Download Specialty: Internal Medicine

Candidate # (
)
Internal Medicine Board Exam
Paper 1
Time Allowed 2.5 hours
 The following paper contains 100 questions
 Choose the best answer out of the 5 options to each question
 Record your answer using the correct alphabet letter on the answer sheet

On finishing please hand the question paper with your answer sheet.
1
1. A patient with ↑ ICP must be carefully monitored because:
a.
b.
c.
d.
the pressure may become > cerebral perfusion pressure
the ↑ ICP may compress the brainstem → greatly elevated BP
brain tissue may be damaged by herniation under the falx or tentorium
all of the above
2. Language disorders (aphasia) that may occur after a stroke:
a.
b.
c.
d.
are due to dysfunction in the right temporal lobe
only involve the understanding of words heard
are usually the result of a CVA involving the middle cerebral artery
are temporary
3. A 68 year old woman has a 10 year history of Parkinson’s disease which has been treated with
a combination of levodopa & benserazide 3 times a day & benztropine 3 times a day. During the
last year she has experienced periods of mid rigidity ½ hour prior to the next dose of levodopa,
but her overall mobility is reasonable. She now presents with a 1/12 history of increasing
confusion & agitation, particularly at night. The most appropriate next option is :
A.
B.
C.
D.
E.
Addition of bromocriptine & reduction in levodopa
Cease benztropine
Reduction in levodopa
Addition of haloperidol at night
Addition of selegiline & reduction of levodopa
4. An infarct causing mutism or dysfluency with little or no difficulty in verbal comprehension is
likely to be secondary to occlusion of the :
a) Anterior Choroidal Artery
b) Anterior Cerebral Artery
c) Superior division of the MCA territory
d) Inferior division of the MCA territory
e) stem of the MCA territory
5. In migraine all are true except:
A.
B.
C.
D.
Headache is caused by vasoconstriction of the intra-cranial vessels
Fortification spectra are characteristic
Transient hemiparesis is a recognised complication
The frequency of attacks tends to decrease in late middle age
6. A concussion is a brain injury that causes:
a.
b.
c.
d.
small haemorrhages and some swelling of brain tissues
momentary interruption of brain function with or without loss of consciousness
tearing or shearing of brain structures
bruising of the brain
2
7. All of the following are risk factors for colorectal cancer except:
A. High calcium diet
B. High fat diet
C. Cholecystectomy
D. I1307K mutation of the APC gene
E. All of the above
8. Which of these generally does not parallel disease activity?
A. Erythema Nodosum
B. Sclerosing cholangitis
C. Episcleritis
E. Peripheral arthritis
9. A 65-year-old woman arrives for a scheduled endoscopy for new-onset dysphagia. She reports
that she is generally healthy but has bilateral artificial hip prostheses. One of these developed
a peri-graft infection 3 years previously and required several months of home intravenous
antibiotic therapy. She is quite concerned about the risk of infection to the prosthesis. She is
allergic
to
penicillin.
Which
of
the
following
is
correct?
A. She should receive 600 mg of clindamycin PO 1 hour before the procedure
B. She should receive 1 gm of vancomycin IV (over 1-2 hours) before the procedure and 1.5 mg/kg
of
gentamycin
within
30
minutes
of
starting
the
procedure
C. She should receive 500 mg of azithromycin PO 1 hour before the procedure
D. She should receive antibiotic prophylaxis only if esophageal dilation required
E. She should receive no antibiotic prophylaxis
10. Which of the following HBsAg-positive patients is not currently a candidate for treatment
with alpha interferon or lamivudine, or adefovir:
A. 35-year-old man with ALT of 150, HBeAg-positive and HBV DNA-positive
B. 35-year-old woman with ALT of 250, HBV DNA-positive but HBeAg-negative
C. 35-year-old woman with ALT of 20, HBeAg-negative, HBV DNA-negative
11. Deficiency of plasma ceruloplasmin, Kaiser-Fleischer rings on refractive eye examination.
A. 18 year old female with jaundice, prolonged prothrombin time, movement disorder ("flapping
tremors" of the upper extremities) and manic-depressive psychosos. Liver biopsy shows nonspecific
steatosis
fibrosis.
B. 37 year old male with a history of ulcerative colitis presents with progressive fatigue, jaundice
and
elevated
serum
alkaline
phosphatase.
C. 5 year old boy with a recent history of upper respiratory tract infection presents with sudden
vomiting
and
change
in
mental
status,
terminating
in
coma.
D. 35 year old male with "bronze" skin pigmentation, diabetes mellitus, abnormal liver function
tests and markedly elevated serum ferritin.
3
12. A 40-year-old, moderately obese man presents with a persistent productive cough. The cough
has been present for several weeks, but recently the man noted that his sputum has
assumed a greenish color. Further questioning elicits a history of productive cough , usually
in the winter months, over the past several years. He has smoked two packs of cigarettes
per day since he was 16 years old. On examination, the man is febrile (100° F), and coarse
rhonchi and wheezes can be appreciated bilaterally. Which of the following is the most likely
diagnosis?
A. Bronchogenic carcinoma
B. Chronic bronchitis with superimposed infection
C. Cystic fibrosis
D. Emphysema
E. Pulmonary tuberculosis
13. A healthy, 37-year-old, recently divorced woman loses her job at the auto factory. She picks
up her three young children from the factory day care center and gets into an automobile
accident on the way home. Her 5-year-old son, who was not wearing a seat belt, sustains a severe
head injury. The woman was not hurt in the accident, but is hyperventilating as she sits in the
waiting room at the hospital. She complains of feeling faint and has blurred vision. Which of the
following is decreased in this woman?
A. Arterial oxygen content
B. Arterial oxygen tension (PO2)
C. Arterial pH
D. Cerebral blood flow
E. Cerebrovascular resistance
14. A 43-year-old, insulin-dependent diabetic patient is diagnosed with hypertension and begins
therapy with an antihypertensive agent. Three days later, he measures his blood glucose at
home and finds that it is 53 mg/dL. He recalibrates his glucose testing apparatus and repeats
the test, only to find that the first reading was accurate. He is concerned that his
hypoglycemia did not produce the normal premonitory signs and symptoms. Which of the
following medications was most likely prescribed to treat his hypertension?
A. Captopril
B. Diltiazem
C. Methyldopa
D. Prazosin
E. Propranolol
15. A 74-year-old man is noted to have purplish-discolored right third and fourth toes 4 days
after coronary angiography and a creatinine level of 2.4 mg/dL (creatinine level was normal
on admission). He has a history of adult-onset diabetes mellitus, hypertension, and 50 packyears of smoking. Cholesterol crystal atheromatous embolization is suspected. Which of the
following may be present?
A. Livedo reticularis
B. Elevated erythrocyte sedimentation rate and/or leukocytosis and/or eosinophilia
C. Prominent gastrocnemius pain or claudication
D. Source(s) of the cholesterol emboli are usually the abdominal aorta or iliofemoral arteries rather than
the more distal arteries.
E. All of the above
4
16. A 50-year-old white man is transferred to your hospital with a presumptive diagnosis of
tuberculosis. His chest radiograph shows nodular cavitary lesions in both lung fields. His
urinalysis shows 50 RBCs per high power field and 3+ proteinuria. He is scheduled for
bronchoscopy with transbronchial lung biopsy in the morning. That evening he has a sudden
deterioration consisting of massive hemoptysis and progressive renal failure. The most
appropriate therapeutic intervention at this point would be supportive management and
A. IV corticosteroids
B. Antituberculous medications
C. IV cyclophosphamide 4 mg/kg
D. Oral cyclophosphamide 2 mg/kg
E. IV corticosteroids and IV cyclophosphamide 4 mg/kg
17. Rheumatoid factor may be present in each of these conditions, except
A. Adult Still's disease
B. Subacute bacterial endocarditis
C. Vasculitis syndromes
D. Sarcoidosis
E. Sjögren's syndrome
18. A 93 year old man has a syncopal episode after being well most of his life. Workup reveals
aortic stenosis and you plan to operate. You expect to find:
A. A calculated triscupid aortic valve without fused commisures; a normal mitral valve for age
B. A calcified tricuspid aortic valve without fused commisures; a normal mitral valve with fused,
thickened chordae
C. A calcified tricuspid aortic valve with fused commisures; a normal mitral valve for age
D. A calcified bicuspid aortic valve; a normal mitral valve for age
E. A calcified bicuspid aortic valve: a calcified pulmonic valve
19. A 74 year old man presents with severe chest pain to the emergency room, and is found to
have a widened mediastinum on chest radiograph and a murmur of aortic insufficiency on
examination. He dies on the operating table from blood loss from a ruptured but very dilated
ascending aorta. At autopsy, severe aortic atherosclerosis, especially in the ascending aorta, is
seen together with a longitudinal intimal ridging resembling tree bark affecting the ascending
aorta. the aortic root is also dilated. Histological sections of the aortic arch confirm the
atherosclerotic plaques, and also show obliterative endarteritis of the vasa vasorum. Your
diagnosis:
A. Kawasaki arteritis; atherosclerosis
B. Atherosclerosis with secondary bacterial aortitis
C. Aortic dissection., Type A
D. Syphilitic aortitis with accelerated atherosclerosis
E. Takayasu arteritis
5
20. Jones criteria for the diagnosis of acute rheumatic fever include major and minor criteria. In
the presence of evidence of a preceding group A streptococcal infection, which one of the
following statements is correct?
a. the diagnosis requires the presence of one major criterion only.
b. the diagnosis requires the presence of at least three major criteria.
c. the diagnosis requires the presence of two major or one major and two
minor criteria.
d. three minor criteria alone are sufficient for the diagnosis.
e. two major criteria in the absence of minor criteria are insufficient for the
diagnosis
21. The most common cause of death of in-hospital patients with myocardial infarctions:
A. Cardiogenic shock (severe pump failure)
B. Arrhyrhmia
C. Cardiac free wall rupture
D. Rupture ventricular aneurysm
E. Constrictive pericarditis
22. Which of the following does not have oral manifestations
A. Systemic gold therapy.
B. Bulimia.
C. Erysepelas.
D. Pemphigus vulgaris.
E. Lichen planus.
23. A 50 year old male has some unusual lesions on his skin. They are reddish purple lesions with
a well defined, albeit irregular, border. They tend to peel. He sees his family doctor and is
treated for eczematous dermatitis. He continues to have these lesions for several years. The
lesions do not respond to treatment. The lesions progress into plaques and nodules. He his
particularly distressed because the lesions involve his face and scalp. A biopsy is done and the
pathologist report indicates the presence of micro-abscesses containing atypical lymphoid
cells. What is the most likely diagnosis?
a) eczematous dermatitis
b) mycosis fungoides
c) psoriasis
d) atopic dermatitis
e) pityriasis rosea
6
24. Outbreaks of dermatitis and folliculitis associated with swimming pools and hot tubs are
often caused by which one of the following?
A) Listeria
B) Pseudomonas
C) Streptococcus
D) Shigella
E) Staphylococcus
25. Which of the following statements is/are true regarding PTH?
A. Secretion is stimulated by hypocalcemia.
B. Secretion is inhibited by hypercalcemia.
C. The effect of magnesium on secretion is the same as that of calcium.
D. Secretion is stimulated by low 1,25-hydroxyvitamin D and inhibited by high levels of 1,25hydroxyvitamin D.
E. A, B, and D
F. All of the above
26. A 27-year-old white woman was admitted 2 days ago through the emergency room for
seizures. She has a history of moderate alcohol use. Two weeks ago she received benzathine
penicillin for secondary syphilis. She is complaining of muscle cramps, weakness, and
headache. She received 1 g of phenytoin on the day of admission and is now taking 100 mg
three times a day. She is also taking acetaminophen, multivitamins, and tapering doses of
chlordiazepoxide. There is a history of seizures in her family. She is 5 feet tall and weighs 120
pounds. Her blood pressure is 130/80 mm Hg; pulse is 90 beats/minute. The rest of the
physical exam is normal except for a round face, a short neck, short fourth and fifth
metacarpals, and bilateral cataracts. Abnormal labs include a calcium of 1.5 mmol/L (normal
range, 2.2-2.6 mmol/L), phosphorus of 1.7 mmol/L (normal range, 0.8-1.4 mmol/L), and an
intact parathyroid hormone (PTH) of 200 pg/mL (normal range, 15-65). Which of the
following is most likely?
A. Hypothyroidism
B. Hypogonadism
C. Basal ganglia calcification
D. Mental retardation
E. All of the above
7
27. A 38-year-old black woman comes to you for renewal of her medications. She has had
hypertension since her last pregnancy at age 30 and has been maintained on clonidine 0.2 mg
twice a day. She gets headaches, dyspnea on exertion, swelling of her feet, and orthopnea but
denies chest pain. Her father is also being treated for hypertension. She is married and does
not smoke. She is five feet seven inches tall and weighs 257 pounds. Her blood pressure is
180/110 mm Hg; pulse is 92 beats/minute. The rest of her exam is remarkable for
hypertensive retinopathy, bibasilar rales, and 1+ pitting edema bilaterally. Initial labs were
normal except for a serum potassium of 3.0 mEq/L (normal range, 3.5- 5.0 mEq/L) and
serum bicarbonate of 33 mEq/L (normal range, 22-28 mEq/L). You correct hypokalemia and
obtain a random serum aldosterone level of 25 ng/dL (normal range, 5-30 ng/dL) with a
plasma renin activity of 0.5 ng/mL/hour (normal range, 1.6- 7.4 ng/mL/hour) while the
patient is on a normal diet. What additional tests might be appropriate?
A. Adrenal computed tomography (CT) scan
B. Adrenal vein sampling
C. 18-hydroxycorticosterone
D. Saline loading test
E. A, B, and C
28. Anosmia in a patient with poorly developed secondary sexual characteristics, should suggest
a diagnosis of
a) Isolated LH deficiency
b) Hemochromatosis
c) Kallmann's syndrome
d) Klinefelter's syndrome
e) Laurence-Moon-Bardet-Biedel syndrome
29. A 54-year-old white man is admitted to the hospital because of abdominal pain and "black
stools." He has not seen a doctor in years. He smokes two packs of cigarettes daily. Physical
exam reveals poor dentition, normal cardiovascular exam, moderate splenomegaly with mild
epigastric and left upper quadrant tenderness, and a guaiac stool test positive for occult
blood.
Laboratory values reveal a hemoglobin of 9.5 g/dL, hematocrit of 29%, WBC count of
14,500/μL with a fairly normal differential, a platelet count of 540,000/μL, and a ferritin level
of 4 μg/L. Serum vitamin B12 levels are elevated.
A bone marrow exam shows hypercellularity without other specific findings, and
chromosomes are reported as normal. Endoscopy reveals a gastric ulcer and biopsies are
negative for malignancy but positive for Helicobacter pylori infection. Appropriate
management at this stage should be
A. Splenectomy
B Transfusion of two units of packed RBCs
C. Observation
D. Antibiotic treatment for the H. pylori infection and iron supplementation for the iron deficiency
anemia
E. Antibiotic treatment for the H. pylori infection
8
30. A 53-year-old woman comes to see you regarding a possible diagnosis of essential
thrombocytosis. She says her gynecologist has noted a platelet count of >550,000/μL on three
separate occasions over the past 2 years. Apart from two uneventful childbirths, the woman
says she really has no significant medical history. She says she has never been told she was
anemic. Lab values reveal a normal hemoglobin, hematocrit, and MCV. The platelet count is
580,000/μL. Your review of the peripheral smear reveals no microcytosis or hypochromia but
does show RBC Howell-Jolly bodies. The platelet count on the smear appears elevated, but
there are no giant platelets or platelet clumps. What is the next most appropriate step in your
diagnostic work-up?
A.Perform bone marrow aspirate and biopsy.
B. Obtain a C-reactive protein and a sedimentation rate, looking for a state of chronic
inflammation.
C. Obtain a ferritin level to confirm that there is no iron deficiency.
D. Go back and obtain a more thorough history and repeat the physical exam.*
E. Perform chest, abdominal, and pelvic CT scans, searching for an occult malignancy.
31. Pregnancy-related microangiopathic hemolytic anemia is caused by all of the following,
except
A. Preeclampsia/eclampsia
B. Pregnancy-related ITP
C. HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count)
D. Postpartum hemolytic-uremic syndrome (HUS)
32. A 33-year-old woman presents with fever, vomiting, severe irritative voiding symptoms, and
pronounced costovertebral angle tenderness. Laboratory evaluation reveals leukocytosis with
a left shift; blood cultures indicate bacteremia. Urinalysis shows pyuria, mild hematuria , and
gram-negative bacteria. Which of the following drugs would best treat this patient's
infection?
A. Ampicillin and gentamicin
B. Erythromycin
C. Gentamicin and vancomycin
D. Phenazopyridine and nitrofurantoin
E. Tetracycline
33. A previously healthy 11-year-old girl develops a gastrointestinal infection with cramping and
watery stools. After several days, she begins to pass blood per rectum, and is hospitalized for
dehydration. In the hospital, she is noted to have decreasing urine output with rising blood
urea nitrogen (BUN). Total blood count reveals anemia and thrombocytopenia, and the
peripheral smear is remarkable for fragmented red cells (schistocytes). Infection with which
of the following bacterial genera is most likely responsible for this syndrome?
A. Campylobacter
B. Clostridium
C. Salmonella
D. Shigella
E. Vibrio
9
34. A 17-year-old white male comes to your office worried about Lyme disease. He recently
returned from a camp in the Upper Peninsula of Michigan where he went hiking in the
woods. He recalls no tick bite, but about 1 week after returning home he developed a lowgrade fever, myalgias, and fatigue. He has had these symptoms for 1 week when he comes in
to see you. A physical examination is completely normal.
The single most important diagnostic clue in establishing the diagnosis of Lyme disease is:
A) new-onset bundle-branch block.
B) nuchal rigidity compatible with meningitis.
C) high, spiking fevers.
D) erythema migrans.
E) acute arthritis of a large joint.
35. Twenty to thirty 1-2 cm nodular densities are found in both lower lung fields on a chest
radiograph in a 55 year old man. He has a recent history of rectal bleeding and a 20 pound
weight loss over the last months. He is a life long non-smoker. He is afebrile and denies
pulmonary symptoms such as shortness of breath or a productive cough. Your most likely
preliminary diagnosis:
A. Bronchopneumonia
B. Metastatic colon carcinoma
C. Primary tuberculosis
D. Pulmonary hamartoma
E. Bronchial carcinoid
36. If it were determined from a cohort study that 90 heavy smokers out of 20,000 in the study
developed a particular illness over a 10 year period while nine nonsmokers out of 10,000 in
the study developed the same illness over that same time period, what was the risk ratio for
heavy smokers as compared with nonsmokers?
A) 54
B) 45
C) 36
D) 10
E) 5
37. Which of the following is the best method for detecting protein calorie malnutrion in the
elderly hospital inpatient?
A. Serum albumin
B. Body mass index
C. Triceps skin fold thickness
D. Total lymphocyte count
E. Calculated arm muscle area
10
38. A patient presents to his primary care physician complaining of fatigue and hair loss. He has gained
6.4 kg since his last clinic visit 6 months ago but notes markedly decreased appetite. On review of
systems, he reports that he is not sleeping well and feels cold all the time. He is still able to enjoy his
hobbies and spending time with his family, and does not believe that he is depressed. His examination
reveals diffuse alopecia and slowed deep tendon reflex relaxation. Hypothyroidism is high on the
differential for this patient. Which of the statements regarding that diagnosis is correct?
A. A normal thyroid-stimulating hormone (TSH) excludes secondary, but not
primaryhypothyroidism.
B. T3
measurement
is
not
indicated
to
make
the
diagnosis.
C. The
T3/T4
ratio
is
important
for
determining
response
to
therapy.
D. Thyroid peroxidase antibodies distinguish between primary and secondary hyyperthyroidism
E. Unbound T4 is a better screening test than TSH for subclinical hypothyroidism
39. A 62-year-old woman presents to your office with dyspnea of 4 months duration. She has a history of
monoclonal gammopathy of unclear significance (MGUS) and has been lost to follow-up for the past 5
years. She is able to do only minimal activity before she has to rest but has no symptoms at rest. She
has developed orthopnea but denies paroxysmal nocturnal dyspnea. She complains of fatigue, light
headedness, and lower extremity swelling. On examination, blood pressure is 110/90 mmHg and heart
rate 94. Jugular venous pressure is elevated, and the jugular venous wave does not fall with
inspiration. An S3 and S4 are present, as well as a mitral regurgitation murmur. The point of maximal
impulse is not displaced. Abdominal examination is significant for ascites and a large, tender,
pulsatile liver. Chest radiograph shows bilateral pulmonary edema. An electrocardiogram shows an
old left bundle branch block. Which clinical features differentiate constrictive pericarditis from
restrictive cardiomyopathy?
A. Elevated jugular venous pressure
B. Kussmaul's sign
C. Narrow pulse pressure
D. Pulsatile liver
E. None of the above
40. A 32-year-old man seeks evaluation for ongoing fevers of uncertain cause. He first noted a feeling of
malaise about 3 months ago, and for the past 6 weeks, he has been experiencing daily fevers to as high
as 39.4°C (103°F). He awakens with night sweats once weekly and has lost 4.5 kg. He complains of
nonspecific myalgias and arthralgias. He has no rashes and reports no ill contacts. He has seen his
primary care physician on three separate occasions during this time and has had documented
temperatures of 38.7°C (101.7°F) while in the physician's office. Multiple laboratory studies have been
performed that have shown nonspecific findings only. A complete blood count showed a white blood
cell count of 15,700/ L with 80% polymorphonuclear cells, 15% lymphocytes, 3% eosinophils, and
2% monocytes. The peripheral smear is normal. The hematocrit is 34.7%. His erythrocyte
sedimentation rate (ESR) is elevated at 57 mm/h. Liver and kidney function are normal. HIV,
Epstein-Barr virus (EBV), and cytomegalovirus (CMV) testing are negative. Routine blood cultures
for bacteria, chest radiograph, and purified protein derivative (PPD) testing are negative. In large
groups of patients similar to this one with fever of unknown origin, which of the following categories
comprises the largest group of diagnoses if one is able to be determined?
A. Drug or other ingestion
B. Hereditary periodic fever syndromes, such as familial Mediterranean fever
C. Infection
D. Neoplasm
E. Noninfectious inflammatory disease
11
41. A 45-year-old female with known rheumatoid arthritis complains of a 1-week history of
dyspnea on exertion and dry cough. She had been taking hydroxychloroquine and prednisone
7.5 mg until 3 months ago, when low-dose weekly methotrexate was added because of active
synovitis. The patient's temperature is 37.8°C (100°F), and her room air oxygen saturation
falls from 95% to 87% with ambulation. Chest-x-ray shows new bilateral alveolar infiltrates.
Pulmonary function tests reveal the following:
FEV1, 3.1 L (70% of predicted)
TLC, 5.3 L (60% of predicted)
FVC, 3.9 L (68% of predicted)
VC, 3.9 L (58% of predicted)
FEV1/FVC, 79%
Diffusion capacity for carbon monoxide (DLCO), 62% of predicted
She had a normal pulmonary function test (PFT) 1 year ago. All but which of the following
would be an appropriate next step?
A. Start broad-spectrum antibiotics.
B. Increase the methotrexate dose.
C. Perform bronchoalveolar lavage with transbronchial lavage.
D. Increase prednisone to 60 mg/d.
E. Discontinue methotrexate.
42. Which of the following treatments has not been shown to improve mortality in septic shock?
A. Activated protein C (drotrecogin alpha)
B. Administration of antibiotics within 1 h of presentation
C. Bicarbonate therapy for severe acidosis*
D. Early goal-directed therapy
43. Fall risks in the elderly include all of the following except
A. creatinine clearance <65 mL/min
B. diabetes mellitus
C. fear of falling
D. history of falls
E. hypertension*
F. psychotropic medications
12
44. The triad of portal vein thrombosis, hemolysis, and pancytopenia suggests which
of the following diagnoses?
a. Acute promyelocytic leukemia
b. Hemolytic-uremic syndrome (HUS)
c. Leptospirosis
d. Paroxysmal nocturnal hemoglobinuria (PNH)
e. Thrombotic thrombocytopenia purpura (TTP)
45. All of the following are compatible with tumor lysis syndrome EXCEPT:
A. Raised Calcium levels
B. Raised potassium levels
C. Common with low grade lymphoma
D. Hyperuricemia
E. Acute renal failure
46. A 32-year-old man has bloody diarrhea of 1 day’s duration associated with abdominal pain,
fever,
and
small,
frequent
stools.
He
was
previously
well.
Which of the following pathogens is most likely causing this patient’s acute illness?
A. Giardia lamblia
B. Cryptosporidium
C. Campylobacter jejuni
D. Rotavirus
E. Enterotoxigenic Escherichia coli
47. A 40-year-old woman is found to have abnormal liver chemistry test results during an
evaluation for abnormal uterine bleeding. The patient states that she has had a dry mouth
and mild pruritus for the past year. She does not drink alcoholic beverages and takes no
medications. Physical examination shows only an enlarged, firm liver.
Laboratory studies:
Serum alkaline phosphatase 741
U/L
Serum
aspartate
aminotransferase
100
U/L
Serum alanine aminotransferase
150
U/L
Serum total bilirubin
1.4
mg/dL
Serum direct bilirubin
0.8
mg/dL
Serologic studies for hepatitis A, B, and C
Negative
Abdominal
ultrasonography
shows
no
focal
hepatic
lesions.
Which of the following diagnostic studies is most likely to determine the cause of her
abnormal liver chemistry test results?
A. Transferrin saturation
B.Antimitochondrial antibody titer
C.α1-Antitrypsin phenotype
D.Serum ceruloplasmin level
E.Anti-smooth muscle antibody titer
13
48. 34-year-old woman has had fatigue, weight gain, irregular menstrual cycles, and milky
discharge from both breasts for 6 months. Physical examination reveals a small goiter, dry
skin, and bilateral expressible galactorrhea. Laboratory results include a negative pregnancy
test, a serum thyroid-stimulating hormone of 43 1iU/mL, and a serum prolactin level of 55
ng/mL.
What is the most appropriate next step in the management of this patients
hyperprolactinemia?
A. Remeasure serum prolactin
B .Start estrogen therapy
C. Start dopamine agonist therapy
D. Start levothyroxine therapy
E. Obtain an MRI of the pituitary gland
49.
A 52-year-old man presents with erectile dysfunction of 2 years duration. He has an
unchanged libido and is happily married. The patient is 172.5 cm tall, and over the past 10
years he has slowly gained weight to his present weight of 110 kg. Five years ago, he was
diagnosed
with
type
2
diabetes
mellitus.
On physical examination, he has acanthosis nigricans on his neck and normal body hair for
an adult man. Each testis is 5.0 cm long. The total serum testosterone level is low, while
serum luteinizing hormone and serum follicle-stimulating hormone levels were normal.
Which of the following is the most likely explanation for this mans low level of testosterone?
A. Pituitary adenoma
B. Cushing’s syndrome
C. Hemochromatosis
D. Low level of sex hormone-binding globulin
E. Estrogen-producing adrenal tumor
50. A 59-year-old postmenopausal white woman has the following results from a recent dualenergy X-ray absorptiometry test. She has never experienced a fracture.
Spine: T score = -2.6; Z score = -1 .2
Hip: T score = -1.4; Z score = -0.9
What is the correct diagnosis using the World Health Organization (WHO) criteria for bone
mass?
A. Osteopenia
B. Osteoporosis
C. Severe osteopenia
D. Osteomalacia
E. Normal bone mass
14
51. A 44 year old builder presents with weakness over the past 48 hours
A neurological exam reveals the following (N=normal):
Tone
Power (MRC)
Coordination
Sensation
Upper
Limbs
Right
N
4/5
N
N
Left
reduced
4/5
N
N
Lower
Limbs
Right
N
3/5
N
N
Left
N
4/5
N
N
Fine touch
N
N
N
N
Biceps
- (absent)
- (absent)
Knee
- (absent)
- (absent)
triceps
- (absent)
- (absent)
Ankle
- (absent)
- (absent)
supinator
+
+
with Plantar
reinforcement
down
down
Proprioception
Reflexes
Which of the following is the most likely diagnosis?
a. Polio
b. Motor Neurone disease
c. Myasthenia gravis
d. Stroke
e. Multiple sclerosis
f. Creutzfeldt Jacob disease
g. Guillain Barre Syndrome
52. A 64 year old man presents to hospital with his first epileptic seizure whilst sat reading a
newspaper at home.
Drug history - Nil
A clinical examination reveals the following:






Temp 371
BP 182/102
O2 Sats 99% Air
GCS 15/15
Finger prick blood glucose 76 mg%
No Jaundice, Anaemia, Clubbing, Cyanosis, Lymphadenopathy (J/A/C/C/L)
15



CVS: NAD
RESP: NAD
GI: NAD
Neurological examination: including cranial nerves and fundoscopy: NAD
His blood tests show the following:
Investigation
FBC
Na
K
Urea
Creat
eGFR(estimated
glomerular filtration rate)
His
chest
X-ray
Result
Normal
129 (134-145meq%)
4.9 (3.5-5.2 meq%)
WNL
WNL
80ml/min
shows
a
ill
defined
lesion
in
the
left
midzone.
What is the most likely aetiology of his seizure?
a. Brain Metastases
b. Hypercalcaemia
c. Syndrome of inappropriate ADH secretion (SIADH)
d. Hyponatraemia not caused by SIADH
e. Idiopathic epilepsy
53. A 62 year old man presents with a swollen right calf 3 weeks after undergoing a total left hip
replacement. He is known to have rheumatoid arthritis.
An Emergency Department doctor tells you that he feels the patient can be discharged. He tells
you this because he shows you the D-Dimer result, which is “negative”. The result is shown
below.
D-Dimer 0.08 (Normal range 0-0.18)
Which of the following statements is true about D-Dimer testing in general patients with a
suspected DVT?
a. Following a clinical assessment, clinicians should not rely on the test as a basis to 'discharge' or
'investigate'
b. It is of no use in patients who have had recent surgery (e.g. within the last 12 weeks)
c. It is of no clinical use in patients with malignancy and secondary metastases
d. It can be used to discharge patients based on their underlying estimated clinical risk score
e. None of the listed answers are correct.
16
54. From the following list select the 3 tumour markers that are of clinical use in the "work up"
of a patient with an unknown suspected primary malignancy:
(e.g. weight loss/ malaise)
Please select 3 answers only: 3 marks available
a. Beta HCG
b. CA 19-9
c. AFP (alfa fetoprotein)
d. CA 153
e. Thyroglobulin
f. PSA (prostate specific antigen)
g. CA125
55. A 42 year old man develops a sore throat. He does not consult his GP but takes some over the counter
painkillers and an anti-inflammatory. 1 week later he has a non itchy rash starting on his feet then
spreading to his trunk. The rash has the appearance of tiny teardrops.
He is correctly diagnosed with guttate psoriasis.
The patient is put on penicillin orally 250mg QDS for 1 week. He then starts passing small volumes of
urine. His urine is described as "orangey brown" . He continues taking a non steroidal anti inflammatory
drug (ibuprofen 800mg TDS). What is the most likely explanation for this?
a. Post infective glomerulonephritis
b. Rheumatic fever
c. Secondary to penicillin
d. Interstitial nephritis secondary to anti inflammatory medication
e. None of the listed answers
56. A 76 year old man presents with atrial fibrillation which is permanent. He is lucid and has specifically
made an appointment with you to discuss the best way of stopping him "dying " as a result of the AF.
PMHx:
Hypertension
(treated),
DHx
Verapamil
Amlodipine
Simvastatin
PRN
SHx
Lives
alone.
Mild
(as
COPD.
Nil
treatment
else
of
for
note.
AF)
inhalers
Independent.
Can
carry
out
all
ADL's
(activities
What is the anticoagulation schedule you would recommend to prevent stroke?
a. Clopidrogel
b. Warfarin
c. Aspirin
d. No anticoagulation
e. Warfarin and Aspirin
17
of
daily
living)
57. A medical student sustains a needlestick injury from an intravenous drug user.
Unfortunately this user is Hepatitis C positive.
Regarding Hepatitis C which of the following statements is true?
a. Vaccination to hepatitis C is routinely available to healthcare professionals and confers some
protection
b. The chance of transmission of hepatitis C is around 3%
c. The chance of transmission is around 0.3%
d. Hepatitis C if transmitted will lead to liver failure in that individual
e. The chance of transmission is around 30%
58.A 56-year-old male with HTN presented with palpitations and dyspnea with exertion. He is unsure
when the symptoms started, but feels he has had a gradual decline over a one week period. He takes
HCTZ for his HTN. He has no other known medical history. His systolic BP is 170 mmHg and the
diastolic pressure is 80 mmHg. An ECG reveals AF with a rapid ventricular rate at 120 bpm.
All of the following are acceptable options in his subsequent care except:
a. Initiate anticoagulation, add a rate control medication, and return for cardioversion in 3 weeks
b. Initiate anticoagulation, perform a TEE, and, if negative for an intracardiac thrombus, proceed with
DC cardioversion
c. Initiate anticoagulation, start amiodarone
d. Initiate anticoagulation, add a rate control medication, and aggressively improve his BP treatment
59. A 14-year-old male presents for what is described as seizure-like activity with participation in
athletics. The patient’s parents describe an episode that occurred while
playing soccer in which he suddenly collapsed with what appeared to be tonic-clonic seizure
activity and loss of urine. Outside of these discrete episodes the patient is otherwise healthy,
takes no medications, and denies illicit drug use. There is no family history of arrhythmia,
CV disease, or sudden death. What is the next step in his care?
a. Referral to a neurologist for an EEG
b. Empiric treatment with an antiepileptic medication
c. ECG and additional testing if necessary for long QT syndrome
d. Beta blockade and exercise restrictions
e. EP test
60. A 27-year-old woman presents 18 wks pregnant with a diagnosis of MS. She has a past
history of rheumatic fever as a teenager and was told that she had an abnormality on her
mitral valve 10 yrs ago. However, over the last few weeks she has developed mild symptoms
of exertional dyspnea. This is her first pregnancy, and she definitely wants to keep the baby.
She has no other medicalproblems.
On examination her BP is 110/70 mmHg and pulse is 90 bpm. The JVP is not elevated and
carotid upstroke is without delay. The lungs are clear. The LV impulse is tapping. The first
heart sound is loud and the second heart sound is split with inspiration with a mildly
increased intensity of the pulmonic component.
There is a crisp opening snap present approximately 60 msec from the second heart sound and a
2/6 diastolic rumble is heard at the apex with a presystolic accentuation.TTE reveals normal LV
size and function with a moderate increase in LA size.
There is a typical “hockey stick” deformity of MS and the valve leaflets appear to be pliable and
noncalcified with no significant subvalvular fusion. The mean gradient across the mitral valve is
10 mmHg and the valve area calculates to 1.1 cm2 by the half-time method. The PA systolic
pressure is calculated to be approximately 36mmHg.
18
What would you do at this point in time?
a. Proceed with TEE and if no LA/appendage thrombus then PMBV
b. Advise termination of her pregnancy
c. Try to avoid any intervention for the next 4 weeks with the patient being as inactive as possible;
then plan for elective mitral valve operation at 22 to 24 wks
d. Medical therapy to control her HR
e. Closed commissurotomy
61. A 34-year-old woman notices blue toes and a lacey rash on her knees when outside in the
winter months. She has chronic hepatitis C virus infection. She has also noticed weakness,
joint discomfort, and red spots on her legs. On
examination, she has livedo reticularis-type skin on her thighs, and areas of palpable purpura
on her toes. She has abnormal proteins detected in her serum. Which of the following is the
most likely mechanism for the vessel injury seen in this condition?
(A) breakdown of erythrocytes
(B) medium vessel vasculitis
(C) aggregation of abnormal platelets
(D) temperature-dependent antibodies
(E) cold precipitable proteins
62. A 45-year-old woman develops symptoms of shortness of breath on exertion, easy fatigue,
and jaundice. On examination she is pale, and there is a palpable spleen, but no
lymphadenopathy.Her hemoglobin is 9.0 g/dL, the reticulocyte count 9%, and the direct
antibody test (Coombs’) is positive. Which of the following bone marrow findings is most
likely to be seen in this patient?
(A) megaloblastic changes
(B) giant metamyelocytes
(C) increased erythroid-to-myeloid ratio
(D) increased lymphocytes
(E) shift to left of the myeloid series
63. A 59-year-old man presents to the emergency room with left face and arm weakness that lasts
for 3 hours. He reports no other symptoms of palpitations, chest pain, or headache.
Neurologic examination is now normal. A computerized tomography (CT) head,
electrocardiogram (ECG), and laboratory workup are normal. He is started on clopidogrel,
and referred for further evaluation as an outpatient. Which of the following is the most likely
mechanism of action on platelet function from this medication?
(A) cyclooxygenase-1 inhibition
(B) modulation of cyclic adenosine monophosphate (cAMP) levels
(C) adenosine diphosphate (ADP) receptor blockade
(D) GPIIB-IIIA blocker
(E) cyclooxygenase-2 inhibition
19
64. A 23-year-old woman has symptoms of leg swelling and discomfort, but no chest pain or
shortness of breath. She has no risk factors for a blood clot. On examination, the left leg is
swollen when compared to the right. Leg Doppler ultrasound is positive for deep vein
thrombosis, and further investigations reveal decreased plasma antithrombin III (AT-III)
levels. Which of the following is the most likely clinical effect from the low AT-III levels?
(A) aspirin sensitivity
(B) heparin resistance
(C) warfarin (Coumadin) resistance
(D) platelet dysfunction
(E) disseminated intravascular coagulation
65. A27-year-old female presents with easy fatigue and light-headedness. She also has a dry
cough and fever for the past few days. On examination, she is pale, her lungs are clear, and
the rest is normal. A chest x-ray (CXR) shows patchy bilateral infiltrates; the hemoglobin is
8.4 g/dL, reticulocyte count of 6%, and many spherocytes on the peripheral blood film.
Which of the following is the most likely significance of the spherocytosis on the blood film?
(A) multiple long bone fracture
(B) hereditary elliptocytosis
(C) Coombs’-positive hemolytic anemia
(D) glucose-6-phosphate dehydrogenase
(G6PD) deficiency
(E) leukemia
66. An 18-year-old woman has periodic episodes that begin with severely decreased vision,
followed by ataxia, dysarthria, and tinnitus. The symptoms last for 30 minutes and are then
followed by a throbbing occipital headache. Which of the following is the most likely
diagnosis?
(A) vertebral-basilar insufficiency
(B) chronic basilar artery dissection
(C) classic migraine
(D) ophthalmoplegic migraine
(E) basilar migraine
67. A 53-year-old man complains of clumsiness with both hands, like having difficulty doing up
buttons or using his keys. Physical examination reveals fasciculations of his thigh and
forearm muscles; diffuse muscle weakness, loss of muscle bulk, and increased tone in the
upper and lower limbs. There is generalized hyperreflexia, and positive Babinski signs
bilaterally. Which of the following is the most likely natural progression of this condition?
(A) a long history of remissions and exacerbations
(B) sensory loss in the distribution of peripheral nerves
(C) focal seizures
(D) a progressively downhill course
(E) cogwheel rigidity
20
68. A56-year-old man is brought to the emergency department by his wife because of memory
loss and difficulty walking. She has noticed
personality changes, truancy from work, and lack of personal care over the past 1 year. On
examination he appears unkempt, smells of urine, and is uncooperative. He cannot recall the
date or season, and gets angry when asked questions. His answers are often fabricated when
checked with his wife. The blood pressure is 150/90 mm Hg, pulse 100/min, and he is
diaphoretic and tremulous. His gait is wide based, and motor strength and reflexes are
normal. His ocular movements are normal but there is nystagmus on lateral gaze. In the past
he has had multiple admissions for alcohol withdrawal. Which of the following is the most
appropriate next step in management?
(A) prophylactic phenytoin administration
(B) prophylactic diazepam administration
(C) prophylactic carbamazepine administration
(D) calcium administration
(E) steroid administration
69. A 19-year-old man has had progressive ataxia of gait and great difficulty in running. In the
past year, he has developed hand clumsiness. Physical examination reveals pes cavus,
kyphoscoliosis, and both cerebellar and sensory changes in the legs. There is a positive family
history of Friedreich’s ataxia. Where are the pathologic changes seen in this condition most
likely to be found?
(A) spinal cord tracts
(B) basal ganglia
(C) cerebral cortex
(D) peripheral autonomic nerves
(E) peripheral motor nerves
70. A 47-year-old woman presents with increasing headaches and visual changes. On
examination, her pupils are normal and reactive to light, the extraocular movements are
normal, and there are visual field defects of
the outer half in both eyes (bitemporal hemianopsia). Which of the following is the most
likely diagnosis?
(A) pituitary adenoma
(B) falx meningioma
(C) cranio-pharyngioma
(D) aneurysm of the internal carotid artery
(E) glioblastoma
71. A 45-year-old man presents with weakness and fasciculations in his arms and legs. His
cranial nerves are normal, but there is weakness of his left handgrip and right leg quadriceps
with loss of muscle bulk. There are obvious fasciculations over the left forearm and right
thigh. Tone is increased in the arms and legs and the reflexes are brisk. Which of the
following is the most likely diagnosis?
(A) amyotrophic lateral sclerosis (ALS)
(B) myotonic muscular dystrophy
(C) amyotonia congenita
(D) tabes dorsalis
(E) migraine
21
72. A45-year-old woman has severe symptoms of epigastric and abdominal pain after eating. A
trial of acid suppression therapy with proton pump inhibitors (PPI) only partially improved
her symptoms. She undergoes elective outpatient
upper endoscopy, which is positive for a small duodenal ulcer. Two hours later, she is short of
breath and complaining of severe anterior chest pain, which is made worse with deep
inspiration. On examination, she looks unwell, blood pressure is 150/90 mm Hg, pulse
110/min, and lungs are clear. Heart sounds are
normal but an extra “crunching” type sound is intermittently heard. CXR demonstrates air
surrounding the heart. Which of the following is the most likely diagnosis?
(A) acute pericarditis
(B) acute cardiac ischemia
(C) acute mediastinitis
(D) aortic dissection
(E) pneumothorax
73. A23-year-old man presents with coughing up blood and sputum. He gives a history of recurrent
pneumonias and a chronic cough productive of foul-smelling purulent sputum. The sputum
production is worse when lying down and in the morning. On physical examination, he appears
chronically ill with clubbing of the fingers. Wet inspiratory crackles are heard at the lung bases
posteriorly. There are no hepatosplenomegaly or any palpable lymph nodes. CXR shows scaring
in the right lower lobe, which on chest CT scan is identified as airway dilatation, bronchial wall
thickening, and grapelike cysts. Which of the following is sometimes seen in this condition?
(A) lung cancer
(B) dextrocardia
(C) fungal infection
(D) carcinoid syndrome
(E) Hodgkin’s disease
74. An 83-year-old man with Parkinson’s disease presents with low-grade fever and cough for several
weeks. Lately, he has been experiencing more rigidity and difficulty with his walking. He is on a
levodopa/carbidopa combination for treatment for the past 5 years. On examination, his gait is
shuffling and slow. He has a tremor in his left hand at rest, and there is cogwheel rigidity of the
forearm. There are crackles in the left lower lung field. CXR reveals a lung abscess in the left
lower lobe. Which of the following is the most likely bacteriologic diagnosis for the lung abscess?
(A) oropharyngeal flora
(B) tuberculosis
(C) Staphylococcus aureus
(D) Pseudomonas aeruginosa
(E) Candida albicans
75. A 23-year-old woman presents with weight loss and chronic diarrhea. She appears unwell and
cachectic. Routine laboratory tests reveal a low hemoglobin level and an increased international
normalized ratio (INR) even though she is not taking any anticoagulants. The liver enzymes are
normal, but the albumin and calcium levels are low, suggesting generalized malnutrition. Which
of the following is the most appropriate initial diagnostic test for malabsorption?
(A) xylose absorption
(B) Schilling test
(C) x-ray studies
(D) stool fat quantitation
(E) small intestinal biopsy
22
76. A63-year-old man with a long history of alcohol abuse presents with ascites. He is
experiencing mild abdominal discomfort and nausea. Examination reveals tense ascites and
generalized tenderness but no rigidity. A diagnostic paracentesis of the fluid is performed.
Which of the following ascitic fluid results is most likely to suggest an uncomplicated ascites
due to portal hypertension from cirrhosis?
(A) hemorrhage
(B) protein >25 g/L
(C) bilirubin level twice that of serum
(D) serum to ascites albumin gradient >1.1 g/dL
(E) more than 1000 white cells/mm3
77. Which of the following is the mostly likely mechanism of acetaminophen hepatotoxicity
toxicity?
(A) an allergic mechanism
(B) an active metabolite
(C) a reaction with hepatic glycogen stores
(D) direct toxicity of the parent compound
(E) circulating immune complexes
78. A64-year-old man presents with symptoms of difficulty swallowing and weight loss of 10 lb.
He has no prior history of heartburn, stomach ulcers, or difficulty swallowing. He smokes
one pack a day for the past 45 years and drinks approximately 5 oz of alcohol a day. He is
thin appearing, there are no oral lesions, and the remaining examination is normal.
Esophagoscopy reveals a midesophageal narrowing with ragged ulcerating, and biopsies are
taken.
Which of the following is the most likely diagnosis?
(A) adenocarcinoma of esophagus
(B) esophageal web
(C) achalasia
(D) squamous cell carcinoma of esophagus
(E) esophageal leiomyoma
79. A 25-year-old woman presents with intermittent double vision and fatigue. Her symptoms
are worse at the end of the day. She reports no other focal muscle weakness or sensory
symptoms. On examination her eye movements,motor strength, and reflexes in the upper and
lower limbs are normal. Repetitive handgrip exercises cause loss of strength in the grip.
ACXR reveals an anterior mediastinal mass. Which of the following is the most likely
diagnosis of the anterior mediastinal mass?
(A) teratoma
(B) thyroid
(C) thymoma
(D) lymphoma
(E) mediastinal cyst
23
80. A 47-year-old man presents with dark black stools and vague crampy abdominal pain. On
examination he is pale, blood pressure 100/70
mm Hg, pulse 110/min, and the abdomen is soft and nontender. Rectal examination confirms
melena, and the patient is transfused 2 units of packed red blood cells. Upper endoscopy does
not identify the source of bleeding, so a small bowel barium study is ordered. It reveals a
small bowel tumor. Which of the following statements concerning small bowel tumors is
correct?
(A) carcinoid is a common cause of small bowel tumors
(B) malignant adenocarcinoma most frequently occurs in the duodenum
(C) malignant tumors bleed more frequently than benign tumors
(D) Peutz-Jeghers syndrome is characterized only by benign hamartoma
(E) most primary gastrointestinal (GI) lymphomas are located in the ileum
81. An 83-year-old woman has chronic congestive heart failure (CHF) due to grade IV left
ventricular function (ejection fraction <20%). She requires 80 mg/day of furosemide as part
of her treatment. Which of the following metabolic abnormalities is most likely to be seen
while she is taking this medication?
(A) metabolic acidosis
(B) respiratory alkalosis
(C) metabolic alkalosis
(D) hyperkalemia
82. A 56 year old builder presents with cough and breathlessness. He is known to have
chronic obstructive pulmonary disease and Ulcerative Colitis. He smokes up to 20
cigarettes a day. The cough is productive of clear sputum up to 500ml a day. He has
had no haemoptysis. The breathlessness now restricts his exercise tolerance to 50
metres. Further questioning reveals he has had diarrhoea with some bleeding per
rectum. He has lost over 2 stone in 2 months. Examination revealed dullness to
percussion at the right lung base. His abdomen was generally tender but there was no
guarding. What is the most likely diagnosis?
A. Bronchiolitis obliterans with organizing pneumonia
B. Bronchioloalveolar cell carcinoma
C. Alveolar Proteinosis
D. Adenocarcinoma of the lung
E. Bronchopleural fistula
24
83. Diagnosis of diabetes mellitus, all are true except
A.
glycated hemoglobin is not used for the diagnosis
B. the presence of glycosuria should warrant further investigation and should not be used as a
diagnostic test per se
C. ketonuria per se is not pathognomonic for diabetes and may found in normal people after
prolonged fasting or exercise
D. the fasting blood glucose is always preferred over the random one in the diagnosis
E. the random blood glucose of more than 11.1 mmol/L on 2 or more occasions is diagnostic for
diabetes mellitus
84. Effects of anti-diabetic agents, all are true except
A.
sulphonylureas have no effect on lipid profile
B. insulin does not reduce post prandial glycemia
C. acarbose has no hypoglycemic effect
D.
glitazones do not raise serum insulin
E.
metformin does not increase body weight
85. Causes of High anion Gap metabolic acidosis with their accumulating compounds ….…..all
are true...Except
A.
methanol poisoning- formic acid
B.
lactic acidosis- lactic acid
C.
ketoacidosis- acetoacetic acid and beta hydroxybutyrate
D.
ethylene glycol poisoning – formic acid
E.
chronic renal failure – phosphoric acid and sulphuric acid
25
86. Renal angiography and venography …all are true except
A. the main indication of renal angiography is the diagnosis of renal artery stenosis and renal
hemorrhage therapeutic intervention may be undertaken at the same time of doing renal
angiography like dilatation and stenting of renal artery stenosis and occluding and AV fistula
B. unlike IVU, there is a risk of cholesterol athero-embolisation
C. when compared to IVU, the risk is contrast nephropathy is lower
D. renal venography mainly used in the diagnosis of renal vein thrombosis and renal cell carcinoma
extension
E. therapeutic intervention may be undertaken at the same time of doing renal angiography like
dilatation and stenting of renal artery stenosis and occluding and AV fistula
87. A man has a arrest in the street due to torsades de pointes. After resuscitation his rhythm
showed a prolonged QT interval. Further questioning revealed erythromycin for a recent
URTI. Which drug interaction is most likely to explain his arrest?
A)
Quinidine
B)
Loratidine
C)
Sotalol
D)
Cimetidine
E)
Terfenadine
88. A middle aged man with longstanding RA is not responding to piroxicam and methotrexate.
He is commenced on cyclosporin. You note that BP 130/86 increasing to 155/90 and
creatinine 0.05 to 0.09. You would?
A)
Cease NSAID
B)
Cease Cyclosporin
C)
Add Nifedipine
D)
Add Diltiazem
E)
Cease Methotrexate
89. A 25 year old woman is at 20 weeks gestation in her first pregnancy. She is a known chronic
epileptic since childhood whose seizure control has been satisfactorily on phenytoin 300mgn
daily. She has had 2 fits in the past 5 years. Her plasma phenytoin concentration measured
annually for at the least 5 years has been in the range 13 – 16 mg/L (therapeutic 10 – 20
mg/L). She now presents with a generalised seizure and is found to have a plasma phenytoin
concentration of 5mg/L. The most likely reason for the seizure recurrence at this stage in her
pregnancy is:
A)
Reduced protien binding of phenytoin
B)
Increased clearance of Phenytoin
C)
Increased volume of distribution of Phenytoin
D)
Enhanced seizure tendency due to her pregnancy
E)
Reduced GI absorption of Phenytoin
26
90. A 25 year old woman in her first pregnancy is concerned about her sister’s history of a child
that died in the neonatal period with complete heart block. Best choice of investigations for
this woman?
A. ANA
B. anti la (SSB) antibodies
C. anti-phospholipid antibodies
D. anti-cardiolipin antibodies
E. anti DNA
91.A 53 year old diabetic on haemodialysis develop nausea, vomiting, restlessness, headache,
hypertension, myoclonic jerking, seizures and coma. The most likely diagnosis is
A- Diabetic ketoacidosis
B- Hyperosmolar coma
C- Hypertensive encephalopathy
D- Dialysis disequilibrium
E- Grand mal epilepsy
92.A 26 year old man is diagnosed to have tuberculosis. His wife is asymptomatic.
Her tuberculin test is positive and her CXR is negative.
The best option for the management of his wife is which one of the following?
A. Repeat the tuberculin test in 4-6 weeks to confirm that it is positive
B. Repeat the CXR in 4-6 weeks to determine whether the patient has tuberculosis
C. Initiate anti-tuberculosis treatment
D. Prescribe anti-tuberculosis chemoprophylaxis with BCG vaccination
E. Nothing more needs to be done
93.
Which one of the following statements is true concerning recommendations
about health care for adolescents?
A. For confidentiality reasons, parents should be excluded from the adolescent health care delivery
process
B. Routine screening of all adolescents for tuberculosis with a yearly skin test is recommended
C. Immunization of unimmunized adolescents against hepatitis B is not recommended unless they
are at high risk
D. Sexually active female adolescents should have a Papanicolaou (Pap) test at 3-year intervals*
E. All sexually active adolescents should be screened for sexually transmitted diseases
94. Which one of the following is generally considered to be an irreversible side effect of
phenothiazines?
A. Tardive dyskinesia
B. Dystonic reaction
C. Akathisia
D. Parkinsonian symptoms
27
95.A 15-year-old girl is referred to clinic complaining of generalised muscle weakness, fatigue
and polyuria. Her blood pressure in clinic is measured at 90/74 mmHg. Investigations:
Serum sodium
127 mmol/l
Serum potassium
3.0 mmol/l
Serum urea
18 mg%
Serum creatinine
1.2mg%
Serum chloride
92 mmol/l (NR 97-108 mmol/l)
Serum bicarbonate 34 mmol/l (NR 22-28 mmol/l)
Serum magnesium 0.82 mmol/l (NR 0.8-1.1 mmol/l)
Urine sodium
160 mmol/l (NR 40-130 mmol/l)
Urine calcium
8.0 mmol/24hr (NR 2.5-8.0 mmol/24hr)
Which of the following is the most likely diagnosis?
ABCDE-
Addison's disease
Bartter's syndrome
Laxative abuse
Liddle's syndrome
Thiazide diuretic abuse
96. Milrinone
97. Noradrenaline
98. adrenaline(epinephrine)
99. Dopamine
100. Dobutamine
Select the best match for each of the above
A. phosphodiesterase inhibitor
B. stimulates both alpha and beta adrenergic receptors but at low doses beta effects seems to
predominate
C. This is predominantly an alpha agonist
D. Acts on beta receptors and alpha receptors as well as DA1 and DA2 receptors
E. This is predominantly a beta agonist
28
Candidate # (
)
May 2009
Palestine Medical Council Certificate Examination
Specialty: Internal Medicine
Paper 1
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