Medicine 6th year 05-04-2016

1- A 71 years old man in the surgical intensive care unit is seen for acute renal failure. After an
operation for removal of gallstones, he had a persistent drainage from his biliary catheter
associated with spiking fevers to 38.9 C. He has been taking Gentamicin (70 mg every 8 hours)
and Cephalexin (0.5 g four times a day) for the past 10 days.
Over the last 4 days, his serum creatinine has increased at rate of 1 mg/dl/day, but his urine
output of 1.5 l/day has not diminished. At no time has he had any hypotension during this
hospitalization. Physical examination shows normal blood pressure and vital signs. Results of
laboratory studies indicate a creatinine level of 7.1 mg/dl and renal ultrasonography reveals no
evidence of obstruction. Which of the following is the most likely cause of the acute renal
failure?

Select one:

a. Sepsis.

b. Gentamicin nephrotoxicity

c. Trauma to the ureter during surgery

d. Cephalexin-induced acute renal failure

e. Acute GN.

2- A 16 year old lady presented to the cardiology clinic for assessment. She had been diagnosed
with Turner syndrome. She had normal early developmental milestones but had multiple ear
infections in childhood and presented with primary amenorrhea later. On examination, she had
short stature, cubitus valgus and a webbed neck. Cardiac examination revealed a soft ejection
systolic murmur in the aortic area.
What is the most likely cause of the murmur?

Select one:

a. Bicuspid aortic valve

b. Aortic stenosis

c. Partial anomalous venous drainage

d. Ventricular septal defect

e. Pulmonary stenosis

3- A 23 year old present with palpitations intermittently. She is known to suffer from anxiety
attacks. However on auscultation of the heart there is evidence of a late systolic murmur with a
mid systolic click. It is worsened by the standing position. What is the most likely diagnosis?

Select one:

a. Atrial myxoma

b. Aortic stenosis

c. Normal variant
d. Mitral valve prolapsed

e. Mitral stenosis

4- One of the following is not an indication for treatment of asymptomatic bacteriuria :

Select one:

a. Immunecompramised patient

b. Pregnancy

c. Urinary obstruction

d. Children with VU reflux

e. Elderly patients

5- A42-year-old dentist is reviewed in the medical clinic complaining of persistent lethargy.

Routine bloods show abnormal liver function tests so a hepatitis screen is sent. The results are
shown below: Anti-HAV IgG negative,
HBsAg negative, Anti-HBs positive, Anti-HBc negative, Anti-HCV positive. What do these
results most likely demonstrate?

Select one:

a. Previous vaccination to hepatitis B and C

b. Hepatitis C infection

c. Hepatitis C infection with previous hepatitis B vaccination

d. Hepatitis B and C infection

e. Hepatitis B infection

6- Systemic complications of inflammatory bowel disease that tend to occur during an active
relapse include all of the followings, except:

Select one:

a. Mouth ulceration

b. Pyoderma gangrenosum

c. Deep venous thrombosis

d. Episcleritis.

e. Sacroiliitis.

7- A 49-year-old woman has been an inpatient for the past 10 days for treatment of a
bronchopneumonia. She has developed the onset of chills, fever, and skin rash over the past
two days. A peripheral blood film reveals eosinophilia. On urinalysis she has ++ proteinuria.
There is no past history of renal disease. Her hemoglobin A1C is normal. These findings would
most strongly suggest which of the following diagnoses?
Select one:

a. Acute tubular necrosis

b. Post-streptococcal glomerulonephritis

c. Acute serum sickness

d. Drug-induced interstitial nephritis

e. IgA nephropathy

8- Regarding pneumonia caused by Legionella pneumophila, which of the following is true?

Select one:

a. Is readily diagnosed by standard aerobic culture of sputum

b. Is best treated with intravenous amoxicillin and clavulanic acid

c. Should be managed on the ward in a respiratory isolation cubicle

d. Is associated with hyponatremia

e. Is common in AIDS patients

9- A 42- year-old woman with severe uterine bleeding and iron-deficiency anemia is receiving a
blood transfusion prior to hysterectomy. Thirty minutes after the transfusion starts, she
complains of chills and severe flank pain. The patient's temperature is 3 9 .1 C (1 02.4 F), blood
pressure is 133 /80 mm Hg, pulse is 12 0/min, and respirations are 20/min. The transfusion is
stopped, but
she continues to complain of symptoms and eventually begins bleeding around her intra
venous catheter site.
Which of the following is the most likely cause of this patient's transfusion reaction?

Select one:

a. Reaction to cy1okines stored in the transfused blood product

b. Anamnestic antibody response against a minor red blood cell antigen

c. Acute hemolytic reaction due to ABO incompatibility

d. lgA deficiency

e. Blood product contamination with bacteria

10- Portosystemic encephalopathy may be precipitated by all of the following EXCEPT: Choose
one answer

Select one:

a. Gastrointestinal haemorrhage

b. Diuretics

c. Lactulose

d. Constipation
e. Benzodiazepines

11- A 55 year old female presents with episodic sweats and tremors which are are relieved by
glucose. she has gained approximately 6 kg in weight of late and drinks approximately 10 units
of alcohol weekly. Her investigations show normal full blood count, normal urea and
electrolytes and a fasting plasma glucose concentration of 4 mmol/l (3-6). What is the most
appropriate investigation for this patient?

Select one:

a. Insulin and c-peptide concentration

b. EEG

c. Oral glucose tolerance test

d. 72 hour fast

e. CT scan of pancreas

12- A 72-year-old nursing home resident develops diarrhea while on cefuroxime for pneumonia.
She has a white blood cell (WBC) count of 19,000/μL and mild diffuse abdominal tenderness.
Which of the following is the next best step in the management of this patient?

Select one:

a. Cholestyramin

b. Symptomatic management

c. Oral vancomycin

d. Intravenous vancomycin

13- A75-year-old woman has abrupt onset of soreness, and severe stiffness of the shoulders and
upper thighs with low grade fever. Physical examination is entirely normal, but ESR is over 100
mm/h. Which of the following is the most likely diagnosis?

Select one:

a. sarcoidosis

b. midline granuloma

c. dermatomyositis (DM)

d. polymyalgia rheumatica (PMR)

e. osteoarthritis

14- Adrenal insufficiency all are true except

Select one:

a. Usually have metabolic alkalosis

b. Caused by bleeding in patients taking Coumadin

c. Have high ACTH or low ACTH

d. caused by pituitary hypophysitis

e. Antiphospholipd antibody syndrome is well known to cause it

15- A 30-year-old man and his wife present to a reproductive endocrinology clinic because of
infertility. The man is tall with bilateral gynaecomastia. Examination of the testes reveals
bilateral, small, firm testes. Which of the following investigations is most likely to be abnormal
in someone with Klinefelter's syndrome?

Select one:

a. Semen analysis

b. Measurement of serum gonadotrophins

c. Measurement of serum testosterone

d. CT scan of the pituitary gland

e. Chromosomal analysis

16- Which ONE of the following statements is true about the diastolic Austin Flint murmur?

Select one:

a. It is associated with a loud first heart sound.

b. It can be distinguished from the murmur of mitral stenosis by absence of presystolic accentuation

c. It is due to partial closure of the anterior leaflet of the mitral valve

d. It does not occur in aortic incompetence secondary to an aortitis

e. It is an early sign of aortic regurgitation

17- A 68-year-old man is admitted to the intensive care unit with respiratory failure. Upon
admission he noted 5 days of a cough productive of yellow sputum. He has a longstanding
history of bronchiectasis, currently smokes cigarettes, and has had five admissions to the
hospital in the past 2 years for pneumonia. His admission chest radiograph shows new
infiltrates in left upper and right lower lobes. Which of the following statements regarding
treatment of this patient is true?

Select one:

a. Legionella coverage is not required, as it is an uncommon in patients with bronchiectasis

b. Staphylococcus aureus is the most likely cause of pneumonia in this patient

c. Bronchoscopy should be performed to obtain sputum cultures

d. Antibiotic selection should include coverage for Pseudomonas aeruginosa

18- A 63-year-old woman develops exertion and angina and has had two episodes of syncope.
Examination shows a systolic ejection murmur with radiation to the carotids and a soft
S2.Which of the following is the most likely diagnosis?
Select one:

a. Aortic Stenosis

b. Aortic insufficiency

c. Mitral Stenosis

d. Mitral insufficiency

19- A 72 year old gentleman has recently had a mitral valve replacement. He is now complaining of
fatigue and shortness of breath. On examination he is pale and his sclera appear yellow.
Bloods: low hemoglobin, increased bilirubin, increased reticulocyte count and fragmented red
cells on blood film. What is the most likely diagnosis?

Select one:

a. Iron deficiency anemia

b. B12 deficiency

c. Hemolytic anemia

d. Cholangitis

e. Infective endocarditic

20- A 65 year old gentleman with previous valvular heart surgery presents with dyspnea, ankle
edema and fatigue. On examination there is evidence of a raised JVP worsened by inspiration
and has rapid x and y descents. There is also evidence of a pericardial knock and pulsatile
hepatomegaly. What is the most likely diagnosis?

Select one:

a. Dilated cardiomyopathy

b. Hypertrophic cardiomyopathy

c. Pericardial effusion

d. Restrictive cardiomyopathy

e. Constrictive pericarditis

21- A 35-year-old man is admitted following a serious attempt of paracetamol overdose. Despite
efforts to treat him he develops liver failure. Which of the following is most likely with the
ensuing liver failure?

Select one:

a. It is harmful to give N-acetylcysteine

b. Lactic acidosis is recognized complication

c. Better prognosis in older patients

d. Hypoglycemia rarely happens within 12 hours of onset of encephalopathy

e. Better prognosis in those with high alcohol consumption

 22- The following data are important in interpreting blood gas for acid base balance except:

Select one:

a. HCO3.

b. PCO2.

c. pH.

d. PO2.

23- In COPD, emphysema type, the physical exam of the patient is likely to show the following
signs:

Select one:

a. Blue lips

b. Barrel chest.

c. Clubbing stage IV.

d. Morbid obesity.

24- You notice on a routine examination that an asymptomatic 35-year-old man has a short, soft
systolic murmur, loudest at the left upper sternal border, associated with an ejection click that
has been documented since childhood.
His ECG is shown, The most likely explanation is

Select one:

a. Ventricular septal defect

b. Coarctation of the aorta

c. Pulmonic stenosis

d. The most likely explanation is

e. Ebstein’s anomaly of the tricuspid valve

 25- A 48 year old female is suffering from oligomenorrhoea. She is also complaining of tiredness,
dizziness, weight gain, cold intolerance, constipation, hair and nail changes and is found to
have low potassium and glucose on bloods. Her FSH, LH and estrogen levels are low. What is
the most likely cause of her amenorrhea?

Select one:

a. Primary ovarian failure

b. Panhypopituitarism

c. Addisons

d. Hypothyroidism

e. Polycystic ovarian syndrome

26- A 56-year-old man presents to the emergency department with 2 weeks of fevers and chills. He
underwent placement of a prosthetic mitral valve 4 weeks ago. You are concerned he may have
prosthetic valve endocarditis. Which of the following organisms is the most likely pathogen?

Select one:

a. Staphylococcus aureus

b. Pseudomonas aeurginos

c. Streptococcus viridians

d. Candida albicans

27- A 45-year-old had an onset of severe, crushing, substernal chest pain while attending a football
match. He collapsed on his way to the car. Bystander Cardiorespiratory Resuscitation was
begun immediately and continued until arrival in ER where an endotracheal tube was inserted
and ventilation was maintained on 100% oxygen.
Investigations revealed: pH 7.13 - PaO2 560 mmHg -PaCO2 18 mmHg
Bicarbonate 5.8 -SaO2 98%
Based on these laboratory values, which of the following statements best describes his current
pathophysiology?

Select one:

a. His oxyhemoglobin curve is shifted to the left

b. He probably developed a large right to left intracardiac shunt

c. His pulmonary artery pressure is probably elevated

d. His anion gap is probably normal

e. He is demonstrating a primary respiratory alkalosis

28- A 59-year-old man complains of periorbital edema and ankle swelling which has been gradually
increasing over the past few months. Blood pressure is 120/80 mm Hg. Urinalysis shows a 4+
proteinuria but no cells or casts. Serum albumin is moderately decreased but blood urea
 nitrogen (BUN) and creatinine are normal.
Which of the following is the most likely diagnosis?

Select one:

a. Acute proliferative glomerulonephritis

b. Lupus nephritis

c. IgA nephropathy

d. Diabetic nephropathy

e. Membranous glomerulopathy

29- Which of the following antibodies present in the maternal circulation may lead to congenital
heart block?

Select one:

a. Rheumatoid factor

b. p-ANCA

c. Anti Ro

d. Anti dsDNA

e. Anti Jo1

30- A 22 year old female is admitted to emergency room. Her friends think she has "taken
something". She appears euphoric and can't sit still. She is being sexually inappropriate. You
note her pupils are dilated. Which of the following is the most likely culprit?

Select one:

a. Heroin

b. Diazepam

c. Morphine sulphate

d. Cocaine

e. Ethanol

31- A 24-year-old woman notices pain in her left arm, made worse with use. She also has fatigue,
fever, night sweats, and arthralgias. On examination, there are no palpable lymph nodes, and
the joints and muscle strength are normal.
The left radial pulse is absent, and there is a bruit over the left subclavian and common carotid
arteries. Preliminary laboratory investigations reveal an elevated ESR and mild anemia. Which
of the following vascular findings is most likely to be found in her?

Select one:

a. high-pitched diastolic murmur

b. low pressure in the legs and high pressure in the arms

c. high pressure in the legs and low pressure in the arms

d. hypotension

e. a relentless course to death

32- 45 year old male patient, presents with fever, cough and fatigue. His physical exam according
to the below shown CXR would reveal:

Select one:

a. No abnormal sounds are expected

b. Tympanic resonance over the right upper lobe

c. Bronchial breathing sound at the right upper lobe

d. Dullness at both lung bases

33- 3 hours after found unconscious at home, you are consulted to see a 60 year old male at the
ER. He has the following ABG's on room air:
pH: 7.24, PCO2: 60, HCO3: 26, PO2: 40.
His electrolytes: Na 146, K 3.8, Cl 110, He has normal albumin and PO4 levels. What is the acid
base abnormality?

Select one:

a. There is acute respiratory acidosis

b. There is no abnormality

c. There is combined anion and non anion gap acidosis

d. There is metabolic alkalosis

 34- A 26 year old female presents with fatigue, myalgia and pruritis. She is complaining of vague
right upper quadrant pain and has noticed her skin and eyes appearing yellow in color. On
examination there is evidence of hepatomegaly and jaundice. Bloods reveal deranged LFTs
(predominantly raised aminotransferases), a normocytic anemia, elevated IgGs and anti LKM
antibodies. Given the most likely diagnosis, what treatment should be commenced?

Select one:

a. Ursodeoxycholic acid

b. Azathioprine

c. Cyclosporin

d. Prednisolone

e. Colestyramine

35- A young woman presents with a facial rash, arthralgias, and fatigue. The rash on her face is
erythematous and raised, her heart and lungs are normal, and wrists are swollen and tender on
palpation. She has mild thrombocytopenia (90,000/mL). Which of the following is the most
appropriate initial autoantibody test?

Select one:

a. ANA

b. anti-Sm

c. anti-double-stranded (ds) deoxyribonucleic acid (DNA)

d. anti-Ro or La

e. antiphospholipid antibodies (lupus anticoagulant)

36- A decrease of the pulse intensity during deep inhalation is called:

Select one:

a. Abdominal breathing

b. Pulsus alternans.

c. Pulse pressure

d. Pulsus paradoxus

37- 3 hours after found unconscious at home, you are consulted to see a 60 year old male at the
ER. He has the following ABG's on room air:
pH: 7.24, PCO2: 60, HCO3: 26, PO2: 40.
His electrolytes: Na 146, K 3.8, Cl 110, He has normal albumin and PO4 levels.You expect the
following:

Select one:

a. Sodium bicarbonate has to be urgently given in IV form.

b. His respiration is likely to be Kussmaul type.

c. He likely took a stimulant

d. His respiratory rate is likely to be low

38- A 40-yr-old female with Grave’s disease was recently started on methimazole. One month later
she comes to the clinic for a routine follow-up. She reports low grade fevers, myalgias,
arthralgias, and general malaise.
The most important test to order now is which of the following?

Select one:

a. TSI

b. TSH

c. Radio iodine uptake

d. WBC

e. ALT

39- A 70-year-old woman has a history of dyspnea and palpitations for six months. An ECG at that
time showed atrial fibrillation. She was given digoxin, diuretics and aspirin. She now presents
with two short-lived episodes of altered sensation in the left face, left arm and leg. There is
poor coordination of the left hand. ECHO was normal as was a CT head scan. What is the most
appropriate next step in management?

Select one:

a. Carotid endarterectomy

b. Clopidogrel

c. Corticosteroid treatment

d. Anticoagulation

e. No action

40- An 85 –year – old man is referred with a three – month history of dysphagia
.Gastroesophagoscopy and biopsy confirmed the presence of Squamous cell carcinoma of the
esophagus. Each of the following conditions might be associated with this tumor, EXCEPT:

Select one:

a. Head and neck cancers

b. Achalasia

c. Smoking

d. Tylosis

e. Barretts oesophagus
 41- While being evaluated in the ER, a 48-year-old man with acute chest pain suddenly collapses,
becoming apneic and pulseless. The electrocardiogram monitor shows ventricular fibrillation.
What is the most appropriate immediate intervention?

Select one:

a. IV epinephrine

b. Pericardiocentesis

c. Endotracheal intubation

d. Central venous line placement

e. Defibrillation

42- A 70 years old man with long-standing HTN. Has developed more severe HTN over a 6-month
period. In spite of anti-HTN medication his BP has risen from 140/90-175/105 mm Hg. In
addition, he had an episode of flash pulmonary edema, that led to his hospitalization for 1
week. He has continued to take his antihypertensive medication faithfully, but he has
developed some intermittent claudication in his left leg. Although he has a long history of
smoking, he has had no other medical problems. Which of the following is the most likely
cause of this clinical disorder?

Select one:

a. Hyperaldosteronism

b. Primary worsening of HTN.

c. Renal artery stenosis

d. Pheochromocytoma

e. Coarctation of the aorta

43- Which of the following organisms is associated with cavitating upper lobe pneumonia?

Select one:

a. Strep. Pneumoniae

b. Klebsiella pneumonia

c. Pneumocystis jiroveci

d. Mycoplasma pneumoniae

e. Chlamydia

44- A 48-year-old woman is referred for treatment of worsening dyspnea attributable to her asthma.
She had no significant pulmonary history until 1 year ago when she noted the insidious onset
of dyspnea, which was particularly noticeable when she was under stress or when she
exercised. She denied nocturnal symptoms but had a sensation of not being able to take in a
deep breath. She had been treated with albuterol, various antihistamines, and
fluticasone/salmeterol with no noticeable effect. Her past medical history was remarkable for a
nasal polypectomy 20 years ago. She was atopic with positive reactions to dust and pollen on
 skin testing many years earlier. She is a lifelong nonsmoker, has never used recreational
drugs, and has no significant occupational exposure history. On physical examination, there
was no dysphonia, clubbing, or cyanosis; her chest was clear; and results of her cardiac
examination were normal. A flow-volume loop is shown in the figure below. Her FEV1 was 2.14
L (84% predicted), FVC was 2.83 L (92% predicted), and FEV1/FVC was 76%. Results of a chest
radiograph were normal. You think:

Select one:

a. This is a normal flow volume loop

b. The patient is malingering

c. Methacholine challenge test should be done.

d. This findings can be seen patients with history of long term intubation

45- A 35 year old lady has sudden onset right upper quadrant pain and abdominal distension. She
was well until 5 weeks ago, when over several days she rapidly developed abdominal
distension and pain. She was also nauseous and vomiting. On examination, temperature was
37.1°C, her JVP was not raised and breath sounds were clear. Abdominal examination revealed
tender hepatomegaly, jaundice and gross ascites. There was also bilateral ankle edema. What
is the likely diagnosis?

Select one:

a. Budd Chiari syndrome

b. Gilbert's syndrome

c. Myeloma
d. Lymphoma

e. Dubin Johnson syndrome

46- A 45 year old female patient presents with chest pain and shortness of breath. She has
rheumatoid arthritis. She is tachycardic and hypotensive. She has a raised JVP and diminished
heart sounds. An ECG shows low QRS voltages. What is the most likely diagnosis?

Select one:

a. Pulmonary fibrosis

b. Cardiac tamponade

c. Pericarditis

d. Constrictive pericarditis

e. Myocarditis

47- A 45-year-old woman presents with fever and delirium. No other history can be obtained from
the patient. On physical examination, the patient is febrile (temperature 39.4° C) and confused.
Neurologic testing is otherwise nonfocal. Laboratory examination shows normal electrolytes.
Creatinine level 3.3 mg/dL. Liver enzymes are normal. Hematocrit is 28%, mean corpuscular
volume is 101 fL, white blood cell count is 13,000/μL, and platelet count is 6,000/μL. A
peripheral blood smear shows red blood cell fragments and schistocytes. The optimal
treatment for this patient is:

Select one:

a. Corticosteroids

b. Platelet transfusion

c. Plasmapheresis

d. Desmopressin (DDAVP)

48- In secondary prevention of myocardial infarction; which one of the following agents has been
shown to reduce mortality?

Select one:

a. Oral nitrates

b. Enalapril

c. Nifedepine

d. Oral magnesium

e. Verapamil

49- A 16 year old male patient complains of recurrent hematuria following a recent upper
respiratory Tract Infection, two days later he developed reddish urine . On examination looks
well, Urine examination: RBC ++. Proteinuria of 0.5 g/24 hr. The serum levels of C3 are normal.
 A renal biopsy demonstrates glomerulonephritis with evidence of deposition of IgA in the
glomeruli. The most likely diagnosis is:

Select one:

a. Polycystic disease of the kidneys

b. Henoch Schonlein syndrome

c. Goodpasture's syndrome

d. IgA nephropathy

e. Alport's syndrome

50- A patient who is ICU is found to have a slightly low TSH, low T3 and normal T4. She has no
history of thyroid disease. What is the most likely cause?

Select one:

a. Subclinical hyperthyroidism

b. Hyperparathyroidism

c. Euthyroid sick syndrome

d. Hypothyroidism

e. Pituitary Hypothyroidism

51- A 30-year-old man presents with frank hematuria and hemoptysis. A blood test shows
microcytic hypochromic anemia. Chest X-ray reveals bilateral infiltrates in the lower zones.
What is the most likely diagnosis?

Select one:

a. Renal cell carcinoma

b. Renal calculus

c. Bronchial carcinoma

d. Renal tuberculosis

e. Goodpasture's syndrome

52- A 78-year-old man with atrial fibrillation on warfarin presents to the emergency room with a
severe headache after a fall at home. He soon becomes difficult to arouse. An emergent
computed tomography scan of the head reveals a subdural hematoma. What is the ideal
therapy?

Select one:

a. Intravenous (IV) vitamin K 10 mg and fresh-frozen plasma (FFP)

b. Fresh-frozen plasma (FFP)

c. Recombinant human factor VIIa (rhFVIIa)

d. Vitamin K 10 mg orally

53- A 25-year-old woman presents to a reproductive endocrinology clinic with a history of being
unable to conceive after 2 years of using no contraception. It is thought she may have
polycystic ovarian syndrome. Which of the following is most likely to be associated with this
condition?

Select one:

a. Low levels of circulating insulin

b. Normal free-androgen index

c. Normal BMI (body mass index)

d. A 28 day menstrual cycle

e. Elevated LH/FSH ratio

54- What is the most useful indicator of prognosis following a paracetamol overdose?

Select one:

a. Liver transaminases

b. Prothrombin time

c. Bilirubin

d. Renal function

e. APTT

55- A 67-year-old woman is brought to the emergency room by her son. He states that she has
been “acting strangely” for the last day or so. Her son indicates that she ran out of her
medication 1 week ago. On examination, the patient is confused, and complaining of headache.
Her blood pressure (BP) is 230/114 mm Hg bilaterally. Funduscopic examination shows
arteriolar narrowing and indistinct optic disk margins. And cardiac examination is significant
for an S4 gallop and a grade 2 midsystolic ejection murmur at the right upper sternal border.
Appropriate management would be :

Select one:

a. Observe in the emergency room and administer clonidine.

b. Admission to the ward and resume outpatient oral antihypertensive regimen

c. Admit to the ward and treat with intravenous hydralazine

d. Admit to the intensive care unit (ICU) and treat with intravenous nicardipine

56- A 60 year old female is suffering from back pain which has woken her from her sleep for the
last few months. She has also noticed feeling thirsty and has been more constipated. Bloods
reveal a normochromic normocytic anemia, thrombocytopenia, leucopenia, renal impairment
and hypercalcemia. What is the most likely diagnosis?
Select one:

a. Monoclonal gammopathy of undetermined significance

b. Multiple myeloma

c. Pernicious anemia

d. Amylodosis

e. Non-Hodgkins lymphoma

57- A 35-year-old female presents with malaise, thirst and increasing nocturia over the last month.
Six months ago she attended the emergency department with an episode of renal colic. One
month previously her GP had noted an eruptive, painful, erythematous rash on the anterior
shins, which was self-limiting. What is the likely cause of her symptoms?

Select one:

a. Hypocalcaemia

b. Hypercalcaemia

c. Hyperglycaemia

d. Hyperoxaluria

e. Hypokalaemia

58- A coagulation screen reveals a normal PT, prolonged APTT and a prolonged bleeding time.
What is the most likely diagnosis?

Select one:

a. Warfarin therapy

b. Hemophilia A

c. Von Will brands disease

d. Hemophilia B

e. Factor V Leiden mutation

59- A physician and his 45-year-old male patient with type 2 diabetes chose to start a basal insulin
glargine while continuing to use 3 oral agents with a goal of controlling his fasting glucose with
the basal insulin and seeing if the metformin pioglitazone, sitagliptin combination also
controlled postprandial glucose levels.
Glargine was started at 10 U at night and was titrated by phone calls to the physician’s office
so that at 26 U, his fasting glucose was 90–120 mg/dL; most of his postprandials were 120–160
mg/dL. He came back 1 month later and his weight was up 1 lb.However, when he had noticed
that occasional fasting glucose levels were elevated, he, on his own, increased his glargine
insulin to 34 U. It did not help and he still saw intermittent elevated fasting glucose levels
sometimes even worse than before and he gained 4 lbs. in a month. He frequently wakes up
with headaches and complains of nightmares and night sweats.
Which one of the following is the MOST likely explanation for this patient’s problem?
Select one:

a. Not taking his insulin

b. Dawn effect

c. Noncompliance with diet, intermittently

d. Middle of night hypoglycemia with a.m. rebound

60- How is Hemophilia B inherited?

Select one:

a. X-linked recessive

b. Autosomal recessive

c. Sporadic

d. X-linked dominant

e. Autosomal dominant

61- Which of the following drugs cause odynophagia by mucosal disruption?

Select one:

a. Metoclopramide

b. Amoxicillin

c. Acetaminophen

d. Tetracycline preparations

e. Ciprofloxacin

62- A 34 year old woman with joint pains is suspected of having rheumatoid arthritis. She is found
to be rheumatoid factor positive. A specific feature of rheumatoid arthritis is:

Select one:

a. Papular rash

b. Subperiosteal thickening

c. Pulsus paradoxos

d. Central articular erosions

e. Marginal articular erosions

63- A 72-year-old man presents with a 5-day history of productive cough, dyspnea, and fevers. His
past medical history is notable for diabetes and hypertension. On physical examination, he
appears tired but is able to speak in full sentences. Temperature is 38.4° C, pulse is 100
beats/min, respirations are 31 breaths/min, and blood pressure is 130/60 mm Hg. Crackles are
noted in the right lower lung field. A chest x-ray shows an infiltrate in the right lower lung.
Which of the following is the next best step in the management of this patient?
Select one:

a. Hospitalize ,treat empirically with trimethoprim-sulfamethoxazole

b. Send home on levofloxacin, return to clinic in 24 hours

c. Send home on doxycycline, return to clinic in 1 week

d. Hospitalize, treat empirically with azithromycin and ceftriaxone or with a fluoroquinolone

64- A54-year-old woman with rheumatoid arthritis (RA) presents with fatigue and low white count
(white blood cells [WBC] 2500/mL) on routine blood work. She has no active joint symptoms
and her RA is controlled on low dose methotrexate and NSAIDs. On examination,
she has chronic joint deformities of her hands and a palpable spleen, which is a new finding.
Which of the following is the most likely diagnosis for her low white count?

Select one:

a. myelofibrosis

b. methotrexate therapy

c. rheumatoid nodules disrupting bone marrow architecture

d. normal variation

e. Felty’s syndrome

65- The objectives in the medical treatment of heart failure; All are true ….except:

Select one:

a. Synchronisation of ventricular activity

b. Optimization of the preload

c. Reduction of the after load

d. Controlling the heart rate.

e. Aggressive diuresis to remove all edema

66- A 45-year-old man reports to his primary care physician that his wife has noted coarsening of
his facial features over several years. In addition, he reports low libido and decreased energy.
Physical examination shows frontal bossing and enlarged hands. An MRI confirms that he has
a pituitary mass. Which of the following screening tests should be ordered to diagnose the
cause of the mass?

Select one:

a. ACTH assay

b. Serum IGF-1 level

c. Growth hormone level

d. 24-hour urinary free cortisol

e. Serum prolactin level

 67- Which of the following antibiotics is associated with prolongation of the QT interval?

Select one:

a. Erythromycin

b. Cefuroxime

c. Co-amoxiclav

d. Isoniazid

e. Gentamicin

68- Chronic liver disease is NOT a complication of:

Select one:

a. Alpha1 antitrypsin deficiency

b. Hepatitis C

c. Haemochromatosis

d. Cystic fibrosis

e. Haemosiderosis

69- Signs of severity in active Ulcerative colitis, all of the followings are true, except:

Select one:

a. Hemoglobin less than 10 g/ dl.

b. ESR more than 30 mm/hr.

c. Serum albumin less than 30 g/ L

d. Daily bowel motions less than twice a day

e. Stool volume more than 400 gram / day.

70- You are treating a patient with limited cutaneous scleroderma or CREST syndrome. She initially
presented with Raynaud’s phenomenon, gastrointestinal symptoms along with sclerodactyly
and telangiectasia. Which
of the following antibodies are strongly associated with the CREST syndrome?

Select one:

a. Anti-Histone.

b. Anti-nuclear RNP (ribonucleoprotein).

c. Anti-centromere

d. ANCA.

e. P-ANCA
 71- A 56-year-old woman presents with increasing abdominal girth. She has no other complaints.
Her examination reveals bulging flanks and shifting dullness. She has had no history of ascites
in the past. Her ascitic fluid is sampled and reveals an albumin level of 1.0 g/dL. Her serum
albumin level is 3.0 g/dL. There are a 125 white blood cells/mL (60% neutrophils). An ethanol
level is positive in the blood. Which of the following is the most appropriate next step in her
management?

Select one:

a. Refer her for liver transplantation

b. Perform a large-volume paracentesis with concomitant albumin infusion

c. Obtain a CA 19-9 level to rule out hepatocellular carcinoma

d. Restrict her sodium intake to 2 g per day and begin spironolactone

72- A 42- year-old woman comes to the physician with bilateral knee pain that severely limits her
mobility. She also complains of diffuse morning joint stiffness that takes several hours to
improve. She has been taking over-the-counter ibuprofen and aspirin but has experienced little
relief of symptoms. She has no other medical problems and does not use tobacco, alcohol, or
illicit drugs. Her vital signs are within normal limits. Physical examination shows tenderness
and s welling of multiple metacarpophalangeal joints, as well as both wrists and knees.
Laboratory results are as follows:
Hemoglobin 8.4 g / dL Serum
Erythrocyte Sedimentation Rate (ESR) 95mm in first hour
Iron 30 mg/dL (normal 50-150 mg/dL)
Total iron-binding capacity 220mg/dL (normal 250-460 mg / dL)
Ferritin 350 ng / mL (normal 15-200 ng / mL)
Best treatment of her anemia would be:

Select one:

a. Folic acid supplementation

b. Cyanocobalamin supplementation

c. Iron supplementation

d. Methotrexate

e. Erythropoietin

73- A 60 year old male presents with general malaise, pyrexia and night sweats. They have a past
history of rheumatic heart disease. On examination there is evidence of a pansystolic murmur,
which is a new clinical finding. What organism is the most likely to have caused these
symptoms?

Select one:

a. Staphylococcus epidermidis

b. Methicillin-resistant Staphylococcus aureus (MRSA)

c. HACEK group
d. Streptococcus viridians

e. Staphylococcus aureus

74- A 27-year-old man has a history of low back pain and stiffness. After several months of mild
symptoms, he notes more severe stiffness at night and hip pain. On physical examination,
there is paravertebral muscle tenderness and
limited flexion of the lumbar spine. X-ray of the lumbar spine shows sacroiliitis. In addition to
recommending physiotherapy and exercise,
which of the following is the most appropriate next step in management?

Select one:

a. azathioprine

b. prednisone

c. phenylbutazone

d. NSAID therapy

e. acetaminophen

75- A 32 year old Palestinian female is found to have a hypochromic microcytic anemia with target
cells. Her iron and Ferritin are at the higher end of normal and her Hemoglobin A2 is 6%. What
is the most likely diagnosis?

Select one:

a. Anemia of chronic disease

b. Alpha thalassemia minor

c. Beta thalassemia trait

d. Iron deficiency anemia

e. Sideroblastic anemia

76- A 37-year-old man with an unremarkable medical history presented to the emergency
department because of abdominal pain. the patient stated that over the previous month he had
experienced gradually worsening discomfort that he described as being dull and located
diffusely throughout the abdomen. He rated the pain as a 7 on a severity scale of 1 to 10. He
also said that during this same period, he had been having mucus like bowel movements that
had increased in frequency to approximately 10 bowel movements daily. He denied any sick
contacts, recent illness, travel, or recent antibiotic use. The patient has no known family history
of inflammatory bowel disease. he stated that about 1 month before the onset of these
symptoms, he began training for a marathon, at which time he also stopped smoking
cigarettes. On physical examination, the patient had no acute distress, but hyperactive bowel
sounds and tenderness were noted on deep palpation. he was found to have a fever of 38°
Celsius and heart rate of 100 beats per minute. results of laboratory analysis, including
complete blood cell count, metabolic profile, and lactic acid level, were unremarkable except
for a hemoglobin level of 10.2 g/dl (reference range, 13.5-17.5 g/dl), and computed tomography
(ct) of the abdomen with contrast medium revealed bowel wall thickening from the hepatic
 flexure to the rectum. mesenteric lymphadenopathy was also noted. He was admitted to the
hospital for further evaluation and treatment. Which one of the following should be the initial
step in the management of the abdominal pain and diarrhea in this patient?

Select one:

a. Colonoscopy

b. Stool studies, including cultures for clostridium difficile, ova and parasites, and bacteria

c. Ultrasonography

d. Upper endoscopy

e. antidiarrheal agents and pain medication symptomatically

77- A 64 yo female has fatigue and dyspnea on exertion. On PE: she is afebrile, pulse of 84/min, RR
of 18/min and BP of 160/95 mm Hg. Heart and lung exams are normal and she has trace pedal
edema with a rash consisting of palpable purpura on both legs.
Labs: Hct 28% WBC 10,800 Plt 248
BUN 45 Creatinine 2.8 C3, C4 nl
ANA neg, pANCA positive
UA: 1-2 RBC casts
Which of the following is the most appropriate initial therapy?

Select one:

a. ACE inhibitor

b. Prednisone

c. Prednisone and cyclophosphamide

d. Prednisone and plasmapheresis

e. Cyclosporine
 78- How would you describe this appearance?

Select one:

a. Optic atrophy

b. Papilloedema

c. Normal fundus

d. Foster-Kennedy Syndrome

e. Retinitis pigmentosa

79- A 35 year old male who is a non smoker presents with increasing shortness of breath. He
complains of a productive cough especially over the winter months. Pulmonary function tests
reveal an obstructive pattern. He states his father and grandfather both had "problems with
their breathing”. What is the most likely diagnosis?

Select one:

a. Multiple recurrent pulmonary emboli

b. COPD

c. Malignancy

d. Alpha 1 antitrypsin deficiency

e. Asthma
 80- Irritable bowel syndrome, all of the followings are true, except:

Select one:

a. The commonest presentation is abdominal pain.

b. Diarrhea predominant type should be differentiated from microscopic colitis,

Lactose intolerance and bile salt diarrhea.

c. Amitriptylin may be used in selected patient

d. Reassurance of the patient has a very important aspect in the management

e. 1% of cases only will meet criteria of a psychiatric disease

81- You are reviewing a 54-year-old man with a phaeochromocytoma. Which of the following is a
suitable a-adrenoreceptor antagonist for the presurgical management of his hypertension?

Select one:

a. Salbutamol

b. Propanolol

c. Nebivolol

d. Atenolol

e. Phenoxybenzamine

82- 3 hours after found unconscious at home, you are consulted to see a 60 year old male at the
ER. He has the following ABG's on room air:
pH: 7.24, PCO2: 60, HCO3: 26, PO2: 40.
His electrolytes: Na 146, K 3.8, Cl 110, He has normal albumin and PO4 levels. The A-a
gradient::

Select one:

a. Is normal for his age.

b. Cannot be calculated

c. Is increased

d. Is decreased.

83- 60 year old man was admitted with community-acquired pneumonia and deteriorated over the
next few hours. Which one of the following indicates a poor prognosis?

Select one:

a. Rigors

b. A total white cell count of 17 x 109/L (4-11)

c. Blood pressure of 110/70 mm Hg

d. Temperature of 39.0c
e. Respiratory rate of 35 breaths/min

84- Which of the following suggests more severe mitral regurgitation?

Select one:

a. Length of murmur

b. Split S2

c. Displaced apex beat and systolic thrill

d. Loudness of murmur

e. Soft S1

85- H.pylori is best diagnosed by a non – invasive test, which one you will do:

Select one:

a. Rapid urease test.

b. Ig G antibodies

c. Urea breath test

d. Ig M antibodies

e. Biopsy and pathology

86- Which of the following does not require alteration in renal failure?

Select one:

a. Vancomycin

b. Piperacillin

c. Clindamycin

d. Clarithromycin

e. Meropenem

87- 56- year-old man complains of fatigue and occasional palpitations. He has a 20- year history of
diabetes mellitus and takes daily insulin therapy. He receives hemodialysis three times a week
for end-stage renal disease. He was recently started on erythropoietin therapy for anemia (his
pretreatment hemoglobin was 8.0 mg / dl). Physical examination at this visit reveals pale
conjunctiva. Repeat laboratory studies show: Hemoglobin 9 .2 mg / dl, MCV 77fl, MCHC 30g / dl,
WBC count 7 ,000/mm3, Platelets 150 ,000/mm3, HemoglobinA1c 7 .5%, ESR 15 mm /hr. Which
of the following is likely to be helpful in improving this patient's symptoms?

Select one:

a. Iron supplementation

b. Splenectomy
c. Higher erythropoietin dose

d. Tighter blood glucose control

e. Folic acid supplementation

88- A patient presents with anterior uveitis. An underlying systemic cause is thought to be present.
What is the least likely cause?

Select one:

a. Sarcoidosis

b. Ankylosing Spondylitis

c. Behcets Syndrome

d. Lymphoma

e. Inflammatory bowel disease

89- A 63-year-old man presents with weakness and hemoptysis, but no fever, cough, or sputum. He
has a 60-pack-per-year history of smoking.
The chest x-ray (CXR) reveals a lung mass with mediastinal widening. On examination, there is
a blue purple discoloration of the upper eyelids and erythema on his knuckles. He has proximal
muscle weakness rated 4+/5, normal reflexes, and sensation. Which of the following is the most
likely diagnosis for his muscle weakness?

Select one:

a. SLE

b. dermatomyositis (DM)

c. Weber-Christian disease

d. polyarteritis

e. scleroderma

90- A 59-year-old man has a myocardial infarction (MI) complicated by hypotension. He recovers
well from the MI, but several days later, his renal function deteriorates. One week after his MI,
he is oliguric and blood urea nitrogen (BUN) and creatinine (Cr) are 53 mg/dL and 3.9 mg/dL,
respectively. Urinalysis shows multiple pigmented granular casts. When measuring the
fractional excretion of sodium (FENa), the resultant fraction is likely to be:

Select one:

a. Less than 1%

b. 3% to 5%

c. Unable to be calculated

d. More than 50%

91- Which ONE of the following is a contraindication to thrombolysis?

Select one:

a. Age over 75 years

b. Background diabetic retinopathy

c. Pregnancy

d. The presence of atrial fibrillation

e. Asthma

92- A 24-year-old woman with a 5-year history of hypothyroidism managed with levothyroxine 100
μg daily finds out that she is pregnant. What would you anticipate will happen to her
levothyroxine requirements during the pregnancy?

Select one:

a. The dose will need to be decreased

b. Tiothyronine (T3) will need to be added to the regimen

c. The dose will not change

d. The dose will need to be increased

93- A 78 years old man enters the hospital because of abnormalities of urination. Today he is
passing large amount of urine, however some days he passes no urine at all . he now has a BP
of 180/90 mm Hg and otherwise , his physical exam is normal . lab show BUN of 120 mg/dl and
S.creatinine of 4.2 mg/dl . Urine analysis reveals a specific gravity of 1.010 , urine is negative
for protein , sugar, ketones , and blood; and an occasional WBC . Which of the following is the
most likely cause of the renal insufficiency?

Select one:

a. Acute GN

b. ATN.

c. Chronic RF of unspecified nature

d. Acute interstitial nephritis

e. Obstructive uropathy

94- In a patient who has developed severe hyperkalemia and associated changes on
electrocardiogram (i.e., peaked T waves, widened QRS complex), administration of which o

Select one:

a. Sodium polystyrene sulfonate, orally

b. Calcium gluconate, intravenously

c. Insulin plus glucose, intravenously

d. A ß2-agonist, via a nebulizer

 95- A 65 year old woman presents with dysphagia and intermittent vomiting. Endoscopy shows a
tight lower esophageal sphincter suggestive of achalasia. Which of the following medical
therapies is most effective?

Select one:

a. Glypressin

b. Diltiazem

c. Glyceryl trinitrate

d. Botulinum toxin

e. Bismuth

96- The risks factors for developing acute pancreatitis include all of the following except:

Select one:

a. Hypocalcemia.

b. Alcoholism.

c. Shock.

d. Gallstones.

97- A 25-year-old man with Wolff-Parkinson-White (WPW) syndrome presents with atrial fibrillation
and a rapid ventricular rate. His blood pressure is 125/75 mm Hg and his heart rate is 180
beats/min and irregular. An electrocardiogram shows atrial fibrillation with rapid irregular
ventricular response with bizarre wide QRS complexes of various morphologies. What would
be the first medication that you would recommend?

Select one:

a. Adenosine

b. Procainamide

c. Diltiazem

d. Metoprolol

e. Digoxin

98- A 28-year-old machinist presents to her general practitioner (GP) with weight loss despite a
good appetite, palpitations and excess sweating. The GP suspects thyrotoxicosis and confirms
this by finding a free (T4) of 58 pmol/l (10-22) with an undetectable thyroid-stimulating hormone
(TSH). On examination she has a normal sized thyroid gland with a suggestion of
bulkiness on the right hand side. A technetium uptake scan reveals a single 'hot' nodule in the
right lobe of the thyroid with suppression of activity elsewhere. Which of the following clinical
features would she be most likely to have?

Select one:

a. Unilateral exophthalmos
b. Lid retraction and lid lag

c. Periorbital edema

d. Diplopia

e. Presence of thyroid-stimulating immunoglobulin (TSI)

99- A 75 year old man presents with a long history of shortness of breath and ankle edema. His
serum biochemistry shows sodium 122 mmols/l and potassium of 2.9 mmols/l. He now
complains of weakness. Which of the following is likely to explain the above biochemical
picture?

Select one:

a. Addison's Disease

b. Diuretic therapy

c. SIADH

d. Primary hyperaldosteronism

e. Nephrotic syndrome

100- 54 year old female, presented to you with 1 week history of progressive dyspnea. She
has CXR done and comes to you for your opinion. You think:

Select one:

a. Her exam will show percussion dullness over the right base

b. This CXR findings are seen in patients with bronchial Asthma

c. If she has no fever, her XR findings should be ignored.

d. This CXR is not compatible with her complaints.