UJIAN TULIS IPD GRUP C

A 47 year old man came with the complaint of cough. The cough began
approximately 3 months prior to this appointment and it has become more
annoying to the patient. The cough is non-productive, 2-3 times/day, worse at
night, 3 times at night/week. He recently restarted an aexercise program after
approximately 2 years of a more sedentary lifestyle and says he is having a
much harder time with the exertion. He just run out of breath earlier than he
used to and cough a great deal. He has not had any blood-tinged sputum or
weight loss. He does not smoke and has no significant medical history. His
examination is notable for a blood pressure 130/70 mmHg and lungs that are
clear to auscultation bilaterally, except for an occasional expiratory wheeze on
forced expiration. A chest radiograph is read as normal.
1. What is the most likely diagnosis?
a. RBC
b. Asthma
c. Pneumonia
d. Bronchiectasis
e. Chronic obstructive pulmonary disease
2. What is the classification?
a. Acute asthma
b. Mild intermittent
c. Mild persistent
d. Moderate persistent
e. Severe persistent
3. What is the best daily medication for this patient?
a. No daily medication
b. Leukotriene modifier
c. Low dose inhaled steroids
d. Medium dose inhaled steroids and long acting B2 agonist
e. High dose inhaled steroids, long acting B2 agonist and oral steroids
A female, 18 years old, came to the clinic with hair fallen. She had pain at all
joints, reddish at her cheeks, with painless oral ulcer. She also felt fatigue. In
physical examination, there was pale at her conjunctivas.
4. What
a.
b.
c.
d.
e.
5. What
a.
b.
c.
d.
e.
6. What

is the most possible diagnosis of this case?

Tuberculosis
Rheumatoid arthritis
SLE
Sepsis
Osteoarthritis
is the confirmation test for the case?
CD4
HIV elisa
Anti dsDNA
Mantoux test
Viral load
is the main principle to manage this case?

a.
b.
c.
d.
e.

Nutrition
Education
Glucocorticoid
Antibiotics
Anti-Retroviral

A 48-year-old man with a long history of tobacco use presents to Emergency

department 4 hours after the onset of severe substernal crushing chest pain with
radiating to the left arm. He has body weight of 90 kg and body height of 179
cm. Physical examination reveals blood pressure 140/90 mmHg, heart rate of 90
bpm, respiratory rate of 20 breaths per minute and temperature of 37C. Heart
sounds are normal, there are no extra heart sounds. Electrocardiography
displays:

7. Which of the following is most consistent with this clinical picture?

a. Inferior NSTEMI, Stage I hypertension, obesity
b. Extensive Anterior NSTEMI, stage I hypertension, obesity
c. Anterior segment STEMI, stage I hypertension, obesity
d. Inferior NSTEMI, and anterior STEMI, stage I hypertension,
obesity
e. Extensive anterior STEMI, stage I hypertension, obesity
8. If the patient has no clear-cur medical contraindications to
anticoagulation, which of the following would be the optimal management
strategy at that time?
a. Intravenous tissue plasminogen activator alone
b. Intravenous tissue plasminogen activator and aspirin
c. Intravenous tissue plasminogen activator and heparin
d. Intravenous tissue plasminogen activator, heparin and aspirin
e. Intravenous tissue plasminogen activator is contraindicated in this
clinical setting
9. Absolute contraindications to the use of thrombolytic agents in the setting
of emergency department include:
a. Left carotid artery occlusion with hemiparesis 1 month ago
b. Diabetic retinopathy
c. Cardiopulmonary rescucitation for 1 to 2 mins
d. Patient age > 70 y.o.
e. Patient on warfarin for atrial fibrillation, with an INR of 1.8
10.The patient was given Atorvastatin 40 mg. Which of the following
statements regarding cholesterol reduction is true?
a. Pharmacologic cholesterol reduction does not significantly decrease
the risk of cardiovascular mortality in patients with known
cardiovascular disease
b. Pharmacologic cholesterol reduction can decrease cardiovascular
mortality in patients with and without coronary artery disease
c. In patients without diabetes mellitus but with cardiovascular
disease, the pharmacologic intervention should be initiated when
the LDL cholesterol level is >160 mg/dl
d. Cholesterol reduction does not alter the restenosis rate in patients
after cutaneous cardiac intervention

e. Cardiovascular morbidity has only been shown to be reduced in the

use of HMG-CoA reductase inhibitor
A 37 year old executive returns to your office for follow up of recurrent upper
abdominal pain. He initially presented 6 weeks ago, complaining of an increase
in frequency and severity of burning epigastric pain, which he has experienced
occasionally for more than 1 year. Now the pain occurs three or four times per
week, usually when he has an empty stomach, and it often awakens him at night.
The pain usually relieved within 2-3 hours. He admitted that stress at work had
recently increased and that because of long working hours, he was drinking more
caffeine and eating a lot of take out foods. His physical examination was
normal, including stool was negative for occult blood. You advised a change in
diet and started him on a n H2 blocker. His symptoms resolved completely with
the diet changes and daily use of the medication. Result of the laboratory tests
performed at his first visit showed no anemia.
11.What is the diagnosis?
a. Gastritis
b. Cholelithiasis
c. Acute hepatitis
d. Peptic ulcer disease
e. Gastroesophageal reflux disease
12.Which of the following is not true of H. pylori infection?
a. It is more common in developing countries
b. The rout of transmission is believed to be fecal-oral
c. It is believed to be the cause of non-ulcer dyspepsia
d. It is associated with the development of gastric lymphoma
e. It is believe to be the cause of most duodenal and gastric ulcers
13.6 months later, the patient as brought to the emergency room after
vomiting bright red blood. He has a blood pressure of 85/40 mmHg and
heart rate 120 bpm. Which of the following is the best next step?
a. Guaiac test for a stool
b. Referred to endoscopy
c. Treatment for H. Pylori
d. Administration of proton-pump inhibitor
e. Intravenous fluid resuscitation and preparation for a
transfusion
14.Which one of the following patients should be promptly reffered for
endoscopy?
a. A 21 year old man with severity of burning epigastric pain
b. A 29 year old H. pylori positive patient with dyspeptic symptoms
c. A 32 year old patient whose symptoms are not relieved with
ranitidine
d. A 65 year old man with new onset of epigastric pain and weight loss
e. A 49 year old woman with intermittent right upper quadrant
pain following meals
A 42-year old female with chief complaint heavy menorrhagia for the past eight
month. She felt fatigue, light headache, and palpitation. Physical examination
showed BP 120/80 mmHg, HR 110 bpm, RR 20 breaths per minute, and

conjunctiva was pale. Hb 7.8 g/dl with MCV 75 (low), leukocytes count 6800/mm 3
and platelet 168,000/L.
15.What is the hematologic problem in this patient?
a. Macrocytic anemia
b. Normocytic anemia
c. Microcytic anemia
d. Anemia of chronic disorder
e. Sideroblastic anemia
16.What do you need to perform to establish the diagnosis?
a. Serum Iron
b. Ferritin
c. Total iron binding capacity
d. Reticulocytes
e. Coombs test
17.What is the most likely diagnosis in this patient?
a. Iron deficiency anemia
b. Anemia of Chronic disorder
c. Thallasemia
d. Aplastic anemia
e. Hypoplastic anemia
A 49-year-old woman presents to emergency room complaining of a 4-week
history of progressive abdominal swelling and discomfort. She has no other
gastrointestinal symptoms, and she has normal appetite and normal bowel
habits. Her medical history was three pregnancies, one of which was complicated
by excessive blood loss, requiring blood transfusion. She is happily married for
20 years, exercises, does not smoke, and drinks only occasionally. On pointed
questioning, however, she does admit that she was wild in her youth, and she
had snorted cocaine once or twice at parties many years ago. She does not use
drugs now. She was HIV negative at the time of the birth of her last child.
On examination, her temperature is 37.9C, heart rate 88 bpm, and blood
pressure 94/60 mmHg. She is thin, her complexion is sallow, her sclerae are
icteric, her chest is clear, and her heart rhythm is regular with no murmur. Her
abdomen is distended, with mild diffuse tenderness, hypoactive bowel sounds,
shifting dullness to percussion, and a fluid wave. She has no peripheral edema.
Laboratory studies are normal except for Na 129 mEq/L, albumin 2.8 mg/dL, total
bilirubin 4 mg/dL, prothrombin time 15 seconds, haemoglobin 12 g/dL with MCV
102 fL, and platelet count 78,000/mm3.
18.What is the most likely diagnosis?
a. Ascites caused by hepatic cirrhosis
b. Ascites caused by hypoalbumin
c. Ascites caused by malignancy
d. Ascites caused by alcoholic hepatitis
e. Ascites caused by acute viral hepatitis
19.What is your next step?
a. Diuretics
b. USG work up
c. Albumin transfusion
d. Perform a paracentesis
e. Serologic examination

20.What are the other possible physical examination findings in this patient?
a. Palmar erythema, spider nevi, epigastric pain
b. Gynecomastia, palmar erythema, epigastric pain
c. Gynecomastia, palmar erythema, spider nevi
d. Gynecomastia, spider naevi, hyperemic conjunctiva
e. Palmar erythema, epigastric pain, hyperemic conjunctiva
21.What are the tests for Hepatitis C?
a. Low serum ceruloplasmin
b. Anti-HCV Ab, presence of HCV RNA
c. Persistent HbsAg, presence of HbeAg
d. ANA, anti-LKM (liver kidney microsome)
e. High transferrin saturation (>50%), high ferritin
A 46 year old woman presents for her yearly physical examination. She has been
fine and has no complain today. With her full-time job and three children, she
finds it difficult to exercise, and she admits that her family eat out frequently.
Today her blood pressure was 140/95 mmHg. Body weight 65 kg, height 155 cm.
The patient has not eaten yet today, so on your preceptor recommendation, a
fasting plasma glucose test is performed, and the result is 140 mg/dL.
22.Which of the following is the most appropriate next step?
a. Reassurance that these are normal blood sugars
b. Diagnose diabetes mellitus and start a biguanide agent
c. Recommend cardiac stress testing
d. Obtain start arterial blood gas and serum ketone levels
e. Recommend repeated fasting or random blood glucose
23.Her last HbA1c was 7.9%. She states that she conscientiously follows her
diet and walk 30 minutes to 1 hour daily. What is the best next step in her
care?
a. Add insulin pump
b. Add metformin
c. Add NPH insulin
d. Hospitalize her urgently
e. Recommend weight loss
24.30 years later, she is brought into the hospital by her daughter for follow
up and her creatinine level is 2.2 mg/dL. She currently takes glimepiride
for her diabetes and captopril. Her daughter reports that, in the past 2
weeks, her mother became sweaty, shaky, and confused. Her random
blood glucose is 90 mg/dL. Which of the following conditions is most likely
to be contributing to these episodes?
a. Excess caloric oral intake
b. Interaction between the ACE inhibitory and the sulfonylurea agents
c. Worsening renal function
d. Hyperglycemic amnesia
e. Prolonged hypoglycemia
25.A 45 year old asymptomatic woman has a random serum glucose level of
165 mg/dL on routine examination. Which of the following studies should
be used next to evaluate this finding?
a. Urine glucose
b. Oral glucose tolerance test
c. Fasting serum glucose
d. 2 hour postprandial serum glucose

e. Haemoglobin A1C measurement

An 37 year old previously healthy woman presents to your clinic for unintentional
weight loss. Over the past 3 months, she has lost approximately 15 kg without
changing her diet or activity level. Otherwise, she feels great. She has an
excellent appetite, no gastrointestinal complaints except for her occasional loose
stools, a good energy level, and no complaints except of fatigue. She denies heat
or cold intolerance. On examination, her heart rate is 110 bpm, blood pressure
160/70 mmHg, and she is afebrile. Her eyes are somewhat protuberant. You note
a diffusely large, smooth, nontender thyroid gland. A 2/6 systolic ejection
murmur on cardiac examination, and her skin is warm and dry. There is no
tremor.
26.What is the most likely diagnosis?
a. Hashimoto thyroiditis
b. Graves disease
c. Multinodular toxic goiter
d. Plummer disease
e. Lymphocytic thyroiditis
27.How could you confirm this?
a. A low TSH level and low free T4 level
b. A low TSH level and increase free T 4 level
c. An increase TSH and increase free T 4 level
d. An increase TSH and low free T4 level
e. Normal both TSH and free T4 level
28.If the woman became pregnant, which of the following is the first choice
therapy?
a. Propylthiouracil
b. Long term propranolol
c. Radioactive iodine ablation
d. Surgical thyroidectomy
e. Fine needle aspiration
29.A 42 year old woman has recently experienced fatigue, sleepiness, dry
skin, constipation, and 10 pound weight gain. Her thyroid is firm and twice
the normal size. Which one of the following laboratory tests is most likely
to confirm the suspected diagnosis of hypothyroidism?
a. Serum thyroxin
b. Serum triiodothyronine T3
c. T3 resin uptake
d. Antithyroid antibodies
e. Serum thyroid stimulating hormone (TSH)
30.A 30-year old woman is noted to have blood pressure in the 160/100
mmHg range. She also has increased obesity, especially around her
abdomen with striate. She has been bruising very easily and has
hirsutism. Which of the following is the most likely diagnosis?
a. Essential hypertension
b. Hyperthyroidism
c. Coarctation of the aorta
d. Cushing syndrome
e. Pheochromocytoma
31.A 45 year old man is diagnosed with essential hypertension based on two
blood pressure of 130/100 mmHg and 156/102 mmHg. Which of the

following would most likely provide prognostic information regarding the

patient?
a. Vascular biopsy
b. Left ventricular hypertrophy
c. Patients enrolment in a clinical trial
d. Measurement of serum homocysteine levels
e. Patients antihypertensive agents
32.A 34 year old woman is noted to be diagnosed with stage 1 hypertension
and after an evaluation is noted to have no complications. Which of the
following antihypertensive agents are generally considered first line
agents for this individual?
a. Thiazide diuretics
b. Angiotensin-receptor blockers
c. Alpha-blocking agents
d. Nitrates
e. Vasodilators such as hydralazine
33.A 45 year-old man with type II diabetes is noted to have blood pressures of
145/90 and 150/96 mmHg on two separate occasions. Which of the
following is the best initial therapy for this patient?
a. Thiazide diuretics
b. ACE inhibitor
c. Beta-blocker
d. Nitrates
e. Alpha-blocking agents
34.A 30 year old man with chronic hypertension presents at the clinic having
run out of his medication, clonidine. He has no complaints and has a blood
pressure of 200/104 mmHg. Which of the following is the best
management?
a. Admit in the hospital and initiate intravenous antihypertensive
agents
b. Restart the clonidine and recheck the blood pressure in 24 to 48
hours
c. Change to an angiotensin-converting enzyme (ACE) inhibitor
d. Refer to a social worker and do not prescribe antihypertensive
agents
e. Change to beta blocker
A 45 year old woman returns today to your outpatient clinic for follow up. You
have seen her frequently over the last 3 months for various complaints. Over
past 2-3 weeks, however, she says that she just felt terrible. Her symptoms
include intermittent headaches, bilateral shoulder and neck pain, overwhelming
fatigue, and difficulty sleeping. She cries easily, and she is irritable with her
children. She feels unable to keep up with the demands of her work and family,
she feels her life is meaningless, and she has trouble concentrating. The patient
smokes half a pack of cigarettes per day and drinks alcohol per weekends. The
patient states that she has regular menses. She works as a waitress and doesnt
work at least for 2 weeks. Physical examination reveals blood pressure 110/70
mmHg, heart rate 80 bpm, and temperature 37C. Her thyroid is normal to
palpation. Her heart has normal rate and rhythm without murmur. Another
physical examination is normal.

35.What is the best next step?

a. Assess thyroid stimulating hormone (TSH), electrolytes, complete
blood count
b. Prescribe a serotonine selective reuptake inhibitor
c. Referral to a psychiatrist
d. Prescribe a tricyclic antidepressant
e. Recommend a bone scan
36.
37.
38.
39.
40.
41.
A woman, 57 years old, came to the out-patient clinic, with the chief complaint of
tenderness of her hand fingers since three months ago. She also complains
tenderness of her left knee, especially when she was squatted or goes down the
stairs.
Based on clinical examination, she looked mildly ill, with body weight 68 kg and
height 157 cm. There was tenderness of 3rd and 4th proximal and distal
interphalanx joint, in both hands, with restricted range of motion. There was also
Heberden nodal in the 2nd distal interphalanx joint. The whole vertebrate was
within normal limit. There was evidence of crepitation without any swelling in her
left knee.
The ESR examination was 15 mm/h. There was slightly narrowing of left knee
joint space in X-Ray examination.
42.What is the appropriate diagnosis for this patient?
a. Ankylosing spondylitis
b. Rheumatoid arthritis
c. Osteoarthritis
d. Gout arthritis
e. Osteoporosis
43.If we found joint effusion and tenderness of the knee, what is the most
appropriate management for this patient?
a. Glucosamine sulphate and chondroitin sulphate
b. Intraarticular hyaluronic acid injection
c. Systemic corticosteroid (oral or IM)
d. Calcium supplement
e. Knee arthrocentesis
A woman, 34 years old, came to the outpatient clinic, with the chief complaint of
tender and swallowing of her wrist hand and fingers in both hands, since eight
months ago, with morning stiffness more than 2 hours. Since two months ago,
she also felt tender and swallowing of her knee and ankle. The arthritis
manifestation was very clear in her both 2nd-4th proximal interphalanx, 1st-5th
metacarpophalanx,
carpometacarpo, knee and ankle joint.
The ESR
examination was 98 mm/h, with positive rheumatoid factor, ANA (-), and anti
dsDNA (-).
44.The most appropriate diagnosis was:

a. Systemic lupus erythematosus

b. Rheumatoid arthritis
c. Psoriatic arthritis
d. Osteoarthritis
e. Gout arthritis
45.This patient took place more than four years without any adequate
treatment, what is the most possible permanent complication in this
patient?
a. Muscle weakness
b. Joint deformity
c. Bamboo spine
d. Digital ulcers
e. Joint effusion
Mr. C is a 35 year-old man who comes to your outpatient office complaining of 3
days of diarrhea.
46.What is the most possible diagnosis?
a. Antibiotics associated diarrhea
b. Chronic diarrhea
c. Acute diarrhea
d. Traveller associated diarrhea
47.He was in good health until the morning before he comes to visit you. He
noticed of poor appetite, nausea, diaphoresis. He described the stool being
watery and brown without any blood. What is the most possible cause?
a. Lactose intolerance
b. Nutritional supplements
c. Any infections (virus or bacterial)
d. Pancreatitis
48.On physical examination his temperature 38.2C, BP 110/80 mmHg, pulse
100 bpm, RR 12 breaths per minute. The abdomen is soft and diffusely
tender with hyperactive bowel sounds. What is your plan?
a. Treat him directly because the clinical information is sufficient
b. Need more information before start treatment
c. Need a laboratory test before starting any treatment
d. He needs to be hospitalized
Mrs. W, 78 years old, carried by her son, come to hospital with chief complaint of
sleepless and disoriented since 1 day ago. Seven days before admission, she
slipped and fell out in bathroom while walking in. she felt pain in her left leg, so
that she had difficulty in walking. She only did her activity on her bed. Four days
before admission, she could not hold her urination. She lost appetite and her
meal intake was less than before. She had diabetes mellitus and hypertension
since 20 years. Before sick, she could manage her daily activities by herself.
Physical examination: blood pressure 160/100 mmHg, heart rate 70x/mins,
respiratory rate 20x/mins, temperature 37C, dry tongue, reddish wound in her
buttock. Heart, lung and abdominal were within normal limit. Laboratory
examination: Hb 12, Ht 41, Leukocyte 7000, thrombocyte 200.000. Segment 68.
Blood glucose level 101. Urinalysis within normal limit.
49.Geriatric syndrome in this patient are:
a. Delirium, inanition, immobilization

b. Inanition, infection, independency

c. Incontinence, immobilization, infection
d. Immobilization, impecunity, incontinence
e. Acute confusional stage, impecunity, instability
50.Comprehensive Geriatric Assessment must be assessed for Mrs. W:
a. Functional status can be assessed by using Mini Mental State
Examination
b. Nutritional Status must be assessed by using the timed up and go
test
c. Psychoaffective status was assessed by using AMT (Abbreviated
Mental Test)
d. Activity of Daily Living (ADL) Barthel must be assessed, before and
during illness
e. Systemic anamnesis will be done, if history of present illness is done
b alloanamnesis