Section: 1

Question: 1
A 30-year-old man presents with severe pruritus that is
worse at night and reports similar symptoms among other
family members. Upon examination, areas of excoriated
papules are observed in the interdigital areas. Which one of
the following is the most likely diagnosis?
dermatitis herpetiformis
cutaneous larva migrans
contact dermatitis
scabies
pinworm infestation
Question: 2
A 33-year-old woman who is 29 weeks pregnant with her
fourth child presents to the obstetric unit with onset of
painless vaginal bleeding two hours ago, accompanied by
passage of significant blood and clots. Fetal heart rate is
regular at 150 beats/minute. She is having no uterine
contractions. Which one of the following is the most likely
diagnosis?
placenta praevia
abruptio placentae
vasa praevia
bloody show
disseminated intravascular coagulation
Question: 3
A 3-year-old boy presents to the emergency room following
a 40 second generalized tonic-clonic seizure. The infant
has been ill with a high fever for 24 hours. His history is
unremarkable, and physical examination is normal, CBC

and urinalysis are normal. Which one of the following

would be the best initial step?
Arrange to have an EEG performed urgently.
Admit to hospital for an immediate CT scan of the
head.
Carry out blood cultures.
Reassure the mother and recommend close
observation.
Perform a lumbar puncture.
Question: 4
Throughout the winter months, about 18% of 1000 people
working in a modern office building complain of headache,
eye irritation and sore throat. These symptoms develop
each day about noon and persist through the afternoon.
The most likely explanation for this phenomenon is
allergic rhinitis.
occupational stress.
mass psychogenic illness.
sick building syndrome (indoor air pollution).
endemic transmission of rhinovirus.
Question: 5
A 15-year-old boy presents with a history of repeated fire
setting. He collects lighters and enjoys watching fires in the
neighborhood. His mother and teachers describe his
temper as explosive and he is known to fight, lie and steal.
With his mother, he is frequently argumentative and
disobedient. Which one of the following diagnoses is most
likely?
conduct disorder

oppositional defiant disorder

intermittent explosive disorder
attention deficit hyperactivity disorder (ADHD)
pyromania

Question: 6
A 30-year-old male presents with a three month history of
weight loss, fatigue and night sweats. He has palpable
lymph nodes in his neck and mild hepatosplenomegaly. A
chest x-ray shows a large mediastinal mass. What would
be the most appropriate method of obtaining tissue for
pathologic diagnosis in this patient?
neck lymph node biopsy under local anesthetic
biopsy of mediastinal mass under general
anesthetic
liver biopsy under local anesthetic
liver biopsy under general anesthetic
needle biopsy of the spleen under local anesthetic
Question: 7
For a 52-year-old sedentary, normotensive, non-smoking
white male who is not overweight, drinks 60 mL of whiskey
per day and plays golf occasionally, which one of the
following conditions is most likely to cause death within the
next 10 years?
motor vehicle accident
cerebrovascular disease
suicide
cirrhosis of the liver
ischemic heart disease

Question: 8
A 26-year-old pregnant woman delivers a male infant at 40
weeks, with a birthweight of 2.0 kg. His head
circumference is 34 cm and there are no dysmorphic
features. Antenatal ultrasounds have been normal until 32
weeks, when intrauterine growth restriction has been
diagnosed. Which one of the following is the most likely
cause of the low birth weight?
congenital intrauterine infection
chromosomal or genetic abnormality
placental insufficiency
congenital hydrocephalus
maternal age
Question: 9
A previously normal 65-year-old African-American man
presents with a urinary tract infection. He is treated with
sulfamethoxazole-trimethoprim. One week later, routine
laboratory testing reveals a new normocytic anemia with
hemoglobin 89 g/L. Which one of the following is the most
likely diagnosis?
Glucose-6-phosphate dehydrogenase (G6PD)
hemolysis
thalassemia trait
occult blood loss from renal carcinoma
sickle cell trait
favism
Question: 10
A 27-year-old man is brought to the emergency room after
trying to smash a computer in the library. He says the
computer is being used to control his thoughts and that he

has a good idea that the government is behind this. This

patient is exhibiting which one of the following?
auditory hallucinations
delusions
visual hallucinations
obsessions
ruminations
Question: 11
What would be the best test to confirm the diagnosis of
hereditary spherocytosis?
Coombs test
bone marrow aspiration
osmotic fragility studies
red blood cell enzyme studies
human leukocyte antigens (HLA) studies

Question: 12
The son of a 79-year-old woman wants a psychiatric
evaluation for his mother because she has been more
confused and lethargic during the past 6 months. She
takes several medications daily, although her son doesn't
know what they are. Mental status examination shows the
woman to be dishevelled, mildly agitated, and
delirious. Which one of the following is the most useful
next step in this woman's evaluation?
identifying her medications
eliciting a family history
ordering serum electrolytes

obtaining a CT scan of the head

prescribing haloperidol for agitation
Question: 13
A first-born male child develops vomiting at the age of five
weeks. The vomit is free of bile. The child remains hungry
and vomits after taking feedings. Examination reveals
visible peristalsis in the upper abdomen. Which one of the
following is the most likely diagnosis?
esophageal atresia
hypertrophic pyloric stenosis
duodenal web
midgut volvulus
incarcerated inguinal hernia

Question: 14
International comparisons suggest that the health status of
a population is most influenced by the
presence of a national health insurance plan.
physician/population ratio.
range of social and welfare programs.
method of paying the physicians.
number of hospital beds.
Question: 15
A patient with delirium tremens manifests all of the
following, EXCEPT
clouded consciousness.

hypothermia.
coarse tremor.
tachypnea.
hyperhidrosis.
Question: 16
A 4-year-old girl presents with areas of bluish discoloration
of the lower extremities, buttocks and upper trunk. She has
a low-grade fever but otherwise well looking. The complete
blood count reveals the following results: hemoglobin, 120
g/L; white blood cell, 8.2x109/L and platelets 170 x109/L.
Which one of the following is the most likely diagnosis?
henoch-Schnlein purpura
hemophilia A
meningococcemia
idiopathic thrombocytopenic purpura
acute leukemia

Question: 17
A 28-year-old pregnant woman develops sudden onset of
dyspnea and tachycardia. Which one of the following is the
most likely explanation?
acute mitral valve regurgitation
pulmonary embolism
myocardial infarction
acute respiratory distress syndrome
lobar pneumonia
Question: 18
A 10-year-old boy complains of headaches and

stomach aches each morning before school and has

missed most of the last 2 weeks of school. He has no
history of vomiting, change in stool patterns, weight
loss or visual disturbances. His physical examination is
negative. The most appropriate course of action is
propranolol prophylaxis for migraines.
referral back to school with reassurance to
parents.
computed tomography scan of the head.
Maalox before meals.
suggest withdrawal of privileges to deal with
truancy.
Question: 19
A 55-year-old overweight, non-smoking woman,
recently separated from her husband, complains of
severe chest pains radiating to both arms. During the
attacks, which are provoked by drinking cold liquids,
she is nauseated and may experience difficulty in
swallowing. The most likely diagnosis is
ischemic heart disease.
peptic ulcer disease.
panic disorder.
esophageal spasm.
biliary colic.
Question: 20
A 4-year-old boy has a history of easy bruising,
nosebleeds, and a similar history among male and
female family members. Laboratory investigations
show normal INR and prolonged APTT. Which one of
the following is the most likely cause of this boy's
tendency?

hemophilia A
Christmas disease
factor XIII deficiency
von Willebrand's disease
familial platelet function disorder
Question: 21
A 45-year-old business executive with advanced
cirrhosis of the liver and a history of alcohol abuse
says that he drinks only because of the constant
nagging of his wife. This is an example of which of the
following defense mechanisms?
rationalization
repression
sublimation
reaction formation
intellectualization
Question: 22
A 3-year-old boy presents with a swelling in the right
scrotum. On examination the swelling is irreducible, it
is possible to get above it and it is translucent. Which
one of the following is the most likely diagnosis?
indirect inguinal hernia
varicosity of testicular veins
torsion of the testis
acute epididymo-orchitis
primary hydrocele

Question: 23
To estimate survival from a follow-up study, "time
zero" must be defined precisely for each patient. This
is best ensured by
"back dating" the entrance to the date of onset
of the first symptoms, as obtained from the
history.
enrolling all patients on the same calendar date.
measuring from the first instance when each
patient's symptoms met certain criteria for
severity.
measuring from the time the disease is detected
by a screening program.
selecting all patients at clinically comparable
points in the course of their disease.
Question: 24
A 45-year-old female presents with a history of a
direct blow over the shaft of her left humerus. Her xray shows a spiral fracture of the distal third of the
humerus. On examination of her hand, sensation is
intact on the palmar side but absent on the dorsum of
her hand. Which one of the following nerves is most
likely injured?
axillary nerve
musculocutaneous nerve
median nerve
radial nerve
ulnar nerve

SECTION 2
Section: 2
Question: 1
A 24-year-old man is brought to the emergency room
after being found unresponsive in a city park. Physical
examination reveals pinpoint pupils unresponsive to
light and a respiratory rate of 7 breaths per
minute. Which one of the following is the most likely
cause?
tricyclic antidepressant overdose
morphine overdose
arsenic poisoning
lead intoxication
alcohol intoxication
Question: 2
The following laboratory values were obtained during
investigation of a 45-year-old man:
Hemoglobin

90 g/L

Mean corpuscular volume

82 fL

Mean corpuscular hemoglobin

concentration

300 g/L (N = 310360 g/L)

Serum iron

7 mol/L (N = 1327 mol/L)

Total iron binding capacity

36 mol/L (N = 5472 mol/L)

Sideroblasts in the bone

marrow

0.25 (N = 0.300.50)

Bone marrow iron

Normal

These results could be due to all the following

conditions, EXCEPT
iron deficiency anemia.
alcoholism.
chronic infection.
malignant disease.
rheumatoid arthritis.
Question: 3
The incidence of a particular disease is greater in men
than in women, but the prevalence shows no sex
difference. The most probable explanation is that
the mortality rate is higher in women.
the case fatality rate is higher in women.
the duration of the disease is longer in women.
women receive less adequate medical care for
the disease.
this diagnosis is more often missed in women.
Question: 4
A 50-year-old woman has a 2 cm carcinoma in the
upper outer quadrant of her left breast, with no
palpable axillary nodes. Which one of the following is
the most appropriate treatment?

lumpectomy and tamoxifen

lumpectomy and axillary dissection
modified radical mastectomy
lumpectomy, axillary dissection and radiotherapy
lumpectomy followed by radiotherapy
Question: 5
A 16-year-old boy presents in the emergency room
with a history of a football injury to the left flank
earlier that day. He reports that at the time of injury
he only had the wind knocked out of him and
recovered in a few minutes. About 1 hour later he
began to experience pain in the left upper quadrant
and left shoulder and light-headedness on
standing. Which one of the following is the most likely
diagnosis?
dislocation of the left shoulder
broken rib on the left side
left-sided pneumothorax
contusion of the left kidney
ruptured spleen
Question: 6
A 6-month-old girl presents with vomiting and diarrhea
of acute onset. Her systolic blood pressure is 40 mm
Hg, pulse is 160/minute, she has poor peripheral
circulation and is very lethargic. Her serum sodium
concentration is 158 mmol/L. Which one of the
following is the best initial management?
intravenous 5% dextrose in 0.9% saline, 20
mL/kg over 60 minutes
intravenous 5% dextrose in water at 80

mL/kg/24 hours
oral solution containing 50 mmol sodium per liter
septic workup
hydrocortisone 200 mg intravenously
Question: 7
A 28-year-old woman has a 3-year history of primary
infertility. She presents with increasing symptoms of
steady, aching lower abdominal pain at the time of
menses. The pain persists throughout menstruation
and often after, and radiates into the rectum. Tender
nodules in the uterosacral ligaments are noted on
pelvic examination. Which one of the following would
be the most contributory investigation?
postcoital test
diagnostic laparoscopy
hysterosalpingogram on day 9 of her cycle
endometrial biopsy on day 26 of her cycle
basal body temperature charting

Question: 8
A 54-year-old man presents with extreme pain and
swelling of the left middle finger. Four days earlier, he
suffered a small puncture wound to the volar aspect of
the finger at the level of the distal flexor
crease. Passive extension of the proximal
interphalangeal (PIP) and distal interphalangeal (DIP)
joints severely aggravates his symptoms. Which one
of the following is the most likely diagnosis?
pulp space infection
cellulitis
mid-palmar space infection

septic tenosynovitis
septic arthritis distal interphalangeal (DIP) joint
Question: 9
A 52-year-old patient is complaining of hot flushes,
sweating, and sleep disturbance. After discussion she
feels hormone replacement therapy would not be
suitable for her. She wants to discuss herbal remedies
for menopause. Which one of the following natural
products is most likely to help her symptoms?
Kava
Ginseng
coenzyme Q10
Evening primrose oil
Bilberry
Question: 10
On physical examination of a 21-year-old woman, you
auscultate at the apex of her heart a low-pitched midto-late diastolic murmur with accentuation of
S1. Upon careful listening you notice a clicking sound
just after S2 and immediately preceding the rumbling
murmur. Which one of the following is the most likely
condition?
aortic insufficiency
atrial myxoma
mitral valve prolapse
mitral valve stenosis
patent foramen ovale
Question: 11
A 21-year-old primigravida at 20 weeks' gestation is