Q1 50M Compulsory discuss Clinical medicine and paediatrics
(a) Discuss in brief the role of ultrasound in the investigation of pain in right hypochondrium. (10 marks)
(b) Outline the pharmacological and non-pharmacological treatment of depressive disorders. (10 marks)
(c) A neonate born at 30 weeks of gestation is found to have tachypnea, chest retractions and grunt within 30 minutes of birth.
(i) What is the most likely diagnosis? Mention the basis of your diagnosis and state briefly the pathophysiology of the condition.
(ii) Describe the management of this condition. (5+5=10 marks)
(d) A 6-month-old infant attending paediatrics OPD is found to have central cyanosis, clubbing and no hepatomegaly.
(i) What is the most likely cardiovascular condition? State its cardiovascular examination findings and accompanying haemodynamic changes.
(ii) Write about the clinical course and complications related to this condition. (5+5=10 marks)
(e) An adolescent girl fond of wearing artificial jewellery presented with itchy, papulo-vesicular skin lesions on the ears, wrists and neck.
(i) What is the likely diagnosis?
(ii) Name the gold standard test which you would use for the confirmation of diagnosis.
(iii) How would you interpret the test results?
(iv) State the complications of this test. (2+2+3+3=10 marks)
Answer approach & key points
Begin with a brief introduction acknowledging the diverse clinical scenarios across adult and paediatric medicine. For part (a), discuss ultrasound applications in right hypochondrial pain with specific organ-wise approach; for (b), outline depression treatment with balanced pharmacological and non-pharmacological coverage; for (c), diagnose neonatal respiratory distress syndrome with clear pathophysiology and stepwise NICU management; for (d), identify tetralogy of Fallot with characteristic examination findings and natural history; for (e), diagnose allergic contact dermatitis to nickel with patch testing interpretation and complications. Allocate approximately 15% to (a), 15% to (b), 20% to (c), 20% to (d), and 30% to (e) given its four sub-parts, ensuring each sub-part receives proportional attention within its section.
- (a) Ultrasound in right hypochondrial pain: gallbladder pathology (cholelithiasis, cholecystitis, CBD stones), liver assessment (hepatomegaly, abscess, mass), renal/ureteric evaluation, and limitations of ultrasound
- (b) Depression treatment: SSRIs/SNRIs/TCAs/MAOIs with examples, ECT indications, CBT/interpersonal therapy, and lifestyle modifications
- (c)(i) Diagnosis of respiratory distress syndrome (RDS): basis of prematurity, surfactant deficiency, pathophysiology of alveolar collapse and V/Q mismatch
- (c)(ii) RDS management: surfactant replacement therapy, CPAP/mechanical ventilation, temperature control, and supportive care
- (d)(i) Tetralogy of Fallot: cyanotic CHD with pulmonary stenosis, VSD, overriding aorta, RVH; ejection systolic murmur, single S2, and right-to-left shunt physiology
- (d)(ii) Clinical course: hypercyanotic spells, squatting, iron deficiency, infective endocarditis risk, and need for corrective surgery
- (e)(i-iii) Allergic contact dermatitis to nickel: patch test as gold standard, positive reaction interpretation (erythema, papules, vesicles at 48-96 hours), and grading system
- (e)(iv) Patch test complications: active sensitization, irritant reactions, persistent hyperpigmentation/hypopigmentation, and anaphylactoid reactions
Q2 50M outline Emergency medicine, paediatrics and dermatology
(a) A sixty-year-old diabetic male presented to the emergency department with acute onset, central squeezing type of chest pain, which is severe in intensity and not relieving even after taking rest.
(i) What is the most probable diagnosis?
(ii) How will you investigate the case to reach the diagnosis?
(iii) Outline the steps in the management of the case. (2+4+14=20 marks)
(b) A 12-month-old infant with history of delayed initiation of complementary feeding and few diarrhoeal episodes was found to have length of 72 cm, weight of 5 kg, mid arm circumference of 10 cm and loss of subcutaneous fat.
(i) State the diagnosis. Under what severity of condition would you place this infant?
(ii) Enumerate the complications associated with the condition.
(iii) Describe the steps and phases of treatment. (4+5+6=15 marks)
(c) (i) Write the atypical presentations of scabies.
(ii) Describe the management of scabies in a neonate, in a child less than 2 years of age, an adult and a pregnant female.
(iii) State the causes which can lead to persistent itching following the administration of scabicide therapy. (5+5+5=15 marks)
Answer approach & key points
The question demands outlining across all six sub-parts: for (a) spend ~40% of time (20 marks) covering STEMI diagnosis, ECG-cardiac biomarker correlation, and stepwise management including thrombolysis; for (b) allocate ~30% (15 marks) on SAM classification using WHO criteria, complications like hypoglycemia and refeeding syndrome, and phased nutritional rehabilitation; for (c) use remaining ~30% (15 marks) on crusted scabies variants, age-stratified permethrin/ivermectin protocols, and post-scabetic pruritus causes. Structure each part with immediate diagnosis → investigation → management flow.
- (a)(i) Diagnosis: Acute STEMI in diabetic patient with atypical presentation masking typical chest pain
- (a)(ii) Investigations: ECG within 10 min, troponin I/T, CK-MB, echocardiography for wall motion abnormality, coronary angiography
- (a)(iii) Management: MONA protocol, primary PCI vs thrombolysis (tenecteplase), dual antiplatelet, beta-blockers, ACE inhibitors, statins
- (b)(i) Diagnosis: Severe acute malnutrition (SAM) by WHZ <-3SD or MUAC <11.5 cm with bilateral pitting edema check; severity: complicated SAM if edema/infection present
- (b)(ii) Complications: Hypothermia, hypoglycemia, hypokalemia, refeeding syndrome, septic shock, heart failure
- (b)(iii) Treatment phases: Initial stabilization (F-75, 100 kcal/kg/day), transition, rehabilitation (F-100/RUTF, 150-220 kcal/kg/day), follow-up
- (c)(i) Atypical scabies: Crusted/Norwegian scabies, scabies incognito, nodular scabies, bullous scabies in infants, scalp involvement in elderly/immunocompromised
- (c)(ii) Age-specific management: Permethrin 5% cream (neonate 1-2 months: 2.5% or sulfur 5-6%; child: full 5%; adult: 5% overnight; pregnant: permethrin first-line, avoid ivermectin)
- (c)(iii) Persistent pruritus causes: Treatment failure (resistance, incorrect application), reinfection from untreated contacts, post-scabetic nodules, secondary eczema, delusion of parasitosis
Q3 50M describe Pulmonary embolism, neonatal jaundice, lichen planus
(a) A 40-year-old male who was bedridden for the last two months following a fracture in the lower limb developed sudden breathlessness.
(i) What is the most probable diagnosis ?
(ii) How will you investigate the case ?
(iii) How will you manage the case ? (2+8+10=20 marks)
(b) A term neonate born to 'O' negative blood group mother was found to have deep jaundice involving palms and soles, excessive crying and convulsions at 20 hours of life.
(i) How would you assess the clinical severity of jaundice in this neonate ?
(ii) List the key investigations to arrive at the diagnosis.
(iii) Describe the management of this neonate. (3+4+8=15 marks)
(c) (i) Give the clinical findings of lichen planus at the following sites :
- Nails
- Scalp
- Mucosa
- Palms and Soles
(ii) State the histopathological findings of oral lichen planus.
(iii) Discuss the management of oral lichen planus. (5+5+5=15 marks)
Answer approach & key points
The directive 'describe' demands systematic, detailed exposition of clinical features, investigations, and management across all three scenarios. Allocate approximately 40% of time/words to part (a) pulmonary embolism (20 marks), 30% to part (b) neonatal jaundice (15 marks), and 30% to part (c) lichen planus (15 marks). Structure each part as: brief clinical interpretation → diagnostic workup → stepwise management, with part (c) additionally requiring site-specific clinical descriptions and histopathology.
- Part (a): Identify pulmonary embolism (PE) as the diagnosis; explain Virchow's triad relevance in post-immobilization state; outline D-dimer, CTPA/Wells score, and ECG findings (S1Q3T3); detail anticoagulation (LMWH→warfarin/DOACs), thrombolysis criteria, and IVC filter indications
- Part (b): Recognize ABO/Rh hemolytic disease with early-onset severe hyperbilirubinemia; describe Kramer's rule for jaundice staging and clinical signs of kernicterus; list direct Coombs test, peripheral smear, reticulocyte count, serum bilirubin (direct/indirect), and maternal antibody titres; explain intensive phototherapy, IVIG, exchange transfusion criteria, and neurological monitoring
- Part (c)(i): Site-specific findings—nails (pterygium, thinning, ridging), scalp (cicatricial alopecia, follicular lichen planus), mucosa (Wickham's striae, erosive/reticular/bullous types), palms/soles (palmoplantar lichen planus, hypertrophic variant)
- Part (c)(ii): Histopathology showing saw-tooth rete ridges, band-like lymphocytic infiltrate, Max-Joseph spaces, civatte bodies (colloid bodies), and basement membrane degeneration
- Part (c)(iii): Management hierarchy—topical corticosteroids (high potency), calcineurin inhibitors, systemic agents (corticosteroids, retinoids, immunomodulators), and surveillance for malignant transformation
Q4 50M discuss Liver cirrhosis, pediatric dehydration, psoriatic arthritis
(a) Discuss in short the etiology, diagnosis, treatment and complications of cirrhosis of liver. (5+5+5+5=20 marks)
(b) A 15-month-old child brought by the mother with history of 6 episodes of vomiting and 4 episodes of watery diarrhoea was found to have lethargy and is unable to drink. The child weighed 10 kg before this event of illness.
(i) How would you assess the severity of the illness in this child ?
(ii) Write the fluid management in the first 3 hours.
(iii) Write the treatment guidelines after 3 hours if the child still exhibits signs of dehydration.
(iv) Write the composition and preparation of the WHO Oral Rehydration Salts (ORS). (4+4+4+8=20 marks)
(c) (i) What is the differential diagnosis of psoriatic arthritis ? How would you distinguish psoriatic arthritis from other conditions ?
(ii) Discuss the management of psoriatic arthritis. (5+5=10 marks)
Answer approach & key points
The directive 'discuss' demands a comprehensive, analytical treatment across all sub-parts. Allocate approximately 40% of effort to part (a) on liver cirrhosis (20 marks), 40% to part (b) on pediatric dehydration with its four sub-sections (20 marks), and 20% to part (c) on psoriatic arthritis (10 marks). Structure as: brief introduction acknowledging the clinical spectrum from chronic liver disease to acute pediatric emergency to autoimmune arthritis; systematic body addressing each sub-part with appropriate depth; conclusion emphasizing integrated clinical decision-making and public health relevance of ORS and early arthritis intervention.
- Part (a): Etiology of cirrhosis (viral hepatitis B/C, alcohol, NAFLD, autoimmune, metabolic); diagnosis via Child-Pugh/MELD scoring, imaging, liver biopsy; complications including portal hypertension, variceal bleeding, hepatic encephalopathy, hepatorenal syndrome, HCC; treatment modalities (lifestyle, pharmacological, transplant candidacy)
- Part (b)(i): Assessment using WHO IMCI criteria—lethargy, sunken eyes, skin turgor, inability to drink indicate severe dehydration; weight loss calculation from 10 kg baseline
- Part (b)(ii): First 3 hours fluid management—IV Ringer's Lactate or NS 100 ml/kg for severe dehydration, rapid assessment every 1-2 hours, monitoring for signs of improvement or fluid overload
- Part (b)(iii): Post-3 hour management—reassessment, continued IV fluids if signs persist, transition to oral rehydration when tolerated, zinc supplementation, continued feeding, monitoring for hypoglycemia and electrolyte disturbances
- Part (b)(iv): WHO ORS composition (Na+ 75, K+ 20, Cl- 65, citrate 10, glucose 75 mmol/L; osmolarity 245 mOsm/L); preparation by dissolving one packet in 1 liter clean water; low-osmolarity formula rationale
- Part (c)(i): Differential diagnosis—rheumatoid arthritis (RF/anti-CCP positive, symmetric), ankylosing spondylitis (axial predominance, HLA-B27), reactive arthritis, gout, osteoarthritis; distinguishing features of PsA (dactylitis, enthesitis, nail changes, DIP involvement, asymmetric oligoarthritis)
- Part (c)(ii): Management—NSAIDs for mild disease, DMARDs (methotrexate, sulfasalazine) for peripheral arthritis, biologics (TNF-α inhibitors, IL-17/IL-12/23 inhibitors) for inadequate response; treat-to-target approach, skin-nail psoriasis co-management
Q5 50M Compulsory describe Surgery, Obstetrics, Gynecology, Community Medicine
(a) Briefly describe the clinical features, diagnostic workup and management of a patient of choledochal cyst. (3+4+3=10 marks)
(b) A 60-year-old lady presents to the casualty after a fall on her right outstretched hand. X-ray image is suggestive of Colles' fracture.
(i) Briefly write the clinical features of this condition. (5 marks)
(ii) Enumerate five complications of this fracture. (5 marks)
(5+5=10 marks)
(c) (i) Define Foetal Growth Restriction (FGR). (2 marks)
(ii) List the common causes of FGR. (4 marks)
(iii) Outline the strategy for managing a severely growth restricted pregnancy diagnosed at 26 weeks of gestation. This female has no living issues and has a past history of undergoing Caesarean Section at 32 weeks of pregnancy. (4 marks)
(2+4+4=10 marks)
(d) (i) Define menopause. (2 marks)
(ii) List the medical indications for prescribing Hormone Replacement Therapy (HRT). (4 marks)
(iii) State briefly the controversies that have demerited the concept of 'Universal HRT'. (4 marks)
(2+4+4=10 marks)
(e) Dengue has become a major health problem for the country. The number of cases and disease severity have worsened over the years.
Keeping this in context, answer the following questions:
(i) What are the reasons which have led to a major shift in the geographic extent of dengue in the country? (5 marks)
(ii) How is climatic change impacting the disease? (5 marks)
(5+5=10 marks)
Answer approach & key points
The directive 'describe' demands systematic, structured exposition of clinical entities across all sub-parts. Allocate approximately 20% time to (a) choledochal cyst, 20% to (b) Colles' fracture, 20% to (c) FGR, 20% to (d) menopause/HRT, and 20% to (e) dengue epidemiology. Begin each sub-part with definition/classification, proceed to clinical features/pathophysiology, and conclude with management or public health implications. For part (c)(iii), explicitly integrate the high-risk obstetric history (previous CS at 32 weeks, no living issues) into management decisions.
- (a) Choledochal cyst: Todani classification (Types I-V), triad of pain-jaundice-mass, MRCP/ERCP diagnosis, excision with Roux-en-Y hepaticojejunostomy
- (b) Colles' fracture: 'Dinner fork' deformity, posterior displacement, radial shortening; complications including malunion, carpal tunnel syndrome, Sudeck's atrophy, arthritis, tendon rupture
- (c) FGR: Definition as EFW <10th percentile or lagging AC; causes include placental insufficiency, maternal malnutrition, infections (TORCH), chromosomal anomalies; management with Doppler surveillance, steroids, timed delivery balancing prematurity vs. intrauterine demise
- (d) Menopause/HRT: 12 months amenorrhea, indications for vasomotor symptoms, osteoporosis prevention; WHI study controversies regarding breast cancer and cardiovascular risk
- (e) Dengue: Geographic expansion due to urbanization, Aedes aegypti adaptation, serotype shifts (DEN-2 dominance in India); climate change effects on vector breeding temperature range and transmission season extension
Q6 50M discuss Obstetrics, ENT/Oral Surgery, Nutrition
(a) (i) Write in brief the reasons for rising Caesarean Section rates globally and in India. (5 marks)
(ii) Discuss briefly the advantages and disadvantages of Vaginal birth and Caesarean Section. (5 marks)
(iii) What measures can be adopted to reduce Caesarean Section rates? (5 marks)
(iv) How will you counsel a patient who had previous Caesarean Section for vaginal delivery? (5 marks)
(5+5+5+5=20 marks)
(b) A 55-year-old male, tobacco chewer, presents to OPD with difficulty in opening mouth for one month. On examination, he is found to be having poor oral hygiene and a white patch on right buccal mucosa.
(i) Briefly describe leukoplakia and its significance. (5 marks)
(ii) What are the premalignant conditions for oral cavity cancer? (5 marks)
(iii) What are the different cervical lymph nodes which can get involved in a patient with oral cavity cancer? (5 marks)
(5+5+5=15 marks)
(c) (i) When is a protein said to be "biologically complete"? (5 marks)
(ii) How do vegetable proteins compare and compete with animal proteins? (5 marks)
(iii) What are proteins needed for in the body? (5 marks)
(5+5+5=15 marks)
Answer approach & key points
The directive 'discuss' demands a balanced, analytical treatment across all sub-parts. Allocate approximately 40% of effort to part (a) given its 20 marks, 30% each to (b) and (c). Structure: brief introduction on rising C-section rates and oral cancer burden in India; body addressing each sub-part sequentially with clinical depth; conclusion emphasizing integrated public health strategies for maternal and oral health.
- Part (a)(i): Reasons for rising C-section rates—medical (breech, placenta previa), non-medical (patient request, defensive medicine, commercial incentives), Robson classification; India-specific (institutional deliveries under JSY, private sector dominance, urban-rural disparity)
- Part (a)(ii): Vaginal birth advantages (microbiome colonization, maternal recovery, lower hemorrhage) vs C-section (reduced birth trauma, planned delivery); disadvantages of each mode with evidence from WHO and ICMR studies
- Part (a)(iii): Robson 10-group classification for audit, WHO partograph use, midwife-led care, financial disincentives for unnecessary C-sections, institutional protocols
- Part (a)(iv): VBAC counseling—TOLAC criteria (previous low transverse incision, no contraindications), success rates (60-80%), risks (uterine rupture ~0.5%), shared decision-making, NICE guidelines adaptation
- Part (b)(i)-(iii): Leukoplakia definition (WHO 2005), histopathological grades, malignant transformation rates; premalignant conditions (erythroplakia, oral submucous fibrosis, lichen planus, syphilitic glossitis); cervical lymph node levels I-V with oral cavity drainage patterns (submental, submandibular, jugulodigastric)
- Part (c)(i)-(iii): Biological value/PER/NPU criteria for complete proteins; limiting amino acids in cereals (lysine) and pulses (methionine), mutual supplementation; protein functions—structural, enzymatic, hormonal, immune, transport, energy
Q7 50M outline Clinical medicine, public health, reproductive medicine
(a) A 60-year-old male presents with progressively increasing jaundice for 2 months. He is having clay coloured stools and pruritus. On examination, he is having a palpable and distended gall bladder.
(i) How will you investigate this patient? (5 marks)
(ii) Briefly mention Courvoisier's law and its exceptions. (7 marks)
(iii) What are the treatment options for this patient? (8 marks)
(b) The Mother and Child Tracking System (MCTS) is a significant initiative of the government.
(i) Briefly explain what is MCTS. (5 marks)
(ii) What are its objectives? (5 marks)
(iii) How is it being put into operation? (5 marks)
(c) (i) How will you investigate a couple; wife 35 years, husband 37 years, married for 3 years, but trying for conception since 6 months? (5 marks)
(ii) What are the major factors affecting fertility? (5 marks)
(iii) Outline the treatment options available for unexplained infertility. (5 marks)
Answer approach & key points
This question demands a structured, multi-part response covering surgical gastroenterology, public health systems, and reproductive medicine. Spend approximately 40% of the word budget on part (a) as it carries 20 marks (the highest weightage), with 25% each on parts (b) and (c) (10 marks each). Begin with a brief clinical vignette interpretation for (a), followed by systematic investigation algorithms, then transition to public health description for MCTS, and conclude with reproductive medicine protocols. Use bullet points and flowcharts where appropriate to maximize clarity within time constraints.
- For (a)(i): Investigation sequence for obstructive jaundice — USG abdomen first-line, followed by CT/MRCP, ERCP with biopsy, tumor markers (CA 19-9), and liver function tests showing conjugated hyperbilirubinemia with elevated alkaline phosphatase
- For (a)(ii): Courvoisier's law (painless palpable gallbladder with jaundice suggests malignancy, not stone disease) and its exceptions — pancreatic stone, choledocholithiasis with chronic cholecystitis, Mirizzi syndrome, and pancreatic head inflammatory mass
- For (a)(iii): Treatment options based on etiology — Whipple's procedure for resectable periampullary/head of pancreas cancer, palliative biliary stenting (ERCP/PTBD) for unresectable disease, chemotherapy (FOLFIRINOX/gemcitabine-nabpaclitaxel), and best supportive care
- For (b)(i)-(iii): MCTS as an ICT-based tracking system under NRHM (now part of RCH portal), objectives of ensuring ANC registration, institutional delivery, and complete immunization, with operation through ASHA/ANM data entry, SMS alerts to beneficiaries, and web-based monitoring dashboard
- For (c)(i)-(iii): Infertility workup — semen analysis, ovulation tracking (follicular monitoring), hysterosalpingography, hormonal profile (FSH, LH, AMH), and laparoscopy if indicated; factors affecting fertility (age, BMI, smoking, endometriosis, tubal factors, male factors); treatment for unexplained infertility — ovulation induction (clomiphene/letrozole), IUI, and IVF/ICSI as third-line
Q8 50M describe Iodine deficiency, MTP Act, thyroid surgery
(a) (i) Summarise the spectrum of Iodine Deficiency Disorders. (10 marks)
(ii) State the goal, objectives and salient features of Iodine Deficiency Disorder Control Programme. (10 marks)
(b) (i) What are the major changes that have been introduced under the MTP (Amendment) Act, 2021? (6 marks)
(ii) What are the different contraceptive methods employed by people in India? List them in the order of their usage stating the statistics of how commonly they are used. (5 marks)
(iii) What measures can help increase the use of contraceptives in India? (4 marks)
(c) A 47-year-old female presents to the surgery OPD with a solitary nodule in the right lobe of thyroid gland.
(i) How will you investigate this case? (5 marks)
(ii) What is the ideal treatment if investigations are suggestive of follicular neoplasm? (5 marks)
(iii) How will you follow-up a patient who has undergone total thyroidectomy for papillary carcinoma thyroid 5 days back? (5 marks)
Answer approach & key points
This multi-part descriptive question requires systematic coverage of public health (40%), legal/ demographic (30%), and clinical surgical (30%) components. Begin with a brief introduction acknowledging iodine deficiency as India's historically significant public health problem, then proceed part-wise: (a) requires structured enumeration of IDD spectrum and programme details with NIDDCP/NNM references; (b) demands precise legal changes from MTP Amendment 2021, contraceptive hierarchy per NFHS-5 data, and evidence-based demand-generation strategies; (c) needs algorithmic clinical reasoning for thyroid nodule workup, surgical decision-making for follicular neoplasm, and post-thyroidectomy follow-up protocol. Conclude with integrative remark on preventive-to-curative continuum in endocrine care.
- (a)(i) Spectrum of IDD: Goitre (diffuse/nodular), hypothyroidism, cretinism (neurological/myxedematous), endemic cretinism, stillbirths, impaired mental function, iodine-induced hyperthyroidism (Jod-Basedow)
- (a)(ii) NIDDCP/NNM goals: Universal salt iodization (USI), <5% endemic goitre, objectives of eliminating IDD by 2020, salient features of IDDCP including NIDDCP 1992, NNM 2018, double fortified salt, monitoring through urinary iodine estimation
- (b)(i) MTP Amendment 2021: Extension to 24 weeks for special categories, removal of marital status requirement, confidentiality clause, registered medical practitioner definition, gestation-based categorization, board constitution for >24 weeks
- (b)(ii) Contraceptive hierarchy per NFHS-5: Female sterilization (37.9%), male sterilization (0.3%), IUD (2.1%), OCPs (2.4%), condoms (9.5%), traditional methods (5.1%), any modern method (56.5%)
- (b)(iii) Demand generation: ASHA counseling, male involvement, social marketing, postpartum/post-abortion family planning integration, removal of method-specific targets, community-based distribution
- (c)(i) Thyroid nodule investigation: TSH, T4, ultrasound (TI-RADS), FNAC (Bethesda system), serum calcitonin if MEN2 suspected, TPO antibodies, radionuclide scan if TSH low
- (c)(ii) Follicular neoplasm management: Hemithyroidectomy/lobectomy as diagnostic and therapeutic, intraoperative frozen section, completion thyroidectomy if invasive cancer confirmed, avoid total thyroidectomy upfront due to benign majority
- (c)(iii) Post-total thyroidectomy follow-up: Calcium and PTH monitoring for hypoparathyroidism, thyroglobulin as tumor marker, TSH suppression with levothyroxine, radioactive iodine ablation planning, laryngeal nerve function assessment