1.

The child is suffering from Xerophthalmia

2. Management in a child of 11 months according to WHO:

Child under 1yr/8kgs:

1 lac units orally or 0.5 lac units IM
Repeated on the next day and 4 weeks later
Child over 1yr/8kgs:
2 lac units orally or 1 lac units IM
Repeated on the next day and 4 weeks later
Women of reproductive age showing signs of xerophthalmia:
XN to X1B: 10,000 IU per day/2 weeks
X2 and higher: Child over 1yr regimen
3. Bitot’s spots
4. Measles is a risk factor
1. Since the woman has completed her family, we should advise tubal ligation/tubectomy
(terminal method of contraception)

2. Advantages:
a. Permanent procedure
b. No need for continuous follow up (except at 7 days to remove stitches)
c. Local anaesthesia
d. Effective Immediately
e. Does not interfere with sexual intercourse or milk production
f. No long term side effects

3. Techniques:
a. Laparoscopic
b. Mini-laparoscopic

4. Tubo-peritoneal fistula
Q. Basanti, a primigravida presents for the 1st time at 24
weeks. Weight 52kg, BP 120/80, Hb 8.5g/dl

a. Is time of presentation ideal. Give reasons.

b. Which micronutrient deficiency is she suffering from?

Give reasons.

c. How will you treat this deficiency?

1. No the time of presentation is not ideal. Ideally the first ANC visit should be
within 12 weeks of gestation (or as soon as pregnancy is suspected) This visit
includes both the registration of pregnancy and the 1st ANC check up.

2. She is suffering from iron deficiency anaemia (moderate)

Reason: The normal Hb for pregnant females is > 11g/dl
Mild 9-11
Moderate 6-9
Severe <6

3. IFA (50mg/500mcg) BD for 3 months

Follow up at 45 days and again at 90 days
IF Hb>12 after 90 days then discontinue treatment and start prophylactic dose
IF Hb<11 after 90 days refer to FRU/DH

When Hb<6 refer to THC for detailed checkup

Q. 2 yrs 3 months old child came to
immunization clinic. Mother said that
immunization had started at their native place
but didn't have any immunization card and
couldn't say what vaccine was given.

As an immunization officer posted there what

should be your consideration of the child's
immunization status? Prepare an
immunization schedule for this child.
Probable immunisation status of child: UNIMMUNISED (Assumed)
Presenting age: 27 months
Q. A person is obese (BMI=32). He is a smoker also. Last year his
father died due to sudden cardiac attack. His elder brother is
suffering from Diabetes for last 2years..

1. What are the risk factors present for developing diabetes in

him?
2. What are other diseases for these risk factors?
3. What are the investigations and what dietary changes should
be adopted?
1. Risk Factors:
1. Obesity
2. Smoking
3. Family history of sibling

2. Other diseases for these risk factors:

1. Obesity
2. Atherosclerosis
3. Hypertension
4. Hyperinsulinemia and insulin resistance
5. Dyslipidemia
6. CAD, CVA
7. Metabolic Syndrome

3. Investigations:
1. Fasting and post-prandial blood glucose
2. HbA1c
3. Lipid Profile (HDL, LDL, VLDL, Chylomicrons)
4. BP monitoring
5. Routine Urinanalysis

4. Dietary Changes:
Low in carbohydrates and processed sugars with low glycemic index
High fibre and protein
Low salt (DASH diet)
Low fats
Fruits, green leafy vegetables and pulses
Q. A 25 year old female P1+0 having a 6 months baby who is
undergoing exclusive breast feeding. Her husband is not
willing to undertake any barrier method. The female gives a
history of previous ectopic pregnancy. She has come to the
OPD for family planning services

A) What are the contraceptive methods you cannot use for

this woman?
B) What is the contraceptive method you will recommend
for this woman?
C) Which national program is there for this contraceptive?
D) How will you counsel the mother and advice during the
use of this contraceptive?
1. Unsuitable methods:
a. Barrier methods
b. OCP (breastfeeding)
c. IUD (history of ectopic pregnancy)
d. Terminal Methods (too young and incomplete family)

2. Recommended Contraceptive: DMPA (injectable hormonal

contraceptives)

3. ANTARA Programme under Mission Parivar Vikas

4. Counselling (New Client with no Method in Mind):

a. Discuss the situation of the patient and viable options of
contraception
b. Help the client realise the best method of contraception on her
own
c. Support the choice made
d. Instructions of use and management of side effects
e. Assure that switch of method is possible
f. Schedule a follow up
Q. The BP of a person is given 150/90mmHg.
What is he suffering from?

1.Classification according to JNC 8

2. Risk factors
3. Life style modifications
Study the rest from textbooks.
Q. (Partial Recall)

A 6 year old girl reports to the OPD with maculo-

papular rash that began behind the ears and spread
rapidly to the body and then to the extremities.
There was history of fever, coryza and nasal discharge
4-6 days back.

1. Diagnosis?
2. What are the steps of management to be taken by
MO at PHC?
3. What are the complications of this disease?
4. Vaccination
1. Measles infection
2. There is no specific management of measles.
Supportive Measures:
a. Symptomatic treatment of fever, cough, nasal congestion and rhinorrhoea
b. Nutritional support is recommended to counteract the malnourishing
effects of diarrhoea, vomiting and poor appetite (Encouragement of
breast feeding wherever applicable)
c. Vitamin A: To be given to all cases of severe measles, and all cases in high
fatality areas.
Dosing: Age Dose
<6 months 50,000 IU
6-12 months 1,00,000 IU
>12 months 2,00,000 IU

One dose on day 0, second dose on day 1. If child exhibits

signs of Vit A deficiency then third dose after 4-6 weeks.
d. Isolation of patient and immunisation of contacts (Within 3 days of exposure)

3. Complications: 4. Vaccine:
Otitis media Live attenuated vaccine combination (MMR or MR)
Croup Dosing: 1000 viral units/0.5ml
Diarrhoea 1st Dose: 9-12 months
Pneumonia 2nd Dose: 16-24 months
Post measles encephalitis Route: Subcutaneous
Sub-acute sclerosing panencephalitis
Q. 6months old child with BCG, bOPV-0, Hep B
(birth dose) immunisation status reports to
vaccination clinic. Develop an Immunisation
plan to become fully immunised within infancy.
1. 3 doses of bOPV and Pentavalent are to be given 1 month apart (ie at 6,7,8th months)
2. 2 doses of f-IPV to be given 2 months apart (ie at 6th and 8th months)
3. 2 doses of PCV to be given 2 months apart (ie at 6th and 8th months)
4. 3 doses of Rotavirus vaccine to be given 1 month apart (ie at 6,7,8th months)
5. Administer the first dose of MR and JE vaccines 9-12 months of age

Thus the child now becomes “Fully Immunised”

Thereafter, counsel the mother to comply with NIS schedule.

Q. Wastage rate of MR and OPV vaccine is 15
and 17.
Is it acceptable?
How will you reduce wastage?
What is Wastage Factor?
 Thus the wastage of MR(15<25%) is acceptable but that of OPV(17>10%) is not.
Causes of Vaccine Wastage:
1. Failure of Cold Chain services
2. Mishandling of vaccines (ie breaking/damage to vials)
3. Exposure to heat (improper use of ice packs/vaccine carriers/improper transportation) or
extreme cold (improper storage)
4. Discarding of unused doses

Ways to prevent vaccine wastage:

1. Strengthening of Cold Chain Services esp. at transportation points, UPS, training of personnel
2. Training for proper handling of vaccines
3. Open Vial Policy for unused doses
4. Conducting planned vaccination days so that an optimal number of doses are to be dispensed
on a certain day
Q. Cold chain temperature is more than 8.
How will you manage the case?
1. Immediately send the vaccines in the “failed” cold chain to the nearest facility available
(in case of MCK this facility in in Madhyangram) with properly prepared vaccine vial carriers

2. Investigate the cause of failure of cold chain (improper storage, disruption of UPS etc)

3. Repair the cold chain infrastructure before allowing anymore vaccines to be stored here.

4. In the batch of vaccines sent to the nearest facility, ensure that VVMs are thoroughly tested
before dispensing these vaccines. If the VVMs indicate thermal damage, discard these vaccines.
Management of TB:
Sputum Positive: Microbiologically Confirmed TB
Send the sputum sample for CBNAAT confirmation and resistance testing

If Rif Sensitive report comes from CBNAAT: Then start ATT regimen for DS-TB dispensed
according to DOTS:
Management of alcoholism:
IP: HRZE CP: HRE
(75/150/400/275) (75/150/275)
1. Nutritional support (correction of vitamin
Weight Band ie 4-FDC for ie 3-FDC for deficiencies and malnourishment)
2 months 4 months 2. Deaddiction and counselling
25-34kg 2 2
MDR TB: Resistant to atleast isoniazid and rifampicin
35-49kg 3 3
50-64kg 4 4 XDR TB: Resistance to any fluroquilonone and atleast
65-74kg 5 5 one second line injectable drugs (capreomycin,
>75kg 6 6
amikacin, kanamycin)

Newer Initiatives under RNTCP :

1. Nikshay and Nikshay Aushudiya
2. Nikshay POSHAN Abhiyan for monetary support to TB pts for supplementary nutrition
3. DOTS-99
4. Notification of TB patients (both incentivised and punishable)
5. Ban on TB serology
6. FDC for pediatric TB pts
7. Bedaquiline conditional access programme
Q. A man comes with headache and high
fever and retro-orbital pain. His brother had
been diagnosed with Dengue

a. Provisional diagnosis and treatment

b. Investigation
c. Indication for Platelet Transfusion
1. Provisional Diagnosis: Dengue

Treatment:
1. Encourage consumption of ORS and other fluids eg juice
2. Give paracetamol 650 mg to control fever. (Aspirin is contraindicated)
3. Instruct the care givers that the patient is to be brought to the hospital if:
a. no improvement of deterioration around the time of defervescence
b. severe abdominal pain
c. vomitting
d. cold clammy extremities
e. lethargy/irritability
2. Investigations:
a. RT PCR and real time RT PCR
b. NS1 Antigen ELISA
c. Serology: ELISA/HIA (paired sera method for IgM/IgG seroconversion)
IgM/IgG ELISA (Ig Detection)
d. CBC with platelet count

3. Indications for platelet transfusion:

a. Prophylactic platelet transfusion when count< 10,000
b. Prolonged shock with abnormal coagulation/coagulopathy
c. In case of systemic massive bleeding platelet transfusion may be needed above and
beyond RBC transfusion
For Mrs Rekha, probability of giving birth to a
baby of birth weight < 2.5 kg- 0.5, and the
probability of giving birth to baby having body
weight 2.5-2.9kg is 0.2. Calculate the
probability of giving birth to baby of birth
weight less than 3 kg.?
The probabilities are mutually independent and exclusive

Therefore, both probabilities are added

P(Total)= P(A)+P(B)=0.5+0.2=0.7
Q. A 16yr old girl reports to the vaccination centre for
administration of TT. She suddenly faints with hypotension,
cold clammy hands and bradycardia.

1. Probable diagnosis
2. Differential diagnosis
3. How will you differentiate between the differentials?
4. Management of the probable diagnosis
1. Probable Diagnosis: Fainting Attack
2. Differential Diagnosis:
1. Panic/Anxiety Attack: No hypotension, pallor, wheeze or utricarial rash.
Skin maybe blotchy. Tachycardia is common.
2. Anaphylaxis: Tachyopnea with tachycardia, anxiety and restlessness. Loss of
consciousness is not relieved by supine positioning
(relieved in case of fainting). Utricaria and generalised erythema
is present.

3. Management:
1. Fainting Spell: Spontaneous recovery after 1-2 minutes. Loss of consciousness
is usually reversed by supine positioning.
2. Panic Attack: General reassurance. Benzodiazapenes is given to calm the
patient if otherwise not contraindicated.
3. Anaphylaxis: a. 0.5ml of Adrenaline solution (1:1000) IM/ to be repeated
every 20 minutes till SBP>=100
b. 10-20mg of chlorpheniramine maleate IV
Next Visit: Between 16-24 months of age

Vaccines to be given:

JE 2
MR 2
DPT Booster-1
bOPV Booster
Vitamin A dose (2 lac IU)
Q. A 12 week old boy comes to the immunization clinic with a
history of convulsion after having Pentavalent-1 , OPV 1 , fIPV 1
at 6week of age.

1. What vaccines are contraindicated in this child?

2. Plan the immunization schedule for the child keeping the past
history in mind
1. The AEFI was presumably due to the whole cell component of pertussis of the vaccines.

Therefore all vaccines containing pertussis is contraindicated:

1. Pentavalent
2. DPT

2. 12wk: Hepatitis B vaccine + DT vaccine

bOPV-2

16wk: Hepatitis B vaccine + DT vaccine

bOPV-3
fIPV-2

Thereafter, follow NIS pattern.

Q. An intern has needle prick injury with blood
contaminated with HepB.

1. Describe steps to prevent infection in the intern.

2. What other disease are spread through needle prick?
3. Describe steps to ensure safety of medical practitioners
in cases of needle stick injury.
1. Post exposure prophylaxis of Hep-B:
1. Hepatitis B immunoglobulin (0.05 to 0.07ml/kg) 2 doses 30 days apart
2. Hepatitis B vaccine 1ml (20mcg/1ml) IM within seven days of exposure. Second and
third doses to be given at 1 month and 6 months respectively.
2. Other needle stick infections:
1. Hepatitis C
2. HIV

3. Prevention of needle stick infections:

Q. Sita, 14 month old reports to the OPD.
Symptoms of respiratory distress for past 1 day.
The child is observed to have stridor even when
calm. Respiratory rate on examination is 46/min.
a) Diagnosis
b) Management
c) Advice to mother regarding care of child after
recovery.
1. Provisional Diagnosis: Severe Pneumonia

2. Management:

3. Advice to mother:
1. Follow up in 3 days after discharge
2. To keep the child in a warm comfortable environment away from damp
and cold conditions
3. Improve general hygiene and be wary of droplet infection.
4. To immediately bring the child to the nearest hospital if a similar incident occurs again
Q. An adult person comes to MCK before going to
Nigeria.

1. What vaccine is given (must)?

2. Importance of following the protocol.
3. What other vaccine can be given?
4. Gap between administration of these two vaccines
1. Vaccines to be administered:
a. Yellow fever vaccine
b. Polio vaccine (booster dose)
c. Cholera vaccine

2. Importance:
a. Protecting the individual
b. Protecting the native population in Nigeria
c. Protecting the native population back home (on return)

3. Other Vaccines:
a. Hepatitis A
b. Typhoid vaccine
c. Malaria prophylaxis
d. Other routine vaccinations (if not completed and contraindicated)

4. Gap between Yellow Fever

Q. A 10 year old child presented with large fleeting joint pain,
intermittent fever and 3 weeks before developed pharyngitis,
level of ESR raised. He has 3 siblings living together in urban
slums.

a. Provisional diagnosis
b. Risk factors in this case
c. Primary and secondary prevention of this condition.
1. Provisional Diagnosis: Rheumatic Fever

2. Risk Factors:
1. H/O pharyngitis
2. Urban Slum environment/low socio economic status and poor hygiene
3. Overcrowding

3. Primary Prevention:
1. Ideally, all children with streptococcal pharyngitis must be detected and screened
and treated with penicillin. However this is not possible in developing countries.
A high-risk approach may suffice:
Single IM injection of benzathine penicillin (1.2 million units) for adults or a
single IM injection of benzathin peniciilin (0.6 million units) for children
OR
Oral Penicillin G for 10 days
2. For patients with allergy to penicillin may undertake a course of erythromycin

Secondary Prevention:
More Suitable for developing countries
IM injection of benzathine penicillin(1.2mil/0.6mil units) at intervals of 3 weeks for atleast 5 years
or atleast the child is of 18 years of age (which ever is later)
For patients with carditis: continue regimen for 10 years/ 25 years of age, whichever is later
For patients with valvular disease: continue regimen lifelong
1. AFP Differential:

2. Surveillence: Park (25E) Pg 223/224

3. Ensuring higher sensitivity of surveillance:

Surveillance Indicators (Park Pg 224)
Q. A 10 month old child came to the OPD with cough
and cold, respiratory rate 48 per min, stridor and
wheeze is absent.

1. What is provisional diagnosis? Justify.

2. Management of the case
Provisional Diagnosis: Pneumonia
Only fast breathing is present
No stridor or general warning signs present

Management:
1. Amoxicillin/5 days(maybe reduced to 3 days if chest indrawing is absent and HIV risk is low)
OR
Cotrimoxazole 3tablets or 1.5 tbsp (300mg/60mg) daily for 3 days.

2. Anti histamines
3. Decongestants
4. Dextromethorphan for cough
5. Paracetamol for fever

Follow up in 3 days.
Status of Dehydration: Severe Dehydration
1. Lethargic
2. Drinking very poorly

2. Management of case:
Refer immediately to hospital and advise mother to feed sips of ORS on the way.
Plan C for rehydration
Q. (Difficult biostat question)

The prevalence of a disease is 10%. Using a screening test and a gold standard test the
Following data was obtained: Gold Standard
+ -
+ 160 360
Screening Test
- 40 1440

If the prevalence was to drop to 1%, calculate the PPV and NPV
Other topics that were seen in problem cards (but the whole cards were not available):

Streptococcal infection, risk factors, prevention

Two vaccines of polio were given at the same time. Justify

Yellow Fever

AEFI and AEFI following DPT

VVMs

HIV prick and post exposure prophylaxis

Nutritional anaemia and scheme related to it

Rabies post exposure prophylaxis and wound category