hot compresses
6. Distortion of eyelid margin anatomy with lash loss should always raise suspicion for eyelid malignancy, particularly sebaceous
gland carcinoma or basal cell carcinoma. Benign conditions usually do not destroy lash follicles.
7. Congenital ptosis presents since birth with drooping eyelid, absent lid crease, poor levator function and incomplete lid closure
during sleep. It is due to developmental dystrophy of the levator palpebrae superioris muscle.
8. Chalazion is the most common painless eyelid swelling. It is caused by chronic lipogranulomatous inflammation of a meibomian
gland and is often associated with blepharitis.

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9. Plication of inferior lid retractors is used in involutional (senile) entropion to correct lower lid instability.
10. Cicatricial ectropion occurs when scarring of eyelid skin pulls the lid margin outward. Trauma is a common cause. This leads to
exposure, watering and inability to close the eye properly.
11. Fasanella-Servat operation is indicated in mild ptosis such as Horner syndrome or mild aponeurotic ptosis with good levator
function.
12. Stye (external hordeolum) is an acute staphylococcal infection of the lash follicle or Zeis gland. It presents with painful, tender
swelling at the lid margin.
13. Preseptal cellulitis causes diffuse eyelid swelling, redness, tenderness and fever without orbital signs such as proptosis or
restricted movements. The eye itself remains unaffected.
14. Distichiasis is the presence of an accessory row of eyelashes, often arising from meibomian gland orifices. These lashes may rub
against the cornea causing irritation.
15. Third nerve palsy is a neurogenic cause of ptosis because the oculomotor nerve supplies levator palpebrae superioris. Damage
leads to ptosis with ophthalmoplegia.
16. A chalazion scoop is specifically used to remove granulomatous material after incision and curettage of a chalazion.
17. Punch is not a suture material; it is a surgical instrument. Vicryl, catgut, silk and nylon are all used as sutures in ophthalmology.
18. Ice pack test is a simple bedside test for myasthenia gravis. Cooling improves neuromuscular transmission temporarily, leading
to improvement in ptosis.
19. Cicatricial conjunctivitis causes scarring and inward turning of the eyelid, resulting in cicatricial entropion. This leads to lashes
rubbing against the globe.
20. Basal cell carcinoma rarely metastasizes but can cause extensive local tissue destruction, invading surrounding structures
including skull and CNS if neglected.
21. Mild ptosis with heterochromia suggests congenital Horner syndrome. Sympathetic denervation leads to lighter iris color on the
affected side due to impaired melanocyte stimulation.
22. Stye is an acute painful, red, tender infection at the eyelid margin, usually involving Zeis gland.
23. Facial nerve palsy causes ectropion, not entropion. Entropion is associated with cicatricial scarring, congenital defects or spastic
lid changes.
24. Tarsorrhaphy is indicated in seventh nerve palsy because facial nerve dysfunction causes lagophthalmos and exposure keratitis.
25. Fasanella-Servat operation is a ptosis correction procedure, not used for ectropion management. Other listed procedures are
ectropion surgeries.
26. Distichiasis refers to an accessory row of eyelashes, often causing corneal irritation.
27. Fascia lata sling surgery is preferred when multiple ptosis surgeries have failed and levator function is poor.
28. Internal hordeolum is an acute suppurative infection of the meibomian gland.
29. Thyroid ophthalmopathy causes proptosis, lid retraction, conjunctival chemosis and extraocular muscle enlargement, but ptosis
is not typical.
30. Variable diplopia with ptosis and fluctuating muscle weakness strongly suggests ocular myasthenia gravis.
31. Chalazion remains the commonest painless lid swelling due to meibomian gland blockage.
32. Ulcerative blepharitis presents with yellow crusts that bleed when removed, due to staphylococcal infection of lash follicles.
33. Diabetic third nerve palsy typically causes ptosis and ophthalmoplegia with pupil sparing due to microvascular ischemia.
Chalazion is a chronic painless meibomian gland swelling located slightly away from the lid margin.
34. ….
35. Sl n sur ry shoul b vo ns v r ry y or poor B ll‘s ph nom non b use postoperative lagophthalmos may worsen
corneal exposure.
36. Recurrent chalazion should always be evaluated histopathologically to exclude sebaceous gland carcinoma, which can mimic
chalazion.
37. Initial treatment of blepharitis includes hot compresses and mechanical lid hygiene to remove debris and improve meibomian
gland function.
38. Viral upper respiratory tract infection is least associated with chronic blepharitis. Common associations include seborrhea,
staphylococcal infection, rosacea and meibomian dysfunction.

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04. Conjunctiva

1. A 14-year-old boy presents to the eye OPD with unilateral lid swelling, discharge, and painful red eyes for the last 3 days. On
examination, follicular reaction was present along with lymphadenopathy. Most probable diagnosis is?
a) Allergic conjunctivitis c) Bacterial conjunctivitis
b) Adenoviral conjunctivitis d) Chemical conjunctivitis
e) Drug-related conjunctivitis
2. A 45 Years old laborer by profession comes to you with a fleshy triangular growth encroaching upon area his vision is also affected
you diagnose him and advise multiple treatment options. which of the following is the best management plan?
a) Bare Sclera technique c) Excision with Conjunctival autograft
b) Beta radiation d) Inferior fornix technique
e) Excision with MMC
3. A 3-year-old child is presented with bilateral subconjunctival hemorrhages. He has been suffering from fever, severe cough, and
chest infection. The most common cause of subconjunctival hemorrhages in this case is?
a) Fever c) Side effect of antibiotics
b) Chest infection d) Trauma to the eye
e) Cough
4. An 8-year-old child was brought by his parents with chief complaints of mucopurulent discharge, redness, and swelling of both eyes
for the last two months. On examination, there are follicles on the upper tarsal conjunctiva and superior corneal pannus. What is the
most probable diagnosis?
a) Allergic conjunctivitis c) Chronic bacterial conjunctivitis
b) Trachoma d) Ligneous conjunctivitis
e) Viral conjunctivitis
5. A 7-year-old child presents every spring season for the last 4 years with itching, redness, and watering. There are no follicles but
papillae in both upper tarsal conjunctivae, and there are no preauricular lymph nodes. What is the most likely diagnosis?
a) Adenoviral conjunctivitis c) Chemical conjunctivitis
b) Bacterial conjunctivitis d) Trachoma
e) Vernal conjunctivitis
6. An infant presented with hyperpurulent, sticky discharge from both eyes and extreme congestion of the conjunctiva. The
provisional diagnosis is ophthalmia neonatorum, which is caused by?
a) Diphtheria c) Gonococcus
b) E. coli d) Staph aureus
e) Streptococcus
7. Current epidemic in which eyes are swollen, red, congested, and watery in all family members is due to?
a) Herpes virus c) Picornavirus
b) Adenovirus d) Bacteria
e) Fungus
8. All of the following are complications of vernal keratoconjunctivitis except?
a) Cataract c) Uveitis
b) Glaucoma d) Ulcer
e) Keratoconus
9. A 45-year-old laborer presented to your clinic with complaints of watering and irritation, more frequently during sun exposure. On
slit lamp examination, you observe a wedge-shaped growth of the conjunctiva that extends onto the nasal cornea. What is your
diagnosis?
a) Limbal dermoid c) Pinguecula
b) Nodular phlyctenule d) Pterygium
e) Scleritis
10. A 30-year-old male presented to you with red eyes and watering. Initially, it involved the right eye and after two days, it spread to
the left eye. His young daughter developed a similar problem the other day. On examination, VA is 6/6. There is conjunctival redness
with ropy discharge. Rest of the ocular examination is unremarkable. What is the most probable diagnosis?
a) Allergic conjunctivitis c) Viral conjunctivitis
b) Bacterial conjunctivitis d) Cicatricial conjunctivitis
e) Fungal conjunctivitis

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11. A 12-year-old child was brought to you with complaints of irritation of eyes that is most severe in summer season and recurrent.
On examination, the child has VA of 6/12 in the right eye and 6/9 in the left eye. On eversion of the lid, you find giant papillae,
conjunctival congestion most marked in the limbal region with associated pseudogerontoxon. What is the most probable diagnosis in
this case?
a) Adenoviral conjunctivitis c) Gonococcal conjunctivitis
b) Bacterial conjunctivitis d) Trachoma
e) Vernal keratoconjunctivitis
12. In grading the trachoma, trachoma inflammation follicular (TF) stage is defined as the presence of:
a) Five or more follicles on upper limbus c) Five or more follicles on lower tarsal conjunctiva
b) Five or more follicles on upper tarsal conjunctiva d) Three or more follicles on upper tarsal conjunctiva
e) Five or more follicles all around the limbus
13. A recurrent bilateral conjunctivitis occurring with the onset of hot weather in young boys with symptoms of burning, itching, and
lacrimation with polygonal raised areas in the palpebral conjunctiva is:
a) Trachoma c) Mucopurulent conjunctivitis
b) Phlyctenular conjunctivitis d) Vernal kerato conjunctivitis
e) Epidemic keratoconjunctivitis
14. SAFE strategy is recommended for the control of
a) Cataract c) Diabetic retinopathy
b) Conjunctivitis d) Glaucoma
e) Trachoma
15. Sub conjunctival hemorrhage is a typical feature of:
a) Adenoviral conjunctivitis c) Fungal Keratitis
b) Corneal ulcer d) Ophthalmia neonatorum
e) Subarachnoid hemorrhage
16. A three years old child is presented with bilateral subconjunctival haemorrhages. He has been suffering from fever, severe cough
and chest infection for the last few days. The commonest cause of subconjunctival haemorrhage in this case can be:
a) Fever c) Cough
b) Side effect of antibiotics d) Chest infection
e) Trauma to the eye
17. 8 years old child brought by his parents with chief complaints of mucopurulent discharge, redness and swelling of both eyes for
the last two months. On examination there are follicles on the upper tarsal conjunctiva and superior corneal pannus. Which one is the
most probable diagnosis?
a) Allergic conjunctivitis c) Ligneous Conjunctivitis
b) Chronic bacterial conjunctivitis. d) Trachoma
e) Viral conjunctivitis
18. WHO grading of trachoma includes all except:
a) TF follicles c) TS scarring
b) TI inflammation d) TT trichiasi
e) TP pannus
19. Follicles are commonly seen in conjunctivitis due to:
a) Alkali burns c) Chlamydial infection
b) Seasonal allergy d) Pseudomonas conjunctivitis
e) Gonococcal conjunctivitis
20. Mucin layer tear film deficiency occurs in:
a) Canalicular block c) Keratoconjunctivitis sicca
b) Herpetic keratitis d) Lacrimal gland removal
e) Dacyocystitis
21. Eyes should not be bandaged in:
a) Corneal ulcer c) Glaucoma
b) Purulent conjunctivitis d) Retinal detachment
e) Acute iridocyclitis
22. The following ocular investigation has a risk of anaphylactic shock:
a) B/Scan b) Biometry

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c) FFA d) HRT
e) OCT
23. Cobblestone appearance of the conjunctiva is seen in
a) Spring catarrh c) Eczematous conjunctivitis
b) Angular conjunctivitis d) Trachoma
e) Follicular conjunctivitis
24. A 7 years old child presents in every spring season for the last 4 years with itching, redness, watering. There is no purulent
discharge. He has got a history of eczema. On examination there are no follicles but papillae both upper tarsal conjunctivae. There are
no preauricular lymph nodes. What is the diagnosis?
a) Adenoviral conjunctivitis. c) Chemical conjunctivitis
b) Bacterial conjunctivitis. d) Trachoma
e) Vernal conjunctivitis
25. A patient presented with photophobia and watering in left eye. On examination with fluorescein staining revealed dendritic ulcer
which is caused by:
a) Fungus c) Herpes simplex virus
b) Herpes zoster virus d) Mycobacterium
e) Staphylococci
26. As a complication of acute mucopurulent conjunctivitis, the corneal ulcers that develop are
a) Marginal c) Anywhere on cornea
b) Central d) No where
e) Ring-shaped (ring ulcer)
27. A young boy presented in emergency with watering and photophobia in right eye after a trauma, which test is most appropriate?
a) Applanation tonometry c) Rose Bengal staining
b) Fluorescein staining d) Schirmer's test
e) Tear break-up time
28. An infant presented with sticky discharge both eyes and extreme congestion of conjunctiva. Provisional diagnosis is the
ophthalmia neonatorum which is caused by:
a) Diphtheria c) Gonococcus
b) E Coll d) Staph. aureus
e) Streptococcus
29. Deficiency of vitamin A can cause all EXCEPT:
a) Xerosis c) Night blindness
b) Keratomalacia d) Dermoid
e) B tot‘s spots
30. A 15 years old boy presents with progressive decrease in vision. He suffers from Vernal Keratoconjunctivitis. He was started using
some eye drops which have dramatically reduced itching and photophobia some 2 years ago. He is found to have Bilateral Posterior
Sub Capsular Cataracts with Visual acuities of 6/12 both eyes. The most likely topical anti allergic drug to cause cataract is:
a) Cromoglycate c) Emedastine
b) Dexamethasone d) Ketrolac
e) Lodoxamide
31. A 30 years old male from Swabi has returned from a business/pleasure trip to Thailand and developed sore red right eye. He went
to the local Ophthalmologist who prescribed Chloramphenical Eye Drops but his condition did not improve. On examination his
visual acuities are 6/9 both eyes. On Slit Lamp examination he has minimal discharge with bilateral conjunctival follicles and
epithelial infiltrates in both corneas. Rest of the examination of the eyes is normal. He has enlarged Pre auricular lymph nodes and has
been complaining of urethral discharge. The likely diagnosis is:
a) Allergic conjunctivitis. c) Chlamydial Conjunctivitis.
b) Bacterial Conjunctivitis d) Vernal Conjunctivitis
e) Rosacea Conjunctivitis
32. Promising treatment of epidemic keratoconjunctivitis is by:
a) Oxytetracycline c) Chloramphenicol
b) Sulphacetamide 30% d) Adenine arabinoside
e) Topical lubricants and cold compresses

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33. A 45-year-old male patient presented with burning and redness in both eyes for last three days. On examination, there is watery
discharge, follicular conjunctival reaction and painful preauricular lymphadenopathy. What is the most likely diagnosis?
a) Epidemic keratoconjunctivitis c) Vernal keratoconjunctivitis
b) Trachoma d) Gonococcal conjunctivitis
e) Allergic conjunctivitis
34. A 15-year-old boy presents with sudden onset of bilateral pink eye with fever and pharyngitis. On examination, his visual acuity is
6/6 and there are follicles present in the inferior fornix in association with diffuse conjunctival congestion. Corneal examination shows
punctate keratitis bilaterally. What organism causes this disease?
a) Adenovirus serotype 3, 4 & 7 c) Chlamydia
b) Adenovirus serotype 8 & 19 d) Herpes virus
e) Neisseria
35. Pathognomonic feature of Trachoma:
a) Pannus formation c) Purulent discharge
b) Punctate keratitis d) Absent corneal reflex
e) Conjunctivitis
36. A 15 years old boy present with itching and swollen eyelids Since, one year. On examination there is diffuse congestion of bulbar
conjunctiva. Eversion of the upper eyelids on both sides shows large papillae with cobble stone. His skin examination is normal. What
is the probable diagnosis?
a) Epidemic keratoconjunctivitis c) Vernal keratoconjunctivitis
b) Trachoma d) Gonococcal conjunctivitis
e) Allergic conjunctivitis
37. 15 years old boy presents in OPD with complains of mucoid discharge from both eyes. Examination revealed hyperemia,
chemosis, and giant papillae on the palpebral conjunctiva on both sides. What is your diagnosis for this case?
a) Epidemic keratoconjunctivitis c) Spring catarrh
b) Trachoma d) Gonococcal conjunctivitis
e) Allergic conjunctivitis

ANSWER KEY
1. B 2. C 3. E 4. B 5. E 6. C 7. B 8. C 9. D 10. C
11. E 12. B 13. D 14. E 15. A 16. C 17. D 18. E 19. C 20. C
21. B 22. C 23. A 24. E 25. C 26. A 27. B 28. C 29. D 30. B
31. C 32. E 33. A 34. A 35. A 36. C 37. C

1. A teenager with unilateral red eye, watery discharge, follicular conjunctival reaction, and preauricular lymphadenopathy most
likely has adenoviral conjunctivitis. Adenovirus commonly causes epidemic keratoconjunctivitis or pharyngoconjunctival fever
and is characterized by watery discharge, follicles, and tender lymph nodes. Bacterial conjunctivitis usually produces purulent
discharge without follicles, while allergic conjunctivitis is associated with itching rather than lymphadenopathy.
2. A fleshy triangular fibrovascular growth extending onto the cornea in a laborer exposed to sunlight is pterygium. The best
treatment is surgical excision with conjunctival autograft, which has the lowest recurrence rate. Bare sclera excision has high
recurrence, while adjunctive therapies like beta radiation or mitomycin C may reduce recurrence but carry complications.
3. Bilateral subconjunctival hemorrhages in a child with severe cough are most commonly due to rupture of fragile conjunctival
vessels from raised venous pressure during coughing bouts. Fever or infection itself is less likely to directly cause vessel rupture.
4. Chronic mucopurulent conjunctivitis with follicles on the upper tarsal conjunctiva and superior corneal pannus is classic for
trachoma caused by Chlamydia trachomatis. Pannus formation and upper tarsal follicles are hallmark features.
5. Seasonal recurrent itching, redness, papillae, and absence of follicles or lymphadenopathy in a child strongly indicate vernal
conjunctivitis (spring catarrh). It is an allergic disorder, often seen in boys and exacerbated in warm weather.
6. Ophthalmia neonatorum with hyperpurulent discharge and marked conjunctival congestion is classically caused by Neisseria
gonorrhoeae. Gonococcal infection is severe and may rapidly lead to corneal perforation if untreated.
7. Epidemic conjunctivitis affecting multiple family members with swollen red watery eyes is most commonly caused by adenovirus
due to its high infectivity.
8. Vernal keratoconjunctivitis may lead to steroid-induced cataract, glaucoma, shield ulcers, and keratoconus from chronic rubbing.
Uveitis is not a recognized complication.

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9. A wedge-shaped conjunctival growth crossing onto the nasal cornea is pterygium. It is strongly linked to chronic UV exposure
and environmental irritation.
10. Sequential spread from one eye to the other, contagious family history, redness, and watery/ropy discharge suggest viral
conjunctivitis, most commonly adenoviral. Bacterial causes typically produce thicker purulent discharge.
11. Giant papillae, limbal congestion, pseudogerontoxon, and recurrent summer exacerbations are classic for vernal
keratoconjunctivitis, a chronic allergic ocular surface disease.
12. WHO defines trachomatous inflammation-follicular (TF) as the presence of five or more follicles, each at least 0.5 mm in
diameter, on the upper tarsal conjunctiva.
13. Recurrent hot-weather bilateral conjunctivitis with itching, lacrimation, and polygonal papillae is characteristic of vernal
keratoconjunctivitis.
14. SAFE strategy (Surgery, Antibiotics, Facial cleanliness, Environmental improvement) is specifically designed for trachoma
control.
15. Subconjunctival hemorrhage is a common feature of adenoviral conjunctivitis, especially epidemic keratoconjunctivitis, due to
vascular fragility.
16. In children, severe coughing is the most common precipitating factor for subconjunctival hemorrhage due to sudden increased
venous pressure.
17. Chronic follicular conjunctivitis with superior pannus strongly supports trachoma diagnosis.
18. WHO trachoma grading includes TF (follicular), TI (intense inflammation), TS (scarring), TT (trichiasis), and CO (corneal
opacity). TP (pannus) is not an official WHO stage.
19. Follicles are classically associated with chlamydial or viral conjunctivitis. Chlamydia is a major cause of chronic follicular
conjunctivitis.
20. Mucin layer tear film deficiency occurs in keratoconjunctivitis sicca because goblet cell dysfunction reduces mucin production,
destabilizing the tear film.
21. Eyes should never be bandaged in purulent conjunctivitis because occlusion promotes bacterial proliferation and worsens
infection.
22. Fluorescein fundus angiography (FFA) carries a risk of anaphylactic reaction due to intravenous fluorescein dye injection.
23. Cobblestone papillae on the upper tarsal conjunctiva are typical of vernal conjunctivitis.
24. Recurrent springtime itching, papillae, eczema history, and no lymphadenopathy indicate vernal conjunctivitis.
25. Dendritic corneal ulcer seen on fluorescein staining is pathognomonic for herpes simplex virus keratitis.
26. Corneal ulcers complicating acute mucopurulent conjunctivitis are usually marginal due to peripheral toxin-mediated damage.
27. Following trauma with photophobia and watering, fluorescein staining is the most appropriate test to identify corneal abrasion or
epithelial defects.
28. Ophthalmia neonatorum with severe sticky discharge and conjunctival congestion is most commonly gonococcal.
29. Vt mnA n y us s x ros s, B tot‘s spots, n ht bl n n ss, n k r tom l , but not rmo , wh h s on n t l.
30. Long-term topical corticosteroid use, such as dexamethasone, in vernal keratoconjunctivitis can cause posterior subcapsular
cataract.
31. Bilateral follicular conjunctivitis with corneal infiltrates, preauricular lymphadenopathy, and urethral discharge strongly suggests
adult chlamydial conjunctivitis.
32. Epidemic keratoconjunctivitis is mainly managed supportively with lubricants and cold compresses. No definitive antiviral
therapy is universally effective.
33. Type IV hypersensitivity to tuberculoprotein classically manifests as phlyctenular conjunctivitis, a delayed hypersensitivity
response often seen in children with tuberculosis exposure.

05. Sclera

1. A 47-year-old man presented with ocular pain in the right eye for the last week. There is redness of the right eye with associated
pain. On phenylephrine eye drops installation, the redness is not reduced. The patient is also giving a history of rheumatoid arthritis.
What is your diagnosis?
a) Blepharitis c) Corneal ulcer
b) Conjunctivitis d) Episcleritis
e) Scleritis

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2. A 55 years old lady suffers from rheumatoid arthritis. She has developed intensely painful red left eye. Her Visual acuities are 6/12
both eyes improving to 6/6 with pin hole. In her Left eye she has red nodular swelling approximately 2 mm from the temporal limbus.
The swelling is tender and fixed. It does not blanch with the use of phenylephrine. The most likely is:
a) Scleritis c) Keratitis
b) Iritis d) Conjunctivitis
e) Choroiditis
3. Symptom differentiating scleritis from episcleritis is presence of:
a) Cornea and uveal involvement c) Secondary glaucoma
b) Ulceration d) Severe deep boring ocular pain with nocturnal worsening
e) All of the above
4. Common causes of staphyloma include:
a) Increased IOP c) Injury
b) Scleritis d) Congenital scleral weakness
e) all of the above
5. Treatment of episcleritis includes EXCEPT:
a) Corticosteroids c) Analgesics
b) Anti-inflammatory d) Atropine
e) Lubricating eye drops
6. The complications of scleritis include all EXCEPT:
a) Annular scleritis c) Posterior staphyloma
b) Ciliary staphyloma d) Sclerosing keratitis
e) Episcleritis
7. Intercalary staphyloma is a type of
a) Equatorial staphyloma c) Ciliary staphyloma
b) Posterior staphyloma d) Anterior staphyloma
e) Corneal staphyloma
8. The vena vorticosa exit from sclera
a) At the equator c) 4 mm in front of equator
b) 4 mm behind the equator d) At posterior pole
e) At limbus
9. Anterior staphyloma occurs due to
a) Perforating corneal ulcer c) Secondary glaucoma
b) Penetrating corneal injury d) E. Scleral thinning disorders
e) All of the above
10. The optic nerve pierces the sclera
a) Anteriorly c) At the equator
b) Posteriorly d) 4 mm behind the equator
e) At limbus
11. The following conditions are associated with blue sclerotic:
a) Deafness c) Both a & b
b) Fragilitas ossium d) None
e) Osteogenesis imperfecta only
12. The classical features of episcleritis include all EXCEPT:
a) Circumscribed nodule, 2-3 mm from limbus c) Hard, movable and tender
b) Conjunctiva moves freely over it d) Cornea and uveal tract involvement
e) Mild redness with minimal pain
13. The thickness of sclera is
a) 0.5 mm c) 1 mm
b) 0.1 mm d) 2 mm
e) Variable depending on site
14. Scleritis is often associated with
a) Polyarteritis nodosa b) SLE

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c) Dermatomyositis d) Rheumatoid arthritis

e) All of the above
15. A 47-year-old female with a history of rheumatoid arthritis presents with a painful and red left eye. Visual acuity is normal.
Fundoscopy is also unremarkable. What is the most likely diagnosis?
A. Scleritis C. Glaucoma
B. Episcleritis D. Anterior uveitis
E. Keratoconjunctivitis sicca

ANSWER KEY
1. E 2. A 3. D 4. E 5. D 6. C 7. A 8. B 9. E 10. B
11. C 12. D 13. C 14. E 15. A

1. A painful red eye in a middle-aged man with rheumatoid arthritis, where redness does not blanch with phenylephrine, is highly
suggestive of scleritis. Scleritis involves deep scleral vessels that are not affected by vasoconstrictors, unlike episcleritis.
Rheumatoid arthritis is a common systemic association. Severe pain is a distinguishing feature from conjunctivitis or blepharitis.
2. A tender, fixed nodular swelling near the limbus in a patient with rheumatoid arthritis that does not blanch with phenylephrine is
characteristic of nodular scleritis. The deep inflammation and severe pain differentiate it from episcleritis, while rheumatoid
arthritis is a classic predisposing condition.
3. Severe deep boring ocular pain, often worse at night and radiating to the temple or jaw, is the most important symptom
distinguishing scleritis from episcleritis. Although corneal or uveal involvement and secondary glaucoma may occur in severe
cases, deep pain is the hallmark feature.
4. Staphyloma refers to ectasia of weakened ocular coats lined by uveal tissue and may result from raised intraocular pressure,
inflammatory scleral thinning such as scleritis, trauma, or congenital weakness. Therefore, all listed factors can contribute.
5. Episcleritis is usually a benign, self-limiting inflammatory condition treated with lubricants, NSAIDs, mild steroids, and
analgesics. Atropine is not routinely required because there is no significant ciliary spasm or uveal involvement.
6. Scleritis complications include ciliary staphyloma, scleral thinning, sclerosing keratitis, and visual impairment. Episcleritis itself
is not a complication but rather a separate, milder condition.
7. Intercalary staphyloma is considered a form of ciliary staphyloma, occurring in the scleral region between the limbus and ciliary
body.
8. Vortex veins (vena vorticosa) leave the sclera approximately 4 mm behind the equator, an important anatomical landmark in
ocular surgery.
9. Anterior staphyloma may develop after severe corneal ulcer perforation, penetrating trauma, secondary glaucoma, or other causes
of corneoscleral weakening. All options are valid causes.
10. The optic nerve pierces the sclera posteriorly at the posterior pole of the globe.
11. Blue sclera is associated with osteogenesis imperfecta (fragilitas ossium) and may also occur with deafness syndromes such as
Van der Hoeve syndrome. Therefore, both deafness and fragilitas ossium are associated.
12. Episcleritis is characterized by mild redness, minimal discomfort, freely mobile conjunctiva over the lesion, and localized
nodularity. Corneal and uveal tract involvement are absent, making this the exception.
13. Average scleral thickness is approximately 1 mm posteriorly, though it varies by location, being thinnest near rectus insertions
and thickest posteriorly.
14. Scleritis is strongly associated with systemic autoimmune disorders including rheumatoid arthritis, SLE, polyarteritis nodosa, and
other collagen vascular diseases.
15. In a rheumatoid arthritis patient with painful red eye and normal vision, scleritis is the most likely diagnosis. Severe pain and
systemic autoimmune association strongly favor scleritis over episcleritis or dry eye.

06. Cornea

1. A 16-year-old boy presents to the eye OPD with frequent changes in prescription of glasses. Diagnosis of keratoconus with apical
scarring is confirmed. The best treatment would be?
a) Hard contact lenses c) Glasses
b) Soft contact lenses. d) Femtolasik
e) Keratoplasty

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2. A 35-year-old patient presents to the eye OPD with unilateral pain and watering. Fluorescein staining of the cornea was found to be
positive with a branching pattern. What is your diagnosis?
a) Bacterial keratitis c) Corneal abrasion
b) Acanthamoeba keratitis d) Fungal keratitis
e) Viral keratitis
3. A patient presented with photophobia and watering in the left eye for the last week. On examination, fluorescein revealed a
dendritic ulcer. Which organism is most likely to cause this condition?
a) Fungus c) Herpes simplex virus
b) Herpes zoster virus d) Mycobacterium
e) Staphylococci
4. In non-healing sloughing corneal ulcers where perforation is expected, the best management is?
a) Scraping of the cornea c) Subconjunctival antibiotics
b) Conjunctival flap d) Cauterization of the ulcer bed
e) Evisceration
5. A female of 40 years presents with painless decrease in vision for four years. The patient is myopic with irregular astigmatism.
There is thinning of the central cornea. The most sensitive investigation for the patient is?
a) Refraction c) Keratometry
b) Ocular biometry d) Anterior segment OCT
e) Corneal topography
6. A 30-year-old farmer presents with pain and redness in the right eye for the last 2 days. On inquiry, he had trauma to his right eye
with a bush. On examination, visual acuity in his right eye is 6/36. He has a 2.5 x 1.3 mm corneal ulcer with satellite lesions. What is
your diagnosis?
a) Acanthamoeba keratitis c) Fungal keratitis
b) Bacterial conjunctivitis d) Marginal keratitis
e) Viral keratitis
7. A 16-year-old boy is brought to you with trauma by scissors while playing. On examination, you find that his cornea is perforated.
What is your first step in management as a community doctor?
a) Repairing of the cornea c) Steroid ointment, then refer the patient
b) Topical steroids then refer the patient d) Topical antibiotics, pad the eye then refer
e) Refer the patient without doing anything
8. A 53-year-old man presented with pain and redness in his left eye for the last 5 days. On examination, he has corneal ulceration
involving the inferior 1/3 of the cornea. He also has a left-sided facial palsy. What is your diagnosis?
a) Exposure keratopathy c) Infectious crystalline keratopathy
b) Filamentary keratopathy d) Neurotrophic keratopathy
e) Thygeson superficial punctate keratitis
9. A 58-year-old male presented with pain, dimness of vision, and watering in the left eye. On examination, he has a visual acuity of
6/6 in the right eye and 6/60 in his left eye. He has a 2.3x2.8 mm corneal ulcer. Which of the following measures should be avoided in
this patient?
a) Antibiotics c) Bandage contact lens
b) Antifungals d) Cycloplegics
e) irrigation with saline
10. A 40-year-old lady complains of left eye redness of 2 days duration associated with photophobia and watery discharge. On
examination, visual acuity is 6/12 in both eyes. The cornea reveals dendritic lesions that stain well with fluorescein. Corneal
sensations are reduced in the left eye. Which of the following is the most appropriate management?
a) Artificial tears c) Topical cyclosporine
b) Topical antivirals d) Topical NSAIDS
e) Topical steroids
11. A 55-year-old patient presented with decreased vision in the right eye for the last 3 days associated with watering and foreign body
sensation. There are pustules and blisters involving the right side of the forehead, lid up to the tip of the nose, with severe pain and
tingling sensation. Ocular examination shows corneal dendritic ulceration. What is the most probable diagnosis in this case?
a) Herpes simplex keratitis c) Bacterial keratitis
b) Herpes zoster ophthalmicus d) Allergic conjunctivitis
e) Fungal keratitis

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12. A young patient with vernal catarrh presents with dimness of vision. On examination he is having Astigmatism with best corrected
VA 6/12 in both eyes. On retinoscopy there is scissor reflex and while looking down Munson's sign is positive. What can be the cause
of his decreased vision?
a) Keratoglobus c) Corneal nebula
b) Keratoconus d) Corneal leucoma
e) Acute hydrops
13. The presence of Keyser Fleischer ring is pathognomonic of:
a) Keratoconus c) Malignant melanoma of ciliary body
b) Pterygium d) Wilson's disease
e) Siderosis bulbi
14. A young lady wearing -2.00 contact lenses develops redness, pain, watering, and dimness in her right eye. On examination, her
cornea is hazy having central opacity. What can be the most probable cause of her problem?
a) Fungal ulcer c) Acanthamoebic corneal ulcer
b) Allergic conjunctivitis d) Acute hydrops
e) Acute anterior uveitis
15. A 30-year-old farmer presents with a history of trauma to the left eye with a leaf 5 days ago. Now he presents with pain,
photophobia, and redness of the eye. On examination, he has a grey-white lesion on the cornea with fluffy margins and hypopyon.
What would be the most likely pathology?
a) Anterior uveitis c) Fungal keratitis
b) Bacterial Conjunctivitis d) Viral keratitis
e) Bacterial keratitis
16. A 45-year-old woman is found by her optometrist to have band keratopathy and is referred to the Eye Clinic. Which one of the
following investigations is likely to be helpful in determining a cause?
a) Cholesterol c) U&E
b) Ferritin d) Gamma GT
e) Serum calcium
17. A 25-year-old man develops cirrhosis of the liver and is referred from the Gastroenterology Clinic to the Ophthalmology Clinic to
look for evidence of Wilson's disease. What will the ophthalmologist be looking out for?
a) Corneal arcus c) Kayser-Fleischer rings
b) Hudson-Stahli lines d) Cornea verticillata
e) Band keratopathy
18. Diopteric power of cornea is:
a) 18 diopters c) 33 diopters
b) 23 diopters d) 43 diopters
e) 60 diopters
19. A consultant ophthalmologist during ward round ask his house officer regarding what is the normal corneal hydration depends
upon:
a) Epithelium c) Stroma
b) Bowman's membrane d) Endothelium
e) Descemet membrane
20. Treatment of impending perforation of corneal ulcer includes all EXCEPT
a) Contact lens c) Therapeutic corneal graft
b) Acetazolamide (diamox) d) Cautery
e) Topical corticosteroids
21. The best suture material for repair of corneal injuries is:
a) 10/0 Nylon c) 5/0 Ethiband
b) 6/0 vicryl d) 6/0 prolene
e) 8/0 virgin silk
22. Bullous keratopathy involves
a) Descemet's membrane c) Endothelium
b) Epithelium d) Bowman's membrane
e) Corneal stroma

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23. Keratoconus has got association with the following conjunctival condition:
a) Membranous conjunctivitis c) Subconjunctival haemorrhage
b) Follicular conjunctivitis d) Vernal keratoconjunctivitis
e) Chemical burns
24. The most common organism responsible for hypopyon corneal ulcer is
a) Staphylococcus c) Pseudomonas
b) Pneumococcus d) Candida albicans
e) Moraxella
25. The diagnostic finding of fungal keratitis is:
a) Satellite Lesions c) Epithelial defect
b) Hypopyon d) Radial Keratitis
e) Subepithelial infiltration
26. Rupture of Descemet's membrane is seen in
a) Keratoconus c) Glaucoma
b) Rubella d) Retinoblastoma
e) Interstitial keratitis
27. A man presented with pain, redness, decreased vision in the right eye. He was diagnosed, as a case of Corneal Ulcer with
Hypopion, which medication should not be used;
a) Analgesic c) Antifungal
b) Antibiotics d) Cycloplegics
e) Steroids
28. A farmer presented with a fleshy triangular conjunctival mass encroaching upon the nasal side of the cornea for 3mm. The most
appropriate treatment will be:
a) Artificial Tears/decongestant c) Excision biopsy
b) Complete excision with conjunctival auto-graft d) Excision with Mitomycin -C application
e) Topical Antibiotic / steroids combination
29. A 40 years old lady from Darra Adam Khel presents with intense pain, photophobia and decreased vision in both eyes. Her Visual
Acuities are 6/24 both eyes and she has Keratic Precipitates, cells in the anterior chamber and posterior synechiae. Intraocular
pressures are 10 and 12 Right and left Eyes respectively. She also complains of lower back ache. All of the below are appropriate
treatments except:
a) Analgesics c) Topical Moxifloxacin
b) Sub Tenon Steroids d) Topical Cycloplegics
e) Topical Steroids
30. Band-shaped keratopathy is due to
a) Calcareous degeneration c) Fatty degeneration
b) Hyaline degeneration d) Elastotic degeneration
e) Amyloid degeneration
31. In lamellar keratoplasty:
a) Full thickness corneal graft is used c) Partial thickness corneal graft is used
b) A combination of corneal and conjunctival graft is used d) Donor cornea is stitched on top of recipient cornea
e) Hard contact lens is applied after removing corneal epithelium of the recipient
32. The commonest complication of excessive use of steroids in the eye is:
a) Keratoglobus c) Trachoma
b) Herpes simplex keratitis d) Hyphaema
e) Exophthalmos
33. In non-healing sloughing corneal ulcer, where the perforation of cornea is apprehended, the best option is:
a) Scrapping of the corneal ulcer c) Evisceration
b) Subconjuctival antibiotics d) Conjunctival flap
e) Carbolization of the ulcer bed
34. A 45 years old farmer is cutting wheat when he feels something went into his right Eye 2 days afterwards his right eye becomes
painful and photophobic and he is referred to a tertiary care hospital. His visual acuity in the right eye is 6/24 improving to 6/12 with
pin hole. The right pupil is constricted but there is no RAPD. The eye is injected with signs of Keratitis with a few cells in anterior
chamber. One of the following is the first mandatory procedure in the management of this patient?

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a) Anterior Chamber Paracentesis. c) Vitreous tap

b) Corneal Scrape for Microscopy and Gram Staining d) Topical antibiotics
e) Topical steroids
35. A 24 years old man presents with watering, photophobia and dimness of vision in his right eye. On examination his visual acuity
in the affected eye is 6/18 and normal in the other eye. On fluorescein staining cornea shows a lesion with branching pattern. His
corneal sensitivity is decreased. What is most likely diagnosis?
a) Adenoviral keratoconjunctivitis c) Bacterial keratitis
b) Autoimmune keratitis d) Fungal keratitis
e) Herpes Simplex Keratitis (HSK)
36. A 15 years old girl presents with painless and gradual dimness of vision in both eyes since last 4 years. She has a history of vernal
keratoconjunctivitis since the age of 5 and frequent change in glasses for four years. On examination her visual acuity is counting
finger in both eyes and cornea looks clear but bulging and conical. The most probable diagnosis is?
a) Bilateral corneal opacities c) Corneal dystrophies
b) Congenital glaucoma d) Keratoconus
e) Keratoglobus
37. 'Salmon patches' are seen in:
a) Haemorrhage into the cornea c) Retinitis pigmentosa
b) Interstitial keratitis d) Phlyctenular keratitis
e) Episcleritis
38. A lady develops bacterial keratitis in the left eye. She is started on topical antibiotics the cornea continues to slough but ultimately
the keratitis heals with extreme corneal thinning, descemetocele. This descemetocele leads to corneal perforation in 2 weeks. All of
the following except one are appropriate treatments in cases of corneal perforation:
a) Amniotic membrane graft c) Conjunctival flap
b) Bandage Contact Lens d) Cyanoacrylate adhesive
e) Descemet Stripping Automated Endothelial Keratoplasty (DSAEK)
39. A man of 30 years presents with pain in the left eye for one week. Clinically there is ciliary congestion, corneal lesion in the form
of a branch and decreased corneal sensation. What is the most likely diagnosis?
a) Amoebic keratitis c) Disciform keratitis
b) Dendritic keratitis d) Nummular keratitis
e) Filamentary keratitis
40. A patient is referred to the Dermatology Clinic with facial flushing and early rhinophyma. The dermatologist seeks an ophthalmic
opinion. Which one of the following findings supports a diagnosis of acne rosacea?
a) Iritis b) Central retinal vein occlusion
c) Cataract d) Keratitis
e) Raised intraocular pressure
41. A 42-year-old man with a history of Type 2 diabetes and hypertension comes to the Emergency department for review. He is a
contact lens wearer and he has pain, photophobia and decreased vision in his left eye after accidentally leaving his contact lens in situ
overnight. He wears monthly soft lenses and admits he does not clean them each time before and after use. On examination he has
reduced visual acuity in the left eye to 6/24, with diffuse conjunctival injection and corneal haze. There is a 2x2mm circular opacity
near the central cornea which stains with fluorescein dye, surrounded by an infiltrate. The anterior chamber has cells 2+. Which of the
following is the most likely diagnosis?
a) Corneal abrasion c) Hypopyon
b) Glaucoma d) Infective keratitis
e) Sjogren's syndrome
42. A 42-year-old woman was seen in the Emergency Department. She complains of an acutely painful and gritty right eye. On
examination, she has normal visual acuity. Which diagnosis should prompt an immediate same-day review by Ophthalmology?
a) Contact lens-related ulcer c) Infective conjunctivitis
b) Episcleritis d) Subconjunctival haemorrhage
e) Trichiasis
43. A 71-year-old man presents with a burning sensation around his right eye. On examination an erythematous blistering rash can be
seen in the right trigeminal distribution. What is the most likely diagnosis?
a) Ramsay Hunt syndrome c) Fungal keratitis
b) Cluster headache d) Herpes zoster ophthalmicus
e) Trigeminal neuralgia

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44. A 24-year-old man presents to the emergency department complaining of left eye pain. He has not been able to wear his contact
lenses for the past 24 hours due to the pain. He describes the pain as severe and wonders whether he has 'got something stuck in his
eye'. On examination there is diffuse hyperaemia of the left eye. The left cornea appears hazy and pupillary reaction is normal. Visual
acuity is reduced on the left side and a degree of photophobia is noted. A hypopyon is also seen. What is the most likely diagnosis?
a) Acute angle closure glaucoma c) Keratitis
b) Viral conjunctivitis d) Episcleritis
e) Anterior uveitis
45. A 72-year-old woman presents with a vesicular rash around her left eye. The left eye is red and there is a degree of photophobia. A
presumptive diagnosis of herpes zoster ophthalmicus is made and an urgent referral to ophthalmology is made. What treatment is she
most likely to be given?
a) Oral aciclovir + topical aciclovir c) Oral famciclovir + topical aciclovir
b) Intravenous aciclovir + topical aciclovir d) Topical aciclovir
e) Oral aciclovir
46. A 45-year-old woman is found by her optometrist to have band keratopathy and is referred to the Eye Clinic. Which one of the
following investigations is likely to be helpful in determining an underlying cause?
a) Cholesterol c) U&E
b) Ferritin d) Gamma GT
e) Serum calcium
47. A 30 years 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. What is the diagnosis?
a) Bacterial corneal ulcer c) Marginal keratitis
b) Acanthamoeba keratitis d) Herpes simplex keratitis
e) Fungal keratitis
48. A 23 years old young lady has complaint of severe pain, red eye, photophobia and blurred vision for one day. She has history of
using colored contact lenses one day ago. On examination, a white patch is visible on cornea. What is the most likely diagnosis?
a) Fungal Keratitis c) Herpes Simplex Keratitis
b) Acanthamoeba Keratitis d) Marginal Keratitis
e) Bacterial corneal keratitis
49. An old man accidently got his right eye injured with brooms straw. He reported in eye clinic with mild pain, photophobia and
blurred vision after 3 weeks. Ocular examination revealed greyish white central corneal lesion surrounded by similar small satellite
feathery opacities. What is the causative agent?
a) Aspergillus c) Herpes simplex virus
b) Acanthamoeba d) Corynebacterium
e) Pseudomonas
50. A 40 years old female having rheumatoid arthritis on immune modulator presented with reduction in vision, irritation, redness and
photophobia in her right eye. Examination shows dendritic corneal ulcer stained with fluorescein. What is the most common causative
organism?
a) Aspergillus c) Herpes simplex virus
b) Acanthamoeba d) Corynebacterium
e) Pseudomonas
51. A young boy who has recently recovered from the complains of painful left red eye. He has branching type of lesion on the cornea
with fluorescein staining. What is the diagnosis?
a) Fungal Keratitis c) Herpes Simplex Keratitis
b) Acanthamoeba Keratitis d) Marginal keratitis
e) Bacterial corneal keratitis
52. Chacteristic feature of Keratoconus:
a) Increased corneal thickness d) Confluent ulcer
b) Positive scissor's reflex e) Hyperopia
e) Corneal opacification
ANSWER KEY
1. A 2. E 3. C 4. B 5. E 6. C 7. D 8. A 9. C 10. E
11. B 12. B 13. D 14. A 15. C 16. E 17. C 18. C 19. D 20. E

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21. A 22. C 23. D 24. C 25. A 26. A 27. E 28. B 29. E 30. E
31. C 32. B 33. D 34. B 35. E 36. D 37. B 38. E 39. B 40. D
41. D 42. A 43. D 44. C 45. E 46. E 47. A 48. E 49. A 50. C
51. E 52. B

1. Keratoconus with apical scarring indicates advanced ectatic disease where corneal thinning and scarring prevent useful vision
with glasses or contact lenses. Hard (rigid gas permeable) contact lenses are the best initial option because they mask irregular
astigmatism and improve visual acuity by providing a smooth refractive surface. Soft lenses and glasses are ineffective in
advanced keratoconus due to irregular corneal shape. Femtolasik is contraindicated as laser ablation further weakens the cornea
and worsens ectasia. Keratoplasty (corneal transplant) is reserved for cases where contact lenses fail or there is significant central
scarring affecting vision.
2. A branching fluorescein staining pattern (dendritic lesion) is classical for viral keratitis, especially herpes simplex virus. The
lesion represents epithelial ulceration along infected corneal nerves with terminal bulbs. Acanthamoeba keratitis typically shows
ring infiltrates, fungal keratitis shows feathery margins with satellite lesions, bacterial keratitis is a dense suppurative ulcer, and
corneal abrasion shows simple epithelial defect without branching pattern.
3. Dendritic corneal ulcer with decreased corneal sensation strongly indicates herpes simplex virus keratitis. HSV causes
characteristic branching ulcers with terminal bulbs and reduced corneal sensitivity due to trigeminal nerve involvement. Herpes
zoster causes pseudodendrites without true terminal bulbs and is usually associated with dermatomal rash. Fungi, bacteria, and
mycobacteria do not produce true dendritic ulcers.
4. In non-healing sloughing corneal ulcers with impending perforation, conjunctival flap is the best option. It provides tectonic
support, vascular supply, and promotes healing. Corneal scraping is diagnostic but not definitive treatment. Subconjunctival
antibiotics alone are insufficient in progressive tissue loss. Cauterization may be used in small lesions but not in severe sloughing
ulcers. Evisceration is reserved for unsalvageable painful blind eyes, not impending perforation.
5. Irregular astigmatism with progressive myopia and corneal thinning suggests keratoconus. Corneal topography is the most
sensitive investigation as it maps anterior and posterior corneal curvature and detects early ectasia. Refraction and keratometry
detect only established changes. Anterior segment OCT is helpful but less sensitive than topography for early ectatic changes.
Biometry is not useful for corneal shape disorders.
6. Corneal ulcer with satellite lesions after vegetative trauma is typical of fungal keratitis. Plant material introduces fungal spores
such as Fusarium and Aspergillus. Satellite lesions and slow progression are hallmark features. Acanthamoeba is associated with
contact lens use and severe pain. Marginal keratitis is immune mediated and peripheral. Bacterial ulcers are rapidly progressive
without satellite lesions.
7. In full-thickness corneal perforation, immediate eye protection is essential. The correct first step is topical broad-spectrum
antibiotics, eye padding, and urgent referral. Direct corneal repair is specialist work and not done at community level. Steroids are
contraindicated as they worsen infection and delay healing. No intervention is unsafe as the eye may collapse or become infected.
8. Inferior corneal ulceration in a patient with facial palsy suggests exposure keratopathy. Facial nerve palsy causes lagophthalmos
leading to drying and inferior corneal damage. Filamentary keratitis shows mucus filaments rather than ulceration. Infectious
crystalline keratopathy is slow-growing stromal infection. Neurotrophic keratopathy causes painless ulcers with reduced sensation
but no facial nerve association. Thygeson keratitis causes punctate epithelial lesions, not localized inferior ulcer.
9. Bandage contact lens should be avoided in infected corneal ulcers because it creates a closed environment that promotes
microbial growth and worsens infection. Antibiotics, antifungals, cycloplegics, and saline irrigation are standard supportive
treatments. Bandage lenses are useful only in healing epithelial defects without active infection.
10. Dendritic ulcer with reduced corneal sensation indicates herpes simplex keratitis. The most appropriate management is topical
antiviral therapy (e.g., acyclovir or ganciclovir). Steroids are contraindicated as they worsen viral replication. Artificial tears are
supportive only. NSAIDs and cyclosporine are not effective for active epithelial HSV infection.
11. Painful vesicular rash along ophthalmic division of trigeminal nerve with dendritic keratitis is herpes zoster ophthalmicus. It
occurs due to reactivation of varicella zoster virus in the trigeminal ganglion. HSV causes isolated dendritic keratitis without
dermatomal rash. Bacterial, allergic, and fungal causes do not produce dermatomal vesicles.
12. Scissor reflex on retinoscopy, irregular astigmatism, and positive Munson sign indicate keratoconus. The ectatic cornea causes
conical protrusion and distortion of light reflex. Keratoglobus causes generalized thinning but less scissor reflex. Corneal nebula
and leucoma are opacities, not ectatic disorders. Acute hydrops is a complication, not underlying cause.

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13. Kayser-Fl s h r r n s nost o W lson‘s s s u to opp r pos t on n D s m t‘s m mbr n . It s s n n hron

liver disease with neurological signs. Other options like corneal arcus and band keratopathy are unrelated to copper metabolism.
Corn v rt ll t o urs n F bry s s , not W lson‘s s s .
14. Contact lens-associated corneal infection with central opacity suggests Acanthamoeba keratitis. It is strongly linked to poor lens
hygiene and water exposure. Fungal ulcers occur after trauma with vegetative matter. Acute hydrops is a complication of
keratoconus. Uveitis does not produce corneal infiltrates. Anterior uveitis affects anterior chamber, not cornea primarily.
15. Vegetative trauma with grey-white infiltrate, fluffy margins, and hypopyon is classical fungal keratitis. Organic matter introduces
fungal spores. Bacterial keratitis is more rapidly progressive with dense suppuration. Viral keratitis causes dendritic lesions.
Anterior uveitis does not produce corneal infiltrates.
16. B n k r top thy s u to l um pos t on n Bowm n‘s l y r n sup r l strom . S rum l um st m t on s mport nt
to detect hypercalcemia or systemic causes like sarcoidosis, renal disease, or hyperparathyroidism. Cholesterol, ferritin, and liver
enzymes are not directly related.
17. Kayser-Fl s h r r n s r pr s nt opp r pos t on n W lson‘s s s t n D s m t‘s m mbrane. It is strongly associated
with liver cirrhosis and neuropsychiatric symptoms. Other options represent different corneal deposits unrelated to copper
metabolism.
18. Cornea contributes about 43 diopters of refractive power. This is due to its curvature and refractive index difference between air
and cornea. Lower or higher values are incorrect physiologically.
19. Corneal hydration is primarily maintained by the endothelium via Na-K ATPase pump mechanism. Endothelial dysfunction leads
to corneal edema and loss of transparency. Epithelium acts as barrier, stroma holds water, while Descemet membrane is
structural.
20. Topical corticosteroids should be avoided in impending corneal perforation because they delay healing, increase collagen
breakdown, and worsen infection risk. Other options like antibiotics, acetazolamide, contact lens, and surgical grafting may be
appropriate depending on severity.
21. 10/0 nylon is the best suture material for corneal repair because it is fine, inert, and causes minimal tissue reaction, ensuring
precise wound closure and minimal scarring. Silk and vicryl cause inflammation and are not suitable for cornea.
22. Bullous keratopathy involves corneal endothelium failure leading to stromal and epithelial edema with bullae formation.
Endothelium is primarily affected due to its pump failure, causing fluid accumulation.
23. Vernal keratoconjunctivitis is strongly associated with keratoconus due to chronic eye rubbing and elevated IgE-mediated
inflammation weakening corneal structure. Other conjunctival conditions are not significantly linked.
24. Pseudomonas aeruginosa is the most common cause of hypopyon corneal ulcer, especially in contact lens users, due to its rapid
tissue destruction and proteolytic enzymes.
25. Satellite lesions are characteristic of fungal keratitis, representing peripheral fungal spread in corneal stroma.
26. Ruptur o D s m t‘s m mbr n o urs n k r to onus u to ut hy rops us by su n qu ous n lux nto strom t r
membrane break.
27. Steroids are contraindicated in corneal ulcer with hypopyon of infectious origin because they worsen microbial replication and
delay epithelial healing.
28. Pterygium is best treated by excision with conjunctival autograft as it reduces recurrence by restoring limbal barrier. Bare sclera
technique has high recurrence. MMC reduces recurrence but has complications. Artificial tears are only symptomatic.
29. In uveitis, topical steroids are main treatment along with cycloplegics; topical antibiotics like moxifloxacin are not indicated
unless secondary infection is suspected. Thus antibiotics are not appropriate.
30. B n k r top thy s u to l um pos t on ( l r ous n r t on) n Bowm n‘s l y r n nt r or strom .
31. Lamellar keratoplasty involves partial thickness corneal graft, preserving healthy layers of host cornea and replacing only
diseased layers.
32. Most common complication of topical steroid misuse is reactivation of herpes simplex keratitis due to immunosuppression.
33. Sloughing corneal ulcer with impending perforation is best managed by conjunctival flap which provides vascular support and
structural integrity.
34. Corneal scraping for microscopy and Gram stain is the first mandatory step to identify organism before starting targeted therapy
in corneal ulcer.

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35. Decreased corneal sensation with dendritic branching lesion indicates herpes simplex keratitis.
36. Keratoconus is most likely diagnosis in progressive bilateral ectasia with cone-shaped cornea and visual decline.
37. Salmon patches are seen in interstitial keratitis, classically associated with congenital syphilis due to deep stromal vascularization.
38. DSAEK is not used for corneal perforation; it is an endothelial transplant procedure, not a tectonic repair option.
39. Branching corneal lesion with reduced sensation is dendritic keratitis due to herpes simplex virus.
40. Keratitis is commonly associated with acne rosacea due to meibomian gland dysfunction and chronic ocular surface
inflammation.
41. Contact lens misuse with corneal infiltrate and anterior chamber cells indicates infective keratitis.
42. Contact lens-related corneal ulcer requires immediate same-day ophthalmology review due to risk of rapid progression and
corneal perforation.
43. Vesicular rash in trigeminal distribution indicates herpes zoster ophthalmicus.
44. Contact lens wearer with corneal haze, infiltrate, and hypopyon suggests infective keratitis.
45. Herpes zoster ophthalmicus is treated with oral aciclovir along with topical antiviral therapy.
46. Serum calcium helps identify systemic cause of band keratopathy such as hyperparathyroidism.
47. Acanthamoeba keratitis is best treated with polyhexamethylene biguanide (PHMB), often combined with other anti-amoebic
agents.

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