Published on February 19, 2014
GYNECOLOGY & OBSTETRICS Model Paper - 04 2 hours Single Best Respons Q1/Recurrent glycosuria in pregnancy 1. Indicates diabetes 2. Indicates pre-diabetes 3. Should always be investigated by oral glucose tolerance test 4. Is encountered in 10-15% of women 5. Associated with pre-eclampsia Q2/Obese lady with NIDDM is on Metfomin for 5 years, but her glycaemic control is not satisfactory She wishes to get pregnant. What will be your most suitable preconceptional management 1. She should not get pregnant 2. She needs strict glycaemic control for 3 months before conceiving 3. She should continue on Metfomin 4. She should lose weight prior to pregnancy 5. She should undergo HBA1c Q3/A 24—year-old multigravida , who has previously had a normal vaginal delivery of a 3900g male infant at term, is found to have a breech presentation at 36 weeks gestation in her second pregnancy. OG TT performed at 32 weeks of gestation as follows FSB -86 mg/dl 1H PPBS -178 mg/dl 2H PPBS – 160mg/dl She was on Insulin and her glycaemic control is satisfactory .On examination SFH is 42 cm . She is keen to deliver this baby vaginally if possible. Which one of the following is most accurate step to be done next? 1. Caesarean section now after dexamethasone 2. Caesarean section at term 3. X- ray Pelvimetry 4. Induction of labour at term 5. Await spontaneous onset of labour and assisted vaginal breech delivery Q4/ A 25 year old unmarried girl presents with lower abdominal pain and backache for 3 months duration. She is having a family history of breast cancer. Her ultrasound scan report indicates presence of a multilocular 6cm x 6cm, right sided, adenexal mass with thick septae. Other ultrasound scan findings were normal. The serum CA 125 level was over 500 IU/I (normal range 0-16 u/m) What is the best treatment option? 1. Laparoscopic cystectomy 2. Monthly Depo-Provera injections for 4 3. Pelvic irradiation 4. Combination chemotherapy of Taxol and Carbolplatin 6 cycles 5. Right sided oophorectomy Q5/ A 36 year old primigravida had incomplete miscarriage at 12 weeks of gestation. Her subsequent menstrual periods were normal. Her history and clinical examination were insignificant except for the 1
presence of a 3cm x 3cm fundal subserosal fibroid. What is the most appropriate management of this patient? 1. Cervical circlage in next pregnancy 2. Broad spectrum antibiotic administration in the first trimester of next pregnancy 3. Myomectomy 4. Early Initiation of Low dose aspirin therapy in next pregnancy 5. Preconceptional folic acid treatment Q6/A 24 year old primigravida presents in labour at POA of 31 weeks. The fetal heart rate was 140 beats per minute. Vaginal examination reveals a breech presentation , cervical dilatation of 5cm and absent membrane with meconium stained liquor. The next step of management is. 1. External cephalic version 2. Breech extraction 3. Emergency caesarean section 4. Tocolysis 5. Assisted breech delivery Q7/A 2l-year-old nulliparaus woman presents with lower abdominal pain at I5 weeks of POA. Her temperature is 37.9°C. She is otherwise well and eating normally. At the time of her previous antenatal visit at 11 weeks of gestation her uterus had been found to be retroverted but of the expected size. Which one of the following is the most likely diagnosis? 1. Impaction of a retroverted gravrd uterus 2. Urinary tract infection 3. Complication of a corpus luteum cyst 4. Tubal ectopic pregnancy 5. Threatened miscarriage Q8/About 15—20% of women carry the Group B Streptococcal (GBS) organism in the vagina. But still in SL there is no universal screening programme for screening GBS. When they complain of vaginal discharge they undergo HVS. If a pregnant woman is found to be GBS positive at HVS at 37 weeks of POA, which one of the following treatments is most appropriate? 1. Oral penicillin therapy throughout the remaining antenatal period 2. A two week course of oral penicillin given antenatally 3. A one week course of oral penicillin given antenatally about one week before term 4. Parenteral penicillin given six—hourly in labour · 5. Intramuscular penicillin given to the baby after its birth Q9/Fetal distress is more common when the head is in the occipito-posterior position in labour. Which one of the following is the most likely reason for this 1. Prolonged labour 2. Intrauterine infection 3. Increased analgesia requirement 4. Obstructed labour 5. Uncoordinated uterine action Q10/28 year old primigravida at term induction of labour was done with ARM and on Oxytocin infusion. CTG showed fetal bradycardia, uterine contractions lasting 90 seconds, interval between contractions 30 seconds. What is the most appropriate 1st step in the management? 1. start terbutaline infusion 2. emergency LSCS 2
3. stop oxytocin infusion 4. turn mother to left lateral position 5. give oxygen via face mask Q11/ A primigravida has been in the second of labour for 90 minutes. The fetal heart rate remained normal. The presentation is vertex and the position right occipito-posterior. The fetal head is only 1/ 5 above the pelvic brim and has a caput succedaneum with moulding. What is the most appropriate method of delivery? 1. Vacuum extraction 2. Emergency caesarean section 3. Manual rotation of head and forceps delivery 4. Wide episiotomy and maternal pushing 5. Rotational forceps delivery Q12/A primigravida at 41 weeks following a normal pregnancy has a single normally grown fetus in a longitudinal lie, cephalic presentation with the head engaged and in left occipito-anterior position. The fetal movements, heart rate and CTG are normal.SFH is 40 cm. Per vaginal examination shows the uneffaced cervix and os closed with the head at the level of spines. The pelvis is adequate for vaginal delivery. What is the best method of management? 1. Caesarean delivery 2. Oxytocin intravenous drip 3. Prostaglandin E2 analogue vaginal jel 4. Await spontaneous onset of labour 5. Insertion of a foley catheter for induction Q13/A mother of one child who delivered normally one year ago is now in the 10 week the second pregnancy. She gives a history of fever and swelling of the larger joints of the body when she was at the age of 12 years after a history of tonsilitis. Since then she has led a relatively normal life. She was admitted to obstetrics casualty unit with a history of breathlessness on doing normal household work during last four weeks in this pregnancy. Her blood pressure is 120/80 Hg PR 110 bpm. She has brought the following investigations results which were done at her booking clinic visit at 8 weeks of POA Haemoglbin - 10.4g/dl Haematocrit - 39% VDRL – NON reactive PPBS – 110mg /dl UFR – Pus cells 25-15,RBC – Nil Blood Group - B negative What is her priority of the management at obstetrics casualty unit? 1. Start Digoxin orally 2. Urine for culture and ABST 3. Oral iron therapy 4. 2D Echocardiogram 5. ECG Q14/ A couple aged 29 years (male) and 27 years (female) presents with primary subfertility of 14 months duration. Female partner has normal menstrual cycle of 28 to 30 days and both partners are normal on clinically examination. What should be their first investigation for this couple? i. Laparoscopy with tubal patency test ii. Seminal fluid analysis 3
iii. Hormone profile of the female partner iv. Post coital test v. Testosterone level of the male partner Q15/ 27-year-old newly married female who is employed, is clinically normal. She does not have wishes to become pregnant at the moment. What is the best contraception for this client? 1. IUCD 2. DMPA 3. COCP 4. Norplant 5. Mirena Q16/25yr old subfertile lady with severe intra-uterine endometriosis under went laparoscopic adhesiolysis. The best post-op care is with 1. Gonadotrophin analogue 2. Bromocriptine 3. Mefenamic acid 4. Danazol 5. Non of the above Q17/ 32-year-old primi gravida after a vaginal delivery is having a life-threatening PPH. Placenta removed completely. But uterus is still atonic. There is minimal response to Syntocinone. Her labour was over 12 hours with syntocinon induction. She delivered a child of 3.5kg.On examination no vaginal or cervical tear were found except the episiotomy which was not bleeding at the moment. Most suitable next step of management of this patient is 1. Examination under anaesthesia for a uterine tear 2. Uterine tamponade method with ―Bakiri‖ catheter 3. Subtotal Hysterectomy 4. Total hysterectomy 5. None of the above Q18/ Multi gravida who had a termination of a pregnancy at 10/52, before 6/12 ago now presents with secondary dysmenorrhoea & dyspareunia for 2 months duration. Most likely cause for her problem is 1. Hydrosalphinx 2. PID 3. Acute cervisitis 4. Retro—verted uterus 5. Ashermann syndrome Q19/ 55-year- old mother who is having 3 children, presented with 2 episodes of post menopausal bleeding. Her vaginal examination and speculum examination were normal. Next line of management is 1. Oral Norethlsterone 2. Combined form of Hormone Replacement Therapy 3. PAP smear 4. Trans vaginal USS 5. Endometrial biopsy Q20/Primi is in the second stage of labour for 2hrs. Head above the ischael spine, with a large caput & moulding. Position is in transverse. Best management would be 4
1. 2. 3. 4. 5. Observe for another 1 hr Rotational vaccum delivery Rotational Forceps Augmentation with Oxytocin EM LSCS 21) A 32-year-old woman is admitted to the hospital because of severe left-sided abdominal pain and vaginal bleeding for the past 24 hours. She says that her last menstrual period was 7 weeks ago, which is unusual because her menstrual period "always" occurs every 29 days. She states that she may be pregnant, but also says that she has started a new job and has been working long hours lately. She just assumed that her cycle is "adjusting to this new lifestyle." She is married, does not have any children, and has never been pregnant. Physical examination shows a tender left-sided adnexal mass and blood at the cervix. An ultrasound shows a left-sided adnexal mass. Beta-human chorionic gonadotropin levels are positive, but low for gestational age. Her blood type is O, Rh-negative. A laparoscopy is performed and an ectopic pregnancy is resected. She recovers from the procedure and is scheduled to be discharged in 24 hours. The most appropriate next step in management to A. administer betamethasone B. administer medroxyprogesterone C. administer RhoGAM D. infuse type O-negative blood E. schedule a dilation and evacuation 22) A primigravid 24-year-old woman at 34-weeks gestation comes to the clinic because of a pruritic rash that has been developing on her abdomen over the last week. She is otherwise well and has had normal prenatal visits and blood work. She lives with her husband who does not appear to be affected. Physical examination shows numerous 1-2 mm erythematous, edematous vesicular papules along the periumbilical striae distensae but sparing the umbilicus. There is an extension of similar lesions to her upper medial thighs. No pustules, bullae, or burrows are appreciated. The remainder of the physical examination is unremarkable. A biochemical profile is normal. She should be told that she has A. a form of pustular psoriasis and should be started on systemic corticosteroid B. Herpes gestationis and will most likely develop similar lesions in subsequent pregnancies C. prurigo gravidarum and will be at increased risk for postpartum hemorrhage D. pruritic urticarial papules and plaques of pregnancy and it typically will resolve postpartum without treatment E. scabies and needs to be treated with permethrin 23) A 17-year-old runaway comes to the emergency department because of a 24-hour history of lower abdominal pain and vomiting. She tells you that she hates doctors and hospitals and is only here because another girl on the street told her that "this may be serious." She asks you to give her medicine quickly so she can leave. She is sexually active with multiple partners and she "occasionally" uses condoms for contraception. She lives "on the streets" and begs for money at the doorways of banks. She has not received any medical care in 6 years. Her last menstrual period was 9 days ago. She is unsure if she ever had a sexually transmitted disease in the past. Her temperature is 38.8 C (101.8 F), blood pressure is 110/70 mm Hg, and pulse is 65/min. Physical examination shows bilateral lower abdominal tenderness, but rebound tenderness and guarding are absent. Pelvic examination shows cervical motion tenderness, adnexal tenderness, and a yellowish-white cervical discharge. There are no palpable masses. A urine pregnancy test is negative. Cervical cultures are taken and sent to pathology for evaluation. The erythrocyte sedimentation rate and C-reactive protein level are elevated. The most appropriate next step is to A. admit her to the hospital and begin cefoxitin and doxycycline therapy, intravenously B. admit her to the hospital and prepare her for an immediate operation C. do a culdocentesis D. prescribe ofloxacin and metronidazole therapy, orally, and discharge her E. try to contact her male sexual partners for evaluation and treatment 5
24) While in the hospital discharging a patient, you are notified that another one of your patients, a 32-yearold woman who is at 28-weeks gestation, is in labor on the delivery floor. By the time you arrive at the correct room, the baby has already been delivered by cesarean section and transferred to the neonatal intensive care unit. The apgar scores were 7 at 1 minute and 8 at 5 minutes. After evaluating the mother, you go to the neonatal intensive care unit to see the baby. When you arrive, you notice that she has nasal flaring, subcostal and intercostal retractions, cyanosis, and tachypnea. The most appropriate next diagnostic step is to A. call for a pediatric cardiology consult B. obtain an umbilical artery blood gas C. obtain sputum samples for cytology D. obtain vaginal cultures from the mother E. order a chest x-ray 25) A 39-year-old woman is admitted to the gynecologic surgical ward because of a ruptured ectopic pregnancy. She was seen in the emergency department with pelvic pain and vaginal bleeding. She has had one prior pregnancy, which was terminated by a therapeutic abortion. She has a past medical history of hypothyroidism for which she takes levothyroxine daily. She reports that she used to take oral contraceptives, but stopped 1 year ago in order to become pregnant. The patient's vital signs are normal and plans are being made for emergent surgery. The factor that most likely contributed to an ectopic pregnancy in this patient is A. age B. hypothyroidism C. oral contraceptive use D. prior abortion E. prior pregnancy 26) A 24-year-old woman comes to the office complaining of 2 days of intermittent severe right lower quadrant pain. Initially, she was able to continue her work as a waitress, but now is afraid that another "bout of pain" will occur while she is at work. She feels a "heaviness" in her lower abdomen and has low-grade pain all the time. A few times a day the pain becomes severe in the right lower quadrant and then she may vomit. She has had no fever or chills, but has had a poor appetite secondary to the waves of nausea occurring when the pain became severe. She is otherwise healthy and has never been hospitalized or had surgery. She has never been sexually active and is not using any form of contraception. The patient also relates that she was evaluated in the emergency department last night, "although the pain became much better by the time I got to the hospital." She presents a piece of paper with laboratory values and urinary tests from her visit: hematocrit 39%, white blood cell count 11,400/mm3, platelet count 367,000/mm3, sodium 138 mEq/L, potassium 4.0 mEq/L, creatinine 1.0 mg/dL, SGOT 18 U/L, and SGPT 22 U/L. A urinalysis was negative for leukocyte esterase, nitrite, and red or white blood cells. A urine pregnancy test was negative. No diagnostic studies were performed in the emergency department. Her temperature is 37.5 C (99.5 F), blood pressure 130/70 mm Hg, pulse is 100/min, and respirations are 20/min. On physical examination, there is most likely to be A. abdominal rebound tenderness and guarding B. an adnexal mass C. isolated tenderness at McBurney point D. normal pelvic exam E. vaginal bleeding 27) A 16-year-old girl is brought to the office by her mother because she "never got her period." She is very upset and constantly feels "left-out" of her girlfriend's conversations. They all tell her that she is so lucky that she does not have to worry about using birth control with her boyfriend. She takes no medications and denies strenuous exercise or excessive dieting. Physical examination shows mature, adult breasts, a scanty amount of axillary and pubic hair, a normal clitoris, and a blind-ending vagina. Laboratory studies show a male level of serum testosterone. The patient's 6
mother asks about the severity of this condition and the long-term effects. The most appropriate response is: A. "She is similar to many teenage girls who do not menstruate until they are 16 and they go on to have normal reproductive lives." B. "This condition is very serious and she will require a bilateral mastectomy because of her increased risk of breast cancer." C. "Your daughter will begin menstruating after receiving hormonal therapy and she may be able to become pregnant in the future." D. "Your daughter will begin menstruating after receiving hormonal therapy but she will not be able to conceive." E. "Your daughter will probably require surgery and estrogen replacement, and she will not be able to conceive." 28) You are asked to see a 3-week-old infant in the emergency department with a 1-day history of fever. The parents measured his temperature because he "felt warm" to them and found a temperature of 38.3 C (101.0 F). He has been feeding normally, taking 2 ounces of formula every 3-4 hours. He had 6 wet diapers the previous day. Examination shows an active infant with a temperature of 38.8 C (101.8 F). His skin perfusion is good and his physical examination, including examination of his tympanic membranes, is normal. There are no ill household contacts. The most appropriate next step is to A. discharge the patient with close outpatient follow up B. inquire about the mother's group B streptococcal status at delivery C. obtain the infant's vaccination history D. order a urinalysis and, if negative, do blood and CSF cultures E. send blood, urine, and CSF cultures and begin empiric intravenous antibiotic therapy 29) You are called to the well-baby nursery after a 27-year-old patient of yours, delivers a healthy- appearing term baby boy by normal spontaneous vaginal delivery. You recall that this patient had an uncomplicated prenatal course, however, initial laboratory studies during her first antenatal visit were positive for hepatitis B surface antigen. A complete physical examination of the infant is unremarkable. You should A. advise the mother not to breast-feed her newborn B. give routine care to the newborn C. give the hepatitis B vaccine and hepatitis B immune globulin to the newborn D. reassure the mother that no hepatitis B vaccine or treatment is needed for her newborn E. send hepatitis serology from the newborn and await results before providing care 30) A previously healthy 3-week-old baby is brought by his parents to your emergency department with a 1-day history of emesis. The parents describe the emesis as "forceful", non-bloody, and non-bilious. The baby is exclusively breastfed and continues to be hungry after each episode of vomiting. They deny any fevers. You notice an active baby boy with unremarkable vital signs. Physical examination is significant for a peristaltic wave on the abdomen and a 2x2 cm firm mass palpated in the midepigastric region. Laboratory studies show a bicarbonate level of 18 mEq/L. The most likely diagnosis is A. annular pancreas B. gastroesophageal reflux C. intussusception D. malrotation with volvulus E. pyloric stenosis 7
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