MULTIPLE CHOICE QUESTIONS 1

1. A 60-year-old woman presented with a small right pupil, right ptosis and impaired
sweating over the ipsilateral forehead. Sweating on the rest of the face was unaffected.
Where is the most likely site of this lesion?
A) Cervical spinal cord
B) Common carotid artery
C) Hypothalamus
D) Internal carotid artery
E) Lateral medulla
2. A 53-year-old man presented with hypertension of 150/110 mmHg. He is generally
asymptomatic and has no previous medical history of note. He is a smoker of 5 cigarettes
daily and drinks modest quantities of alcohol. He takes no prescribed medications.
Examination reveals a BMI of 33.5 kg/cm2 but nil else. Investigations:
Serum sodium 146 mmol/l (NR 133-145); Serum potassium 3.2 mmol/l (NR 3.5 - 5);
Urinary potassium excretion 42 mmol/l (NR less than 30)
What is the likely diagnosis?
A) adrenocortical adenoma
B) Bartter's syndrome
C) Liddle's syndrome
D) liquorice ingestion
E) pheochromocytoma
3. A previously healthy 54-year-old man presents to the emergency department
complaining of chest pain. His ECG shows an acute inferior wall myocardial infarction. His
blood pressure is 90/60 mm Hg. On physical examination, he has jugular vein distention
and clear lungs. You should treat him immediately with which of the following:
A) Intravenous fluids.
B) Norepinephrine.
C) Dopamine.
D) Nesiritide.
E) Nitroprusside.
4. While caring for a patient with suspected pericardial tamponade, you would expect to
find:
A) Equalization of right and left ventricular pressures.
B) Isolated systolic hypertension.
C) A hyperdynamic precordium.
D) Poor R wave progression on the 12-lead electrocardiogram.
E) Mitral regurgitation.
5. A female patient aged 30 has a 5 years history of difficulty getting upstairs and out of a
low chair and mild upper limb weakness but no pain. There is no family history. She
presented with severe type 2 respiratory failure. EMG showed evidence of myopathy.
The most likely diagnosis is:
A) Polymyositis
B) Inclusion body myositis
C) Acid maltase deficiency
D) Miller-Fisher Syndrome
E) Lambert-Eaton Myasthenic syndrome
6. A teenage girl presents with Guillain-Barre syndrome. Her weakness continues to
worsen after admission to hospital. Which of the following should be used to monitor her?

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A) Arterial blood gases
B) Chest expansion size
C) FEV1/FVC ratio
D) PEFR
E) Vital capacity
7. A 19-year-old woman presents to the clinic having had 5 blackouts over the last year,
all while she is standing up. She gets warnings of blurred vision, nausea, feeling hot. She
had been witnessed twice to have jerking of all limbs while she is unconscious. The
attacks last 30-60 seconds. She recovers quickly after the attacks. She has never bitten
her tongue or sustained any injuries. Physical examination and an ECG are normal. Her
grandmother and sister suffer from epilepsy. Which of the following investigations is the
most appropriate?
A) EEG
B) 24 hour ECG recording
C) CT brain
D) ECHO
E) Tilt table test
8. A 21-year-old female presented with a sudden onset of left sided head and neck pain.
24 hours later she presents with sudden onset of right hemiparesis, facial weakness and
homonymous hemianopia and left Horner's syndrome. A CT brain showed a left middle
cerebral artery territory infarction. The most likely diagnosis is:
A) Cardiac embolism
B) Migrane
C) Left carotid artery dissection
D) Antiphospholipid syndrome
E) Systemic vasculitis
9. A female presents with headache, lethargy and weight loss. Which of the following
would make the diagnosis of giant cell arteritis unlikely?
A) A normal ESR
B) Bilateral headache
C) Non-tender temporal arteries
D) Papilloedema on fundoscopy
E) The patient is 50 years old

10. A 60-year-old man presents with a 2 month history of progressive confusion, gait
disturbance, and urinary incontinence. Examination reveals mild global cognitive
dysfunction and gait ataxia. CT brain shows enlarged ventricles with no evidence of
obstruction to CSF outflow. Lumbar puncture reveals normal CSF pressure and
constituents. Which one of the following management steps is likely to be most helpful?
A) CSF drainage via repeated lumbar puncture
B) EEG
C) Intracranial pressure monitoring
D) MRI brainstem
E) Serum B12 and folate levels

11. A 72-year-old man presents with an acutely painful right knee. On examination, he
had a temperature of 37°C with a hot, swollen right knee. Of relevance amongst his
investigations, was his white cell count which was 12.6 x109/l and a knee X-ray revealed
reduced joint space and calcification of the articular cartilage. Culture of aspirated fluid

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revealed no growth. What is the most likely diagnosis?
A) Gout
B) Psoriatic monoarthropathy
C) Pseudogout
D) Rheumatoid arthritis
E) Septic arthritis
12. A 40-year-old female who has been prescribed thyroid replacement therapy has
routine thyroid function tests. On examination she appeared clinically euthyroid with no
abnormal findings. Her TFTs revealed: TSH 3.2 mU/L (0. 35 - 5.0) Total T4 20 nmol/L (55
- 144) free T4 2.6 pmol/L (9 - 24) Total T3 2.5 nmol/L (0. 9 - 2.8).
Which one of the following statements is correct?
A) Her thyroid hormone replacement is adequate.
B) Investigation of pituitary function is required.
C) She has tertiary hypothyroidism.
D) She has thyroiditis.
E) She has sick euthyroid syndrome.
13. Which of the following viral causes of acute hepatitis is most likely to cause fulminant
hepatitis in a pregnant woman?
A) Hepatitis A
B) Hepatitis B
C) Hepatitis C
D) Hepatitis D
E) Hepatitis E
14. A 35-year-old healthy woman has a faint systolic murmur on physical examination. An
echocardiogram is performed, and she is found to have a bicuspid aortic valve. In
explaining the meaning of this finding to her, the most appropriate statement is that?
A) An aortic valve replacement is eventually likely to be required
B) Other family members are likely to have the same condition
C) She should be treated with a cholesterol lowering agent
D) The problem resulted from past injection drug usage
E) This is one manifestation of an underlying autoimmune condition.
15. A 54 year old man presents with central crushing chest pain. Examination is normal.
12-lead ECG shows ST segment elevation in leads II, III, aVF and ST depression in V1,
V2 and V3. Which coronary artery is occluded?
A) Circumflex.
B) Left anterior descending.
C) Left main stem.
D) Obtuse marginal.
E) Right coronary artery.
16. Primary hyperparathyroidism may occur in association with the following conditions
A) Chronic renal failure
B) Vitamin D deficiency
C) Gastrinoma
D) Autoimmune polyendocrine syndrome
E) Sjogren's syndrome
17. A 57-year-old man with a history of diabetes mellitus and chronic kidney disease with
a baseline creatinine of 1.8 mg/dL undergoes cardiac catheterization for acute myocardial
infarction. He is subsequently diagnosed with acute kidney injury related to iodinated
contrast. All of the following statements are true regarding his kidney injury EXCEPT:
A) Fractional excretion of sodium will be low.

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B) His creatinine is likely to peak within 3–5 days.
C) His diabetes mellitus predisposed him to develop contrast nephropathy.
D) Transient tubule obstruction with precipitated iodinated contrast contributed to the
development of his acute kidney injury.
E) White blood cell casts are likely on microscopic examination of urinary sediment.
18. A 25 year-old male presents with an eight week history of difficulty walking. On
examination he had increased tone and pyramidal weakness of the right leg. There was
impairment of pinprick sensation in the left leg up to the groin. Which one of the following
is the cause of these signs?
A) A central cauda equina lesion.
B) A cervical spinal cord lesion.
C) A lesion at the foramen magnum.
D) A right-sided thoracic spinal cord lesion.
E) Bilateral cerebral hemisphere lesions.
19. An 81 -year-old man admitted with a stroke becomes increasingly drowsy after
receiving nasogastric feeding for five days. Which biochemical abnormality is the most
likely cause of his drowsiness?
A) Hyperglycemia.
B) Hypermagnesemia.
C) Hypernatremia.
D) Hypocalcemia.
E) Hypophosphatemia
20. One of the nurses working on the Care of the Elderly ward sustains a needlestick
injury while taking blood from a patient. What is the most appropriate immediate
management?
A) Administer prophylactic hepatitis B immunoglobulin regardless of vaccine status.
B) Exclude the nurse from performing exposure-prone procedures for three months until a
negative HIV antibody test has been obtained.
C) Immediately take the nurse’s blood to test for antibodies to hepatitis B, hepatitis C and
human immunodeficiency viruses.
D) Promptly administration of antiretroviral therapy.
E) Wash the wound with soap under running water.
21. A 65-year-old male with left ventricular systolic dysfunction was dyspneic on climbing
stairs but not at rest. The patient was commenced on Ramipril and Furosemide.
Which one of the following drugs would improve the patient’s prognosis further?
A) Amiodarone
B) Digoxin
C) Diltiazem
D) Metoprolol
E) Isosorbide dinitrate.
22. All of the following are recognized feature of pulmonary embolism except?
A) S1Q3T3
B) An increase in serum troponin levels
C) An arterial pH greater than 7.2
D) Increased PCO2 on room airk,m
E) Positive D-dimer levels
23. Which of the following concerning diabetic retinopathy is correct?
A) Is unusual in Type 2 diabetic patients.
B) Improved glycemic control is more effective than hypertensive control in reducing
progression of disease.

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C) Normal visual acuity is seen in proliferative retinopathy.
D) Progression may be reduced with statin therapy.
E) Soft exudates are a feature of background retinopathy.
24. A 52 year old female presents with tiredness. There are no specific abnormalities
noted on examination, but investigations reveal a T4 of 21.1 (NR 9.8 - 23), a T3 of 5.2
pmol/l (NR 3.3 - 5.5) and a TSH of 0.05 mU/l (NR 0.1 - 5 mU/l). Thyroid autoantibody titers
are all undetectable. These results suggest a diagnosis of:
A) De Quervain's thyroiditis.
B) Sick euthyroid syndrome.
C) Solitary toxic nodule.
D) Grave's disease.
E) Hashimoto's thyroiditis.
25. A 46-year-old woman with a 10-year history of primary progressive multiple sclerosis
is admitted to the hospital for surgical debridement and wound management of a sacral
pressure ulcer. The patient is bedbound and is cared for at home by her husband. Her
medications include sertraline, baclofen, and oxybutynin. The remainder of the medical
history is noncontributory. On physical examination, she is thin, in no distress, and has
normal vital signs. There are contraction deformities of the lower extremities, and a 6- × 8-
cm sacral ulcer that extends to the fascia, with minimal purulent exudates and no
evidence of cellulitis. Laboratory studies include a hematocrit of 34%, leukocyte count of
15,000/µL (15 × 109/L) with 80% neutrophils, and a platelet count of 425,000/µL (425 ×
109/L). Subcutaneous prophylactic unfractionated heparin is administered. Six days after
initiation of heparin, her platelet count decreases to 210,000/µL (210 × 109/L), and on the
ninth day after therapy, the platelet count has decreased to 95,000/µL (95 × 109/L). Which
of the following is the most appropriate next step in the management of this patient?
A) Discontinue unfractionated heparin.
B) Discontinue sertraline, baclofen, and oxybutynin.
C) Discontinue unfractionated heparin and begin therapy with a direct thrombin inhibitor.
D) Discontinue unfractionated heparin and begin low-molecular-weight heparin.
E) Discontinue unfractionated heparin and begin novel oral anticoagulants.
26. A 75 year old man has a history of Chronic Lymphocytic Leukemia. He has had
treatment with several courses of chemotherapy and has now been admitted to hospital
with pneumonia. His past medical history revealed that he had suffered several previous
upper respiratory tract infections over the previous six months.
Which of the following components of his immune system is likely to be deficient?
A) complement
B) immunoglobulin G
C) macrophages
D) mast cells
E) T lymphocytes
27. A 42-year-old man presented to the hospital with right upper quadrant pain. He was
found to have multiple masses in the liver that were found to be malignant on H&E
staining of a biopsy sample. Your initial history, physical examination, and laboratory
tests, including prostate-specific antigen, are unrevealing. Lung, abdominal, and pelvic CT
scans are unremarkable. He is an otherwise healthy individual with no chronic medical
problems. Which immunohistochemical markers should be obtained from the biopsy
tissue?
A) α-Fetoprotein
B) Cytokeratin
C) Leukocyte common antigen

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D) Thyroglobulin
E) Thyroid transcription factor 1
28. A 47-year-old man is evaluated for 1 year of recurrent episodes of bilateral ear
swelling. The ear is painful during these events, and the right ear has become floppy. He
is otherwise healthy and reports no illicit habits. He works in an office and his only sport is
tennis. On examination, the left ear has a beefy red color, and the pinna is tender and
swollen; the earlobe appears minimally swollen but is neither red nor tender. Which of the
following is the most likely explanation for this finding?
A) Behçet's syndrome.
B) Cogan's syndrome.
C) Hemoglobinopathy.
D) Recurrent trauma.
E) Relapsing polychondritis.
29. One of the following pulmonary function test results is with the respiratory disorder
chronic obstructive pulmonary disease.
A) Increased total lung capacity (TLC), decreased vital capacity (VC), decreased
FEV1/FVC ratio.
B) Decreased TLC, decreased VC, decreased residual volume (RV), increased
FEV1/FVC ratio, normal maximum inspiratory pressure (MIP).
C) Decreased TLC, increased RV, normal FEV1/FVC ratio, decreased MIP.
D) Normal TLC, normal RV, normal FEV1/FVC ratio, normal MIP.
E) Decreased TLC, normal RV, normal FEV1/FVC ratio, increased MIP.
30. A 23 year old single woman referred with 3-month history of weight loss and heat
intolerance. On examination pulse is 120 beat/min regular, blood pressure 120/72 mmHg,
weight 58 kg, height 165 cm. she had diffuse goiter with bilateral exophthalmos.
Investigations: serum free T4 3.9 ng/dl (N: 0.9-2.0), serum TSH 0.001 mu/l (N: 0.4-4.0),
TSH receptor antibody 8 U/L(N:<2). She was started on methimazole 30 mg/day. Six
weeks later she developed severe migratory arthralgia associated with the presence of
palpable purpura over both legs and dermal infarcts in the finger tips. Laboratory studies
shows ESR 54 mm/h, urine showed microscopic hematuria, ANCA titer was 1:640,
antimyeloperoxidase antibodies 112U/l (N:0-9), antiproteinase 3 antibodies 6.4 U/l (N:0-
3.5). The best action is:
A) Continue methimazole and add NSAID.
B) Continue methimazole and add prednisolone 40 mg per day.
C) Substitute propylthiouracil for methimazole.
D) Refer the patient for definitive therapy with radioactive iodine.
E) No intervention.

ANSWERS
1. D
2. A
3. A
4. A
5. C
6. E
7. E

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8. C
9. D
10. A
11. C
12. A
13. E
14. A
15. B
16. C
17. E
18. D
19. C
20. E
21. D
22. D
23. C
24. C
25. C
26. B
27. B
28. E
29. A
30. E

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MULTIPLE CHOICE QUESTIONS 2
1. A 42-year-old woman has a12-year history of ulcerative colitis that has responded well
to mesalamine and occasional corticosteroid enemas. Recent surveillance colonoscopy
with biopsies showed low-grade dysplasia. Which of the following would be the most
appropriate next step in the management of this lady?
A) No intervention, repeat colonoscopy in 6 months
B) No intervention, repeat colonoscopy in 1 year
C) Administer continuous corticosteroid enemas
D) Refer to the surgeon for colectomy
E) Administer a high-dose corticosteroid intravenously
2. A 28-year-old man undergoes an endoscopic transthoracic sympathectomy for palmar
hyperhidrosis. Postoperatively, he has developed ptosis of his eye. This is due to
iatrogenic damage to which one of the following nerves?
A) 8th cervical nerve
B) 1st thoracic nerve
C) Lower cord of brachial plexus
D) 2nd thoracic ganglion
E) 7th cervical nerve
3. A 51-year-old woman undergoes a successful bone marrow transplant from a matched
unrelated donor for refractory Hodgkin’s disease. She is discharged from the hospital on
no medications and is feeling well. At an appointment 6 months posttransplant, she is well
with no evidence of malignancy. Three weeks later, she travels to Florida with her family.
She is cautious of the sun but develops sunburn on her face, despite wearing sunscreen
and a protective hat. When she returns from her trip 5 days later, she presents with
persistent erythema of her face. She also states that her wrists and hands have been sore
for the past 2–3 weeks. On examination, her face is mildly tender to touch, and a rash is
present. Her hands are diffusely swollen. She is afebrile, and the remainder of her
physical examination is benign. What is the most likely diagnosis?
A) Graft-versus-host disease
B) Hypersensitivity to sunlight due to the patient’s antirejection regimen
C) New-onset systemic lupus erythematosus
D) Rosacea
E) Staphylococcal skin infection acquired during travel
4. A 35-year-old woman arrives on the floor after an uneventful hysteroscopy to evaluate
her long history of uterine fibroids. About 30 minutes after her arrival, she begins to
complain of nausea and has two episodes of vomiting. The physician administers 0.625
mg of droperidol and 400 mg of acetaminophen by mouth. On follow-up evaluation, the
patient's neck is involuntarily flexed to one side. She is alert, oriented, and conversant and
has an otherwise normal neurologic examination. Which of the following is the most likely
diagnosis?
A) Cerebral vascular accident
B)Conversion disorder
C) Dystonic reaction to droperidol
D) Munchausen syndrome
E) Seizure
5. A 50-year-old woman with diabetes mellitus presents with backache and inability to
walk unaided. This came on suddenly, while she was trying to lift her shopping bag from
the car boot. Which of the following is most suggestive of a lesion of the sciatic nerve?

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A) Absent knee tendon jerk
B) Foot drop
C) Inability to flex the hip
D) Decreased sensation on the anterior thigh and medial leg
E) Intervertebral disc prolapse at L2/L3 level
6. A 59-year-old man has a body mass index (BMI) of 42. As might be expected, his
fasting blood glucose level is high, 210 mg/dL, as was his HbA1c level, 9.8%. In addition,
he suffers from hypertension and dyslipidemia. His physician advised him to lose weight
both for his general well-being and to help control his diabetes. Consequently, for the past
4 years, he has desperately tried to lose weight. He worked his way through an alphabet
of popular and fad diets, from the Atkins diet to the Weight Watchers diet. If he lost a few
pounds while on a particular diet, he gained back the pounds lost, plus a few more within
a few months of terminating the diet. Finally, he and his physician decided he should try
bariatric surgery, the Roux-en-Y gastric bypass procedure. A week after leaving the
hospital, his fasting blood glucose level was 100 mg/dL. Three months later, it was 96
mg/dL and his HbA1c was 6.0%. Which of the following choices is most likely to explain
this remarkable improvement is his diabetes?
A) The reduction in level of his circulating glucagonlike peptide-1 (GLP-1)
B) The reduction in level of his circulating peptide YY (PYY)
C) The reduction in his mass of adipose tissue
D) The reduction in the level of his circulating ghrelin
E) The reduction in the level of his circulating leptin
7. A 51-year-old man has recurrent bouts of lightheadedness and mild confusion.
Episodes of hypoglycemia were recently documented that are improved with ingestion of
food. The patient has no headache, blurred vision, or double vision. He has gained
approximately 4.5 kg (10 lb) in the past 2 months. Medical and family histories are
noncontributory. Physical examination is normal. The following laboratory data are
obtained after an overnight fast: plasma glucose 30 mg/dL (1.67 mmol/L), serum insulin
30 mlU/L (215.25 pmol/L), and an elevated serum C-peptide level. Screening for
sulfonylurea is negative and CT scan of the abdomen is normal.
Which of the following diagnostic studies should be done next?
A) Endoscopic retrograde pancreatography.
B) Transabdominal (Endoscopic) ultrasonography.
C) MRI of the abdomen.
D) Positron emission tomography.
E) Somatostatin receptor scintigraphy.
8. A 23-year-old married woman comes to the office after recent exposure to a person
with active hepatitis A. She has a long history of recurrent sinopulmonary infections and
bronchial asthma. In addition, after her last pregnancy, she received a blood transfusion
for severe postpartum hemorrhage. After receiving an intramuscular dose of immune
serum globulin as prophylaxis against hepatitis A, she develops an anaphylactic reaction.
Which of the following is the most likely cause of this patient’s reaction?
(A) Immunoglobulin A (IgA) deficiency with anti-IgA antibodies
(B) A hemolytic transfusion reaction
(C) Contaminated immune serum globulin
(D) A type IV hypersensitivity reaction against a protein in the immune serum globulin
(E) A febrile reaction
9. A 47-year-old man recently consulted a physician about developing weakness,
particularly in his right hand. Upon providing a history, the man explained that he does
house repair and has been working on a neighborhood rehabilitation project for the past
several months. In doing this, he sandblasts and sands and scrapes by hand to remove

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the old paint. These
homes were first constructed in the 1920s and since have been covered with several
layers of paint. He also revealed that he habitually ate his lunch at the work site, which he
described as being dusted with old paint particles. In addition to the weakness in his arm,
he admitted to sporadic stomachaches, constipation, and said his wife had complained
that he is always irritable. He also states that, until recently, he had been in good health.
Upon examination, he was found to be 6 feet (19.7 m) tall and to weigh 170 lb (77.1 kg).
His heart, lungs, and abdomen were normal, as were most analytical values, but he did
show signs of right wristdrop consistent with radial nerve palsy and his complete blood
count (CBC) showed a microcytic anemia; his serum iron levels were found to be normal.
Which of the following diagnostic tests would provide the most useful information
regarding the appropriate treatment?
(A) Nerve conduction velocity (NCV) study of the right arm
(B) Radiography of the right arm and wrist
(C) Magnetic resonance imaging (MRI) scans of the right arm and wrist
(D) Urine screen for heavy metals (lead, mercury, arsenic)
(E) Screening for diabetes mellitus.
10. Which of the following clinical findings is least likely in a patient with infarction in the
distribution of the left anterior choroidal artery?
A. Right hemiparesis
B. Right hemi-sensory loss
C. Right hemianopia
D. aphasia.
11. A 76-year-old man presenting with dysphagia was found to have inoperable
esophageal adenocarcinoma. He has an endoscopically placed esophageal stent for
palliation of his symptoms, but unfortunately found it very painful, and it was removed a
few days later. There is no perforation. He asks whether there are any other treatment
options to help with his symptoms. Which of the following modalities is an appropriate
first-line treatment option to discuss?
A) Band ligation
B) Botulinum toxin injection
C) Brachytherapy
D) Local ethanol injection
E) Photodynamic therapy.
12. An AIDS patient develops symptoms suggestive of a severe, persistent pneumonia
with cough, fever, chills, chest pain, weakness, and weight loss. The patient does not
respond to penicillin therapy, but goes on to develop very severe headaches. The
presence of focal neurologic abnormalities leads the clinician to order a CT scan of the
head. This demonstrates several metastatic brain abscesses. Biopsy of one of these
lesions demonstrates beaded, branching, filamentous gram-positive bacteria that are
weakly acid fast. Which of the following is the most likely causative organism?
A) Actinomyces
B) Aspergillus
C) Burkholderia
D) Francisella
E) Nocardia.
13. You are a hospitalist called to admit a 70-year-old man to the ICU. His wife states that
he was sitting at the table eating breakfast with her when he dropped his fork and had
difficulty speaking. Within a couple of minutes he was unable to move his right side. She
called the paramedics, who brought him to the hospital. Now in the ICU, his vital signs are
as follows: BP 200/98 mm Hg, HR 100, RR 10, O2 saturation 94% on room air. He is

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afebrile. On physical examination he is lethargic and unable to speak. His pupils are equal
and round but sluggish. He has flaccid paralysis of the right arm and leg with a Babinski
sign present on the right. His heart is irregularly irregular, and an ECG confirms atrial
fibrillation. A CT of the head shows a large bleed in the left frontoparietal area with mass
effect and midline shift. You decide to intubate the patient to protect his airway. What is
the next most appropriate step in the treatment of this patient while you are awaiting your
urgent neurosurgical consult?
A) Hyperventilate the patient to a goal pCO2 of 20 mm Hg
B) Give a bolus of IV mannitol
C) Give a bolus of IV dexamethasone
D) Give sublingual nifedipine to decrease the BP
E) Anticoagulate with IV heparin because of the atrial fibrillation.
14. A 73-year-old woman is brought in by paramedics after fainting in the mall and hitting
her face. She does not remember any preceding symptoms, and she did not lose control
of her bowel or bladder. Witnesses at the scene say that she was down for less than a
minute, then woke up and was fairly alert. She was bleeding from a laceration on her chin
and paramedics were called. When she arrived at the hospital, her initial laboratory
values were normal and an EEG did not show epileptiform activity. She is placed on a
cardiac monitor. The following day, she becomes lightheaded and loses consciousness
while lying in bed, and her monitor shows tachycardia with the QRS complexes being
uniformly longer than 120 ms.
What is the most common cause of this rhythm disturbance?
A) Uncontrolled hypertension
B) Distention of the pulmonary veins
C) Accessory pathway
D) Ischemic heart disease.
15. A 47-year-old woman presents at night to the Emergency Department with chest pain.
She states that the pain started that evening and has progressively been getting worse.
She is concerned that she is having a heart attack. The pain is described as a burning
sensation associated with a sour taste in her mouth, and it started shortly after she ate
dinner; it has occurred on previous occasions, but never as bad as it is now.
Previously, she used calcium carbonate tablets that were effective for the pain. She has
no history of heart disease or other medical problems, and she takes no regular
medications. She does not smoke cigarettes or use cocaine. Her vitals are normal, and
her physical examination is unremarkable. Initial laboratory tests and an ECG are normal.
Which of the following is the most likely cause of this patient’s chest pain?
A) Unstable angina
B) Myocarditis
C) Pulmonary embolism
D) Gastroesophageal reflux disease
E) Costochondritis.
16. A 28-year-old patient with end-stage renal disease (ESRD) on continuous ambulatory
peritoneal dialysis (CAPD) for two months presents with fever, abdominal pain and cloudy
dialysis fluid. There is no diarrhea or vomiting and the pain has been present for about 12
hours. The patient has ESRD secondary to chronic glomerulonephritis, there is no history
of diabetes, urinary infections or antibiotic use. Examination reveals a temperature of 38.9
C (102 F), and blood pressure of 110/70 mm Hg. The throat is clear, as are the lungs.
Cardiac examination reveals a grade 2/6 systolic murmur. Abdominal examination reveals
decreased bowel sounds with diffuse tenderness. There is mild rebound. There is no
edema or skin rash. A complete blood count shows a leukocyte count of 14,200/mm3,
hemoglobin is 12.5 g/dL. Peritoneal fluid is cloudy with 1,000 white blood cells, 85% of
which are polymorphonuclear leukocytes. Gram's stain of fluid is negative. Cultures of

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blood and peritoneal dialysis fluid are taken. Which of the following is the most appropriate
initial step in management?
A) Fluconazole
B) Immediate removal of dialysis catheter.
C) Intravenous vancomycin
D) Intravenous gentamicin
E) Oral ciprofloxacin
17.A 59-year-old lady is admitted with a 30 minute history of heavy central chest pain
associated with nausea and sweating. Her ECG shows ST elevation in leads V1, V2, V3
and V4.
Which of the following coronary arteries is most likely to be occluded?
A) Circumflex artery
B) Left anterior descending artery
C) Obtuse marginal artery
D) Posterior descending artery
E) Right coronary artery
18. A family physician cares for a family consisting of a 45-year old husband, 43-year-old
wife and a 12-year-old daughter. The family reports that recently the 77-year-old maternal
grandmother who lived with them died after a prolonged respiratory infection. Autopsy
subsequently confirms that she had active pulmonary tuberculosis at the time of death.
The organism tested sensitive to all anti-tuberculosis drugs. In responding to the
grandmother's illness, which of the following is the most appropriate step in
management?
A) Obtain leukocyte counts on all family members
B)Obtain sputum cultures for acid fast bacilli
C)Obtain chest computerized tomograms on all members
D)Place protein purified derivative (PPD) test on all members
E)Schedule bronchoscopy lavage for the adults.
19. Which of the following extraintestinal manifestations is associated with Crohn disease
but not ulcerative colitis?
A) Ankylosing spondylitis
B) Erythema nodosum
C) Nephrolithiasis
D) Thromboembolic disease
E) Uveitis
20. A 30 year old woman presents with unprovoked left popliteal deep vein thrombosis.
Her family history is negative for venous thromboembolism. She has a history of SLE and
takes prednisone 10mg daily, hydroxychloroquine and supplements of calcium and
vitamin D. She has one child but has had two miscarriages. An aPTT test performed
before starting anticoagulation in this patient is prolonged, but her PT is normal.
Which statement is most likely to be correct?
A) Because her APTT is increased already, Heparin should be withheld and warfarin
treatment initiated at INR 2.5 to 3.5, perhaps forever
B) The patient should be encouraged to use oral contraceptive to prevent pregnancy
during the time she is anticoagulated
C) She will need Heparin and then anticoagulation with Warfarin at INR 2 to 3, perhaps
indefinitely
D) Start anti-coagulation with Heparin and then Warfarin at INR 2.5 to 3.5 for 3 to 6
months
E) She will need lifelong new oral anticoagulants.

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21. A 65-year-old man has been stable on the general medical ward following an
admission with acute coronary syndrome several days previously. His drug history
consists of aspirin, enalapril and glyceryl trinitrate (GTN) spray. He has developed
dyspnea over the last few hours. On examination he has a raised jugular venous pressure
(JVP) and crackles to his mid zones. His electrocardiogram (ECG) shows a rate of 140
beats per minute in atrial fibrillation. Which of the following is the most appropriate
management?
A) Intravenous amiodarone
B) Intravenous digoxin
C) Intravenous flecainide
D) Observe and screen for MI
E) Synchronized DC cardioversion.
22. A 48-year-old man is admitted through the ER with a possible left lower extremity
cellulitis. The patient says that he has been having fever, swelling, and redness of his left
lower extremities that comes and goes spontaneously over the past couple of months. He
also tells you about an episode in which he lost vision in his left eye for several minutes a
couple of weeks ago, but the vision returned without incident. He had a urologic
evaluation for penile trauma 3 months ago. On physical examination, his BP is 125/80, HR
70, RR 14, and he is currently afebrile. His examination is significant for a 3/6 systolic
murmur heard at the left lower sternal border without radiation while lying supine. Blood
cultures return positive results for Enterococcus species, and an echocardiogram reveals
large mitral vegetation. You review treatment for enterococcal endocarditis. Which of the
following antibiotics always misses enterococcal infections?
A) Ampicillin-sulbactam
B) Nitrofurantoin
C) Cefipime
D) Vancomycin
E) Linezolid.
23. A 70-year-old woman with a history of type2 DM and CAD with a known left bundle
branch block on ECG is admitted to the ICU with sepsis from a urinary source. She is fluid
resuscitated, and empiric broad-spectrum antibiotics are begun after the appropriate
cultures are obtained. Despite what appears to be adequate resuscitative efforts with
volume replacement, the patient has had minimal urine output over the past couple of
hours. You decide to place a pulmonary artery catheter to help to determine the patient’s
hemodynamic situation. Which of the following complications of pulmonary artery catheter
placement is the patient at increased risk for because of her past medical history?
A) Pulmonary artery perforation
B) Pulmonary infarction
C) Complete heart block
D) Pneumothorax
E) Ventricular tachycardia.
24. The first four tests that should be ordered in the initial evaluation of patients with a
suspected coagulopathy are all of the following except
A) Platelets count
B) Bleeding time
C) Platelet aggregation studies
D) PT
E) aPTT
25. Which of the following is not true about tetanus?
A) The toxin affects inhibitory GABA and glycine receptors, leading to unopposed
contraction and spasm of skeletal muscle.

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B) It is characterized by acute onset of skeletal muscle rigidity and convulsive spasm.
C) Initial symptoms involve lockjaw and risus sardonicus.
D) Fractures, dislocations, and rhabdomyolysis may occur due to forceful sustained
muscle
E) Tetanus disease usually leads to long-lasting immunity.
26. A 55-year-old woman, who has never smoked, presents to you on the ward with a
history of weight loss, decreased appetite and finger clubbing. You are told that her chest
x-ray revealed opacity in the hilar region of the right lung suggesting a bronchogenic
carcinoma. She is currently awaiting a CT-chest with bronchoscopy to follow. From the list
below, select the most likely diagnosis:
A) Squamous cell carcinoma of the lung
B) Adenocarcinoma of the lung
C) Small cell carcinoma of the lung
D) Large cell carcinoma of lung
E) Carcinoid tumour of the lung.
27. A 68-year-old woman recently diagnosed with multiple myeloma presents to her GP
with progressively increasing breathlessness, exercise intolerance and ankle swelling. On
examination, there is bilateral pitting leg edema to her thighs, ascites and raised JVP. The
apical impulse is impalpable. An ECG shows diffusely diminished voltage. Chest X-ray is
normal and the echocardiogram shows small thick ventricles and dilated atria with a
thickened interatrial septum. The ventricular myocardium has a granular sparkling texture
on echo, and minimal fluid in the pericardial space is noted. What is the most likely
diagnosis?
A) Chronic pericardial effusion with tamponade
B) Chronic pericardial effusion without tamponade
C) Constrictive pericarditis
D) Restrictive cardiomyopathy
E) Congestive heart failure.
28.A 65-year-old male patient is admitted with renal failure and is diagnosed with acute
tubular necrosis. Which of the following is least likely to be the cause of acute tubular
necrosis?
A) Rhabdomyolysis
B) Paracetamol poisoning
C) Hypovolemia
D) Hypertension
E) Corticosteroid therapy
29. A 65-year-old woman with long-standing diabetes mellitus visits your clinic for follow-
up 2 weeks after the initial visit. Her fasting home glucose monitoring shows elevated
blood sugar levels ranging between 200-250 mg/dl. Two weeks ago, her HbA1c was 7.2%
and the fasting plasma glucose was 212 mg/dl. You recommend the following to evaluate
the discrepancy between the fasting values and the HbA1c:
A) Order a CBC
B) Prescribe a new glucometer
C) Order a fructosamine
D) Repeat the HbA1c
E) Repeat the fasting plasma glucose.
30. A 43-year-old man presents to the clinic with complaints of fever, night sweats,
anorexia, cough, and chest pain. The chest x-ray reveals infiltrates in both the lower and
upper lobes, with possible cavitations in the apices. A presumptive diagnosis of
tuberculosis is made on the basis of finding acid-fast bacilli (AFB) on microscopic

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examination of sputum. The patient is started initially on isoniazid, rifampin, pyrazinamide,
and ethambutol.
What is the best way to monitor this patient?
A) Sputum acid-fast stains every month for 6 months
B) Sputum cultures every month until cultures become negative
C) Serial chest x-rays
D) Blood testing for drug toxicity
E) Observe for clinical deterioration.

ANSWERS
1. D
2. B
3. A
4. C.
5. B
6. D
7. B
8. A
9. D
10. D
11. C
12. E
13. B
14. D
15. D
16. C
17. B
18. D
19. C
20. C
21. E
22. C
23. C
24. C
25. E
26. B

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27. D
28. E
29. A
30. B

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MULTIPLE CHOICE QUESTIONS 3
1. A 33-year-old anthropologist from New York had been doing research in a desert region
of Arizona for about 6 months. After returning home, he visits his physician complaining of
an influenza-like illness with cough, mild chest pain, and occasional fever. He says that
the illness started during the last few weeks of his stay in Arizona. Red, tender nodules
are present on his shins. Chest x-rays fail to reveal evidence of pulmonary infiltrates or
pleural effusion. Which of the following is the most appropriate next step in the
management of this patient?
A) Delay treatment until culture results are obtained.
B) Begin treatment with fluconazole.
C) Begin treatment with amphotericin B.
D) Aspirate bone marrow and culture.
E) Institute immediate isolation.
2. A young man is referred by his GP following investigation for recurrent mouth
ulceration. Subsequent blood count shows HB of 13.2, WBC 3.8 (neutrophil 1.2, lymph
1.5) PLT 332, examination reveals a fit young male with no evidence of organomegaly or
lymphadenopathy, further questioning reveals the history of mouth ulceration occurring
over the previous 3-4 years. Select the most likely diagnosis
A) AML
B) Post-viral neutropenia
C) HIV infection
D) Drug induced neutropenia
E) Cyclical neutropenia.
3. A 35-year-old woman presented with tender lesion on both legs. She had no respiratory
symptoms and was not on any medications. O/E: she was febrile, pulses 90 regular and
blood pressure 136/88. Her chest was clear. There were bilateral erythematous raised
lesions on her shins. Chest x ray shows bi-hilar lymphadenopathy. The most helpful test
that would give a definitive diagnosis would be:
A) Kveim test
B) Serum ACE level
C) Serum calcium
D) Skin biopsy
E) Transbronchial needle biopsy
4. A 78-year-old man complains of increasing fatigue and bone pain, especially around
the knees and ankles. He has a long-standing anemia with hemoglobin of 9 to 10 g/dL
and MCV of 102. He had not responded to therapeutic trials of iron and vitamin B12, but
had been symptomatically stable until the past month. Examination reveals pallor and
spleen tip just palpable at the left costal margin. CBC reveals hemoglobin of 8.2 g/dL, but
for the first time his platelet count is low (15,000); the white blood cell count is 14,000.
What is the likely cause of his worsening anemia?
A) Folic acid deficiency
B) Acute myeloid leukemia
C) Myelofibrosis
D) Tuberculosis
E) Viral infection
5. A 58-year-old man with history of chronic myeloid leukemia was admitted with
pneumonia and deep venous thrombosis. He was started on antibiotics and I.V. heparin.
His condition deteriorated and had acute respiratory distress syndrome and hypotension.
Despite large amounts of i.v. fluids and inotropes, he remained hypotensive. You are

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considering adrenal insufficiency. What should you do next?
A) Order random cortisol then treat with hydrocortisone
B) Start hydrocortisone then do the ACTH stimulation test
C) Start dexamethasone then do the ACTH stimulation test
D) Start hydrocortisone
E) Do the ACTH stimulation test; treat according to the results
6. A 68-year-old diabetic woman with chronic renal insufficiency is admitted to the hospital
with urosepsis. She has a history of anaphylactic reaction to penicillin that required
intubation for severe bronchospasm. Urinalysis shows > 100 WBC, and Gram's stain
shows 3+ plump gram-negative rods.
Which of the following antibiotics would be most appropriate for this patient with a known
severe penicillin allergy?
A) Ampicillin
B) Ceftazidime
C) Vancomycin
D) Aztreonam
E) Imipenem
7. 65-year-old man with history of chronic AF presents to ER with acute memory
impairment (recent amnesia), confusion and impaired vision. Physical examination
confirms the confusion state and right homonymous hemianopsia. No paresis was noted.
The current status is most probably related to occlusion of:
A) Left posterior cerebral artery
B) Basilar artery
C) Left middle cerebral artery (posterior branch)
D) Left common carotid artery
E) Right vertebral artery
8. A 24-year-old man is in the operating room for a massive liver injury sustained when his
motorcycle hit a truck. After one hour of surgery he has received 15 units of packed cells
and has developed diffuse oozing from the surface of his liver. Clots are no longer
forming. His body temperature is 34oC.
Coagulation abnormalities expected in this patient include all of the following EXCEPT
A) Prolonged PT
B) Prolonged aPTT
C) Prolonged bleeding time
D) Low fibrinogen level
E) Viscoelastic test (point of care coagulation testing) is usually normal.
9. A 42-year-old female with a recent diagnosis of systemic sclerosis, is referred to
hospital with a complaint of headaches and blurred vision. She has a past medical history
of asthma. On examination, her blood pressure is 230/120, and there is bilateral
papilloedema. Which of the following medications should be prescribed immediately?
A) IV Furosemide
B) IV Labetolol
C) Oral angiotensin II receptor blockers plus IV Sodium Nitroprusside
D) Oral captopril plus IV Sodium Nitroprusside
E) Sublingual Nimodipine
10. A 55 year old patient with acute necrotizing pancreatitis has been in the Intensive
Care unit with multiple organ failure for approximately 4.5 weeks. Although his clinical
situation improved over the last few days, the patient now deteriorates. There is fever up
to 104 °F, a rising CRP of 398 and white blood cell count of 27 x 109/L. A contrast
enhanced CT demonstrates a large, heterogeneous, walled off, peripancreatic collection

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with gas inside. What is the preferred treatment strategy at this point?
A) Conservative treatment
B) Image-guided percutaneous or endoscopic catheter drainage
C) Primary open necrosectomy
D) Primary minimally invasive surgical necrosectomy
E) Video assisted retroperitoneal debridement.
11. A 25-year-old female is admitted with acute dyspnea and chest pain. A diagnosis of
pulmonary embolism is confirmed and her investigations reveal urine dipstick protein ++
but no blood, anti-double stranded DNA antibodies of 200 U/mL (0 - 73), with a 24 hour
urinary protein concentration of 5g (< 0.2). Which one of the following diagnoses is most
likely to be found on renal biopsy?
A) AA amyloid
B) Focal segmental glomerulonephritis
C) IgA nephropathy
D) Membranous nephropathy
E) Minimal change nephropathy.
12. A 46-year-old woman is referred for preoperative evaluation before undergoing
resection of newly diagnosed glioblastoma. Her HB is 12 gm/dl, leukocyte count 6.7
x109/L, and PLT 198 x109/L, the surgeon is particularly interested in an opinion
concerning her risk of bleeding. Which of the following will provide the best estimate of her
surgical risk of bleeding?
A) Bleeding time
B) PLT function analyzer-100 analysis
C) PLT aggregation studies
D) Medical history, including outcomes of previous surgical procedures
E) PT and partial thromboplastin time.
13. A 42-year-old woman presents with acute onset of headache and neck pain vertigo,
nausea and vomiting. Neurological examination reveals left nystagmus, left Horner
syndrome and absent left gag reflex. Left appendicular ataxia and anesthesia to pin prick
in the left face and right arm and leg. Which of the following is the most likely diagnosis?
A) MCA
B) PCA
C) ACA
D) dissection of aorta
E) Vertebral artery dissection.
14. A 30-year-old man is evaluated for a thyroid nodule. The patient reports that his father
died from thyroid cancer and that a brother had a history of recurrent renal stones. Blood
calcitonin concentration is 2000 pg/mL (normal is less than 100); serum calcium and
phosphate levels are normal. Before referring the patient to a surgeon, the physician
should do which of the following?
A) Obtain a liver scan
B) Perform a calcium infusion test
C) Measure urinary catecholamines
D) Administer suppressive doses of thyroxine and measure levels of thyroid stimulating
hormone
E) Treat the patient with radioactive iodine.
15. All of the following vaccine can be given to pregnant lady except:
A) Flu vaccine
B) H1N1
C) Hepatitis B vaccine

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D) Rubella vaccine
E) Tetanus vaccine
16. A 78-year-old man is evaluated in the hospital for poor glycemic control before
undergoing femoral popliteal bypass surgery. He has been on the vascular surgery ward
for 3 weeks with a non-healing foot ulcer. The patient has an extensive history of
arteriosclerotic CV disease, including PVD, and a 20 year history of DM 2, his most recent
Hb A1c obtained 2 months before admission was 8.9%, his diabetes regimen consists of
glibenclamide 15 mg/day. While in the hospital his plasma glucose levels have generally
been in the 200 to 250 mg/dl range he is eating well. In addition to stopping glibenclamide,
which of the following is the most appropriate treatment for this patient?
A) Basal insulin and rapid acting insulin before meals.
B) Insulin infusion
C) NPH insulin twice daily
D) Sliding scale regular insulin
E) Insulin glargine once daily.
17. One of flowing statement regarding COPD is true:
A) Most smokers develop COPD during their life
B) Tiotropium is as effective as smoking cessation in reduction the rate of decline in
FEV1.
C) Long term O2 therapy improves survival in all COPD treatment with FEV1 less than
50% of predicted.
D) Rehabilitation may improve survival in patients with severe COPD
E) Inhaled corticosteroids decreases exacerbation rate of COPD patients.
18. What is the best laboratory goal to use to guide fluid resuscitation in acute
pancreatitis?
A) Hematocrit
B) Blood urea nitrogen
C) Serum creatinine
D) Amylase
E) Lipase.
19. A 62-year-old female with a history of a recent pulmonary embolus presents to your
office for follow-up on anticoagulation treatment. She takes warfarin on a daily basis. She
reports that for the last week she has noticed mild rectal bleeding and multiple bruises
over the extremities with minimal trauma. She is comfortable appearing with normal vital
signs and is not orthostatic. You ordered a stat CBC and PT/INR which revealed a mildly
decreased Hgb at 11 g/dL and an elevated INR of 7. Which of the following would be the
most appropriate intervention?
A) Fresh frozen plasma
B) Withhold warfarin
C) Intravenous vitamin K
D) Reduce warfarin dose
E) Oral vitamin K.
20. Which of the following produces the greatest increase in bone mineral density (BMD)
in patients with osteoporosis?
A) Estrogen
B) Calcitonin
C) Alendronate
D) Teriparatide
E) Raloxifene.

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21. A 34-year-old woman was found to have a 2-cm right thyroid nodule at the time of a
well woman examination. The remainder of the thyroid was palpably normal and there
were no lymph nodes palpable. There was no history of thyroid disease or radiation
therapy to her head or neck. She was clinically euthyroid. Thyroid-stimulating hormone
(TSH) was normal. Which of the following tests would be the most useful in establishing a
specific diagnosis?
A) Ultrasound of the thyroid
B) Nuclear scan of the thyroid
C) Thyroid antibody studies
D) Fine needle aspiration of the nodule
E) CT of the neck.
22. A slim, healthy 30-year-old woman is scheduled for a dental prosthodontic procedure
and was sent for medical evaluation of a known history of mitral valve prolapse (MVP).
The patient is a highly active individual and denies palpitations, chest pain, or shortness of
breath. She admits to having a family history of heart disease, notably her father, who had
died of a heart attack in his forties, and her mother, who had mitral valve prolapse. On
physical examination, the patient is comfortable and has normal vital signs. Auscultation
of the heart reveals a normal S1 and S2 and a prominent midsystolic click, which is
accentuated in the standing position. No systolic murmur is appreciated. What is your
overall assessment and plan for this patient?
A) Get an echocardiogram to evaluate mitral valve motion and blood flow prior to clearing
her for the procedure
B) Prescribe empiric antibiotics for endocarditis prophylaxis and clear her for the
procedure
C) Get a cardiology consultation prior to medical clearance because the patient has a
significant family history of heart disease
D) Clear her for the procedure without endocarditis prophylaxis
E) Clear her for the procedure with endocarditis prophylaxis.
23. A 35-year-old man complains of chest pain, which began following the use of cocaine
30 minutes prior to arrival. The patient describes severe substernal chest pressure,
radiating to the left arm and jaw. It is associated with shortness of breath. Initial vital signs:
temperature 100.4°F, heart rate 120/min, respiratory rate 20/min, blood pressure 185/100
mm Hg, pulse oximetry 98% on room air. An ECG is consistent with acute myocardial
infarction. A drug which is contraindicated is:
A) Oxygen.
B) Aspirin.
C) Lorazepam.
D) Bisoprolol.
E) Morphine.
24. A 55-year-old man with a history of alcoholism complains of more than a month of
malaise, low-grade fever, and a productive cough with greenish sputum tinged with blood.
Examination shows periodontal disease with bad breath and clubbing of fingers. On chest
x-ray, there is a 2 cm cavity with an air–fluid level in the posterior segment of the right
upper lobe. Sputum smear shows many neutrophils and a variety of bacteria. Appropriate
treatment includes:
A) Isolate the patient and initiate a four-drug antituberculosis treatment.
B) Start intravenous clindamycin.
C) Refer the patient to a dentist for periodontal care.
D) Schedule a bronchoscopy for the next day.
E) Start administration of methicillin and tobramycin.

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25. A previously healthy 54-year-old man presents to the emergency department
complaining of chest pain. His ECG shows an acute inferior wall myocardial infarction. His
blood pressure is 90/60 mm Hg. On physical examination, he has jugular vein distention
and clear lungs. You should treat him immediately with which of the following:
A) Intravenous fluids.
B) Norepinephrine.
C) Dopamine.
D) Nesiritide.
E) Nitroprusside.
26. Inhalant abusers (“huffers” and “baggers”) are at risk for:
A) Ventricular dysrhythmias.
B) Acute lung injury.
C) Hypoglycemia.
D) Acidosis.
E) Kidney failure.
27. A 37-year-old woman has a 2-week history of intermittent headache and general
malaise. Over the last 24 hours, she has developed back pain, hematuria, vomiting, fever,
and confusion. She denies recent travel or insect bites. There is no history of dysuria,
urgency, frequency, or kidney stones. Her oral temperature is 38°C and her heart rate is
100/min. Physical findings include pale conjunctivae, borderline tachycardia, bilateral
costovertebral tenderness, and several purpuric skin lesions. Her urine dipstick is strongly
positive for hemoglobin, but negative for nitrites and leukocyte esterase. The test that will
most likely reveal the correct diagnosis is:
A) Intravenous pyelogram.
B) CBC with differential and peripheral smear.
C) Complete urinalysis with microscopic examination.
D) Blood cultures.
E) Liver function tests.
28. A 52-year-old man complains of severe right knee pain. He recalls no trauma, but
attended a wine tasting party last weekend. He denies past medical history and is afebrile
with normal vital signs. Physical examination reveals a swollen, red, painful right knee.
Radiograph shows an effusion, but no bony erosions. You perform arthrocentesis and
obtain 27 mL of cloudy straw-colored fluid, which you send to the laboratory for studies.
The cell count is 50,000 WBCs/mm3 with 85% PMNs, glucose 120 mg/dL (serum 130),
and protein 3.5 g/dL. The Gram stain shows numerous WBCs, but is negative for
organisms. Evaluation for crystals shows numerous needle-shaped crystals with negative
birefringence. A good treatment plan would be:
A) Oral colchicine 0.5 mg every hour until symptoms abate, GI toxicity develops or the
maximum dose of 6 mg in 24 hours is reached.
B) Subcutaneous colchicine 1 mg plus oral probenecid 250 mg bid for 1 week.
C) Sublingual colchicine 2 mg followed by oral steroids tapered over 5 days.
D) Intra-articular triamcinolone injection.
E) Oral allopurinol 500 mg tid for 1 week.
29. A 35-year-old woman presents to her gynecologist with complaints of burning on
urination for the past 2 days. Dipstick test of her urine demonstrates marked positivity for
leukocyte esterase, but no reactivity for nitrite. Urine culture later grows out large numbers
of organisms. Which of the following bacteria are most likely to be responsible for this
patient's infection?
A) Enterobacter sp.
B) Enterococcus faecalis
C) Escherichia coli

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D) Klebsiella pneumoniae
E) Pseudomonas aeruginosa.
30. A 23 year old single woman referred with 3-month history of weight loss and heat
intolerance. On examination pulse is 120 beat/min regular, blood pressure 120/72 mmHg,
weight 58 kg, height 165 cm. she had diffuse goiter with bilateral exophthalmos.
Investigations: serum free T4 3.9 ng/dl (N: 0.9-2.0), serum TSH 0.001 mu/l (N: 0.4-4.0),
TSH receptor antibody 8 U/L(N:<2). She was started on methimazole 30 mg/day. Six
weeks later she developed severe migratory arthralgia associated with the presence of
palpable purpura over both legs and dermal infarcts in the finger tips. Laboratory studies
shows ESR 54 mm/h, urine showed microscopic hematuria, ANCA titer was 1:640,
antimyeloperoxidase antibodies 112U/l (N:0-9), antiproteinase 3 antibodies 6.4 U/l (N:0-
3.5).
The best action is:
A) Continue methimazole and add NSAID.
B) Continue methimazole and add prednisolone 40 mg per day.
C) Substitute propylthiouracil for methimazole.
D) Refer the patient for definitive therapy with radioactive iodine.
E) No intervention.

ANSWERS
1. A
2. E
3. E
4. B
5. C
6. D
7. A
8. E
9. D
10. B
11. D
12. D
13. E
14. C
15. D
16. A
17. E
18. A
19. E
20. D

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21. D
22. D
23. D
24. B
25. A
26. A
27. B
28. A
29. B
30. D

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MULTIPLE CHOICE QUESTIONS 4
1. A 92-year-old man is referred from his nursing home for evaluation of lethargy.
Examination is unrevealing, but laboratory results are significant for a serum sodium level
of 118 meq/L (normal, 135 148). Serum osmolality is 260, urine osmolality is 450, and
urine sodium is 80. Which of the following is the most likely cause of this patient's
lethargy?
A) hyperglycemia
B) hyperlipidemia
C) hyperproteinemia
D) SIADH
E) diabetes insipidus
2. Which one of the following is a recognized feature of polymyalgia rheumatica?
A) Weakness of distal muscle groups
B) Elevated serum creatine phosphokinase activity
C) An association with bronchial carcinoma
D) Weight loss
E) A peak incidence in the fourth decade of life.
3. A 17-year-old girl notes an enlarging lump in her neck. On examination, her thyroid
gland is twice the normal size, firm to rubbery, multilobular, nontender, and freely mobile.
There is no adenopathy. Family history is positive for both hypo- and hyperthyroidism. Her
serum triiodothyronine (T3) and thyroxine (T4) levels are low normal, and serum thyroid-
stimulating hormone (TSH) is high normal. Technetium scan shows nonuniform uptake.
Serum and antithyroglobulin titer is strongly
positive. What will thyroid biopsy of this patient most likely disclose?
A) giant cell granulomas and necrosis
B) polymorphonuclear cells and bacteria
C) diffuse fibrous replacement
D) lymphocytic infiltration
E) parafollicular cells.
4. A 60-year-old man presents with a nonproductive cough for a week and generalized
malaise. He also has noted some abdominal pain associated with diarrhea for the past
few days. His temperature is 101.5°F and c linical examination is unremarkable. ACXR
shows a left lower lobe infiltrate. His urinalysis shows 50 RBCs, and his BUN (30) and
creatinine (1.6) are both mildly elevated. In light of the extrapulmonary symptoms and
signs, which of the following is the most likely cause of his pneumonia?
A) Pseudomonas aeruginosa
B) S. aureus
C) H. influenzae
D) S. pneumoniae
E) Legionella.
5. A 78-year-old woman comes to your primary care office practice with her son who is
concerned about changes in her mood. She is less interested in going out to dinner and
does not want to visit family or friends. Her language skills seem to have deteriorated over
the last few years and her memory is not as sharp. Her gait and motor strength are
normal. Which of the following is the most likely diagnosis?
A) Parkinson's disease
B) anxiety disorder
C) meningioma

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D) Alzheimer's disease
E) dysthymia.
6. A 30-year-old woman who has been human immunodeficiency virus (HIV) positive for 4
years was recently diagnosed with AIDS. Which of the following immunologic
abnormalities would be expected?
A) increased numbers of CD4+ (helper) T cells
B) decreased number of CD8+ (suppressor) T cells
C) cutaneous anergy to usual skin test antigens
D) normal B-cell function
E) increased natural killer cell function.
7. A 60-year-old previously healthy man presents with massive rectal bleeding. Which of
the following is the most likely diagnosis?
A) diverticulosis of the colon
B) ulcerative colitis
C) external hemorrhoid
D) ischemic colitis
E) carcinoma of the colon
8. A 59-year-old woman who lives independently and had been healthy, presents to the
emergency department with cough and fever. She related she was well until 2 days before
when she noted onset of fever, chills, and cough productive of yellow sputum. On
examination, you note a tired appearing woman with BP of 160/90, pulse of 105, and
respiratory rate of 32. You start her on ceftriaxone and azithromycin and admit her to the
hospital. Which of the following factors is a poor prognostic sign in community acquired
pneumonia?
A) age less than 60
B) systolic BP = 160 mmHg
C) leukocytosis = 15,000
D) respiratory rate = 32
E) mycoplasma pneumonia infected.
9. You see a 19-year-old Caucasian man in your clinic who presents with a history of
transient jaundice. On direct questioning, you ascertain that the jaundice is noticeable
after periods of increased physical activity and subsides after a few days. The patient has
no other symptoms and physical examination is unremarkable. Full blood count is normal
(with a normal reticulocyte count) and liver function tests reveal a bilirubin of 37 μmol/L.
The most appropriate management is:
A) Reassure and discharge
B) Start on a course of oral steroids
C) Request abdominal ultrasound
D) Request MRCP
E) Refer to Haematology.
10. You see a 56-year-old man who was admitted for an elective upper GI endoscopy due
to longstanding GORD which has failed to improve on antacids and PPIs. Your registrar
suspects that this patient may have Barrett’s oesophagus and asks you to define what this
is. The most appropriate description of Barrett’s oesophagus is:
A) Metaplasia of the squamous epithelium of the lower third of the oesophagus to
columnar epithelium
B) Metaplasia of the columnar epithelium of the upper third of the oesophagus to
squamous epithelium
C) Metaplasia of the columnar epithelium of the lower third of the oesophagus to
squamous epithelium

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D) Metaplasia of the squamous epithelium of the upper third of the oesophagus to
columnar epithelium
E) Metaplasia of the squamous epithelium of the middle third of the oesophagus to
columnar epithelium.
11. You see a 48-year-old lorry driver, who presents to you with a three-month history of
heartburn after meals which has not been settling with antacids and PPIs. You suspect
that the patient has a hiatus hernia. The most appropriate investigation for diagnosing a
hiatus hernia is:
A) Computer tomography (CT) scan
B) Chest x-ray
C) Upper GI endoscopy
D) Barium meal
E) Ultrasound.
12. You see a 47-year-old man in clinic with a three-month history of epigastric dull
abdominal pain. He states that the pain is worse in the mornings and is relieved after
meals. On direct questioning, there is no history of weight loss and the patient’s bowel
habits are normal. On examination, his abdomen is soft and
experiences moderate discomfort on palpation of the epigastric region. The most likely
diagnosis is:
A) Gastric ulcer
B) Gastro-oesophageal reflux disease (GORD)
C) Duodenal ulcer
D) Gastric carcinoma
E) Gastritis.
13. A 60-year-old farmer presented with non specific symptoms of chronic cough and
progressive dyspnea for the last six years. The patient had interstitial pneumonitis. Chest
x-ray revealed reticulonodular infiltrate associated with honey-combing of the lung.
Pulmonary function studies showed a restrictive pattern with loss of lung volumes,
impaired diffusion capacity, decreased compliance and exercise induced hypoxia. This
farmer’s symptoms are most likely secondary to the following environmental hazard:
A) The farmers cheese processing plant
B) The presence of spores of bacillus anthracis in the farmer’s farm
C) The harvesting of crops in rainy weather
D) The presence of asbestos in the water tanks.
E) The presence of antigenic detergents.
14. Which of the following antiarrhythmic agents may promote AF?
A) Adenosine
B) Quinidine
C) Propafenone
D) Amiodarone
E) Atenolol.
15. Torsades de pointes is characterized by all of the following except:
A) Results from triggered activity (early afterdepolarizations) that occurs during
phase 2 or 3 of the cardiac action potential
B) Prolonged QT interval
C) Exacerbation by bradycardia with short-long coupling intervals
D) Polymorphic VT
E) Often provoked during amiodarone administration.
16. A 68-year-old patient is seen for a general examination. Current
recommendations for immunizations include

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A) Tetanus booster every 5 years
B) Influenza vaccination yearly
C) Pneumococcal vaccination yearly
D) Hepatitis booster every 5 years
E) Meningococcal vaccination.
17. Which of the following statements about familial periodic paralysis is true?
A) It is an autosomal-recessive transmitted disorder.
B) It involves disturbances of potassium regulation.
C) It is associated with permanent muscle weakness.
D) It is aggravated by administration of acetazolamide.
E) It most commonly affects the elderly.
18. A 52-year-old man complains of severe right knee pain. He recalls no trauma, but
attended a wine tasting party last weekend. He denies past medical history and is afebrile
with normal vital signs. Physical examination reveals a swollen, red, painful right knee.
Radiograph shows an effusion, but no bony erosions. You perform arthrocentesis and
obtain 27 mL of cloudy straw-colored fluid, which you send to the laboratory for studies.
The cell count is 50,000 WBCs/mm3 with 85% PMNs, glucose 120 mg/dL (serum 130),
and protein 3.5 g/dL. The Gram stain shows numerous WBCs, but is negative for
organisms. Evaluation for crystals shows numerous needle-shaped crystals with negative
birefringence. A good treatment plan would be:
A) Oral colchicine 0.5 mg every hour until symptoms abate, GI toxicity develops or the
maximum dose of 6 mg in 24 hours is reached.
B) Subcutaneous colchicine 1 mg plus oral probenecid 250 mg bid for 1 week.
C) Sublingual colchicine 2 mg followed by oral steroids tapered over 5 days.
D) Intra-articular triamcinolone injection.
E) Oral allopurinol 500 mg tid for 1 week.
19. A 38-year-old woman is brought to the emergency department by her spouse because
of decreased mental status. She had knee surgery 2 days ago and was prescribed oral
oxycodone for pain. Her spouse notes that she finished the entire 7-day supply during that
day. He denies any seizure activity.They have no other drugs or medications in the house.
She is afebrile with blood pressure of 130/75 mmHg, heart rate of 70 bpm, respiratory rate
of 4 breaths/min, and SaO2 of 85% on room air. She barely responds to painful stimuli but
moves all four extremities equally. Which of the following medications is most likely to
improve her mental status?
A) Albuterol
B) Alvimopan
C) Flumazenil
D) N-Acetylcysteine
E) Naloxone.
20. A 45-year-man with longstanding type 1 diabetes mellitus complains of pain in his feet
and ankles that has been present for over a year. All of the following are consistent with
neuropathic pain due to diabetes EXCEPT:
A) Burning pain
B) Electric shock quality
C) Exacerbated by light touch
D) Pain referred to scrotum
E) Tingling.
21. Which of the following sets of drug–drug interaction and mechanism is accurately
described?
A) Ibuprofen and warfarin: increased risk of GI bleeding; ibuprofen inhibition of CYP2C9

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B) Sotalol and furosemide: increased risk of QT prolongation and torsades de pointes;
furosemideinduced inhibition of CYP3A4
C) Sildenafil and sublingual nitroglycerin: increased risk of hypotension; sildenafil
inhibition of the phosphodiesterase type 5 isoform that inactivates cyclic guanosine
monophosphate
D) Ritonavir and lovastatin: increased risk of myotoxicity; ritonavir inhibition of CYP2C19
E) Allopurinol and azathioprine: increased risk of blood dyscrasias; allopurinol inhibition of
Pglycoprotein.
22. Mr. Jonas is a 47-year-old truck driver with a history of HIV, hypertension, coronary
artery disease, atrial fibrillation, and ischemic cardiomyopathy. He is on antiretroviral
therapy. He presents today complaining of a new rash on his chest and axilla, which you
astutely diagnose as tinea corporis. You
would like to prescribe a course of oral ketoconazole for therapy. You should consider
dose adjustment for all of the following medicines that he is already taking EXCEPT:
A) Carvedilol
B) Lovastatin
C) Mexiletine
D) Ritonavir
E) Saquinavir.
23. A 24-year-old woman who has tested positive for human immunodefi ciency virus
(HIV) presents to your officewith mild fever and symptoms of an upper respiratory
tract infection. She is currently in her 26th week of pregnancy and has a recent positive
tuberculin skin test (TST) conversion with a 22-mm induration. Additionally, she has
genital ulcerative lesions that test positive for herpes simplex virus. Which antimicrobial
agent should you avoid prescribing for this patient?
A) Acyclovir
B) Amoxicillin
C) Tetracycline
D) Azithromycin
E) Isoniazid.
24. Which of the following characteristics of Mycobacterium tuberculosis can be used to
distinguish it from Mycobacterium bovis ?
A) Nonchromogenic pigmentation
B) Positive pyrazinamidase test
C) Negative 68°C catalase test
D) Positive nucleic acid probe for M tuberculosis complex
E) Negative arylsulfatase test.
25. A 65-year-old man presents with a left footdrop. On examination,
the left anterior tibialis, extensor hallucis longus, and posterior tibialis muscles are weak.
The strength of the quadriceps, gastrocnemius, and gluteus maximus muscles is normal.
Stretch reflexes of the quadriceps and ankle muscle are normal. To which structure does
the lesion best localize?
A) Peroneal nerve
B) L4 spinal root
C) L5 spinal root
D) Sciatic nerve
E) Thoracic spinal cord.
26. A 55-year-old male who has a long history of marginally-controlled hypertension
presents with gradually increasing shortness of breath and reduced exercise tolerance.
His physical examination is normal except for a blood pressure of 140/90 mm Hg, bilateral

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basilar rales, and trace pitting edema. Which one of the following ancillary studies would
be the preferred diagnostic tool for evaluating this patient? (check one)
A) 12-lead electrocardiography
B) Posteroanterior and lateral chest radiographs
C) 2-dimensional echocardiography with Doppler
D) Radionuclide ventriculography
E) Cardiac MRI.
27. Which one of the following extraintestinal manifestations of inflammatory bowel
disease do not parallel the course of intestinal inflammation and do not improve in parallel
with improvement in intestinal symptoms?
A) peripheral arthritis
B) apthous ulcers
C) spondylitis and sacroiliitis
D) erythema nodosum
E) uveitis and iritis.
28. An 18-year-old Asian woman is being treated for hepatitis B. Prior to therapy she was
found to have ALT 198 U/L, AST 91 U/L, normal bilirubin, albumin, and prothrombin time.
Liver biopsy results showed chronic hepatitis B, grade 3, stage 3. After 12 weeks of
therapy, serum ALT is found to have increased to 1,082 U/L, bilirubin 2.1 mg/dL but
albumin and prothrombin time remain normal. Apart from some fatigue, the patient is
tolerating interferon well. The best course of action is:
A) check for antinuclear antibodies and total immunoglobulin level in serum and consider
instituting corticosteroid therapy
B) stop interferon
C) recheck lab work again in 2 weeks time
D) add lamivudine to the regimen
E) ask the patient to skip three scheduled doses of interferon.
29. A 53-year-old man presented with hypertension of 150/110 mmHg. He is generally
asymptomatic and has no previous medical history of note. He is a smoker of 5 cigarettes
daily and drinks modest quantities of alcohol. He takes no prescribed medications.
Examination reveals a BMI of 33.5 kg/cm2 but nil else. Investigations: Serum sodium 146
mmol/l (NR 133-145); Serum potassium 3.2 mmol/l (NR 3.5 - 5); Urinary potassium
excretion 42 mmol/l (NR less than 30). What is the likely diagnosis?
A) adrenocortical adenoma
B) Bartter's syndrome
C) Liddle's syndrome
D) liquorice ingestion
E) pheochromocytoma.
30. A female patient aged 30 has a 5 years history of difficulty getting upstairs and out of a
low chair and mild upper limb weakness but no pain. There is no family history. She
presented with severe type 2 respiratory failure. EMG showed evidence of myopathy.
The most likely diagnosis is:
A) Polymyositis
B) Inclusion body myositis
C) Acid maltase deficiency
D) Miller-Fisher Syndrome
E) Lambert-Eaton Myasthenic syndrome.

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ANSWERS
1. D
2. D
3. D
4. E
5. D
6. C
7. A
8. D
9. A
10. A
11. D
12. C
13. C
14. A
15. E
16. B
17. B
18. A
19. E
20. D
21. C
22. A
23. C
24. B
25. C
26. C
27. C
28. C
29. A
30. C

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MULTIPLE CHOICE QUESTIONS 5
1. A 38-year-old woman is referred to you by a neurologist who was seeing her for severe
headaches. His final diagnosis was stress headaches, but because a head MRI showed
an empty sella, the neurologist wanted you to see her. On questioning, you learn that she
has 7 children and all are healthy. When the first child was born, she experienced a
difficult delivery and considerable bleeding that required a transfusion. All subsequent
deliveries were uneventful. The review of systems was otherwise negative. Physical
examination shows normally pigmented abdominal striae. The blood pressure is 100/60.
You order some blood tests and find that the electrolytes, glucose, and TSH are normal.
Which of the following is the most correct thing for you to do next?
A) Diagnose Sheehan syndrome and begin replacement therapy.
B) Evaluate for pituitary hypofunctioning.
C) Evaluate for pituitary hyperfunctioning.
D) Refer her to a neurosurgeon for exploration of her pituitary gland.
E) Tell her that everything is normal and discharge her from your clinic.
2. The condition that characteristically results in recurrent axillary and groin abscesses is:
A) Regional enteritis.
B) Diabetes mellitus.
C) Ulcerative colitis.
D) Hidradenitis suppurativa.
E) Acne conglobata.
3. The most important initial therapy for a patient with toxic epidermal necrolysis (TEN) is:
A) Corticosteroids.
B) Antibiotics.
C) Anticoagulants.
D) Analgesics.
E) Crystalloids.
4. In evaluating the skin lesions of patients with AIDS:
A) Kaposi sarcoma is common but seldom more than a cosmetic problem.
B) Candidiasis may occur but is easily treated with standard medications.
C) Tinea corporis is no more likely in these patients than in the general population.
D) Lichen planus of the oral mucosa is associated with the disease.
E) Seborrheic dermatitis-like eruptions are frequently found.
5. A 57-year-old man comes to the emergency department because of excruciating pain in
his right big toe. He describes the pain as so severe that it woke him from a deep sleep.
He has no chronic medical conditions, does not take any medications, and denies any
similar episodes in the past. He admits to a few "drinking binges" over the past 2 weeks.
His temperature is 38.1 C (100.5 F), blood pressure is 130/90 mm Hg, and pulse is
80/min. Examination shows an erythematous, warm, swollen, and exquisitely tender right
great toe. The skin overlying the first metatarsophalangeal joint is dark red, tense, and
shiny. Synovial fluid analysis reveals negatively birefringent, needle-shaped crystals within
polymorphonuclear leukocytes (PMNs). Laboratory studies show:
Serum Leukocytes........16,000/mm3; Uric acid...........15 mg/dL; Calcium.............9 mg/dL
Which of the following is the most appropriate pharmacotherapy?
A. Allopurinol
B. Ceftriaxone
C. Cyclooxygenase-2 inhibitors but in higher dosages than are typically used.
D. Probenecid
E. Sulfinpyrazone

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6. A 28-year-old woman is diagnosed with lupus nephritis, World Health Organization
(WHO) type IV. She has a malar rash, diffuse arthritis, and edema. Her blood pressure is
190/110 mm Hg. Her creatinine is 2.1 mg/dL with a blood urea nitrogen of 28 mg/dL. Her
urine reveals 25 red blood cells per hpf, and 3+ protein. One red blood cell cast is seen. A
24-hour urine collection reveals a protein of 11 grams with a creatinine of 1 gram. Which
of the following would be the most appropriate management?
A) Oral azathioprine
B) Oral cyclophosphamide
C) Oral gold
D) Oral prednisone
E) Pulse IV cyclophosphamide.
7. A 50-year-old man is evaluated for a routine physical examination. He was diagnosed
with rheumatoid arthritis 5 years ago, and his condition is well controlled with
methotrexate and hydroxychloroquine. He does not have fatigue, morning stiffness, or
systemic symptoms. His weight is stable. On physical examination, there are no joint
deformities. There is minimal soft-tissue swelling around the second and third
metacarpophalangeal joints. Grip strength is normal, but squeezing the forefeet elicits mild
discomfort. On laboratory studies, hemoglobin is 14.2 g/dL (142 g/L), alanine and
aspartate aminotransferase and alkaline phosphatase are normal, and erythrocyte
sedimentation rate is 65 mm/h. Which of the following is the most appropriate
management for this patient?
A. Prednisone, 10 mg daily
B. Prednisone, 40 mg daily
C. Anti–tumor necrosis factor therapy
D. CT scan of the chest, abdomen, and pelvis
E. No additional therapy
8. A family physician cares for a family consisting of a 45-year old husband, 43-year-old
wife and a 12-year-old daughter. The family reports that recently the 77-year-old maternal
grandmother who lived with them died after a prolonged respiratory infection. Autopsy
subsequently confirms that she had active pulmonary tuberculosis at the time of death.
The organism tested sensitive to all anti-tuberculosis drugs. In responding to the
grandmother's illness, which of the following is the most appropriate step in management?
A) Obtain leukocyte counts on all family members
B) Obtain sputum cultures for acid fast bacilli
C) Obtain chest computerized tomograms on all members
D) Place protein purified derivative (PPD) test on all members
E) Schedule bronchoscopy lavage for the adults.
9. A patient with a history of papillary thyroid cancer is noted to
have an enlarged lateral neck lymph node on routine
examination. Which one of the following is the most sensitive and specific indicator of
metastatic disease within the enlarged lymph
node?
A. Neck ultrasound
B. Fine needle aspiration cytology
C. Stimulated serum thyroglobulin
D. PET‐CT scanning
E. Thyroglobulin wash‐out testing.
10. A 60-year-old woman is establishing care in your clinic. She has occasional numbness
and tingling in her fingers and toes and has noted some numbness around her mouth,
especially when she is stressed or anxious. She had thyroid surgery for Graves’ disease
about 2 years ago and takes 100 µg of levothyroxine and 1 tablet of calcium daily. On

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exam, her blood pressure is 130/80, pulse 80, and she has cramping in her right forearm
and fingers when the blood pressure cuff is attached. Based on this history and exam,
which of the following is most likely?
A) Calcium 8.5, PTH 65, PO4 4.5
B) Calcium 9.5, PTH 35, PO4 4.0
C) Calcium 6.0 (8.5-10.5), PTH 2 (10-65), PO4 6.0 (2.7-4.5)
D) Calcium 10.8, PTH 108, PO4 2.3
E) Calcium 8.0, PTH 98, PO4 2.1.
11. Which of the following sets of drug–drug interaction and mechanism is accurately
described?
A. Ibuprofen and warfarin: increased risk of GI bleeding; ibuprofen inhibition of CYP2C9
B. Sotalol and furosemide: increased risk of QT prolongation and torsades de pointes;
furosemideinduced inhibition of CYP3A4
C. Sildenafil and sublingual nitroglycerin: increased risk of hypotension; sildenafil inhibition
of the phosphodiesterase type 5 isoform that inactivates cyclic guanosine monophosphate
D. Ritonavir and lovastatin: increased risk of myotoxicity; ritonavir inhibition of CYP2C19
E. Allopurinol and azathioprine: increased risk of blood dyscrasias; allopurinol inhibition of
Pglycoprotein.
12. A 47-year-old truck driver with a history of HIV, hypertension, coronary artery disease,
atrial fibrillation, and ischemic cardiomyopathy. He is on antiretroviral therapy. He
presents today complaining of a new rash on his chest and axilla, which you astutely
diagnose as tinea corporis. You
would like to prescribe a course of oral ketoconazole for therapy. You should consider
dose adjustment for all of the following medicines that he is already taking EXCEPT:
A. Carvedilol
B. Lovastatin
C. Mexiletine
D. Ritonavir
E. Saquinavir
13. A 17-year-old patient who is known to have Wolff-Parkinson-White syndrome presents
with a regular narrow complex tachycardia with a cycle length of 375 milliseconds (160
bpm) that occurred with a sudden onset. You note that there is a 1:1 atrial-to-ventricular
relationship and that the RP interval is 100 milliseconds. The best initial treatment is
A) IV procainamide.
B) atropine.
C) vagal maneuvers.
D) catheter ablation.
14. A 65-year-old man presents after an arrest while eating at a local restaurant. On
arrival, paramedics documented ventricular fibrillation (VF), and he was successfully
resuscitated. He has a history of myocardial infarction (MI) and congestive heart failure
(CHF). Serum electrolytes are remarkable only for mild hypokalemia. MI is ruled out by
ECG and serial blood tests of myocardial enzymes. Subsequent evaluation includes
cardiac catheterization, which shows severe three-vessel coronary artery disease (CAD)
and severe left ventricular (LV) systolic dysfunction. A nuclear myocardial perfusion scan
shows a large area of myocardial scar without significant viability in the territory of the left
anterior descending coronary artery. The decision is made to treat the CAD medically.
Which of the following is the best management strategy for his arrhythmia?
A) PO amiodarone
B) Implantable cardioverter defibrillator (ICD) implantation if an electrophysiologic (EP)
study shows inducible VT or VF

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C) ICD implantation
D) β-Blocker medication.
15. A 56-year-old woman is undergoing a cadaveric renal transplant. After
revascularization of the transplanted kidney the transplanted renal parenchyma becomes
swollen and blue. Which of the following statements is most accurate regarding her
transplanted kidney?
A) The donor had pre-formed antibodies against the recipient’s HLA antigens.
B) It is characterized pathologically by fibrin and platelet thrombosis of renal arterioles and
small arteries and necrosis of the glomerular tufts.
C) Biopsies should not be obtained intraoperatively.
D) This form of rejection is associated with disseminated intravascular coagulation (DIC).
E) The rejection process can be treated with a steroid bolus and OKT3.
16. A 55-year-old man comes to the physician with the chief complaint of weight loss and
a depressed mood. He feels tired all the time and is no longer interested in the normal
activities he previously enjoyed. He feels quite apathetic overall. He has also noticed that
he has frequent, nonspecific abdominal pain. Which of the following diagnoses needs to
be ruled out for this man?
A) Pheochromocytoma
B) Pancreatic carcinoma
C) Adrenocortical insufficiency
D) Cushing syndrome
E) Huntington disease
17. You are seeing a 78-year-old man who was brought to the office by his daughter. The
daughter says her father is becoming increasingly forgetful. His medical history is
significant for a 20-year history of type 2 diabetes and well-controlled hypertension. On
examination, he is mildly hypertensive with otherwise normal vital signs. He is oriented to
time, place, and person, but is unable to complete “serial sevens” on a mini-mental status
examination. Which of the historical features make this diagnosis more consistent with
dementia as opposed to delirium?
A) His history of hypertension
B) His history of diabetes
C) His current level of orientation
D) His inability to complete serial sevens
E) The recent onset of his symptoms.
18. A 45-year-old woman with Crohn’s disease and a small intestinal fistula develops
tetany during the second week of parenteral nutrition. The laboratory findings include Ca
8.2 meq/L; Na 135 meq/L; K 3.2 meq/L; Cl 103 meq/L; PO4 2.4 meq/L; albumin 2.4; pH
7.48; 38 kPa; P 84 kPa; bicarbonate 25 meq/L. The most likely cause of the tetany is
A) Hyperventilation
B) Hypocalcemia
C) Hypomagnesemia
D) Essential fatty acid deficiency
E) Focal seizure.
19. A 60 year-old woman has had a mitral valve replacement for chronic mitral stenosis
and is on cardiac ITU post-operatively. She is awake and self ventilating. SPO2 91%,
FiO2= 0.6. Monitoring shows atrial fibrillation at 90/min, blood pressure 88/60 and
pulmonary artery pressures of 45/15. Which single drug is most appropriate first line
treatment to reduce the pulmonary artery pressure?
A) Inhaled nitric oxide
B) Inhaled prostacyclin

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C) Oral sildenafil
D) Intravenous isoprenaline
E) Intravenous milrinone.
20. A 62-year-old man is admitted to the emergency department with abdominal pain. The
patient has a past history of ischaemic heart disease and atrial fibrillation. Computed
tomography scan features are highly suggestive of ischaemic bowel. The patient's blood
gases are as follows: pH = 7.25; paO2 = 10; paCO2 = 2.8; HCO3 = 18; Base excess = –8
Which of the following best describes the patient's acid–base status?
A) Metabolic acidosis
B) Metabolic acidosis with respiratory compensation
C) Respiratory acidosis with metabolic compensation
D) Metabolic acidosis with inadequate respiratory compensation
E) Cannot be sure without a serum lactate level.
21. Two weeks ago, a 54-year-old man developed a cold sore, which resolved
uneventfully. He now complains of a nonpruritic skin rash. Examination reveals raised red
lesions resembling hives, some with clear fluid bullae. They are located on his hands,
including the palms, and his forearms and anterior tibia. The best way to confirm your
suspected diagnosis is by:
A) Viral culture of blister fluid.
B) Smear of blister fluid for Gram stain.
C) Tzanck preparation of blister fluid to look for multinucleate giant cells.
D) Full thickness skin biopsy of involved area.
E) Wood’s light examination of involved areas.
22. A 54-year-old man presents for a periodic health examination. His family history is
significant for his mother who died of a cerebrovascular accident at age 72, his father who
died of a myocardial infarction at age 68, and a brother who developed sigmoid cancer at
age 60. The patient is on no medications except for aspirin, 81 mg daily. His physical
examination is unremarkable. The patient asks for a recommendation regarding current
cancer screening. Which of the following is the most appropriate screening test for this
patient?
A) Annual digital rectal examination and fecal occult blood testing
B) Flexible sigmoidoscopy
C) Flexible sigmoidoscopy and barium enema
D) Colonoscopy
E) Genetic testing for the p53 gene.
23. Which of the following treatment options has been most consistently shown to be
effective for the primary prevention of sudden cardiac death in patients with CAD and
recent MI?
a. D-Sotalol
b. β-Blocker medications
c. Amiodarone
d. Dofetilide.
24. A 72-year-old woman is about to undergo an elective total hip replacement for
osteoarthritis. She has a history of hypertension and type 2 diabetes mellitus but no
ischaemic heart disease or peripheral vascular disease. Which of the following is the most
appropriate thromboembolic prophylaxis?
A) Intermittent pneumatic calf compression
B) Calf-length thromboembolic deterrent elastic stockings and early ambulation
C) Full-dose unfractionated heparin to increase the activated partial thromboplastin time to
two time control

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D) Insertion of an inferior vena cava filter
E) Subcutaneous low-molecular-weight heparin.
25. An AIDS patient under treatment with a nucleoside analog and a protease inhibitor
comes to medical attention with complaints of leg weakness and incontinence. His vital
signs are within normal limits. Physical examination reveals reduced strength in the lower
extremities with accompanying mild spasticity. There is also diminished sensation in the
feet and legs bilaterally. Lumbar puncture shows:
Opening pressure.....100 mm H20
Cell count................5 lymphocytes/mm3
Glucose...................48 mg/dL
Proteins, total..........33 mg/dL
Gamma globulin.......8% total protein
Additional laboratory investigations show normal hematologic parameters, vitamin B12
within normal values, and negative serology for syphilis. MRI of the head fails to reveal
any focal abnormality. Which of the following is the most likely diagnosis?
A) AIDS dementia complex
B) CMV polyradiculopathy
C) Cryptococcal meningoencephalitis
D) Vacuolar (HIV) myelopathy
E) Zidovudine-related toxicity.
26. A 59-year-old man presents to the ED with left-sided chest pain and shortness of
breath that began 2 hours prior to arrival. He states the pain is pressure-like and radiates
down his left arm. He is diaphoretic. His BP is 160/80 mm Hg, HR 86 beats per minute,
and RR 15 breaths per minute. ECG reveals 2-mm ST-segment elevation in leads I, aVL,
V3 to V6. Which of the following is an absolute contraindication to receiving thrombolytic
therapy?
A) Systolic BP greater than 180 mm Hg
B) Patient on Coumadin and aspirin
C) Total hip replacement 3 months ago
D) Peptic ulcer disease
E) Previous hemorrhagic stroke
27. Which of the following statements is true about the patient with a bleeding disorder?
A) Factor deficiencies generally present with mucosal bleeding/petechiae.
B) Hemarthrosis generally reflects a platelet deficiency.
C) Hematomas are usually the result of a factor deficiency.
D) All of the above are true.
28. Flu season is right around the corner and you are preparing your clinic for the
onslaught. First things first … you need to know how much vaccine to order and who will
be receiving it. The Centers for Disease Control and Prevention (CDC) annually publishes
recommendations for administering influenza vaccine to the American public. The CDC
recommends vaccination for all of the following groups, EXCEPT:
A) Health-care workers.
B) Nursing home residents.
C) Egg-allergic, febrile neonates.
D) Diabetics.
E) The elderly.
29. During an outbreak, what intervention(s) is/are most appropriate for all your
unvaccinated, frail nursing home patients who have no symptoms of febrile respiratory
illness?
A) Antiviral prophylaxis with oseltamivir.

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B) Antiviral prophylaxis with amantadine.
C) Influenza immunization.
D) A and C given together.
E) B and C given together.
30. Which of the following is indicated when evaluating for a suspected inherited
coagulopathy?
A) CBC.
B) PT and PTT.
C) Platelet count.
D) PFA-100.
E) All of the above.

ANSWERS
1. E
2. D
3. E
4. A
5. C
6. E
7. D
8. D
9. D
10. C
11. C
12. A
13. C
14. C
15. C
16. B
17. C
18. C
19. E
20. D
21. D
22. D
23. B
24. E

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25. D
26. E
27. C
28. C
29. D
30. E

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MULTIPLE CHOICE QUESTIONS 6
1. A broncho-pleural fistula is an abnormal communication or a passage between the
bronchial tree and the pleural space, causing a persistent leak. If these patients are
mechanically ventilated, the management strategy should be:
A) Low tidal volumes and high respiratory rate
B) Reduced inspiratory pressures
C) High tidal volumes and low respiratory rate
D) Low inspiratory times and high PEEP
E) High inspiratory times and low PEEP
2. Which of the following is a recognized feature of pulmonary embolism except?
A) S1,Q3,T3
B) an increase in serum troponin levels
C) an arterial pH greater than 7.2
D) increased PCO2 on air
E) positive D-dimer levels
3. A 45-year-old surgeon sustained a needle stick injury from a known HIV-positive
individual during a routine gall bladder operation and subsequently commenced a course
of post-exposure prophylaxis (PEP). Which of the following statements regarding his
management is CORRECT?
A) He can discontinue PEP if it is established that the source patient has an undetectable
HIV viral load
B) He must refrain from operating until he has proven to be HIV-negative after completion
of PEP
C) If he has successfully completed a course of PEP, there is no requirement for him to
have a subsequent HIV antibody test
D) He cannot be considered HIV-negative until he tests HIV antibody-negative at three
months post-PEP
E) He cannot be considered HIV-negative until he tests HIV antibody-negative at six
months post-PEP
4. A patient presents with gradually worsening weakness of the proximal arm and leg
muscles symmetrically over several months. On examination, neck flexors and extensors
are found to be weak also. There is no muscle pain or tenderness. What is the most likely
site of dysfunction in the nervous system?
A) Peripheral nerve
B) Brachial plexus
C) Spinal nerve root
D) Internal capsule
E) Muscle
5. A 67 year old lady is referred to the bone clinic following a fractured wrist. A DEXA scan
is performed which shows a T-score of −2.0. She has no other osteoporotic risk factors.
Which one of the following treatments would you offer?
A) Lifestyle advice and vitamin D supplementation
B) Alendronic acid
C) HRT
D) Risedronate
E) No treatment
6. A 56-year-old man is admitted to the intensive care unit for acute respiratory distress
syndrome (ARDS). The patient was transferred from an outside hospital today after a 2-

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week hospitalization for pneumonia. During that time, the patient's pulmonary status
continued to deteriorate. One week ago he was intubated and placed on mechanical
ventilation and over the past week, his oxygenation has worsened with a PaO2 of 66 on
an inspired concentration of 100% oxygen. The patient has no other medical history
except for rheumatoid arthritis. On transfer to the ICU, the patient is intubated and
sedated on a mechanical ventilator. His chest radiograph shows patchy, bilateral,
diffuse interstitial infiltrates. The most important intervention that will most benefit this
patient is to
A) keep the patient in a prone position during mechanical ventilation
B) keep tidal volumes greater than 15 cc/kg
C) limit peak inspiratory pressure to 45 cm H2O or less
D) limit PEEP levels to less than 10 cm H2O
E) limit tidal volumes to 6cc/kg
7. A previously fit and well 50-year-old male underwent a decompressive craniectomy for
an acute subdural haematoma following a traumatic head injury 24 hours ago. He is now
on the neurosurgical intensive care unit and remains intubated and ventilated. You have
been asked to review his urine output, which is recorded as 800 ml over the last 2 hours,
despite appropriate intravenous fluid administration. You suspect neurogenic diabetes
insipidus.
Which of the following features would support your diagnosis?
A) Urine specific gravity >1.005
B) Serum Na+ <135 mmol/l
C) Urine osmolality <350 mmol/kg
D) Serum osmolality <295mmol/kg
E) Serum creatinine 200 mmol/l
8. A 35 year old man presents to his GP with a 2-week history of painful, swollen knees
and a painful left heel. He also reveals that he has been experiencing a burning pain when
he urinates and has a red, itchy eye. Which one of the following is the most likely
diagnosis?
A) Gout
B) Osteoarthritis
C) Enteropathic arthritis
D) Ankylosing spondylitis
E) Reactive arthritis
9. A 40-year-old female who is intubated and ventilated following a subarachnoid
hemorrhage (SAH) 7 days previously has a serum sodium concentration of 128mmol/l and
serum osmolality of 270 mOsm/kg. Which of the following statements is true?
A) Cerebral salt-wasting syndrome (CSWS) is rarely associated with SAH
B) Cerebral salt-wasting syndrome is associated with a reduced serum osmolality
C) To diagnose SIADH, the patient must be clinically dehydrated
D) SIADH almost always requires pharmacological treatment
E) To diagnose SIADH urine osmolality must be greater than serum osmolality
10. A 47-year-old woman who is 2 weeks post triple bypass surgery presents to the
emergency department with a chief complaint of sudden onset, sharp chest pain for
several hours. She is fatigued and short of breath. On physical examination she has
distended neck veins that grow more distended on inspiration. Muffled heart sounds are
heard. Her temperature is 37.0°C (98.6°F), pulse is 133/min, blood pressure is 70/50 mm
Hg, respiratory rate is 30/min, and oxygen saturation is 100% on room air. An
echocardiogram shows a large pericardial effusion and chamber collapse; therefore,
pericardiocentesis is performed. Although a large amount of blood is aspirated, the
patient’s clinical picture acutely worsens. Her pain level increases substantially; pulse is

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150/min, blood pressure is 60/41 mm Hg, respiratory rate is 30/min, and oxygen
saturation is 100%. Repeat echocardiography shows an even larger pericardial effusion
with chamber collapse. Which complication of pericardiocentesis is most likely in this
patient?
(A) Acute left ventricular failure with pulmonary edema
(B) Aspiration of 10 mL air into the pericardium
(C) Laceration of a coronary vessel
(D) Pneumothorax
(E) Puncture of the left ventricle
11. During this outbreak, what intervention(s) is/are most appropriate for all your
unvaccinated, frail nursing home patients who have no symptoms of febrile respiratory
illness?
A) Antiviral prophylaxis with oseltamivir.
B) Antiviral prophylaxis with amantadine.
C) Influenza immunization.
D) A and C given together.
E) B and C given together.
12. A 38-year-old male presents with episodic wheeze and non-productive cough which
occurs particularly at night. He has been employed in the plastics industry. Which of the
following suggests a diagnosis of occupational lung disease?
A) Absent family history of asthma
B) Commencement of symptoms on his first day in this employment
C) Elevated serum IgE concentration
D) Improved symptomatology when on holiday
E) Increased bronchial reactivity
13. A 68-year-old male is admitted with a two months history of difficulty raising his arms,
ascending stairs, and is also aware of a dry mouth. He smokes 15 cigarettes daily and
admits to heavy alcohol consumption. On examination he has proximal weakness
affecting all four limbs with absent tendon reflexes. His chest X-ray shows a right pleural
effusion. What is the most likely diagnosis?
A) Alcohol induced myopathy
B) Eaton- Lambert syndrome
C) Myasthenia gravis
D) Polymyalgia rheumatica
E) Polymyositis
14. A 65-year-old woman, a heavy smoker for many years, has had worsening dyspnoea
for the past five years, without a significant cough. A chest x ray shows increased lung
size along with flattening of the diaphragm, consistent with emphysema. Over the next
several years she develops worsening peripheral oedema. Her BP 115/70 mmHg. Which
of the following cardiac findings is most likely to be present?
A) Constrictive pericarditis
B) Left ventricular aneurysm
C) Mitral valve stenosis
D) Non-bacterial thrombotic endocarditis
E) Right ventricular hypertrophy
15. A young male developed spontaneous DVT of right lower limb and he is having a
sister who had DVT 5 years back and having protein C deficiency. He was started on
warfarin and the INR came to 2-3 after which he had started following at local hospital
where his warfarin dose was steadily increased as his INR never went higher than 1.5 and
is currently on warfarin dose of 20 mg/day. He was referred back to hospital and was

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evaluated and found to be having warfarin level of 2.385 mg/l (therapeutic range 0.7 – 2.3
mg/l), PIVKA is > 10
(Ref. range < 0.2). What is the most likely explanation for the subtherapeutic INR?
A) Cytochrome p450 mutation
B) VKORC 1 mutation
C) Not taking warfarin
D) Local hospital INR testing quality control is not good
16. Which of the following anatomical considerations is correct?
A) Optic chiasm lesions characteristically produce a bitemporal hemianopia.
B) Central scotoma occurs early in papilloedema.
C) In cortical blindness pupillary reactions are abnormal.
D) Optic tract lesions produce an ipsilateral homonymous hemianopia.
E) Opticokinetic nystagmus is found with bilateral infarction of the parieto-occipital lobes.
17. The most common non-opportunistic protozoon parasite is AIDS patients is:
A) Cryptosporidium
B) Gardia lamblia
C) Blastomyces hominis
D) Entamoeba histolytica
E) Toxoplasma gondii
18. To assist in the decision whether to hospitalize a patient with community acquired
pneumonia (CAP), each of the following may be a factor in favor of hospitalization except
for which one?
A) The patient is confused
B) Serum creatinine >2.0 mg/dL
C) Respiratory rate >30
D) Blood pressure < 90 mm Hg
E) Age >64 years
19. A 35-year-old African-American woman complains of red and irritated eyes with
photophobia for about 2 months. Visual acuity is 20/25 for each eye separately, and she
says this is her “normal.” On questioning she admits to shortness of breath with exertion,
which she attributes to neglecting physical training and advancing age. A chest x-ray
shows perihilar adenopathy. A lung biopsy finds noncaseous granuloma.
Angiotensinconverting enzyme is elevated. On spirometry, FEV 1 is 80% of predicted
normal for her (percent of vital capacity expired in 1 second). Which of the following would
be the best therapeutic approach.
A) Non-steroidal anti-inflammatory drugs (NSAIDs)
B) Bronchodilators
C) Inhaled glucosteroids
D) Observation for 4–6 months while treating the eyes symptomatically
E) Systemic glucosteroids
20. A 30 year old lady underwent prosthetic valve replacement surgery done for rheumatic
heart disease and she is started on UFH by continuous infusion plus warfarin. Six days
after she developed DVT of right lower limb. Her CBC was normal preoperatively and now
she has dropped her platelet count to 50,000/mm3. Her INR is 2.3 and APTT is 90
(control 35). The best therapeutic option would be:
A) IVIg followed by steroids
B) Fondaparinux
C) Stop heparin and add aspirin to warfarin
D) Change to low molecular weight heparin

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21. A 59-year-old male presents with a 1 hour history of central crushing chest pain. He is
known to be diabetic, hypertensive and is a non-smoker. On examination his pulse rate is
90 beats/min, blood pressure 130/85 mmHg, S1 S2 are audible with no murmurs. There is
no evidence of cardiac failure. An ECG is performed. Which of the following would be an
indication for thrombolysis?
A ) Right bundle branch block
B ) Supraventricular tachycardia
C ) ST elevation of 2mm in V4-V6
D ) ST depression of 2mm in leads II,III, avF
E ) Atrial fibirillation >150min-1
22. A 46-year-old Caucasian woman complains of increasingly severe fatigue that she
believe emanates from poor sleep quality. Her husband notes that she moves frequently
during her sleep, and the patient notes that recently as she begins to ready herself for
sleep she has discomfort in her legs that is momentarily relieved by moving them. Each of
the following may be helpful in the treatment of this condition except?
A) Two month trial of ferrous sulfate
B) Stretching exercises before bedtime
C) A glass of red wine before bedtime
D) Gabapentin
E) Oxycodone 5–10 before bedtime
23. A 35-year-old woman complains of tingling and numbness of the little finger on the left
hand. On examination, you corroborate hypesthesia of the 5th finger and also all of the
ring finger, and you also find left-side weakness of flexion of fingers and wrist. The patient
is able to spread the fingers adequately. Which of the following diagnoses is likely to
account for these symptoms?
A) Ulnar nerve injury
B) Carpal tunnel syndrome
C) C6 nerve root compression
D) C7 nerve root compression
E) C8 nerve root compression
24. Characteristic features of Mitral valve prolapse include
A) Early systolic murmur at the apex
B) Mid-systolic click
C) Valve Replacement gives better results than Valve repair
D) A poor prognosis
E) Higher incidence in males
25. A known case of chronic obstructive pulmonary disease presents to A & E, distressed
and cyanosed. Arterial blood gases reveal a pH 7.2, PaO2 55 mmHg and PaCO2 60
mmHg. He is given high concentration oxygen together with a salbutamol nebulizer.
Intravenous hydrocortisone is also given. The patient becomes even worse with poorer
breathing effort although pulse oximetry showed SaO2 of 93%. What is the cause of
patient deterioration?
A) Constriction of bronchioles in response to salbutamol nebulizer
B) High concentration oxygen administration
C) Pulmonary artery relaxation causing mismatch between perfusion and ventilation
D) Pulmonary vein relaxation causing mismatch between perfusion and ventilation
E) Reaction to IV hydrocortisone
26. Which of the following is a recognised treatment for complications of cystic fibrosis?
A) DNAase to assist in reinflating collapsed lung segments
B) Hypotonic saline drinks for hypernatraemic dehydration

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C) Nebulised tobramycin for pseudomonas colonisation of the lower respiratory tract
D) Pancreatic transplant for diabetes mellitus
E) Rectal pull-through and anastamosis for rectal prolapse
27. A 45-year-old busy male attorney complains of headaches and generalized pruritus.
He flew into an eastern American city from Denver, Colorado, to attend a high-level legal
conference. He smokes 1 pack of cigarettes per day. He denies recent upper respiratory
tract infection, foci of specific pain, and urinary and GI symptoms. On examination, he
manifests a blood pressure of 160/105, a temperature of 98.6

F, a ruddy complexion, and splenomegaly and hepatomegaly. Blood gases are not
immediately available. His CBC showed the hemoglobin level to be 18 g/dL, the white
blood cell count to be 14,000, and the platelet count to be 7,00,000. Red blood cells are
normochromic and normocytic. The BUN level is 18 mg/dL and the creatinine level is 1.1
mg/dL. Urinalysis is within normal limits with a specific gravity of 1.015. Which of the
following is the diagnosis?
A) Polycythemia vera
B) Secondary polycythemia from altitude accommodation
C) Secondary polycythemia caused by chronic obstructive pulmonary disease
D) Spurious polycythemia from dehydration caused by air travel
E) Secondary polycythemia compensating for carboxyhemoglobin in a heavy smoker
28. A 26-year-old man has noted painless swelling in the left side of his neck.
Furthermore, he has noted afternoon chills and night sweats for several weeks. He has
stopped smoking because inhaling tobacco smoke makes him ill. Although he seldom
drinks alcohol, during the past week, he took a glass of wine and only then noted pain in
the swelling about the neck. Examination is unremarkable except for the neck,
which exhibits a firm irregular mass measuring approximately 3 cm 5 cm located in the left
anterior cervical region. The CBC and laboratory chemical battery are within normal limits.
Which of the following is the most likely significant cause of these symptoms?
A) Hodgkin disease
B) Sialoadenitis
C) Viral respiratory tract infection
D) Streptococcal pharyngitis
E) Carotid artery aneurysm
29. A 36-year-old male assembly line worker complains that 2 days ago, while hefting a
bucket of metal parts that slipped from his right hand while still grasping the other handle,
experiences sudden pain in the left side of his neck that radiates into the left lateral upper
arm into the thumb, associated with paresthesias in the thumb. Strength testing shows
that his left wrist extension is 3/5. Which of the following is the nerve root involved?
A) C5
B) C6
C) C7
D) C8
E) T1
30. A 55-year-old man is scheduled for abdomen CT with contrast. He has type 2
diabetes; well controlled with pioglitazone, metformin, and glimepride. On the day of the
procedure he is to receive nothing by mouth all morning except for medications until after
the procedure. Which of the following would be the most appropriate oral regimen on the
day of the procedure?
A) Continue all medications
B) Hold metformin, and continue glimepride and pioglitazone
C) Hold glimepride and metformin, and continue pioglitazone

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D) Hold glimepride and pioglitazone and decrease metformin dose by half
E) Hold metformin and pioglitazone, and continue glimepride

ANSWERS
1. B
2. D
3. E
4. E
5. A
6. E
7. B
8. E
9. E
10. C
11. D
12. D
13. B
14. E
15. D
16. A
17. D
18. B
19. D
20. B
21. C
22. C
23. E
24. B
25. B
26. C
27. A
28. A
29. B
30. C

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MULTIPLE CHOICE QUESTIONS 7
1. A 37-year-old woman with a history of intravenous drug use, hepatitis B, asthma, and
acquired immunodeficiency syndrome (AIDS) is admitted to the hospital because of fever,
night sweats, and malaise. Her last CD4 count was 1 month ago and measured 180/mm3.
Vital signs are: temperature 38.5 C (101.3 F), blood pressure 145/76 mm Hg, and pulse
90/min. Physical examination is significant for a soft diastolic murmur heard best at the
lower left sternal border. Auscultation of the lungs reveals diffuse rhonchi. The abdominal
and neurologic exams are unremarkable. The next step in managing this patient is
A) analysis and culture of spinal fluid
B) a blood culture
C) a CT of the head
D) a urinalysis
E) an x-ray of the chest
2. An 18-year-old man presents with pain in the right side of the neck, veering to the right,
and numbness on the right side of the face and in the left arm and leg that came on
acutely with lifting heavy weights. His examination shows right hemiataxia, right miosis
and ptosis, poor palatal elevation on the right, and decreased sensation to pinprick of the
right side of the face and the left arm and leg. To which of the following structures does
the lesion best localize?
A) Right lateral medulla
B) Left lateral medulla
C) Right cerebellum
D) Left midbrain
E) Central pons
3. A 78-year-old woman is admitted to the hospital because of a fever, productive cough,
and a chest x-ray demonstrating right lower lobe consolidation. Her past medical history is
significant for seasonal allergies. She has been taking estrogen/progesterone
replacement since menopause 19 years ago and occasional acetaminophen for
headaches. The patient lives alone at her home and she does not drink alcohol or smoke.
Review of systems is significant for weakness attributed to "old age". On the day prior to
discharge, a repeat chest x-ray shows the pneumonia to be resolving. An incidental note
is made of severe osteoporosis involving all of the bones visualized on the film. Vital signs
are temperature 38.8 C (101.8 F), blood pressure 100/50 mm Hg, pulse 90/min, and
respirations 10/min. Physical examination is significant only for decreased breath sounds
at the right lung base. The patient is neurologically intact and wants to return home.
Laboratory studies show a leukocyte count 15,000/mm3, hematocrit 28%, and platelets
150,000 mm3. The next step in the management of this patient is to
A) discharge her and do a bone marrow biopsy as an outpatient
B) discharge her and send her for a bone scan as an outpatient
C) discharge her and order serum protein electrophoresis as an outpatient
D) do a bone marrow biopsy before discharge
E) order a bone scan and serum protein electrophoresis before discharge
4. Eosinophilia is frequently seen with fever of unknown origin from all but 1 of the
following illnesses. Which illness is not frequently associated with eosinophilia?
A) Systemic lupus erythematosus (SLE)
B) Drug fever
C) Tuberculosis
D) Myeloproliferative disease
E) Polyarteritis nodosa (PAN)

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5. In a patient with a known Chiari I malformation, burning pain develops in both
shoulders. On examination, strength is normal in the limbs, but the sensation to pinprick is
reduced in a capelike distribution around the shoulders extending to the upper part of the
arms. To what structure does the lesion best localize?
A) Bilateral dorsal columns
B) Right lateral funiculus
C) Central spinal cord
D) Bilateral ventral funiculus
E) Bilateral ventral horns
6. A 33-year-old asymptomatic woman was referred because of abnormal ALT. History of
migraine headache for which she takes Sumatriptan. No risk factors or history of liver
disease. Examination is notable for obesity.AST 60, ALT 75, ALP , bilirubin , INR, iron
studies and albumin are normal. What would be the most appropriate next step ?
A) Observe and repeat ALT in 3 months
B) Ultrasound abdomen
C) Check viral markers
D) Liver biopsy
E) Stop Sumatriptan
7. A 63-year-old woman with 4 hour history of abdominal pain , fever and nausea. On
examination , patient has fever, jaundice and mild epigastric tenderness . TC 18000, with
shift to left, bilirubin elevated, ALP 150,(normal upto 125) AST 745 IU, ALT 650 IU, USG
multiple small stones in gall bladder, no bile duct dilatation , normal pancreas. Started on
antibiotics, but following day still has fever. Repeat labs bilirubin elevated, AST 284 IU,
ALT 200 IU, WBC 25000, blood culture positive for E.Coli. which of the following would
you advice next ?
A) Doppler of hepatic vessels
B) Lab cholecystectomy
C) MRCP
D) Endoscopic ultrasound
E) ERCP
8. A 18-year-old woman presents with acute onset of jaundice and somnolence. On
examination , jaundiced , sleepy but arousable. Labs INR 1.6, AST 240, ALT 210, total
bilirubin increased , mostly in direct, hemoglobin 9.4, ceruloplasmin 8ng/L(normal more
than 22), 24 hr urine copper 563mcg/L (normal less than 60).which of the following would
you advise now ?
A) Trientine
B) Penicillamine
C) Urgent liver transplantation
D) Intracranial pressure monitoring
E) Liver biopsy
9. Warfarin is administered to a 56-year-old man following placement of a prosthetic
cardiac valve. The warfarin dosage is adjusted to maintain an INR of 2.5. Subsequently,
trimethoprim-sulfamethoxazole therapy is begun for a recurring urinary tract infection. In
addition to monitoring prothrombin time, which of the following actions should the
physician take to maintain adequate anticoagulation?
A) Begin therapy with vitamin K
B) Increase the dosage of warfarin
C) Make no alterations in the dosage of warfarin
D) Decrease the dosage of warfarin
E) Stop the warfarin and change to low dose aspirin

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10. You are called emergently to the medical floor where a 66-year-old man was found to
be minimally responsive. His past medical history is unclear but his arm band lists
allergies to penicillin and sulfa medications. On arrival, chest compressions are being
performed and 2 operators are mask ventilating the patient. Evaluation with an
electrocardiogram reveals sinus tachycardia and the diagnosis of pulseless electrical
activity is made. Volume is infused and compressions are continued. The patient remains
apneic, so mask ventilation continues. During masking, the patient appears to regurgitate
large volumes of gastric contents. The most appropriate immediate next step in the
management of this patient is to
A) cease mask ventilation and suction the mouth
B) continue masking the patient
C) insert a nasogastric tube
D) intubate the trachea and suction the airway
E) intubate the trachea and ventilate
11. Which statement about evaluating a patient with fever of unknown origin (FUO) is
true?
A) Bone marrow cultures have a high yield when the fever is greater than 39 ° C and other
testing has been unrevealing.
B) A temporal artery biopsy is a reasonable test to perform next for a 75-year-old man
who has FUO and no localizing complaints, an erythrocyte sedimentation rate greater
than 100 mm/h, mild anemia, normal blood chemistry results, and negative blood cultures
at 3 days and who has not had any other evaluation.
C) Lumbar puncture should be done on every patient with FUO.
D) When there are no clues to the underlying diagnosis, extensive serologic testing for
unusual infections is often helpful.
E) Liver biopsy is unlikely to be helpful in a patient with FUO and miliary tuberculosis.
12. A 31-year-old man describes a burning sensation in the substernal area after eating
chocolates, caffeine, or alcohol. The symptoms are exacerbated at night, and he has
woken on several occasions from sleep because of coughing. He has tried over-the-
counter antacids and H2 receptor antagonists with little relief. He often takes antacids
before dinner. Which of the following is the most likely explanation for his symptoms of
coughing?
A) Acid-induced bronchoconstriction
B) Aspiration of antacids taken before bedtime
C) Aspiration of solid food ingested with dinner
D) H2 receptor antagonist-induced bronchoconstriction
E) Tracheoesophageal fistula
13. A 24-year-old lady at 10 weeks of gestation during her first pregnancy. She has had 2
days of nausea and mild fever. She vomited once this morning. On examination
jaundiced, with tender , mild hepatomegaly. Labs AST 56) IU, ALT 1150 IU, bilirubin
increased, platelets 140. most likely diagnosis
A) Hyperemesis gravidarum
B) Acute viral hepatitis
C) Acute cholecystitis
D) Intra hepatic cholestasis of pregnancy
E) Fatty liver of pregnancy
14. A 36-year-old male with alcoholic hepatitis. Which clinical or lab parameter is least
predictive of patient survival ?
A) Bilirubin
B) Prothrombin time
C) AST/ALT ratio

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D) Encephalopathy
E) Creatinine
15. A 64-year-old male executive with remote history of heavy alcohol use is noted to
have cirrhosis on liver biopsy. There are no varices detected on upper GI Endoscopy.
When would you recommend that the patient return for a repeat upper Endoscopy to
screen for esophageal varices ?
A) 6 months
B) 12 months
C) 18 months
D) 24 months
E) Never
16. Which of the following statements about pulmonary function during pregnancy is true?
A) Total lung capacity is reduced.
B) Functional residual capacity is reduced.
C) FEV1 /FVC ratio is reduced.
D) Lung compliance is reduced.
E) The single breath diffusing capacity for carbon monoxide is reduced.
17. Which one of the following is the commonest cause of death in SLE?
A) Infection
B) Cardiovascular disease
C) Lupus nephritis
D) Cerebral lupus
E) Thromboembolism
18. Each of the following is a solid indication for neuroimaging in a patient with headache
EXCEPT:
A) Onset of headaches over the age of 50 years
B) Seizures associated
C) Prolonged aura
D) Nausea and vomiting
E) Headache worsening with movement
19. A lady is newly diagnosed with osteoporosis. She has never been on treatment. Which
one of the following is the first-line treatment?
A) Alendronic acid
B) Etidronate
C) Risedronate
D) Strontium ranelate
E) Zoledronate
20. A 48 year-old lady is referred to the rheumatology outpatient clinic with a 4-month
history of fatigue, aches and weakness of her thighs.She has a past medical history of
hypercholesterolaemia and is on simvastatin. On examination she has normal muscle
bulk. Active hip flexion was reduced. Neurological examination was otherwise normal.
Investigations:
Hb 98 g/L (115–165)
WCC 12.0 × 109 /L (4.0–11.0)
Platelets 400 × 109/L (150–400)
Plasma viscosity 2.0 (1.5–1.72)
Creatine kinase 15000 IU/L
The diagnosis is likely to be which one of the following?
A) Polymyalgia rheumatica
B) Statin-induced myopathy

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C) Polymyositis
D) Dermatomyositis
E) Hip osteoarthritis
21. A 78-year-old man has collapsed several hours ago and been found on the floor by
the paramedics. He was found to be hypothermic at 32°C. His creatinine kinase is 10,000
IU. His serum potassium is 5mmol/L, urea is 20mmol/L and creatinine is 300μmol/L.
The most important form of initial treatment should be:
A) Intravenous infusion of warmed crystalloid.
B) Active warming.
C) Intravenous administration of mannitol 0.25-0.5g/kg.
D) Intravenous furosemide.
E) Urgent haemodialysis.
22. A 25-year-old woman with a history of epilepsy presents to the emergency room with
impaired attention and unsteadiness of gait. Her phenytoin level is 37. She has white
blood cells in her urine and has a mildly elevated TSH. Examination of the eyes would be
most likely to show which of the following?
A) Weakness of abduction of the left eye
B) Lateral beating movements of the eyes
C) Impaired convergence
D) Papilledema
E) Impaired upward gaze
23. A 35-year-old female is referred for evaluation of positive antinuclear antibodies
(ANA). She is asymptomatic. Her lab work reveals ANA 1:320 homogeneous pattern;
extractable nuclear antigens are negative. Hematologic and renal function values are
normal and urinalysis is without sediment. Her examination is unremarkable apart from a
smooth nontender goiter. The past medical history is significant for Hashimoto’s
thyroiditis. No rash, synovitis, or serositis is observed. What further treatment or
investigations are warranted?
A) Start prednisolone 40 mg daily
B) Start prednisolone 20 mg daily
C) Repeat ANA test
D) Start hydroxychloroquine
E) No further intervention is warranted
24. A 41-year-old man is diagnosed with iron deficiency anemia and is found to have
heme-positive stools. Colonoscopy reveals a large ulcerated tumor in his transverse
colon. He also has two smaller polyps in his ascending colon. Pathologic examination of
the tumor biopsy reveals adenocarcinoma, while biopsies of the polyps confirm that these
are adenomas. His sister has been diagnosed with uterine cancer, and two cousins have
died of colon cancer. All of the following are true statements about this case except
A) Referral for genetic counseling is indicated
B) He is at increased risk for other epithelial-derived tumors
C) He likely has familial adenomatous polyposis (FAP), with a germ line mutation in the
APC gene
D) His condition is often associated with a defect in DNA mismatch repair
25. A 60-year-old man presents with abdominal pain and a cupful of haematemesis. On
examination he is noted to have ascites, hepatomegaly and a very enlarged spleen
extending to the right iliac fossa. His initial blood tests reveal a leukoerythroblastic picture
with a haemoglobin of 8, white cell count (WCC) of 3 and platelets of 120. A diagnosis of
myelofibrosis is made. What is most likely to be seen on the peripheral blood smear?
A) Schistocytosis

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B) Sickle cells
C) Spherocytes
D) Dacrocytes
E) Target cells
26. All the following conditions are associated with high output heart failure EXCEPT
A) Iron overload
B) Hyperthyroidism
C) Systemic arteriovenous fistula
D) Thiamine deficiency
E) Paget disease
27. Primary prophylaxis to prevent acute infection in susceptible patients is recommended
for all the following HIV Infected patients EXCEPT
A) Pneumocystis jiroveci (formerly carinii) pneumonia.
B) Disseminated Mycobacterium avium complex.
C) Mucocutaneous candidiasis.
D) Malaria for persons traveling to areas where malaria is endemic.
E) Toxoplasma gondii encephalitis.
28. A 30-year-old male with Alports and gradually worsening renal dysfunction has
reached ESRF and is on hemodialysis. His family is being evaluated for donation for renal
transplant. His 57 year old mother and one aunt have microscopic hematuria but normal
renal functions. Two of his uncles also have ESRD and are on dialysis. He has a 40
brother with normal urine analysis, a 38 year old sister with normal urine analysis and a 25
year old sister with microscopic hematuria, all with normal renal function.
Which of the following can most safely donate kidney for this patient?
A) Brother as he has extremely low probability of having Alports.
B) Sister with normal urine analysis, as she has no probability of having Alports.
C) Sister with microscopic hematuria as she is younger.
D) Mother
E) None of family members should be taken as donor.
29. A 48-year old female with rheumatoid arthritis presents to the emergency department
with 2-week pain and tightness behind the left knee. Examination reveals cystic swelling
over the left popliteal fossa. Which of the following is the most appropriate next action?
A) Arthrogram of the left knee
B) Synovial biopsy of left knee
C) Ultrasound study of left knee and popliteal fossa
D) Venogram of left lower limb
E) None of the above
30. A 37-year-old woman is admitted to accident and emergency with severe facial burns.
Despite prompt management, she develops acute respiratory distress syndrome (ARDS).
Which of the following is not associated with the diagnostic criteria for ARDS?
A) Bilateral infiltrates on chest x-ray
B) Acute onset
C) Pulmonary capillary wedge pressure >19
D) Refractory hypoxemia (PaO2:FiO2 <200)
E) Lack of clinical congestive heart failure

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ANSWERS
1. E
2. A
3. C
4. C
5. C
6. A
7. E
8. C
9. D
10. D
11. B
12. A
13. B
14. C
15. D
16. B
17. A
18. D
19. A
20. C
21. A
22. B
23. E
24. C
25. D
26. A
27. C
28. B
29. C
30. C

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MULTIPLE CHOICE QUESTIONS 8
1. A 24-year-old Asian man presents to his family physician with one episode of painless
gross hematuria. He is otherwise healthy with no significant family history. On physical
examination, his blood pressure is normal and there are no other abnormalities.
Laboratory examination shows a normal metabolic profile, hemogram, liver enzymes, and
renal function tests, as well as a negative urine culture. Serologic tests including
complement evels, antinuclear antibody, antineutrophil cytoplasmic antibody, and a
hepatitis panel are all negative. Urine examinations show 3+ blood, 3+ protein, and many
RBCs and RBC casts on microscopic examination. His renal ultrasound is normal. A
repeat physical examination and laboratory tests after 1 week show 1+ heme, 5 to 10
RBCs, and trace urinary protein, which quantitates to 150 mg/day. Your recommendation
at this point should be:
A) Continue observation.
B) Renal biopsy.
C) Empiric therapy with alternate day steroids.
D) Genetic testing for patient and his family.
E) Urology referral.
2. A 69-year-old man presents with confusion. His carers state that over the last month he
has become increasingly lethargic, irritable and confused. Despite maintaining a good
appetite, he has lost 10 kg in the last month. Blood results are as follows:
Sodium 125 mmol/L
Potassium 4 mmol/L
Urea 3
Glucose (fasting) 6 mmol/L
Urine osmolality 343 mmol/L
The most likely diagnosis is:
A) Hypothyroidism
B) Dilutional hyponatraemia
C) Addison’s disease
D) Acute tubulointerstitial nephritis
E) Syndrome of inappropriate anti-diuretic hormone (SIADH)
3. You see a 19-year-old Caucasian man in your clinic who presents with a history of
transient jaundice. On direct questioning, you ascertain that the jaundice is noticeable
after periods of increased physical activity and subsides after a few days. The patient has
no other symptoms and physical examination is unremarkable. Full blood count is normal
(with a normal reticulocyte count) and liver function tests reveal a bilirubin of 37 μmol/L.
The most appropriate management is:
A) Reassure and discharge
B) Start on a course of oral steroids
C) Request abdominal ultrasound
D) Request MRCP
E) Refer to Hematology
4. A 60-year-old man presented with epigastric and right hypochondrial pain associated
with nausea, vomiting and fever. He consumed alcohol almost daily for the last 30 years.
He recalled that a surgeon had previously suggested a gall bladder surgery but he did
refused to have it. On exam: temp. 38°C, B.P. 120/70, pulse 100/min. Sclerae were
yellow. He had eight spider nevi on his upper body. Chest and heart exam were normal.
Abdomen was tender in the right upper quadrant but no mass was palpable. There was no
detectable ascites and rectal examination was unremarkable. Hemoglobin 14.2, WBC

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count 17,000, Platelets 110,000, Serum albumin 30 g/L, total bilirubin 70 (1-22), ALT 70 (<
40), alkaline phosphatase 500 U/L (45-105), amylase 100 U/L (60-180), INR 1.5 What is
the likely diagnosis?
A) Cholangitis
B) Acute on chronic pancreatitis
C) Alcoholic hepatitis
D) Acute cholecystitis
E) Empyema of the gall bladder
5. A 45-year-old man collapses at home and is brought to accident and emergency. He
has a fever at 39.5°C and blood pressure is 90/60 mmHg, although he is in a lucid state.
Bruises can be seen on his skin which he remembers being present before he fell. Blood
tests show the patient to have a normocytic anaemia with a low platelet count and
increased fibrin split products. The most likely diagnosis is:
A) Warm autoimmune haemolytic anaemia
B) Cold autoimmune haemolytic anaemia
C) Paroxysmal nocturnal haemoglobinuria
D) Disseminated intravascular coagulation
E) Thalassaemia minor
6. A 40-year-old man with cryptogenic liver cirrhosis presents with acute onset of
confusion. His wife reports that over the last few days his abdomen has become
increasingly distended, however she is more concerned about him being disoriented to
time and place. He takes spironolactone 100 mg daily, furosemide 40 mg bid and
lactulose 10 mg bid. Exam: He is confused to time and place and is afebrile. Icteric
sclerae , spider nevi and asterixis . There is tense ascites with distended abdominal veins
is also noted. WBC count 10,200, Hemoglobin 10.5, Platelets 35,000, INR 1.7, Serum
sodium 128, Serum creatinine 90, ALT 60 What should be the next step?
A) Abdominal paracentesis
B) CT-scan of the brain
C) Start IV cefotaxime
D) Start oral neomycin
E) Increase dose of diuretics
7. A 62-year-old woman presents to accident and emergency with a 1-day history of
sudden onset back pain and difficulty walking. She has not opened her bowels or passed
urine for the previous day. She has a past medical history of breast cancer, diagnosed two
years earlier and staged as T2N1M0 disease with oestrogen receptor positive status. She
has been treated for her cancer with a wide local excision and axillary node clearance,
followed by radiotherapy, chemotherapy and tamoxifen. On examination, there is reduced
tone in the lower limbs. Power is diminished throughout the lower limbs, but especially on
hip flexion. There is reduced sensation below the L1 dermatome. What is the most
appropriate diagnostic investigation?
A) A full set of bloods, including bone profile
B) Computed tomography (CT) thorax, abdomen and pelvis
C) Magnetic resonance imaging (MRI) spine
D) Bone scan
E) Positron emission tomography (PET) CT
8. A 35-year-old woman comes to your clinic complaining of shortness of breath. It is
immediately apparent that she has a bluish tinge of her face, trunk, extremities, and
mucus membranes. Which of the following is most likely?
A) Atrial septal defect
B) Myocarditis
C) Raynaud’s phenomenon

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D) Vasospasm due to cold temperature
E) Connective tissue disease
9. A 50-year-old woman, who has received a recent diagnosis of rheumatoid arthritis,
presents to her GP with ongoing pain and stiffness in her hands and feet. Which joints are
usually spared at onset of rheumatoid arthritis?
A) Proximal interphalangeal joints
B) Distal interphalangeal joints
C) Metacarpophalangeal joints
D) Wrists
E) Metatarsophalangeal joints
10. A 45-year-old woman with unexpected weight loss, loss of appetite and shortness of
breath presents to you in clinic. On examination, there is reduced air entry and dullness to
percussion in the right lung. A pleural tap is performed and the aspirate samples sent for
analysis. You are told that the results reveal a protein content of >30 g/L. From the list
below, select the most likely diagnosis:
A) Bronchogenic carcinoma
B) Congestive cardiac failure
C) Liver cirrhosis
D) Nephrotic syndrome
E) Meig’s syndrome
11. A 79-year-old woman presents to her GP with pain in the left knee. This is particularly
bad in the evenings and is stopping her from sleeping. The GP explains that her
discomfort is most likely due to osteoarthritis and arranges for her to have
an x-ray of the knee. Which of the following descriptions are most likely to describe the x-
ray?
A) Reduced joint space, subchondral sclerosis, bone cysts and osteophytes
B) Increased joint space, subchondral sclerosis, bone cysts and osteophytes
C) Reduced joint space, soft tissue swelling and peri-articular osteopenia
D) Increased joint space, soft tissue swelling and peri-articular osteopenia
E) Normal x-ray
12. A 52-year-old man is referred for newly diagnosed diabetes. He reports a two month
history of polyuria and polydipsia. He has no past history of note and was not taking any
regular medications, although he reports recent weak erections. On examination, liver
edge is palpable 2 cm below the right costal margin and his testes are found to be small.
HbA1c 10.8, Hemoglobin15.1 g/dL, Platelets 341 x109/L, Serum iron 50 µmol/L (12-30),
Transferrin saturation 85% (<50%). Which investigation is most likely to assist in making a
diagnosis?
A) Genetic analysis for C282Y and H63D mutations
B) Red cell transketolase
C) Serum ferritin
D) Total iron binding capacity (TIBC)
E) Ultrasound of the abdomen
13. A 49-year-old man complains of sudden onset, painless unilateral visual loss lasting
about a minute. He describes ‘a black curtain coming down’. His blood pressure is 158/90,
heart rate 73 bpm. There is an audible bruit on auscultation of his neck. His past medical
history is insignificant other than deep vein thrombosis of his right leg ten years ago. The
most likely diagnosis is:
A) Retinal vein thrombosis
B) Retinal artery occlusion
C) Amaurosis fugax

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D) Optic neuritis
E) Acute angle glaucoma
14. A 69-year-old man present with a 2-week history of abdominal pain which has
worsened over the last few days. On examination, the patient is jaundiced and the
abdomen is distended with tenderness in the epigastric region. In addition, there is a
smooth hepatomegaly and shifting dullness. Which of the following is a cause of
hepatomegaly?
A) Iron deficiency anaemia
B) Budd–Chiari syndrome
C) Ulcerative colitis
D) Crohn’s disease
E) Left-sided heart failure
15. A 79-year-old woman is admitted to the coronary care unit (CCU) with unstable
angina. She is started on appropriate medication to reduce her cardiac risk. She is
hypertensive, fasting glucose is normal and cholesterol is 5.2. She is found to be in atrial
fibrillation. What is the most appropriate treatment?
A) Aspirin and clopidogrel
B) Digoxin
C) Cardioversion
D) Aspirin alone
E) Warfarin
16. A 53-year-old healthy man was found to have a fasting plasma glucose of 7.3 mmol.
Further testing showed HbA1c of 6.2. What should be done next?
A) Repeat HbA1c
B) Repeat fasting glucose
C) Advise home glucose monitoring
D) lifestyle changes, repeat all tests in 3 months
E) Measure 2-hour postprandial glucose
17. A 66-year-old woman presents to accident and emergency with a 2-day history of
shortness of breath. The patient notes becoming progressively short of breath as well as a
sharp pain in the right side of the chest which is most painful when taking a deep breath.
The patient also complains of mild pain in the right leg, though there is nothing significant
on full cardiovascular and respiratory examination. Heart rate is 96 and respiratory rate is
12. The patient denies any weight loss or long haul flights but mentions undergoing a
nasal polypectomy 3 weeks ago. The most likely diagnosis is:
A) Muscular strain
B) Heart failure
C) Pneumothorax
D) Angina
E) Pulmonary embolism
18. A 78-year-old woman is admitted with heart failure. The underlying cause is
determined to be aortic stenosis. Which sign is most likely to be present?
A) Pleural effusion on chest x-ray
B) Raised jugular venous pressure (JVP)
C) Bilateral pedal oedema
D) Bibasal crepitations
E) Atrial fibrillation
19. A 22-year-old woman complains of dizziness and feeling light-headed. She works in
an office and most frequently experiences this when standing up to visit the toilet. She has
never fainted. The patient has lost 5 kg, but attributes this to eating more healthily. She

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has noticed a recent scar on the back of her hand which has started to turn very dark. The
most appropriate investigation is:
A) Synacthen test
B) Low-dose dexamethasone test
C) Cortisol measurement
D) Urinary free cortisol measurement
E) Abdominal ultrasound (US) scan
20. A 71-year-old man with atrial fibrillation is seen in clinic following an episode of
syncope. He describes getting a poor night’s sleep and, as he got out of bed in the
morning, feeling dizzy for a couple of seconds before the lights dimmed around him. He
was woken a couple of seconds later by his wife who had witnessed the event. She says
he went pale and fell to the floor and his arms and legs jerked. After waking, he was
shaken but was ‘back to normal’ a few minutes after the event. His medication includes
aspirin, atenolol and frusemide. What is the most likely diagnosis?
A) Vasovagal syncope
B) Orthostatic hypotension
C) Cardiogenic syncope
D) Transient ischaemic attack (TIA)
E) Seizure
21. A 29-year-old man presents with a 4-week history of polyuria and extreme thirst. The
patient denies difficulty voiding, hesitancy or haematuria, although the urine is very dilute.
The patient does not believe he has lost any weight and maintains a good diet. No
findings are found on urine dipstick. The most appropriate investigation is:
A) Serum osmolality
B) Fasting plasma glucose
C) Urinary electrolytes
D) Magnetic resonance imaging (MRI) scan of the head
E) Water deprivation test
22. You are discussing a patient with your registrar who has become acutely short of
breath on the ward. After performing an arterial blood gas, you have high clinical suspicion
that the patient has a pulmonary embolism. Which of the following is the investigation of
choice for detecting pulmonary embolism?
A) Magnetic resonance imaging (MRI) of the chest
B) High-resolution CT chest (HRCT)
C) Chest x-ray
D) Ventilation/perfusion scan (V/Q scan)
E) CT pulmonary angiogram (CT-Pa)
23. A patient is admitted with pneumonia. A murmur is heard on examination. What
finding points to mitral regurgitation?
A) Murmur louder on inspiration
B) Murmur louder with patient in left lateral position
C) Murmur louder over the right 2nd intercostal space midclavicular line
D) Corrigan’s sign
E) Narrow pulse pressure
24. A 43-year-old woman suffers from Crohn’s disease. A blood test shows the following
results:
Haemoglobin 10.5 g/dL
MCV 120 fL
Platelet count 300× 109/L
The most likely diagnosis is:

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A) Vitamin B12 deficiency
B) Iron deficiency
C) Hypothyroidism
D) Folic acid deficiency
E) Anaemia of chronic disease
25. A 27-year-old woman develops left leg swelling during week 20 of her pregnancy. Left
lower extremity ultrasonogram reveals a left iliac vein deep vein thrombosis. What is the
best next step?
A) bed rest
B) catheter-directed thrombolysis
C) enoxaparin
D) inferior vena cava filter placement
E) Repeat doppler U/S after 1 week
26. A 67-year-old woman is admitted to accident and emergency with pyrexia (38.1°C)
and a cough productive of green sputum. The observations show a pulse rate of 101, BP
80/60 and respiratory rate of 32. She is alert and orientated in space and time. Blood
results reveal a WCC of 21, urea of 8.5 and chest x-ray shows a patch of consolidation in
the lower zone of the right lung. She is treated for severe community-acquired pneumonia.
Which of the following is the correct calculated CURB-65 score?
A) 6
B) 8
C) 4
D) 0
E) 1
27. A 69-year-old man presents to clinic with a six-month history of progressive lower
back pain which radiates down to his buttock. He found the pain was exacerbated while
taking his daily morning walk and noticed that it eased going uphill but worsened downhill.
He stopped his daily walks as a result and he now walks only slowly to the shops when he
needs to, taking breaks to sit down and ease the pain. He has a history of hypertension,
diabetes and prostatic hyperplasia. What is the diagnosis?
A) Peripheral vascular disease
B) Osteoporotic fracture
C) Spinal stenosis
D) Sciatica
E) Metastatic bone disease
28. A 47-year-old woman is evaluated for difficult-to-control hypertension. She was
previously treated for hypokalemia. On physical examination, temperature is 36.0 °C
(96.8°F), blood pressure is 178/100 mm Hg, pulse rate is 58/min, respiration rate is
16/min, and BMI is 29. No abdominal bruit is detected. Funduscopic examination shows
mild arteriolar narrowing. Laboratory studies:
Electrolytes
Sodium 143 meq/L (143 mmol/L)
Potassium 3.5 meq/L (3.5 mmol/L) (after replacement
therapy)
Chloride 101 meq/L (101 mmol/L)
Bicarbonate 33 meq/L (33 mmol/L)
Aldosterone
Baseline 23 ng/dL (635 pmol/L)
3 Days after high salt intake 15 ng/dL (414 pmol/L)
Renin activity
Baseline <0.1 ng/mL/h (0.1 μg/L/h)

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3 Days after high salt intake <0.1 ng/mL/h (0.1 μg/L/h)
Aldosterone to renin activity ratio >50
Which of the following is the most appropriate next step in management?
A) Adrenalectomy
B) Bilateral adrenal vein catheterization
C) CT of the adrenal glands
D) Duplex ultrasonography of the renal arteries
29. Decreased or absent haptoglobin levels are seen in the following conditions EXCEPT
A) Hemolytic anemia
B) Genetic disorders
C) Acute hepatitis
D) Pregnancy
E) Burns
30. A 41-year-old man is diagnosed with iron deficiency anemia and is found to have
heme-positive stools. Colonoscopy reveals a large ulcerated tumor in his transverse
colon. He also has two smaller polyps in his ascending colon. Pathologic examination of
the tumor biopsy reveals adenocarcinoma, while biopsies of the polyps confirm that these
are adenomas. His sister has been diagnosed with
uterine cancer, and two cousins have died of colon cancer. All of the following are true
statements about this case except
A. Referral for genetic counseling is indicated
B. He is at increased risk for other epithelial-derived tumors
C. He likely has familial adenomatous polyposis (FAP), with a germ line mutation in the
APC gene
D. His condition is often associated with a defect in DNA mismatch repair

ANSWERS
1. A
2. E
3. A
4. A
5. D
6. A
7. C
8. A
9. B
10. A
11. A
12. A
13. C
14. B
15. E

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16. B
17. E
18. D
19. A
20. B
21. E
22. E
23. B
24. A
25. E
26. C
27. C
28. C
29. C
30. B

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