Gyane

1. 30 years old P2 L2 A0. She has been taking depo for contraception
since 6 months. She has had scanty bleeding on and off since the
depot injection. She has no medical disorder. Her Hct is 40% and
platelet is 160,000. What is your advice?
assurance
2. A 25 years old woman is admitted to the labor ward at 39 weeks of
gestation with regular uterine contraction. A partogram is started to assess
labor. what is the most important detail to asses labor cervical dilation

3. A woman comes for ANC visit at 34 weeks of gestation, USG shows 30

weeks with a live fetus. While doing examination you found that symphysiofundal height to be 34 weeks what is your diagnosis intra uterine
growth retardation

4. 18 years old primi is brought to ER at 32 weeks of pregnancy with seizure.

Her BP is 160/100 mm of hg and heart rate is 140 per minute. what is the
drug that can be used in this lady magnesium sulphate

5. 34 years woman comes to you with the chief complain of irregular menses
for 6 months. 2 months ago she had light period, 5 weeks later she had
heavy bleeding. Bleeding since then. What is the next step to be done on
her USG (for diagnosis) where the problem is) after doing USG than
you can check for TFT (said by maam)

6. A 39 years old woman complains of irregular heavy period. She also admits
to intermittent bleeding and often experience painless post coital bleeding.
What is the most likely diagnosis cervical polyp

7. 61 years old lady has 3 children and normal menopause 6 years ago.
Because of her menopause symptoms were severe. Now complains of
intermittent painless bleeding for 3 months. What condition should be ruled
out in this case endometrial cancer

8. 58 years lady with 4 children a normal menopause 8 years ago was started
on HRT coz of severe menopausal symptoms. Chief complain of
intermittent vaginal discharge for 2 months. Risk factor for malignancy
long term HRT use

9. 10 years old child is brought by her mother with chief complain of vaginal.
She does not show any signs of sexual development but seems very
withdrawn and avoids eye contact sexual abuse
10.
9 year old happily playing child came with chief complain of per
vaginal discharge for 1 month. No sexual development history
foreign body insertion in vagina
11.
74 years old obese female somewhat agitated complains of
difficulty in passing urine. Her wt is static, normal appetite but
complains of mass in her abdomen, which she has noted only
recently when you question her further whether she had vaginal
bleeding. What is the most likely diagnosis ovarian malignancy
12.
A patient with 17 weeks of gestation diagnosed of having an
intra uterine fetal demise, she was asked to follow up after a week
but returns to your office 5 weeks later and has not expelled the fetus
although she has occasional spotting consumptive coagulopathy
13.
A 25 years old lady came in the ER with per vaginal bleeding
since 1 day with passage of fleshy mass. She gives history of 2
months amenorrhea. on examination vitals were stable, mild pallor,
per abdomen soft non tender, cervix healthy bleeding, per vaginal
uterus is 6 weeks size open fornix clear non tender what is you
most likely diagnosis incomplete miscarriage
14.

A 24 year old P1 L1 came to ER with complain of bleeding and

passage of vesicular tissue per vagium and amenorria for 3 months.

On examination vitals were stable, per abdomen uterus 16 weeks size
per speculum minimal bleeding, PV- OS closed, beta HCG was 90,000,
HCT was 98%. How will you manage suction evacuation
15.

25 year old lady P1 L1 came to ER came with the complain of

bleeding for more than 1 year. On examination uterus 16 weeks size

non tender and mobile USG showed mass of the 8*6.5*5 width. The
uterus is fibroid. How would you manage this case hysterectomy

16.
A 25 year old unmarried girl with the finding of severe ovarian
cyst measuring 6*7 cm in ultra sound. She had irregular menstrual
cycle of 6 months. What is the best management oral
contraceptive pills
17.
A 25 year old unmarried girl came with severe dismennoria for
few days .she gives the episodes of 6 months. This time the pain was
not relived even with NSAIDS. What is the best management for her
OCP
18.
Tara is 18 and she is concerned that she not yet started her
period although she seems in good health generally. She works very
hard, walking distance in her village is markedly long and admits to
eating a very limited diet physical examination is normal what is most
likely cause of her symptoms primary ammonerria
19.
Tara is 18 and she is concerned that she not yet started her
period although she seems in good health generally. She works very
hard, walking distance in her village is markedly long and admits to
eating a very limited diet physical examination is normal what
management/ investigation will you do to this ladyUSG pelvis
other options are 1. Genetic testing, 2. Thyroid function test

20. Tara is 18 and she is concerned that she not yet started her period
although she seems in good health generally. She works very hard, very thin
and eats less. Physical examination is normal, normal secondary sexual
characteristics. What is most likely cause of ammenoria hypothalamic
amenorrhea other options 1. Imperforated hymen
2. Polycystic ovarian disease
3. Turner syndrome
21 A 19 years old girl presents with primary ammonerrhoea she is thin and
admits she does not eat much physical examination is normal and you
under take a progesterone challenge test. What will you say it is positive

progesterone challenge test Bleeding after 2-7 days administration

withdrawal.
22 Deependra arrives at the clinic with his newly married wife Ashmi since
she wants to delay her pregnancy for 1-2 years they have been using
rhythm method as she is very much against the pill, she was nauseated
when she tried to use it on the previous occasion. What advises do you
give to her sensible use of barrier method other options are 1.
Injectable hormone 2. She should try pills again 3. Suggest IUCD
23 Rita 25 years is P1L1A0. She plans to have another child after 7- 10 years.
She has come to you for contraception on further inqury she complains of
abdominal pain and PV discharge. What would be your choice of the
contraception for her oral contraceptive pills. Other options are 1.
IUCD, 2. Bilateral tubal ligation, 3. Vasectomy
24 A 35 year old lady delivered her second child 1 day ago she had
prolonged labor at home without any medical help. She now feels faint
and slightly breathless. On examination uterus is tender and palpable at
the umbilicus. She has moderate vaginal bleeding .What in particular
contributed to her condition? Prolonged labor. Other option 1.
Inadequate care 2. Multiparity
25 A 35 year old lady delivered her second child 1 day ago she had
prolonged labor at home without any medical help. She presents in ER
with dizziness and slight breathlessness. On examination her uterus is
palpable at umbilicus and she is continuing moderated vaginal bleeding.
What is the immediate treatment IM oxytocin other options 1.
Antibiotics

PBQ

Case of Hypertension (Sabai question ta yaad chaina)

1. What is you diagnosis?

Preeclemsia
2. Define the above give condition (preeclampsia)?
Multisystem disorder characterized by development of hypertension
(140/90 mm hg) with proteinuria after the 20 wks in previously normotensive
& non proteinuric women.
3.

What are commonly used hypertensive drugs?

A.
B.
C.
D.

Methyl dopa (200-250 mg tid)

Labetalol (100 mg tid/qid)
Nifedipine (10-20 mg bid)
Hydralazine (10-25 mg bid)

Later she develops seizure

4. Now what is you diagnosis
Eclampsia

5. What are the 5 investigation that you can do in this case?

A.
B.
C.
D.
E.

Urine albumin
CBC, uric acid
LFT
RFT
RBC

6. What drug will you give for the management of the case?
Magnesium sulfate

7. How will you monitor the toxicity of the drug?

a. Respiratory rate
b. Patellar reflex
c. Urine output
8. What is the antidote for magnesium sulfate poisoning?
Calcium Gluconate
9. How will you manage the case in the hospital setting?

10. Suppose the patient is now on 35 weeks of gestation and her BP is

controlled what will you do?
Plan for the delivery

Practical
Partograph
1. What is the stage of labor?
Stage 1
2. How much time till full cervical dilatation?
4 hours
3. Maternal factor?
I.
II.
III.
IV.
V.

Temperature
Blood pressure
Pulse
Contaratction per 10 min
Cervix dilation

4. Fetal factor?
I.
II.
III.
IV.
V.

Effecement
Station of head
Position of the head
Caput
Meconium

STATION 2
Obstetric examination

STATION 3
BREECH Delivery
1. What mode of delivery do you prefer in this case?

2. What are the methods you can apply to the after coming head in this delivery?

3. What are the types of breech?

4. What are the three main risk factor of breech?

STATION 4
1. What is the most likely diagnosis?
Anti Partum Hemorrhage
2. What is your D/D? (Write 3)

3. What are the types of placenta previa?

4. Write 3 investigations?

5. How will you manage the above case?

STATION 5
1. Why was the vacuum delivery chosen?

2. What are the three other investigation?

3. What are the prerequisite for vacuum delivery?

4. What are the complication (maternal and fetal complication) ?

STATION 6
1. What is your diagnosis?
Fibroid uterus
2. Two D/D?

3. What are the 3 relevant investigation?

4. How will you manage this case?

Hysterectomy (since she already has 4 children)
5. What will you do in case of 28 years old nulliparus lady?
Myomectomy

MEDICINE
1. A 75 years old male complain to his doctor of poor urine output. For
the past 2 days he has recently had a week urine stream but denies

any other urinary syndromes. On physical examination his vitals are

stable. On digital rectal examination there is smooth non tender and
projectile
Ans a trial of alpha blocker
2. A 31 years old lady develops multiple joint pain and swelling, maller
rashes, oral ulcers and after starting the theray of anti tubercular
therapy for pulmonary tuberculosis. On lab investigation urase positive
anti histon anti bodies
Which drug is associated with this condition?
AnsIsoniazide
3. A 17 years old male presents with fever for 7 days with chills ,painful
dark spots on the fingers and a new dark lines in his fingers nails. He
has been misusing iv drugs. His blood culture shows metheciline
resistance staphylococcus aureus . which valve is affected to have
endocarditis
Ans tricuspid valve
4. A 14 years old male presents in Nuwakot district hospital with fever,
sore throat, tender lympnodes and pharyngeal exudates. He denies of
shortness of breath, sputum and nasal congestion, rihonerria. What
should you do next in this setting??
Ans prescribing penicillin V
2. A 55 year old man with cirrhosis and with redcurrent ascitis presents

with fever. He receives a diagnostic paracyntesis. Laboratory

investigation showed WBC greater than 200 with 80% neutrophils,
results of asitic fluid pending
ANS Benign treatment of IV cefotaxime
1. 60 years old man non- smoker diagnosed with essential hypertension
with no target organ damage. His total cholesterol is 210 mg/dl, LDL id
90 mg/dl. His blood pressure is 151/92 mm of HG .what is the next
appropriate treatment
Ans life style modification
2. A 37 years old female complains of double vision for the last few
weeks. She has difficulty in watching TV especially at night. She also
has difficulty swallowing a chewing. On examination, there is ptosis

which gets better on rest. what is the appropriate next step to make
her diagnosis
Ans actyl choline receptor anti bodies
3. A 68 years old male presents in the ER in Patan hospital with sudden
unset of right sided weakness and impaired consciousness. Other
medical problems include HTN, obesity and hypercholestrolemea.
Neurologiacal examination shows right sided upper mother neuron
type of weakness. He has carotid bruit on the left side. What is the
most appropriate next step in the management?
ANS CT scan head
4. A 58 years old male presents with persistent vomiting for 1 month on
examination the abdomen was soft but succession splash was positive.
The doctor thinks that he has Gastric out let obstruction. What else do
you aspect to find in this case
a. Absence of gastric peristalsis
Ans Metabolic alkalosis
5. A 40 year old gentleman presents with the complain of heart burn on
and off for last 6 years. Upper GI endoscopy raveled the abnormality in
the esophagus that is confirmed by histologically by the presence of
metaplastic epithelium characterized by the goblet cells. What is the
significance of the histological finding
AnsIncrease risk of the squamous cell carcinoma of
Esophagus ?????????
6. A 42 years old lady presents with right upper quadrant pain fever and
jaundice. Investigation reveled total leukocyte count 12000 per micro
liter, ALT 20 units, and AST 22 units. Alkaline phosphates 1200 units.
What is the most likely cause
Ans choledocolitiasis
7. A 42 years old school teacher presents in medical report clinic with
concern of the high blood sugar as several member of the family has
DM. he shows you a fasting blood sugar level of 120 mg/dl and another
random blood glucose level showing 185 mg/dl. what is the best term
to characterize the condition
Ans Pre- diabetes
Other option
a. DM
b. Impaired fasting glucose tolerance

8. A 23 years old female is brought to ER with history of an episodic loss

of consciousness after receiving a hepatitis B vaccination. He describes
the feeling of nausea. Sweaty, shortness of breath after receiving the
vaccination and then collapsed up on standing in leaving clinic but
quickly recovered and he is now felling well with normal physical
examination. What is the most appropriate management?
Ans Reassurance
9. A 47 years old woman is evaluated in ICU with respiratory failure. She
has severe lower lobe pneumonia and was in septic shock. what
definition best describes the patient condition
Ans Sepsis with hypertension or hypoperfuion despite adequate fluid
resuscitation
10.
A 25 year old man present with the non- pitting edema and skin
discoloration of the right leg. On the other history he had an episode of
fever and painful right inguinal lymphadenopathy one year ago. He has
other wise been well. What micro- organism is most likely responsible
for his leg selling?
A. Mycobacterium Tuberculosis
B. Staph. Aureus
C. Wecehria brancrofti
11.
A 53 year old scezophrenic patient is admitted to the hospital for
behavioral issues over the night the nurses complains that she is
incontinent of very large volume of urine. On examination you noticed
she had 10 cups of water at the bed side. what would you do to
manage her incontinence
Ans Restrict he oral fluid intake
12.
43 years old woman is came in the follow up after the head
trauma. She is noticed by her family members to be urinating
tremendous amount of urine after the accidents. Lab diagnosis specific
gravity is close to 1. what medication is likely to help her symptoms
a. Amiloride
Ans Desmopressin
13.
A 54 years old male complains of the fever exertional dyspnea,
non productive cough for 1 week, he was diagnosed with HIV infection
earlier. Otherwise he was asymptomatic. His spo2 is 80% on the room
air using 100% non- re-breather mask his oxygen saturation is 92%

chest x- ray shows diffuse bilateral interstitial infiltration. His CD4

count is 140 micro liters. What is the most appropriate next step of this
patient
Ans Trimethropim sulfamethoxazone
14.
A 23 year old female pregnant woman at 28 weeks of gestation
presents in ER with 1 month history of shortness of breath on exertion
on over the past weeks. She has difficulty in breathing at night and
requires 3 pillows while sleeping. She has the history of rheumatic
fever. On examination she has diastolic rumble at apex. What is the
most likely diagnosis
Ans
PBQ
A 65 years old gentleman and a chronic smoker presents to ER with the
complain of sudden onset of shortness of breath, dizziness, headache,
vomiting, difficulty in walking for 12 hours. The doctor made the
diagnosis of the vertigo and planned for the further workup and
differentiating central and peripheral vertigo.
1. What point will help the doctor to differentiate the central and
peripheral vertigo
a. Nistagmus/ fatigability
b. There is neurological sign/
c. Ear syndromes(deafness, tinnitus, posture instability)
2. Write 3 causes of each type of vertigo
A. Central
Brainstermstroke
Cerebebral strkoke
Migranous vertigo
Multiple stenosis
B. Peripheral
BPPV
Vestibular neuritis
Meniere disease
CSOM
Ototoxic drugs like aminoglycoside
The doctor now examines the patient and finds that the muscle
power is decreased in the right upper and lower limbs and the planter

response is extensor in the same side. His face is deviated towards the right
side.
1.What is the most likely diagnosis at this point
Ans Brain steam stroke/ CVA
2. What investigation will be the most useful in this point?
Brain imaging(CT/ MRI)
ECG
Following investigation results it was found that there was a hypo-dense
lesion in the area of hind brain
3. List the important signs that arises when the lesions occur in this part of
the brain

Weakness/ clumsiness of limb

Decreased/ Altered sensation
Dysarthia
Dysphagia

4. What are 3 commonest factors causing this condition?

Hypertension
Diabetes mellitus
Smoking
Dyslipedemia of DCT

The patient is now admitted in the medical ward

1. List four important components of treatment of this condition
Medical support ( feeding, pressure sore prevention, catheterization,
care of eyes and mouth, etc)
Thrombolysis
Endovascular techniques
Antithrombotic
Blood pressure control
Blood sugar control
Rehabilitation

After 72 hours of hospital admission the patient becomes progressively

drowsy. The doctor observes the bilateral papiloedema on fundoscopy .the
doctor suspects raised ICP.
1.What other things that you aspect to find of the gentleman at this point
Bradicardia
Hypertension
Irregular respiration
2. How do you treat the newly developed complications?

Head end elevation with the midline position

Osmotic therapy (mannitol)
Hypertonic saline
Sedation

3. During the course of hospital admission what other acute complication

could the patient develop?

Seizure
SIDH
Raised ICP
Brain herniation
Bed sore
Aspiration pneumonia
GI bleeding (stress ulcer le garda)

OSCE-1
CHEST X-RAY interpretation

A 25 year old smoker male patient who has been healthy previously
presented in the ER with sudden onset of shortness of breath and right
sided chest pain. Chest X-ray is displayed on the computer
1.what are the 2 findings in the chest X ray
Radiolucent shadowing with the collapsed right lung
Shifting of mediastenum to the left side
2.what is your diagnosis?
Right sided pnemothorax
3.On the physical examination what will you expect on palpation, percussion
and auscultation
Palpation
Trachea, mediatenum shift to the left side
Decrease chest exapantion of the right side
decrease vocal fremitus on the right side
Percussion
Hyper-resonance
Auscultaion
Decrease or absent breath sound on the right side
4.what are the modalities of the treatment
Needle aspiration
Chest tube drainage
OSPE-2
An 18 years old college student presented to medical OPD with the
complain of palpation, tremulus extremities and feeling of hot most of
the time. a provisional diagnosis of hyperthyroidism was made. The
ECG is displayed on the table.
1.What is the heart rate
125 beats per minute
2.What is the rhythm
Sinus tachycardia

3.What is the axis

Normal
4.PR interval
0.16 second
5. How do you calculate QTC
QT/RR??
OSPE-3
45 year old male presented in the patan hospital ER with the 3 days history
of fever altered sensorium and vomiting. Lumbar puncture has been done.
The analysis of CSF shows 1405 mg/dl, sugar 13 mg/dl WBC 100 cumm,
neutrophil 80%, lymphocyte-20% .
1. what is you diagnosis?(any of the one lekhne)
Pyogenic/ Bacterial meningitis
Menigio encephalitis
Encephalitis
2.what are the 2 testes to elicit the rigidity of the neck?
Kernigs sign
Brudzinskis sign
3.what are the 3 common bacterial cause of this illness

Streptococcus pnemoniae
Nisgeria mengitidis
Group B streptococcus
Nisgeria monocytogens
Staphylococcus Aureus
Hemophillus influenza

4.What are the 3 important neurological complication of the disease?

Impared mental status

Raised ICP
Cerebral edema
Seizure
Focal neurological deficit (eg. Cranial nerve palsy, sensoneural hearing
loss)

OSCE-4

A 35 years old gentleman with the past history of jaundice presents in the
medical OPD with gradually developing abdominal distension of 1 month
duration. Perform a focus abdominal examination of this gentleman dont
forget to do fluid thrill and shifting dullness in this patient coz the patient is
having abdominal distension
Instruction to student perform a focal abdominal examination of the
patient. Tell the examiner what you are looking for during the examination
OSCE-5
History taking
Take a history of the patient with shortness of breath incorporating
associated symptoms. Ask systemic review and symptoms with the patient
so as to reach the provisional diagnosis.
59 years old house wife from Khokana presents with the month of
shortness of breath
Instruction to the students- Take the focus history of the presenting
complain and associated symptoms of the patient so as to reach the
provisional diagnosis of the breath. Give 3 differential diagnosis of the
patient.

VIVA
A 16 year old high school student is admitted for the work of nephrotic
syndrome
1. What do you mean by this syndrome?
Nephrotic syndrome is defined by the presence of massive proteinuriea
greater than 3.5 grams/dl, peripheral edema, hypoalbumenemia,
hyperlipidemia.
During your rotation in the medical ward you have noticed the several cases
of ascities.
2.What are the 5 common causes of ascities in the Patan hospital
Chirosis of liver
Abdominal tuberculosis

 Malignancy
Chronic kidney disease
Nephrotic syndrome
COPD (cor pulmunale with right ventricular failure)
78 years old retired army general is being admitted through ER for
pneumonia.
3. List 5 clinical features that indicates severity of pneumonia in this
gentleman

Confusion
Altered consciousness
High reparatory rate
Decrease BP
Shock
Elderly more than 65
Toxic look
Cyanosis/ hypoxia

A 51 years old lady is being treated for Deep vein thrombosis of her left leg.
4.How do you treat or monitor her

Initial anticoagulant (conventional or low molecular heparin)

Oral anticoagulant (warfarin should be started along with the heparin)
Monitor heparin effect with aptt
Monitor warfarin with PT-INR.