OG35.{1-14,19},OG36.1-2,OG38.4 | Core Clinical Skills — Graded Quiz

Correct. Key diagnostic reasoning: the mass is separately palpable from the uterus (which is identifiable above it), the mass is firm and irregular (consistent with fibroid), and fetal parts are palpated above it. A full bladder would be central, smooth, dull on percussion, and would resolve after catheterisation. An ovarian dermoid can coexist with pregnancy but is typically unilateral and not irregular. A leiomyoma co-existing with pregnancy is the most coherent provisional diagnosis here.

In a pregnant woman with a pelvic mass, identify whether the mass is continuous with or separate from the uterus. A separate irregular firm mass in a multigravida at term most likely represents a fibroid co-existing with pregnancy.

The clinical clues are: (1) the mass is palpated separately from the uterus, ruling out a large uterus; (2) it is firm and irregular (fibroid morphology); (3) fetal parts are felt above it, confirming the uterus is distinct. A full bladder would be smooth and central and resolves after catheterisation.

Correct. This is a classic presentation of bacterial vaginosis (BV): homogeneous grey-white discharge, pH >4.5 (here 5.5), positive whiff test (amine odour on adding 10% KOH), and clue cells (epithelial cells studded with Gardnerella vaginalis). Three of the four Amsel criteria are met. Treatment is metronidazole 400 mg BD for 7 days (or 500 mg BD, or 2 g single dose). Fluconazole treats Candida; doxycycline treats Chlamydia; acyclovir treats HSV.

Amsel criteria for BV (3/4 required): homogeneous grey discharge + pH >4.5 + positive whiff test + clue cells on microscopy. Treatment: metronidazole 400–500 mg BD for 7 days.

The clinical pattern — homogeneous grey discharge, pH >4.5, positive whiff test, clue cells — meets Amsel criteria for bacterial vaginosis. BV is treated with metronidazole, not antifungals (fluconazole) or antiviral agents (acyclovir).

Correct. The clinical description — painless, indurated, single ulcer with a clean base and bilateral inguinal lymphadenopathy — is the classic presentation of primary syphilis (Hunterian chancre). The most important step is serological testing (VDRL/RPR as a screening test; TPHA/FTA-ABS for confirmation) and appropriate treatment with benzathine penicillin G. Concomitant HIV screening is mandatory. Chancroid (Haemophilus ducreyi) causes painful, non-indurated ulcers. Acyclovir is for herpes (multiple shallow painful vesicles/ulcers).

Painless + indurated + clean base + bilateral lymphadenopathy = primary syphilis (Hunterian chancre). Test: VDRL/RPR (screen) + TPHA (confirm). Treat: benzathine penicillin G. Always screen for HIV concurrently.

A single, painless, indurated ulcer with bilateral lymphadenopathy is the primary chancre of syphilis. The key step is serological testing (VDRL/RPR + TPHA) and treatment with benzathine penicillin G, plus HIV screening. Chancroid is painful; herpes produces multiple painful vesicular ulcers.

Correct. This woman has severe pre-eclampsia with impending eclampsia (epigastric pain, visual disturbance, severe hypertension, heavy proteinuria). At a PHC without MgSO4, the correct action is: (1) give antihypertensive to control BP (e.g., labetalol IV or hydralazine IV if available, or oral nifedipine as oral antihypertensive — note: sublingual nifedipine is not recommended per current guidelines due to rapid BP drop), (2) provide first aid/stabilisation with what is available, (3) arrange immediate emergency referral with a detailed referral note, (4) accompany the patient if possible. Deferring treatment while awaiting an ambulance is unsafe. Diazepam is second-line for eclampsia only when MgSO4 is unavailable.

When facing an emergency beyond the facility's capacity: stabilise first (antihypertensive for severe hypertension) + write a detailed referral note + arrange fastest transfer. Never defer treatment while waiting for transfer.

Impending eclampsia at a PHC requires simultaneous stabilisation and emergency referral — not one or the other. Give antihypertensive immediately, write a detailed referral note (including clinical status and treatment given), and arrange the fastest possible transfer. Do not defer treatment.

Correct. Performing a procedure without explaining it, obtaining consent, or providing a chaperone is a violation of patient autonomy — the fundamental right of a person to make informed decisions about their own body. While beneficence and non-maleficence are also implicated, the primary ethical breach here is autonomy: the patient has not been given the opportunity to consent or refuse.

The four principles of medical ethics (Beauchamp and Childress): Autonomy, Beneficence, Non-maleficence, Justice. Performing any intimate examination without consent primarily violates Autonomy.

The primary ethical violation is autonomy. Proceeding without explanation or consent removes the patient's right to decide. While beneficence (acting for good) and non-maleficence (avoiding harm) are relevant, the absence of consent is fundamentally an autonomy violation.

Correct. A placenta not delivered by 30 minutes after active management of the third stage constitutes a retained placenta. Rising fundus at umbilicus with 400 mL blood loss indicates haemorrhage. Immediate management: call for help → secure IV access → catheterise bladder (full bladder prevents placental descent) → controlled cord traction with uterine countertraction (Brandt-Andrews manoeuvre). Ergometrine is not the first choice here and is contraindicated in hypertension. Laparotomy for accreta is only after failed manual removal attempts.

Retained placenta = placenta undelivered >30 minutes after active management. With bleeding, immediate steps are: IV access + catheterise bladder + controlled cord traction. Ergometrine is contraindicated in hypertension.

By 30 minutes after oxytocin with active management, a non-delivered placenta = retained placenta. With 400 mL blood loss, this is PPH. Immediate steps: call for help, IV access, catheterise bladder, controlled cord traction. Ergometrine is contraindicated in hypertension; theatre comes only if manual removal fails.

Correct. Per WHO MEC, the COCP is category 1 (no restriction) for a healthy young nulliparous woman. It is need-based (reliable reversible contraception for a young woman not planning pregnancy), cost-effective (lowest cost among hormonal methods), and appropriate for her context. DMPA has category 2 concerns regarding bone density in young women and menstrual irregularity. Copper IUCD is appropriate but insertion at a rural health centre requires trained personnel and sterile conditions. Condoms alone have a typical-use failure rate of approximately 15% and are insufficient as the sole method.

Apply WHO MEC categories when selecting contraception: Category 1 = no restriction. For a healthy nulliparous woman with no contraindications, the COCP is category 1, reversible, and cost-effective.

The COCP is WHO MEC category 1 for a healthy nulliparous woman with no contraindications. It is reversible, cost-effective, and suitable for a rural setting. DMPA has bone density concerns in adolescents; IUCD insertion requires trained personnel; condoms alone have a higher typical-use failure rate.

Correct. The adverse outcome here resulted from a failure of triage — a high-risk woman (reduced fetal movements at 34 weeks = a red-flag symptom) waited in the same queue as low-risk women. A three-tier colour-coded triage at registration (red = immediate, yellow = priority within 30 minutes, green = routine) would have identified this woman as red/yellow and ensured she was seen within minutes. More examination tables and HMIS clerks do not address prioritisation; appointment scheduling reduces volume but does not address emergency identification.

The most common, preventable OG clinic failure in India is absence of a functioning triage system. Three-tier colour-coded triage at registration is the highest-impact single organisational intervention.

The root cause is absence of triage — an emergency symptom (reduced fetal movements) was treated as routine. The highest-impact intervention is a triage system at registration that separates urgent from routine cases. Physical capacity (tables) and administrative efficiency (HMIS) do not address prioritisation.

Correct. Under the Maternity Benefit Act 1961 (amended 2017), a woman who has worked for at least 80 days in the preceding 12 months is entitled to 26 weeks paid maternity leave for a first or second child (12 weeks for third child and beyond). The medical certificate should confirm the date of delivery and note that maternity leave entitlement begins from the date of delivery — it is not a fitness certificate for a specified period but a statutory certification for leave entitlement.

Maternity leave certificates are statutory documents under the Maternity Benefit Act 1961 (amended 2017): 26 weeks for first/second child, 12 weeks for third child onward. The certificate confirms the delivery date and establishes leave entitlement — it is not a medical fitness certificate.

The maternity leave certificate is a legal document under the Maternity Benefit Act, not a general fitness certificate. It confirms the date of delivery and establishes entitlement to statutory maternity leave. The duration is governed by the Act (26 weeks for the first two deliveries under the 2017 amendment), not the doctor's medical judgment about recovery time.

Correct. The clinical triad of: (1) SFH 6 cm below expected (clinically small-for-dates), (2) easily palpable fetal parts (suggestive of reduced liquor), and (3) reduced fetal movements → provisional diagnosis of IUGR with oligohydramnios. Fetal heart rate 110 bpm is borderline low (normal 110–160 bpm). Polyhydramnios causes increased fundal height and a fluid thrill. Placental abruption presents with pain and uterine tenderness/rigidity.

Fundal height >4 cm below expected = small-for-dates; easily palpable fetal parts = clinical oligohydramnios. Together with reduced fetal movements, this clinical triad points to IUGR with oligohydramnios — urgent ultrasound and Doppler are needed.

SFH 6 cm below expected + easily palpable fetal parts (sign of reduced liquor) + decreased fetal movements = clinical IUGR with oligohydramnios. Polyhydramnios increases fundal height; placental abruption presents with a painful, tender, rigid uterus.

Correct. Immediate management of a needlestick injury follows this sequence: (1) Do NOT squeeze or suck — this increases, not decreases, risk. (2) Wash the wound immediately under running water for 5 minutes with soap and water; allow free (not forced) bleeding. (3) Report to the designated officer immediately. (4) Evaluate for post-exposure prophylaxis (PEP) — PEP must be started within 72 hours (optimally within 2 hours) for HIV. Source patient testing is important for PEP decision-making but happens after wound care.

Needlestick injury first aid: wash immediately under running water with soap for 5 minutes + allow free bleeding. Do NOT squeeze or suck. Report immediately and start PEP evaluation — HIV PEP must begin within 72 hours (optimally within 2 hours).

First aid for a needlestick injury: wash under running water with soap (5 minutes) + allow free bleeding — NOT squeezing (which increases exposure). Then report and start PEP evaluation within 2 hours. Source patient testing informs PEP decision but is done after wound care.

Correct. Although a 17-year-old is technically a minor in India (age of majority = 18), clinical best practice and ethical guidelines require that the patient be assessed privately to ensure a safe history (safeguarding — consider sexual coercion/trafficking). The doctor's duty is to the patient first. The MTP Act 2021 permits termination up to 20 weeks for rape/contraceptive failure; a minor's consent and confidentiality framework requires a private assessment before parents can be involved. Proceeding with parents present may prevent the patient from disclosing the circumstances of the pregnancy.

For a distressed pregnant minor, clinical safeguarding and ethical duty require a private assessment first. Parents may be present for consent discussions, but the history must be taken privately to screen for coercion/abuse. The MTP Act 2021 framework applies to minors seeking termination.

Ethical duty and safeguarding require assessing a distressed minor privately before involving parents. Parents' presence may prevent disclosure of coercion or abuse. The MTP Act 2021 framework for minors requires a protected clinical assessment; parental proxy consent does not override the patient's right to a private history.