2011 - 7th

Question 1

Which of the following is true regarding hypokalemia?
a. It can be accompanied by the development of U wave on ECG
b. It is associated with metabolic acidosis
c. It can happen in the setting of mineralocorticoid deficiency
d. It is a known side effect of spironolactone
e. It can be counteracted by administration of loop diuretics

Answer 1

a. It can be accompanied by the development of U wave on ECG
Note: The typical triad of ECG findings in hypokalemia is the presence of a U wave, flattening of the T wave and occasional ST depression.

Question 2

A 52-year-old male patient with history of ischemic heart disease underwent a cardiac surgery where an intra-operative coronary angiography was performed as well. He was started on two antibiotics following the surgery. Two days after, the patient was found to have a marked increase in serum creatinine. He was afebrile and vitally stable. Which of the following is the likely diagnosis in this patient?
a. Contrast-induced nephropathy
b. Aminoglycoside toxicity
c. Tubulointerstitial nephritis
d. Ischemic acute tubular necrosis
e. Sepsis

Answer 2

a. Contrast-induced nephropathy
Note: Toxic acute tubular necrosis can be commonly caused by administration of contrast or nephrotoxic medications like aminoglycosides. Contrast-induced nephropathy is characterized by a 25% or 44 μmol/L increase in serum creatinine within 48 to 72 hours of contrast administration. Aminoglycoside toxicity, on the other hand, typically manifests 5 to 7 days after drug administration.

Question 3

What clinical finding helps to differentiate between diffuse and limited scleroderma?
* Skin thickening of the anterior chest wall
* Nail infarcts
* Dysphagia
* Pulmonary fibrosis
* Raynaud’s phenomenon

Answer 3

• Skin thickening of the anterior chest wall
  Note: In patients with scleroderma, if the skin thickening extends only to the elbows and face, it is termed limited scleroderma. If it extends above the wrists to the arms, legs or trunk, it is termed diffuse scleroderma. The finding of chest skin tightness is also called the

Question 4

A 54-year-old female patient, who is otherwise asymptomatic, was found to have a platelet count of 41,000/ml (normal: 150,000-400,000). Her hemoglobin is 13.7 g/dL and white blood cell count is 6.4 x109 (normal: 4-10 x109). Her PT and APTT were found normal. Which of the following is a possible cause of this patient’s thrombocytopenia?
a. Adverse reaction to a new antibiotic
b. Antiphospholipid syndrome
c. Lymphoproliferative disorder
d. Myelodysplastic bone marrow
e. Fanconi syndrome

Answer 4

a. Adverse reaction to a new antibiotic

Note: Antibiotics can commonly cause drug-induced thrombocytopenia. Examples include vancomycin, penicillin, linezolid and sulfonamides. This most likely takes place in an immune-mediated mechanism or through bone marrow suppression.

Question 5

54-year-old male patient presented to the ER with right-sided weakness of the upper limb and facial asymmetry. He was brought by ambulance 30 minutes after the onset of symptoms. A CT scan of the head was done and showed no evidence of cerebral hemorrhage. The patient was interviewed and shown to have no contraindications for thrombolytic therapy. How should this patient be treated? A. Administer dabigatran
B. Give aspirin
C. Start clopidogrel D. Initiate heparin E. Administer tPA

Answer 5

E. Administer tPA

Question 6

Which of the following is true regarding a patient with blood group AB who needs plasma transfusion?
a. He should only receive it from donors with blood group AB
b. He should only receive it from donors with blood group O
c. He should only receive it from donors with blood group AB and O
d. He should only receive it from donors with blood group AB and A
e. He can receive from donors with any blood group

Answer 6

a. He should only receive it from donors with blood group AB

Question 7

A 36-year-old obese male was found to have a blood glucose reading of 11.1 mmol/L after oral glucose tolerance test. On examination, the patient had a high BMI and acanthosis nigricans at the nape of his neck. The patient is worried of having diabetes mellitus as his father had it since the age of 13. What does this patient most likely have?
A.Maturity-onset diabetes of the young (MODY)
B. Type 1 diabetes mellitus
C. Pre-diabetes
D. Type 2 diabetes mellitus
E. Late autoimmune diabetes of adults (LADA)

Answer 7

D. Type 2 diabetes mellitus

Question 8

A 28-year-old female patient complains of three-month history of dry cough. The patient denies any chest pain or shortness of breath. The patient reported occasional fever and malaise. Lower limb examination reveals tender erythematous nodules most compatible with erythema nodosum. A chest x-ray was done and showed bilateral hilar enlargement with no evidence of pulmonary infiltrates or opacities. When further examined, the patient was noted to have bilateral red eyes. What is the ocular lesion in this patient likely to be?
a. Uveitis
b. Conjunctivitis c. Keratitis
d. Episcleritis
e. Scleritis

Answer 8

a. Uveitis
Note: Bilateral granulomatous uveitis is the most common form of ocular sarcoidosis. This can occur in isolation or in the setting of Heerfordt-Waldenström syndrome, also called uveoparotid fever, which is characterized by the presence of parotid gland enlargement, facial nerve palsy, fever in addition to anterior uveitis.

Question 9

A 58-year-old woman is a known case of chronic kidney disease on dialysis. Biochemical investigations showed low serum calcium, elevated parathyroid hormone, elevated alkaline phosphatase and elevated phosphate levels. What skeletal abnormality is likely to be found on bone x-ray of this patient?
a. Rugger jersey spine
b. Dense lesions in the long bones
c. Hair-on-end appearance
d. Lumbar syndesmophytes
e. Cotton-wool appearance of the skull

Answer 9

a. Rugger jersey spine
Note: Longstanding hyperparathyroidism that accompanies chronic kidney disease eventually causes increased bone density (osteoslcerosis), seen particularly in the spine, where alternating bands of sclerotic and porotic bone give rise to a characteristic rugger jersey appearance on x- ray. This happens when osteoblasts increasingly lay down osteoid in an attempt to counteract PTH-mediated bone resorption.

Question 10

16)A 64 year old gentleman has symptoms of chest pain and fatiguability .On examination, the patient was tachycardic with a bounding pulse and had a wide pulse pressure .Neck examination shows a normal JVP but prominent carotid pulsations. The apex was thrusting in a nature and palpated in sixth intercostal space mid auxiliary line. What is expected to be heard on chest auscultation?
A)early diastolic murmur b)Loud SI
C)Opening snap
D)Mid-systolic click
E)Ejection systolic murmur at right sternal border.

Answer 10

A)early diastolic murmu

Question 11

A 31-year-old lady reports symptoms of fatiguability and diplopia. On examination, the patient was found to have bilateral ptosis and decreased muscle power. She said that her fatiguability gets worse towards the end of the day. What is the likely diagnosis?
A. Multiple sclerosis
B. Functioning pituitary adenoma C. Horner syndrome
D. Oculomotor nerve palsy
E. Myasthenia gravis

Answer 11

E. Myasthenia gravis

MG is an autoimmune disease of the NMJ caused by Ab that attack components of
the postsynaptic membrane, impair neuromuscular transmission, and lead to
weakness and fatigue of skeletal muscle.

Question 12

A 61-year-old man presents to the emergency department with an episode of massive lower gastrointestinal bleeding. The patient was started on IV fluids and stabilized soon after. When reassessed, the patient was vitally stable and the bleeding has already stopped. He didn’t have abdominal tenderness or masses on examination. How should this patient be further managed?
* Colonoscopy
* Upper endoscopy
* Obtain a surgical consult
* Discharge the patient after reassurance * Arrange for a CT of the abdomen

Answer 12

• Colonoscopy

Question 13

A 21-year-old man has a history of type 1 diabetes mellitus since childhood. He now presents with fatigue and muscle weakness. Investigations were ordered and came back as follows: Calcium 2.09 mmol/L (normal: 2.2-2.67), phosphate 0.98 mmol/L (normal: 1.12-1.45), serum 25-hydroxy vitamin D 12 ng/mL (normal: 25-80) and alkaline phosphatase 325 U/L (normal: 30- 115). What is likely to be found in this patient?
* Transglutaminase antibodies
* Excessive urine calcium excretion
* Low parathyroid hormone level * Increased bone mineral density * Increased serum ferritin

Answer 13

• Transglutaminase antibodies
  Note: Vitamin D deficiency that complicates celiac disease is primarily caused by malabsorption, resulting in hypocalcemia. In addition, calcium absorption is further decreased by the defective enterocytes due to the underlying inflammatory process in the proximal small bowel, where calcium is mainly absorbed. Additional lab findings of vitamin D deficiency include low urine calcium excretion and elevated PTH level.

Question 14

A 57-year-old man presents with headache and scalp tenderness. He says he cannot even comb his hair due to pain. Visual acuity in the right eye was decreased, but fundoscopy was normal. ESR was found to be markedly elevated. What is the likely diagnosis?
* Giant cell arteritis
* Carotid artery dissection
* Trigeminal neuralgia
* Amaurosis fugax
* Idiopathic intracranial hypertension

Answer 14

• Giant cell arteritis

Question 15

A 36-year-old previously healthy philippino male patient who works as a salesman now presents with fever, cough and chest pain. On examination, he was found tachypnic. A PPD test was done with a result of 18 mm. Chest imaging shows the presence of a mild unilateral pleural effusion that resolved spontaneously few days after. What is the likely diagnosis in this patient?
a. Tuberculous effusion
b. Parapneumonic effusion
c. Malignant effusion
d. V olume overload
e. Pulmonary embolism

Answer 15

a. Tuberculous effusion
Note: Tuberculous pleural effusion usually manifests as an acute illness, especially in younger patients who are more immunocompetent. The typical presentation is with cough, pleuritic chest pain and fever. Factors that are in favor of this diagnosis in this patient are his ethnicity, positive PPD test and the self-limited natural course. However, it typically resolves within weeks to months rather than days.

Question 16

A13-year-old girl was admitted with symptoms of epigastric pain and severe vomiting. When initially assessed, she looked very ill and had dry mucous
membranes. She was tachycardic and confused most of the time. Initial investigations came back as follows: serum glucose: 17.4 mmol/L, hematocrit: 50%, urine ketones: positive. Which of the following would accurately reflect her metabolic profile?
A. Low pH, elevated anion gap, low bicarbonate
B. Low pH, normal anion gap, low bicarbonate
C. High pH, normal anion gap, low bicarbonate
D. Low pH, elevated anion gap, high bicarbonate
E. High pH, elevated anion gap, high bicarbonate

Answer 16

A. Low pH, elevated anion gap, low bicarbonate

Question 17

12)a 27 years old female suddenly loses consciousness after a blood sample was taken from her for a laboratory test ,She regained her consciousness soon after and was generally well .Her laboratory tests were unrevealing immediately after the attack.An
ECG and echocardiogram were performed and come back normal . Holter monitoring was also conducted without an abnormalities detected. What is the most likelv diagnosis in this patient?
A) Vasovagal syncope
B)cardiac syncope
C) Transient ischemic attack
D)orthostatic hypotension

Answer 17

A) Vasovagal syncope

Question 18

52-year-old gentleman develops acute onset of nausea and vertigo accompanied by dysarthria and unilateral facial numbness. On examination, decreased pain and temperature sensation were documented on the right side of the face. The patient was also found to have nystagmus and a constricted pupil. What is the likely diagnosis in this patient?
A. Internal capsule stroke.
B. Carotid artery dissection
C. Lateral medullary syndrome
D. Basal ganglia hemorrhage
E. Pituitary macroadenoma

Answer 18

C. Lateral medullary syndrome

Question 19

3)A 46 year old hypertensive male patient presents to the emergency department with severe pain in the interscapular region .What is the most important differential diagnosis to exclude in a patient with such presentation?
1)Aortic dissection
2)MI
3)Acute costochondritis
4)Pericarditis
5) Spinal cord compression

Answer 19

1)Aortic dissection

Question 20

A 44-year-old man has been in the medical ward for two weeks for a chest infection. He was noted to have lower limb swelling and erythema. In the evening, he desaturated and became short of breath. His blood pressure was 112/71 mmHg. ECG showed sinus tachycardia. How should this patient be managed?
a. Initiate therapeutic dose of warfarin
b. Insert an IVC filter
c. Thrombolytic therapy
d. Low molecular weight heparin
e. Angiography

Answer 20

d. Low molecular weight heparin

Question 21

A young child was admitted with prominent generalized edema following a viral illness. The patient was found to have heavy proteinuria and was labeled as a case of nephrotic syndrome. Given the patient’s clinical examination and preliminary investigations, the senior physician suggests minimal change disease as the underlying cause. What is expected to be found under light microscopy in this patient?
a. No abnormality
b. Effacement of foot processes
c. Thickening of the basement membrane
d. Crescent formation
e. Subepithelial deposits

Answer 21

a. No abnormality

Question 22

What is the most common cause of toxic acute tubular necrosis?
a. Aminoglycosides
b. ACE inhibitors
c. Vasculitis
d. NSAIDs
e. Hypovolemia

Answer 22

a. Aminoglycosides

Question 23

A 41-year-old Indian man reports having a headache and a low-grade fever. The physician suspects a diagnosis of tuberculous meningitis. Which of the following is found in the cerebrospinal fluid analysis of a patient with tuberculous meningitis?
A. High protein level
B. High polymorphonuclear cell count
C. High glucose level
D. Low lymphocyte count E Gram positive organisms

Answer 23

A. High protein level

Question 24

A 65-year-old female has underwent a hip replacement procedure. One week following the surgery, the patient develops right lower limb swelling and erythema. Marked tenderness and non-pitting edema were noted on examination. The patient was started on anticoagulation treatment for deep vein thrombosis. Which of the following factors would change the duration of anticoagulation? [2011 7th year final answered by Dr. Abdelrahman AlAshqar]
a. Levels of d-dimers
b. Factor V Leiden mutation
c. Presence of pulmonary embolism
d. Size of the thrombus
e. Family history of DVT

Answer 24

e. Family history of DVT

Note: Patients with provoked DVT or PE, as in this case, should be anticoagulated for 3 to 6 months. Factor V Leiden mutation is a low- risk thrombophilia and does not require extended anticoagulation if it’s concomitantly found in the setting of provoked DVT. Positive family history of DVT could imply underlying high-risk thrombophilias, like protein C or S deficiency, which if present might require longer periods of anticoagulation, possibly indefinitely. It is worth noting, however, that data on duration of anticoagulation in patients with unprovoked DVT and factor V Leiden mutation is inconsistent, and patients might be anticoagulated for three months or longer depending on whether the mutation is homo- or heterozygous.

Question 25

A 36-year-old female comes to the clinic after she incidentally found a lump in her neck. On examination, the lump was found to be a thyroid nodule. Upon asking the patient, she denied any thyrotoxic or obstructive symptoms. Thyroid function tests showed a normal TSH level. What should be done next to assess this patient’s thyroid nodule? A. Do nothing and reassure the patient B. Thyroid uptake scan C. Neck ultrasound D. Repeat the thyroid function tests E. Fine-needle aspiration

Answer 25

C. Neck ultrasound Note: Asymptomatic (cold) thyroid nodules raise the suspicion of malignancy and should be investigated initially with a neck ultrasound to delineate the nature of the nodule. Further investigations or mere reassurance will follow based on the ultrasonic findings.

Question 26

A 26-year-old male patient was brought to the emergency department after sustaining injuries in a road traffic accident. He was found to have bilateral lower limb weakness and constipation. What is the most sensitive sign of spinal cord injury? A. Loss of temperature and pain sensation B. Documented weakness C. Exaggerated deep tendon reflexes D. Babinski sign E. Presence of a sensory level

Answer 26

E. Presence of a sensory level Note: The sensory level is the most caudal, intact dermatome for both pin prick and light touch sensation. It should be ascertained in any patient with suspected spinal cord injury to classify patients and identify the level of injury.

Question 27

4)A 36 year old man develops severe chest pain while running in the park one hour back. He regularly engages in exercise but never experienced previous similar episodes.He was immediately brought to the ER where an ECG was performed and is shown below.He is now asymptomatic with a heart rate of 90/min and blood pressure of 122/81mmHg.cardiac enzymes were not elevated upon admission.How should this patient be managed in the setting of this presentation? A)Schedule the patient for a stress test B)Reassure the patient and discharge him home C) Admit the patient and take him for PCI D) Admit the patient and administer aspirin ,LMWH, Clopidogrel E)Admit the patient ,administer aspirin,LMWH,Clopidogrel and initiate throbolytic therapy

Answer 27

A)Schedule the patient for a stress test Note:This patient's ECG is compatible with a diagnosis of Prinzmetal's or variant angina showing ST segment elevation and widening of the R wave creating a monophasic wave. It is worth nothing that variant angina typically occurs at rest or during non-strenuous activities contrary to what happened in this patient;however,his age ,baseline risk and ECG findings are not suggestive of MI. Patients presenting with ischemic symptoms of variant angina should be admitted for further evaluation to exclude more serious causes of chest pain.Stress testing is performed for coexisting or contributory CAD.

Question 28

A42-year-old female patient presents to her family physician with one-year history of muscle weakness in her upper and lower limbs. She additionally complains of progressive weight gain, cold intolerance and constipation. On examination, her muscles were of normal power and tone but were tender. Her laboratory investigations showed the following: WBC: 8.1 x 109 Hb: 119 g/L Platelets: 347 x 109 BUN: 4.7 mmol/L Creatinine: 59 μmol/L Serum calcium: 2.5 mmol/L Urinalysis: Normal Creatine phosphokinase: 3470 IU/L (normal: 23-232) AST: 19 IU/L (normal: 5-40) ALT: 17 IU/L (normal: 5-36) What is the most appropriate next step to be conducted in this patient? A. Measure TSH level B. Perform a muscle biopsy C. Start her on prednisolone D. Check anti-Jo1 antibody titers E. Conduct electromyography

Answer 28

A. Measure TSH level Note: Hypothyroid myopathy can take place due to decreased metabolic function of the muscles resulting from the lack of thyroid hormones.

Question 29

A 12-year-old patient is a known case of hemophilia A. He is on regular treatment with factor VIII concentrate infusions. However, he recently was found to have developed resistance against hemophilia A treatment. The patient now presents with an acute bleeding event. How should this patient be managed? a. Desmopressin b. Tranexamic acid c. Cryoprecipitate d. Fresh frozen plasma e. Recombinant factor VIIa

Answer 29

e. Recombinant factor VIIa Note: A proportion of patients with severe hemophilia A can develop antibodies against factor VIII, inhibiting its action and rendering the patient resistant against treatment. In such case, treatment of acute bleeding events requires use of agents that bypass factor VIII. Options include recombinant factor VIIa and activated prothrombin complex.

Question 30

A middle-aged male patient presents to the ER with one-day history of erythematous, swollen and tender first metatarsophalangeal joint. Past medical history reveals a recently diagnosed duodenal ulcer on endoscopy. How should this patient’s arthritis be managed? * Intra-articular steroid injection * Indomethacin * Naproxen * Diclofenac * Infliximab

Answer 30

* Intra-articular steroid injection Note: In cases where NSAIDs are contraindicated or cannot be tolerated, e.g. peptic ulcer disease, renal impairment or poorly-controlled hypertension, intra-articular steroid injections can be alternatively used to control the acute attack.

Question 31

A 52-year-old male patient comes to the diabetology clinic after he was found to have an elevated random blood glucose reading on a regular check up. Which of the following would confirm a diagnosis of diabetes mellitus in this patient? A. Hemoglobin A1c > 8% B. Fasting plasma glucose > 6.5 mmol/L C. Random plasma glucose > 10.8 mmol/L if symptomatic D. Plasma glucose > 10 mmol/L two hours after glucose tolerance test E. Presence of microalbumin in the urine

Answer 31

A. Hemoglobin A1c > 8%

Question 32

A 15-year-old child was brought to the casualty with lethargy and jaundice. The mother says her son became symptomatic after initiation of medications that later turned out to be anti-malarial. She says that her son had similar episodes that were related to certain foods. Investigations showed a hemoglobin of 6 g/dL and a high reticulocyte count. Shown below is the patient’s blood smear. What is the likely diagnosis? a. Drug-indued immune hemolytic anemia b. Sickle cell anemia c. G6PDdeficiency d. Malaria e. Hereditary spherocytosis

Answer 32

c. G6PDdeficiency

Question 33

1)A 51 year old man was admitted to the medical ward after developing an anterior wall myocardial infarction. He was successfully managed with coronary revascularization and stabilized thereafter. Two days later, the patient started to complain of palpitation and dizziness. He became immediately unresponsive with a blood pressure 92/56.His ECG is shown below .What is the appropriate management of this patient? A)DC cardioversion B) Intravenous amiodarone C)Intravenous adenosine D)Atropine )Defibrillation

Answer 33

A)DC cardioversion Ventricular tachycardia can commonly occur following STEM and is typically treated with IV antiarrhythmics,e.g. amiodarone. However, hemodynamic instability as evidenced by hypotension warrants delivery of synchronized cardioversion.

Question 34

A 60-year-old man has been diagnosed recently with a lung malignancy. Routine investigations reveal the presence of hypercalcemia. Which of the following lung malignancies is this patient likely to have? a. Small cell lung cancer b. Large cell lung cancer c. Carcinoid tumor d. Squamous cell carcinoma e. Adenocarcinoma

Answer 34

d. Squamous cell carcinoma Note: Humoral hypercalcemia of malignancy resulting from increased secretion of parathyroid hormone-related protein is the most common cause of hypercalcemia of malignancy. It commonly occurs in squamous cell cancers, urinary tract cancers, breast cancer, non-Hodgkin’s lymphoma and ovarian cancer.

Question 35

A young patient presented to the ER with significant generalized edema more pronounced in the face and lower limbs. He was found to have heavy proteinuria but without hematuria. His vital signs were within normal limits. The physician informs his colleague that the patient’s condition is unlikely to change his GFR. What is the likely underlying cause of this patient’s presentation? a. Minimal change disease b. Focal segmental glomerulosclerosis c. Membranous nephropathy d. Amyloidosis e. Membranoprolifeartive glomerulonephritis

Answer 35

a. Minimal change disease

Question 36

A 36-year-old woman presents to the casualty with agitation, profound diaphoresis and palpitations. When seen by the ER doctor, the patient was restless and flushed. Her heart rate was 142/min and temperature was 38.1 Co. Neck examination showed the presence of a goiter. Which of the following should be part of her immediate management plan? A. Administration of potassium iodide then propylthiouracil B. Radioactive iodine C. Small doses of levothyroxine D. Subtotal thyroidectomy E. Administration of propylthiouracil then potassium iodide

Answer 36

E. Administration of propylthiouracil then potassium iodide Note: As part of the management of thyroid storm, iodine preparations should be administered at least one hour after starting antithyroid medications, e.g. propylthiouracil, as otherwise, this may lead to undesired increased thyroid hormone synthesis by means of increased iodination and enrichment of thyroid hormone stores. Once synthesis is blocked, large doses of iodine have been found to paradoxically suppress hormone release.

Question 37

A 55-year-old man presented to the emergency room with a severe headache, tinnitus, blurry vision and pruritus. On examination, he seemed abnormally flushed. Investigations showed a hemoglobin of 19 g/dL and a hematocrit of 61%. What is the immediate management of this patient? a. Administration of hydroxyurea and radiotherapy b. Hydration, administration of hydroxyurea and venesection c. Tyrosinekinaseinhibitor d. Venesection and iron replacement e. Urgentbonemarrowtransplantation

Answer 37

b. Hydration, administration of hydroxyurea and venesection Note: Venesection is the mainstay of polycythemia management & aims at reducing the hematocrit to <45%. It should be preceded and followed by hydration to replace the intravascular volume. Use of hydroxyurea helps suppress the myeloproliferative activity of the bone marrow.

Question 38

A 71-year-old male patient was admitted to the intensive care unit with pneumonia. The patient improved by the end of the first week after receiving a full course of antibiotics along with supportive management. While in the rounds, the patient was found to have an isolated low platelet count. Which of the following could explain this finding? a. Albumin infusion b. Aminoglycoside-mediated effect c. Enoxaparin given for venous thromboembolism d. High-dose prednisolone e. Dilutional effect of IV fluids

Answer 38

c. Enoxaparin given for venous thromboembolism Note: The finding of low platelet count in this patient is most likely attributable to heparin-induced thrombocytopenia, which this patient has likely received during his prolonged stay in the hospital as a means of DVT prophylaxis. Although less often, this adverse effect can occur with low molecular weight heparin (Enoxaparin) as well.

Question 39

A 54-year-old lady with breast cancer underwent mastectomy and chemotherapy. She was found to have a metastatic disease following treatment. While in the ward, the patient complains of constipation and bloating. She was nauseous most of the day and had a poor appetite. Her constipation had responded poorly to laxatives. Which of the following is the likely cause of this patient’s symptoms? a. Hypercalcemia b. Hypocalcemia c. Hyperkalemia d. Hypokalemia e. Hyponatremia

Answer 39

a. Hypercalcemia Note: Osteolytic hypercalcemia resulting from increased osteoclastic activity and bone resorption surrounding bony metastasis is the second most common cause of hypercalcemia of malignancy. It commonly occurs in breast cancer and multiple myeloma.

Question 40

A 26-year-old male patients presents with a swollen, painful ankle. On examination, the ankle joint looks erythematous and is tender to touch. He was also noted to have a pustular rash on the dorsum of his foot. He reported having a recent urethral discharge. What is the likely diagnosis in this patient? * Gonococcal arthritis * Reactive arthritis * Henöch-Schonlein purpura * Psoriatic arthritis * Systemic lupus erythematosus

Answer 40

* Gonococcal arthritis

Question 41

A 28-year-old gentleman has a longterm history of recurrent chest infections and sinusitis. He was vaccinated with BCG in the past. He just had a PPD test done. After 48 hours, the patient was found to have a 2 mm induration at the site of the PPD test. Which of the following is correct regarding this reading? A. This is a negative result because of T cell abnormality B. Thisisanormalresponse C. This is not a reliable reading and should be repeated D. This is a positive result given his history of BCG vaccination E. Repeat the test in the other arm and compare

Answer 41

A. This is a negative result because of T cell abnormality Note: A PPD reading of 2 mm in this patient is quite the opposite of what is expected. Patients with history of BCG vaccination should, in fact, manifest false positive results (> 5 mm at least) after PPD testing. A negative reading in this patient most likely points to an element of immunodeficiency involving the T cells, a phenomenon termed cutaneous anergy. However, the type of infections he had are suggestive of B cell abnormality. Nevertheless, a possibility of combined B and T cell immunodeficiency in this patient is the most likely explanation.

Question 42

A young patient underwent thoracocentesis that showed a bloody aspirate. The senior physician asks: how to differentiate whether the bloody aspirate is due to bloody pleural effusion or hemothorax? a. Check the hematocrit of the aspirated sample b. Look at the aspirate under light c. Count the RBCs in the aspirate d. The cause needs to be identified to differentiate between the two e. Look at the configuration of fluid on chest x-ray

Answer 42

a. Check the hematocrit of the aspirated sample Note: Hemothorax is defined as pleural fluid to serum hematocrit ratio of ≥50%. In contrast, hemorrhagic pleural effusion has a ratio of <50%.

Question 43

A 50-year-old man was admitted to the ward with fever and expectoration of large amounts of greenish sputum. He says that he has a long-standing lung disease for years with occasional exacerbations. Physical examination documents the presence of basal inspiratory crackles and finger clubbing. How would this patient be best managed? a. Postural drainage and antibiotics b. Intravenous steroids c. Anti-fibrotic agents d. Bronchodilators e. Mucolytics

Answer 43

a. Postural drainage and antibiotics

Question 44

A 72-year-old male patient is a known case of Parkinson’s disease. He presents to the ER with an altered level of consciousness after sustaining a fall. Shown below is his head CT scan. What is the finding in this CT scan? A. Lobar hematoma B. Epidural hematoma C. Subdural hematoma D. Intraventricular hemorrhage E. Subgaleal hematoma

Answer 44

A. Lobar hematoma

Question 45

A 46-year-old man underwent hip replacement two weeks back and was on venous thromboembolism prophylaxis for one week thereafter. The patient is obese and engages in a sedentary lifestyle. Two days back, he travelled on a six-hour flight despite his doctor’s advice not to. He now presents with acute lower limb deep vein thrombosis. Which of the following signifies the highest risk for developing DVT in this patient? a. Obesity b. His travel history c. His surgery d. Sedentary lifestyle e. Hisage

Answer 45

c. His surgery

Question 46

A 43-year-old gentleman presents with severe right upper quadrant pain. On examination, the patient had remarkable right upper quadrant tenderness, fever and was jaundiced. Investigations came back as follows: total bilirubin 49 μmol/L (normal: 5.1-20.5), direct bilirubin 30 μmol/L (normal: 0-5.1), ALT 56 U/L (normal: 0-35), AST 48 U/L (normal: 0-35), alkaline phosphatase 167 U/L (36-92), amylase 149 U/L (normal: 0-130). Abdominal ultrasound detected the presence of gallstones and a dilated common bile duct. Which of the following is the most appropriate next step in the management of this patient? * ERCP * Laparoscopic cholecystectomy * CT scan * Percutaneous drainage * Conservative management with analgesics and fluids

Answer 46

* ERCP

Question 47

15)A 32 year old female athlete had a history of distressing heel pain after running for a long distance in a marathon.She started to take ibuprofen to manage her pain .She now comes to the clinic for follow up and still complains of some pain. When initially assessed, the patient's blood pressure was found to be 171/98 mmg. What is recommended management of this patient's blood pressure? A)Stop ibuprofen B)Start ACE inhibitors C)Perform a renal ultrasound D) Initiate a intravenous sodium nitroprusside E)Put her on calcium channel blocker

Answer 47

A)Stop ibuprofen Note:NSAIDs, including ibuprofen ,are known to increase the systemic blood pressure .NSAIDs inhibit prostaglandin synthesis,and hence, deprive the arteriolar smooth muscles of their vasodilator properties and accentuate their response to vasoconstriction.In addition, diminished prostaglandin synthesis results in decreased natriuresis ,i.e.promote sodium and water retention.

Question 48

5)A 52 year old man was brought to the emergency room with severe retrosternal chest pain and diaphoresis. His ECG shows ST segment elevation ,and his cardiac troponin were above normal. Upon admission, his heart rate was 114/min and blood pressure was 113/71 mm.Once the diagnosis of MI was established , nitrates were administered. The patient immediately collapses with a BP of 92/60. What diagnosis is this presentation suggestive of? A)Right ventricular infraction B)Aortic dissection C) Acute mitral regurgitation D)Prinzmetal's Angina E)Hypertensive crisis

Answer 48

A)Right ventricular infraction Right ventricular infraction is characterized by a triad of hypotension, clear lung fields,and elevated JVP.The infracted free wall of the right ventricle results in decreased systolic function and chamber dilatation, However, due to the constrained pericardium ,the increased intra-pericardial pressure is translated into an interventricular shift of the septum, impairing filling of the left ventricle and reducing cardiac output ,which manifests as hypotension. The latter is further accentuated by administration of vasodilator therapy, like nitrates.

Question 49

A 49-year-old woman has a history of joint pain and morning stiffness for four months. Examination reveals swelling of the wrists and metacarpophalangeal joints. Which of the following is the most specific serological marker for rheumatoid arthritis? * Anti-cyclic citrullinated antibodies * Rheumatoid factor * Antinuclear antibodies * Anti-dsDNA antibodies * Anti-cardiolipin antibodies

Answer 49

* Anti-cyclic citrullinated antibodies

Question 50

A mother brought her 10-year-old child to the physician for recent onset of symptoms. She says that her child suddenly becomes short of breath and expectorates yellowish sputum multiple times throughout the last two months especially when he plays with his peers. However, he is now asymptomatic. The physician suspects bronchial asthma. What test would be used to confirm the diagnosis of asthma in this patient? a. Methacholine challenge test b. Allergy skin prick testing c. Chest radiography d. Eosinophil count e. Spirometry pre- and post-bronchodilator therapy

Answer 50

a. Methacholine challenge test Note: Bronchoprovocation testing with methacholine or histamine is useful when spirometry findings are normal or near normal especially in patients with intermittent or exercise-induced asthma symptoms. A negative test result usually excludes the diagnosis of asthma.

Question 51

A middle-aged man has a longterm history of uncontrolled hypertension despite being on multiple medications. Laboratory studies show high serum sodium and low serum potassium. Renin level was found to be below normal. What is the likely diagnosis in this patient? A. Renal artery stenosis B. Essential hypertension C. Chronic glomerulonephritis D. Primary hyperaldosteronism

Answer 51

D. Primary hyperaldosteronism

Question 52

A 26-year-old female patient complains of dysuria and lower abdominal pain. Upon taking further history, she reports to have multiple sexual partners. A urine sample was collected and was tested for the presence of organisms. Gram stain and urine culture showed no organisms. What is the likely cause of this patient’s presentation? A. Chlamydia trachomatis B. Neisseriagonorrhoeae C. Escherichiacoli D. Proteus mirabilis E. Klebsiella pneumoniae

Answer 52

A. Chlamydia trachomatis Note: Chlamydia trachomatis are obligate intracellular parasites that require human cells for survival. They have a rigid wall that does not contain peptidoglycan or muramic acid, and hence, cannot be stained by gram stain. Urine culture can comeback negative. Therefore, detection via nucleic amplification tests, e.g. PCR, should be done instead.

Question 53

6)A 24 year old man complains of expressions chest pain whenever he exercises.on examination, the patient had a jerky carotid pulse and an ejection systolic murmur. An echocardiogram was performed and revealed a markedly thickened interventricular septum He had a family history of sudden cardiac death .What could be used for symptomatic relief of this patients complain? A)B Blockers B)ACE inhibitors C)Digoxin D)Amlodipine E)Nitrates

Answer 53

A)B Blockers Note:All of the above mentioned medications apart from beta blockers are contraindicated in patient with HOCM since they aggregate the outflow tract obstruction.

Question 54

A 25-year-old female with history of type 1 diabetes mellitus comes to the clinic for follow-up. Her blood glucose is controlled on insulin and her HbA1c is within normal limits. Routine investigations came back as follows: hemoglobin 9.2 g/dL, hematocrit 36% (normal: 38.8-50%), MCV 74 (normal: 80-100 fL), MCH 24.9 (normal: 26-34 pg). Upon further inquiry, she reported symptoms of dizziness and exertional shortness of breath. She said that her menstruation hasn’t changed and is normal in amount. What is the likely cause of this patient’s presentation? A. Gastroparesis B. Diabetic nephropathy C. Dietary restriction D. Celiac disease E. Pernicious anemia

Answer 54

D. Celiac disease Note: Celiac disease is known to exist in close association with type 1 diabetes mellitus. Hence, screening for celiac disease in type 1 diabetics is recommended by means of serological testing.

Question 55

A 45-year-old female complains of fatiguability and exercise intolerance. She experiences occasional palpitations and episodes of dizziness. Investigations revealed the following results: hemoglobin 8.9 g/dL, hematocrit 34% (normal: 38.8-50%), MCV 72 (normal: 80-100 fL), MCH 23.9 (normal: 26-34 pg), RDW 18 (normal: 11.6-14). Serum ferritin was found to be low. Which of the following is a possible cause of this patient’s diagnosis? a. Sleeve gastrectomy b. Pernicious anemia c. Alcoholism d. Bone marrow infiltration e. Hypothyroidism

Answer 55

a. Sleeve gastrectomy

Question 56

A 39-year-old Afghani male patient who works as a plumber presents with recent onset of shortness of breath mainly on exertion. On examination, the patient was found to have finger clubbing and reduced chest expansion. Chest x-ray reveals pleural thickening and diaphragmatic calcifications. What is the likely diagnosis in this patient? a. Asbestosis b. Idiopathic pulmonary fibrosis c. Sarcoidosis d. Hypersensitivity pneumonitis e. Pleural tuberculosis

Answer 56

a. Asbestosis

Question 57

A 66-year-old man complains of a headache and temporal tenderness. He has an ESR of 112. A prominent vessel was visible on the patient's temple and is tender to palpation. He now has a blurry vision in the right eye. What is the next step in this patient’s management? * Start high-dose steroids (the treatment of giant cell arteritis) * Start low-dose steroids * Obtain a temporal artery biopsy * Start intravenous cyclophosphamide * Perform fluorescein angiography of the eye

Answer 57

* Start high-dose steroids (the treatment of giant cell arteritis)

Question 58

A hospital nurse started to develop a fever and generalized fatigue. He also complained of joint pain in his hands and was nauseous most of the time. Examination reveals the presence of scleral icterus and a maculopapular rash. Which of the following confirms a diagnosis of acute hepatitis B infection? * IgM antibodies against hepatitis B core antigen * IgG antibodies against hepatitis B core antigen * Antibodies against hepatitis B surface antigen * Elevated liver transaminases * Antibodies against hepatitis B e antigen

Answer 58

* IgM antibodies against hepatitis B core antigen Note: Patients with suspected hepatitis B infection should be investigated for HBsAg as well as anti-HBc IgM antibodies as in some cases of acute infection, HBsAg may be cleared rapidly and another marker is needed. Anti-HBs antibodies signify immunity against HBV while anti-HBc IgG antibodies suggest past exposure to HBV and anti- HBe antibodies indicate decreased infectivity.

Question 59

9)A26 year old gentleman comes to the emergency room after developing sudden onset of palpitation.The patient says he never had previous similar episodes .He now complains of chest discomfort but no dizziness. When initially assessed, the patient looked generally well and maintained full consciousness. His heart rate was 146/min and blood pressure was 112/71.His ECG is shown below.Non pharmacological measures failed to terminate the episode. How should this patient be managed in this setting? A)Intravenous adenosine B)Electrical cardioversion C) Digoxin D)radiofrequency ablation B)Implantable cardiovertor defibrillator

Answer 59

A)Intravenous adenosine

Question 60

A 66-year-old gentleman is a known case of chronic kidney disease. He was admitted due to deteriorating renal function. His renal function tests and serum electrolytes came back as follows: creatinine 445 μmol/L (normal: 44-110), blood urea nitrogen 21 mmol/L (normal: 2.8- 8.1), sodium 130 mmol/L (normal: 135-145),potassium 6.1 mmol/L (3.5-5). An ECG was done and showed a slowed rhythm, a widened QRS complex and a tall T wave. How should this patient be immediately managed? a. Intravenous calcium gluconate b. Bisphosphonate administration c. Vigorous intravenous hydration d. Class Ia anti-arrhythmics e. Long acting beta agonists

Answer 60

a. Intravenous calcium gluconate Note: Severe hyperkalemia (> 6.5 mmol/L) or hyperkalemia (> 6 mmol/L) with ECG changes is a medical emergency that warrants immediate treatment. Calcium gluconate doesn’t reduce serum potassium levels, but rather antagonizes the toxic cardiac effects of hyperkalemia, i.e. cardioprotective. Measures that reduce potassium levels should follow. *If there were no ECG changes: you give the patient insulin with dextrose.

Question 61

Which of the following is true regarding Coumadin (warfarin)? a. It does not currently have antidotes b. It does not require monitoring of INR c. It works by antagonizing the action of thrombin d. It is used for prophylaxis in patients with valvular atrial fibrillation e. It has a faster onset of action than the new oral anticoagulants

Answer 61

d. It is used for prophylaxis in patients with valvular atrial fibrillation

Question 62

A 59-year-old man was admitted to the ward with decompensated chronic liver disease. He was found to have deranged renal function tests and a serum potassium level of 6.1 mmol/L (normal: 3.5-5). Possible causative mediations were stopped but the potassium level persisted. An ECG was performed and showed a normal trace. What is the appropriate management of this patient? a. Start insulin and glucose infusion b. Administer IV calcium gluconate c. Arrange for hemodialysis immediately d. Start IV potassium chloride e. Dietary potassium restriction and loop diuretics

Answer 62

a. Start insulin and glucose infusion Note: Potassium levels >6 mmol/L require emergent reduction, which can be achieved by administration of 10 units of rapid acting insulin followed by 50 ml of 50% dextrose with or without nebulized albuterol.

Question 63

A 25-year-old male has a family history of hyperlipidemia. He was found to have firm orange-yellow nodules and plaques over his elbows and extensor surfaces of his forearms. What are these lesions likely to be? A. Tuberous xanthoma B. Psoriasis C. Dermatitisherpetiformis D. Asteatotic eczema E. Neurofibromas

Answer 63

A. Tuberous xanthoma

Question 64

A 52-year-old man with history of diabetes mellitus develops acute onset of distal paresthesias in both of his lower limbs. Patellar and ankle deep tendon reflexes were absent bilaterally. CSF analysis shows elevated protein. What is the likely diagnosis in this patient? A. Guillain-Barre syndrome B. Diabetic amyotrophy C. Diabetic polyneuropathy D. Cauda equina syndrome E. Multiple sclerosis

Answer 64

A. Guillain-Barre syndrome Note: In contrast to Guillain-Barre syndrome, diabetic amyotrophy is associated with acute, progressive asymmetrical weakness and pain in the proximal muscles of the lower limbs with minimal sensory impairment. However, it is similarly associated with absent deep tendon reflexes and elevated CSF protein.

Question 65

A 45-year-old male patient complains of a severe unilateral headache that lasted for about 45 minutes. He describes the pain to be retro-orbital in location and associated with nasal congestion and watery eyes. What is the likely diagnosis in this patient? A. Cluster headache B. Subarachnoid hemorrhage C. Migraine headache D. Paroxysmal hemicrania E. Sinusitis headache

Answer 65

A. Cluster headache Cluster headaches are excruciating attacks of pain in one side of the head Msd headaches by suhail

Question 66

A 31-year-old female patient has a history of bleeding tendency. Trivial trauma caused her previous episodes of bleeding into the joints. Investigation were ordered and showed normal platelet count and function. There was no prolongation of either PT, APTT or thrombin time. What is the likely diagnosis in this patient? a. Hypofibrinogenemia b. Factor XII deficiency c. Factor V deficiency d. Factor XIII deficiency e. Vitamin K deficiency

Answer 66

d. Factor XIII deficiency Note: Factor XIII, also known as the fibrin-stabilizing factor, is responsible for cross-linking of fibrin, stabilizing the clot. Since it does not participate in either the extrinsic or intrinsic pathways, regular coagulation screening tests are normal. Once suspected, diagnosis is made by using a urea clot solubility assay or measuring plasma levels of factor XIII.

Question 67

A 34-year-old female patient is known to have systemic lupus erythematosus. On a routine urinalysis, she was found to have proteinuria and hematuria. Renal function tests were abnormal. The patient had a renal biopsy done and was found to have diffuse proliferative glomerulonephritis (grade IV). What should this patient be started on? a. IV cyclophosphamide and prednisolone b. Azathioprine alone c. Prednisolone alone d. Methotrexate alone e. IV cyclophosphamide and azathioprine

Answer 67

a. IV cyclophosphamide and prednisolone Note: Patients with class III to V lupus nephritis should be induced into remission with administration of high-dose steroids and either cyclophosphamide or mycophenolate mofetil for 2 to 6 months, followed by maintenance therapy with lower doses of steroids and mycophenolate mofetil or azathioprine. Class I and II do not generally require therapy, while class VI necessitates the need for renal replacement therapy.

Question 68

A 72-year-old gentleman with history of recently-diagnosed lung malignancy was admitted to the ward after deteriorating. Laboratory investigations showed a serum sodium reading of 131 mmol/L (normal: 135-145). On examination, the patient had a normal JVP, moist mucous membranes and a blood pressure of 118/76 mmHg. No pitting lower limb edema was present. What is the most likely cause of this patient’s hyponatremia? a. Syndrome of inappropriate ADH (SIADH) b. Acute renal failure c. Diabetes insipidus d. Third spacing e. Cerebral salt-wasting syndrome

Answer 68

a. Syndrome of inappropriate ADH (SIADH) Note: SIADH is a common paraneoplastic manifestation of small cell lung cancer and results from tumor cell production of anti-diuretic hormone. It is typically associated with euvolumic hyponatremia.

Question 69

10)A 45 year old Indian gentleman is a known case of rheumatic mitral stenosis.He now present with recent onset of low grade fever and malaise .On initial assessment ,the patient was ill looking with a pansystolic murmur detected at the apex on chest auscultation Echocardiography was performed and showed the presence of suspicious lesions on a regurgitant valve .What is the most likely causative organism of patient's presentation? A)Streptococcus Viridans B)Staphylococcus aureus C)Staphylococcus epidermidis D)Streptococcus boris E)Entereococcus fecalis

Answer 69

A)Streptococcus Viridans Note: The causative organisms of infective endocarditis differ between healthy and diseased valves as well as between native and prosthetic valves. Staphvlococcus aureus is the most common culprit in healthy natives valves and in IV drug abuse endocarditis. Streptococcus viridans is the main cause in diseased native valves and in late(>60 days) prosthetic valve endocarditis. Early (within 60 days)prosthetic valve endocarditis is most commonly caused by staphylococcus epidermidis.

Question 70

Q1. A middle-aged man was admitted after developing lower limb deep vein thrombosis. How long should patients with a first episode of unprovoked proximal DVT be anticoagulated for? a. Indefinitely if the risk of bleeding is low b. One month then reassess the risk c. Three months then reassess the risk d. Six months then reassess the risk e. One year then reassess the risk

Answer 70

a. Indefinitely if the risk of bleeding is low Note: Patients with a first episode of unprovoked proximal DVT or symptomatic pulmonary embolism, recurrent unprovoked DVT regardless of location or recurrent provoked venous thromboembolism with persistent, irreversible or multiple major risk factors, e.g. active cancer or antiphospholipid syndrome, should be anticoagulated indefinitely if the risk of bleeding is low or moderate. In case of high risk of bleeding or first unprovoked distal DVT, three months of anticoagulation is otherwise recommended.

Question 71

A 36-year-old female patient reports history of chronic sinusitis and epistaxis. She also complains of a dry cough that becomes blood-tinged on occasions as well as pain in multiple small and large joints. Physical examination reveals the finding shown below (picture showing saddle nose). Urinalysis showed microscopic hematuria. What is the likely diagnosis in this patient? * Wegener’s granulomatosis * Tuberculosis * Systemic lupus erythematosus * Polyarteritis nodosa * Amyloidosis

Answer 71

* Wegener’s granulomatosis Note: Granulomatosis with polyangiitis, formerly known as Wegener’s granulomatosis, can commonly cause collapse of the nasal bridge resulting the saddle-shaped deformity shown above.

Question 72

A 29-year-old female is a case of ulcerative colitis on maintenance therapy. Which of the following extra-intestinal manifestations of inflammatory bowel disease will most likely improve with treatment of the intestinal symptoms? * Erythema nodosum * Pyoderma gangrenosum * Uveitis * Sclerosing cholangitis * Ankylosing spondylitis

Answer 72

* Erythema nodosum Note: Erythema nodosum, arthralgias, type I peripheral arthropathy, oral aphthous ulcers and episcleritis are extra-intestinal manifestations that parallel the activity of inflammatory bowel disease (IBD). On the contrary, axial and type II peripheral arthropathies have a separate course of IBD. Meanwhile, pyoderma gangrenosum, uveitis and primary sclerosing cholangitis may or may not parallel the disease activity.

Question 73

A young nurse presented to the ER with dizziness and diaphoresis. On initial assessment, she was disoriented with a heart rate of 108/min. Initial investigations showed a random blood sugar reading of 2.8 mmol/L. The patient was not a case of diabetes mellitus but her sister is a known case of type 1 since childhood. Further workup shows high serum insulin and low C-peptide levels. What is the likely cause of this patient’s presentation? A. Factitious insulin use B. Factitious sulphonylurea use C. Starvation ketoacidosis D. Alcohol intoxication E. Insulinoma

Answer 73

A. Factitious insulin use Factitious hypoglycemia due to exogenous insulin administration is accompanied by the presence of low serum C-peptide levels since insulin preparations lack the C- peptide. On the contrary, sulphonylureas stimulate the release of endogenous insulin, increasing levels of C-peptide in the blood. The latter is also found in insulinoma.

Question 74

A 31-year-old Indian patient was brought by ambulance after developing a severe episode of vomiting and abdominal pain. On examination, the patient looked very thin with signs of dehydration. On initial assessment, his heart rate was 112/min, blood pressure was 94/65, and temperature was 38.7 Co . Examination of his oral mucosa shows buccal hyperpigmentation. His chest x-ray shows apical fibrocavitary lesions. What is an appropriate initial investigation in this patient? A. Abdominal MRI B. LongACTHstimulationtest C. Serum autoantibodies assay D. Measure serum cortisol E. Morningsputumsamplingandculture

Answer 74

D. Measure serum cortisol Note: Addison’s disease can be caused by hematogenous spread of mycobacteria to the adrenals in patients with tuberculosis. Despite random cortisol measurements being of little value in patients with chronic Addison’s disease, they should be drawn prior to starting hydrocortisone replacement in the setting of acute adrenal crisis.

Question 75

A 45-year-old male patient presents with generalized edema and proteinuria. On presentation, the patient had a blood pressure of 147/88. Renal function tests were markedly deranged. A renal biopsy was taken and showed diffuse thickening of the glomerular basement membrane and subepithelial deposits. IgG granular deposits were present under immunofluorescence. What should be done for this patient? a. Look for an underlying malignancy b. Investigate the presence of antinuclear and dsDNA antibodies c. Observe the patient since this is a self-limiting condition d. Start the patient on a trial of corticosteroids e. Schedule the patient for renal transplantation as soon as possible

Answer 75

a. Look for an underlying malignancy Note: Membranous nephropathy is associated with malignancy, especially of the breast, colon and lung, in about 25 to 30% of patients with the condition. Oral high-dose corticosteroids and azathioprine are not associated with any significant benefits in treating the condition. Cyclophosphamide and chlorambucil are used instead.

Question 76

A 49-year-old lady presents to her physician complaining of shoulder and thigh weakness. She is unable to get up from a sitting position and reports difficulty in raising her arms above her head to comb her hair. She also complains of polyarthritis in the small joints of her hands. Examination reveals decreased power of the proximal muscles. On chest auscultation, fine crepitations were heard at the bases. Which of the serological markers are likely positive in this patient? * Anti-Jo-1 antibodies * Anti-centromere antibodies * Anti-smith antibodies * P-antineutrophil cytoplasmic antibodies * Anti-ribonucleoprotein antibodies

Answer 76

* Anti-Jo-1 antibodies Note: Antisynthetase syndrome is a rare inflammatory muscle disease related to dermatomyositis and polymyositis. It is characterized by the presence of myositis, interstitial lung disease, non-erosive arthritis, Raynaud’s phenomenon, unexplained fever with or without mechanic’s hands. Anti-Jo-1, or anti-histidyl tRNA synthetase, antibodies are the most commonly detected in these patients.

Question 77

A 41-year-old man comes to the dermatology clinic complaining of patchy hair loss in his scalp. Examination reveals areas of scaly atrophic lesions in the scalp with prominent follicular openings. Hypopigmentation and scarring were also noted. What is the most likely diagnosis in this patient? A. Discoid lupus erythematosus B. Alopeciaareata C. Tineacapitis D. Psoriasis E. Dissecting cellulitis

Answer 77

A. Discoid lupus erythematosus

Question 78

7)A 67 year old gentlemen was admitted to the ward after recurrent transient ischemic attacks.he is a known case of congestive heart failure on medications. His ECH trace upon presentation is shown below. What medication should this patient be started on to prevent complications of the ECG findings? A)Warfarin B) Aspirin C)Heparin D)Clopidogrel

Answer 78

A)Warfarin Note:Patients with non valvular atrial fibrillation should have their candidacy for long term anticoagulation assessed via CHA2DS2 VASe score. The patient in this scenario has a score of 4 and should be started on warfarin or NOACs(however,the dose of the latter should be reduced or rather avoided in elderly).

Question 79

An 18-year-old male patient develops gross hematuria after strenuous exercise. Urine sediment shows 30 RBC/HPF and red cells casts. Patients reports a previous similar episode shortly after an upper respiratory tract infection. Renal function was normal at presentation. What is the likely diagnosis? a. IgA nephropathy b. Post-streptococcal glomerulonephritis c. Hemolytic uremic syndrome d. Interstitial nephritis e. Goodpasture syndrome

Answer 79

a. IgA nephropathy

Question 80

A 41-year-old female patient is a known case of celiac disease since the age of 18. She presents to the gastroenterology clinic complaining of watery diarrhea as well as weight loss despite being on a strict gluten- free diet. The patient was also found to have iron deficiency anemia and low levels of vitamin D. Which of the following is the most likely explanation for this patient’s symptoms? * Dietary noncompliance * Intestinal T-cell lymphoma * Small bowel adenocarcinoma * Lactose intolerance * Ulcerative jejunitis

Answer 80

* Dietary noncompliance Note: The major cause of failure to respond to diet in celiac disease patients is poor compliance, i.e. continuing ingestion of gluten. Once excluded, other causes, including bacterial overgrowth, lactose intolerance, microscopic colitis as well as the possibility of refractory celiac disease can be considered and accordingly investigated.

Question 81

A 55-year-old gentleman with history of type 2 diabetes mellitus was found to have nail lesions on routine examination. Abnormalities noted were nail dystrophy, yellow discoloration and subungual hyperkeratosis. What could have most likely caused these lesions in this patient? A. Psoriasis B. Yellow-nail syndrome C. Trauma D. Onychomycosis E. Thyrotoxicosis

Answer 81

D. Onychomycosis

Question 82

A 23-year-old lady presented to the ER with two-week history of weakness and fatigue. On initial assessment, the patient was drowsy. Her vital signs were taken: heart rate 118/min, blood pressure 109/67 and she had orthostatic hypotension. Examination showed dry mucous membranes and decreased skin turgor. An arterial blood gas analysis was performed and serum and urine electrolytes were measured. They came back as follows: Arterial blood gas & serum Urine electrolytes: pH: 7.51 (normal: 7.35-7.45) Sodium: 32 mmol/L (normal: 20-40) PCO2: 44 mmHg (normal: 35-45) Potassium: 13 mmol/L (normal: <10) HCO3: 31 mmol/L (normal: 22-26) Chloride: 9 mmol/L (normal: 25-40) Sodium: 135 mmol/L (normal: 135-145) Potassium: 3.5 mmol/L (normal: 3.5-5) Chloride: 115 mmol/L (normal: 98-106) What is the likely cause of dehydration in this patient? a. Vomiting b. Current diuretic use c. Laxative abuse d. Conn syndrome e. Addison’s disease

Answer 82

a. Vomiting Note: When approaching patients with metabolic alkalosis, a reasonable algorithm starts with history taking to elucidate any obvious causes. This is followed by assessing the volume status and measuring urinary chloride. Urine Cl- of <10 mmol/L in a volume- contracted patient suggests gastrointestinal chloride loss, e.g. vomiting or villous adenoma, or recent diuretic use— it is termed chloride- responsive metabolic alkalosis and managed effectively with NaCl and KCl administration. On the other hand, urine Cl- of >20 mmol/L in a normo- or hypertensive patient suggests current diuretic use (can be hypotensive/volume-depleted) or mineralocorticoid or corticosteroid excess (mostly hypertensives)— it is termed chloride- resistant metabolic alkalosis and best treated with pharmacologic or surgical measures.

Question 83

A 29-year-old male patient has few-months history of weight gain. When examined, the patient was overweight, particularly around his abdomen with prominent purple abdominal striae. Muscle wasting was also noted mostly in the proximal limbs. Random blood glucose level was elevated. What would be the best initial investigation to establish a diagnosis? A. Midnight salivary cortisol level B. Random cortisol measurement C. MRI of the brain D. Abdominal MRI E. High-dose dexamethasone test

Answer 83

A. Midnight salivary cortisol level Note: Random cortisol samples are of no value in assessing patients with suspected Cushing syndrome. On the other hand, midnight or late- night salivary cortisol measurement emerges as a convenient, noninvasive method to screen for hypercortisolism with some studies suggesting a better performance than urinary free cortisol.

Question 84

A 32-year-old lady complains of ocular symptoms and fatiguability. What is the most sensitive diagnostic investigation for myasthenia gravis? A. Anti-Musk antibodies B. Repetitive nerve stimulation C. Anti-acetylcholine receptor antibodies D. Single fiber electromyography E. Lumbar puncture and CSF analysis

Answer 84

D. Single fiber electromyography Note: Single-fiber electromyography is the most sensitive test to diagnose patients with myasthenia gravis, but it lacks specificity and can be abnormal in other disorders of disturbed neuromuscular transmission. Positive titers of anti- acetylcholine receptor antibodies, on the other hand, are most specific.

Question 85

17)A 31 year old pregnant lady at 36weeks of gestation was admitted after developing right upper quadrant pain and nausea.On examination, the patient had right upper quadrant tenderness and a blood pressure of 181/110.Investigations showed the following:Hb9.5 g/di, schistocytes in peripheral smear, markedly elevated AIT, AST, total and direct bilirubin and platelet count of 65,000. How should this patient be managed? A)Immediate delivery of the baby B)Observation until patient stabilize C)Platelet transfusion D) Administration of tocolytics

Answer 85

A)Immediate delivery of the baby Note:This scenario describes HELLP syndrome, a variant of severe preeclampsia characterized by severe hemolysis, elevated liver enzymes, and thrombocytopenia.

Question 86

A 76-year-old male patient started to complain of easy fatiguability and weight loss. He also reported having upper abdominal fullness and discomfort. When examined, the patient had a markedly enlarged spleen past the umbilicus. Investigations revealed the presence of pancytopenia, and the peripheral smear showed teardrop forms, myelocytes and nucleated red blood cells. His bone marrow biopsy is shown below. Which of the following is the best treatment option for this patient? a. Hydroxyurea b. Ruxolitinib c. Radiotherapy d. Imatinib e. Splenectomy

Answer 86

b. Ruxolitinib Note: Ruxolitinib, a JAK inhibitor, is a new and very promising form of targeted therapy for patients with myelofibrosis, 50% of which have the JAK2 mutation. It results in substantial spleen size reduction and symptomatic relief despite having no role in disease eradication. Hydroxyurea and radiotherapy have been historically used but are largely ineffective. Splenectomy is associated with significant morbidity and mortality.

Question 87

A 35-year-old male patient reports symptoms of unilateral chest pain and hemoptysis. He also complains of a low-grade fever, night sweats and recent weight loss. The patient says that the cough started off purulent then became blood-tinged. The patient has recently immigrated from India for work. How can the diagnosis be confirmed in this patient? a. Morning sputum culture and acid-fast bacilli smear b. Video-assisted thoracoscopic surgery c. Bronchoalveolar lavage and cytology d. CT scan of the chest e. Blood culture and serology

Answer 87

a. Morning sputum culture and acid-fast bacilli smear

Question 88

A 56-year-old man has a 15-year history of gastroesophageal reflux disease that didn’t seem to improve with lifestyle modifications. He now presents to the clinic seeking medical help. The patient was started on a trial of proton pump inhibitors. When followed up, heartburn improved and the patient is now asymptomatic. What should be done next for this patient? * Upper endoscopy * Do nothing and reassure the patient * 24-hour intraluminal pH monitoring * Stop PPIs and start H2-receptor blockers * Barium swallow

Answer 88

* Upper endoscopy Note: Patients with longterm history of GERD should undergo upper endoscopy regardless of their symptom status. This aims to detect the presence of complications, namely Barrett’s esophagus and underlying dysplasia, resulting from prolonged reflux.

Question 89

A 29-year-old female who is pregnant at 10 weeks gestation’ presents to the ER with severe nausea and vomiting. She lost 5% of her weight. The patient looked remarkably dehydrated and fatigued. Hematocrit was elevated and urine was positive for ketones. Which of the following is expected to be found in the biochemical profile of this patient? A. High TSH level B. Low T4 level C. Low cortisol level D. Low transaminase level E. Low TSH level

Answer 89

E. Low TSH level Note: Hyperemesis gravidarum is often associated with transient hyperthyroidism and suppressed TSH in 50% of hyperemetic gravidas. Measuring TSH levels is part of the initial workup in these patients.

Question 90

A 51-year-old male patient develops a new episode of first metatarsophalangeal joint pain and swelling. The impression was an acute gouty attack. The patient comes now one week later asymptomatic after the inflammation had resolved. What treatment should this patient be started on? * Nothing * Indomethacin * Oral colchicine alone * Oral allopurinol alone * Oral colchicine and oral allopurinol

Answer 90

* Nothing Note: Hypouricemic agents, like allopurinol, are only started in gout patients if: 1. they have frequent attacks (≥ 2 attacks/year), 2. Tophi are present on exam or imaging, 3. they have CKD stage 2 or worse, 4. or urolithiasis. This patient has developed a single attack with absence of other indications. Analgesics aren’t needed for a revolved acute attack.

Question 91

A 57-year-old woman presents with a wheezy chest. On physical examination, palpable purpura were present on her lower limbs. Laboratory investigations reveal eosinophilia. What is the diagnosis? * Churg-Strauss syndrome * Cryoglobulinemia * Helminthic infection * Allergic bronchopulmonary aspergillosis * Henöch-Schonlein purpura

Answer 91

* Churg-Strauss syndrome (the manifestation + eosinophilia makes you suspect it)

Question 92

11)A 14 year old female child was brought by her mother to the clinic. The child complains of increasing shortness of breath and fatigue. Examination reveals a bounding pulse and displaced apex at the sixth intercostal space .chest auscultation detected a continuous machine like murmur at the left infraclavicular area .An echocardiogram was done and showed a left to right shunt and a dilated left ventricle .What is the appropriate management of this child? A)Surgical closure device B) Indomethacin C)Surgical ligation D)Ballon angioplasty repair E) Valve replacement

Answer 92

A)Surgical closure device Note: Indications of treatment of patent ductus arterious include left ventricular dilatation as well as mild to moderate pulmonary arterial hypertension .Most PDAs are closed via percutaneous techniques-closure device or coil embolization.

Question 93

A 32-year-old female patient presents with synovitis of the left index and right ring fingers. Evidence of inflammation is more pronounced in the distal interphalangeal joints. She also reports ankle and heel pain.What is the likely diagnosis? * Psoriatic arthritis * Rheumatoid arthritis * Systemic lupus erythematosus * Viral infection * Osteoarthritis

Answer 93

* Psoriatic arthritis ( because in the synovitis in the fingers they mean dactylitis also known as sausage fingers)

Question 94

A nurse has mistakenly pricked herself with a needle-stick while dealing with a hepatitis B positive patient. She is concerned of acquiring the infection. Which of the following signifies immunity against hepatitis B? * Antibodies against hepatitis B surface antigen * IgM antibodies against hepatitis B core antigen * Low titers of HBV DNA * Hepatitis B surface antigen * IgG antibodies against hepatitis B core antigen

Answer 94

* Antibodies against hepatitis B surface antigen

Question 95

A 55-year-old lady presented with fatigue and weight loss. Investigations revealed a finding of normochromic normocytic anemia in this patient. She was admitted to further investigate her anemia. Her laboratory tests came back as follows: Hb 9 g/dL, WBC 2.1 x109 (normal: 4 - 10 x109), platelets 48,000/ml (normal: 150,000-400,000), calcium 3.8 mmol/L (normal: 2.2- 2.67), creatinine 155 mmol/L (normal: 74-107). A bone marrow biopsy was done and is shown below. What is the diagnosis? a. Primary myelofibrosis b. Aplastic anemia c. Multiple myeloma d. Acute myeloid leukemia e. Metastasis

Answer 95

c. Multiple myeloma

Question 96

13)A 65 year old lady presented to the causality after developing a syncopal attack. She reported a previous similar episodes recently.An ECG was performed and is shown below .What is recommended management of this patient? A)Pacemaker implantation B)Observation and reassurance C)Beta blockers D)Implantable cardiovascular defibrillator placement B)Intravenous atropine

Answer 96

A)Pacemaker implantation

Question 97

A 59-year-old male patient is a known case of type 2 diabetes mellitus and COPD on long- term oxygen therapy. He presented to the ER with two-day history of fever and increasing shortness of breath. He also had worsening productive cough of yellowish sputum. On initial assessment, his oxygen saturation was 74%. A chest x-ray showed lobar consolidation. What is the most likely causative organism of this patient’s presentation? a. Hemophilus influenzae b. Streptococcus pneumoniae c. Moraxella catarrhalis d. Staphylococcus aureus e. Pseudomonas aeruginosa

Answer 97

a. Hemophilus influenzae

Question 98

A 61-year-old gentlemen has a 17-year history of diabetes mellitus. He was admitted to undergo coronary angiography for ischemic heart disease evaluation. Routine investigations showed serum creatinine of 282 μmol/L (normal: 44-110). Urinalysis showed 3+ protein. Albumin-to- creatinine ratio was calculated to be 34. What is the likely diagnosis? a. Diabetic nephropathy b. Renal papillary necrosis c. Tubulointerstitial nephritis d. Contrast-induced nephropathy e. Ischemic acute tubular necrosis

Answer 98

a. Diabetic nephropathy The ratio of urine to albumin to creatinine (ACR): If < 30mg/g is considered normal to mildly increased; if between 30-300 mg/g for more than 3months is considered an indication of CKD.

Question 99

A 23-year-old female patient presented to the casualty after having a fight with her family. When initially assessed, she seemed very anxious, distressed and short of breath. She also complained of tingling in her fingers and around her mouth. An arterial blood gas analysis was performed and came back as follows: pH 7.49 (normal: 7.35-7.45) PCO2: 29 mmHg (normal: 35-45), HCO3: 23 mmol/L (normal: 22-26),PO2: 91 mmHg (normal: 80-100). Which of the following laboratory values is likely to be abnormal in this patient? a. Ionized calcium b. Sodium c. Potassium d. Serum glucose e. International normalized ratio

Answer 99

a. Ionized calcium Note: Normally, hydrogen ions and calcium both exist bound to albumin. In the presence of alkalemia, hydrogen ions dissociate from albumin, increasing its free portion. This, in turn, binds to more serum calcium, deceasing the free ionized portion of total calcium and leading to hypocalcemia. The latter manifests as paresthesias and tetany.

Question 100

A 32-year-old male patient presents to the clinic with five-month history of heartburn, particularly after eating a heavy meal or upon lying down. He did not report difficulty or pain upon swallowing. His weight has been constant with no significant changes. No episodes of hematemesis have been reported and bowel habits were unchanged. What is the most appropriate step to take next in this patient? * Start a therapeutic trial of proton pump inhibitors * Perform a barium swallow * Arrange for upper endoscopy * 24-hour intraluminal pH monitoring * Anti-reflux surgery

Answer 100

* Start a therapeutic trial of proton pump inhibitors Note: A clinical diagnosis of GERD can be made without investigations, and patients this young can be started on a trial of PPIs and reassessed thereafter. However, presence of alarm symptoms (dysphagia, odynophagia, weight loss, anemia, hematemesis), age older than 45-55 years of age, longterm history of GERD (>5 years) and failure of acid suppressive therapy necessitates referral for upper endoscopy.

Question 101

A 41-year-old male patient who works in a food processing company for many years presented to the ER with an acute episode of shortness of breath and fever. His temperature was 39.1 Co. Chest examination revealed the presence of fine crackles. Laboratory investigations showed leukocytosis of 15,000/mm3, with 75% neutrophils and 7% eosinophils. He had previous admissions for the same reason. What is the diagnosis? a. Bacterial pneumonia b. Bronchopulmonary aspergillosis c. Hypersensitivity pneumonitis d. Churg-Strauss syndrome e. Sarcoidosis

Answer 101

c. Hypersensitivity pneumonitis

Question 102

A66-year-oldladyreportssymptomsofgeneralizedfatigueandlowmood.Shealso complains of bone pains which were found to be tender to touch. Her laboratory investigations came back as follows: serum calcium 2.8 mmol/L (normal: 2.2-2.67), serum phosphate 1.1 mmol/L (normal: 1.12-1.45). X-ray of the hands shows subperiosteal erosions as well as occasional bone cysts. What is the most appropriate test in investigating this patient’s diagnosis? A. Vitamin D level measurement B. Conduct a parathyroid scan C. Parathyroid hormone level measurement D. Perform a DXA bone density scan E. Measure serum calcitonin

Answer 102

C. Parathyroid hormone level measurement

Question 103

A young lady is on interferon therapy for multiple sclerosis. Which of the following is a known adverse effect of interferons? A. Flu-like symptoms B. Increased appetite C. Polycythemia D. Acute myeloid leukemia E. Pulmonary fibrosis

Answer 103

A. Flu-like symptoms

Question 104

Which of the following is an extra-articular manifestation of ankylosing spondylitis? * Apical pulmonary fibrosis * Pulmonary stenosis * Retinitis * Renal cysts * Biliary cirrhosis

Answer 104

* Apical pulmonary fibrosis

Question 105

A 72-year-old patient has history of end-stage kidney disease due to diabetic nephropathy. The patient maintains a good level of activity and easily performs daily tasks while at home. He is also known to have ischemic heart disease and had two cardiac stents placed. Which of the following is true regarding renal replacement therapy in this patient? a. Renal transplantation is the preferred option for this patient b. Peritoneal dialysis is preferred over hemodialysis because it does not require anticoagulation c. Hemodialysis is the preferred option given his cardiovascular risk d. Diabetic nephropathy is a contraindication for renal transplantation e. The life expectancy of this patient wouldn’t improve with renal replacement therapy

Answer 105

a. Renal transplantation is the preferred option for this patient Note: Patients with ischemic heart disease in whom successful interventions have been performed and are currently asymptomatic are eligible for kidney transplantation. On the other hand, progressively symptomatic patients whose disease isn’t amenable to intervention are not candidates for transplantation. Should that be the case and dialysis is indicated, peritoneal dialysis is preferred over hemodialysis for these patients given the increased cardiovascular complications in patients on hemodialysis, including coronary artery disease, congestive here failure and left ventricular hypertrophy.

Question 106

A 56-year-old female patient complains of joint pains in both of her hands accompanied by morning stiffness of 15 minutes. On examination, distal and proximal interphalangeal nodes were present along with crepitus. Hypothenar muscle wasting was also noted. The patient was found to have high uric acid level and normal ESR. X-ray of the hands showed joint space narrowing and osteophytes. What is the likely diagnosis in this patient? * Osteoarthritis * Chronic tophaceous gout * Rheumatoid arthritis * Pseudogout * Psoriatic arthritis

Answer 106

Osteoarthritis

Question 107

A26-year-oldwomanwasadmittedbecauseofhypertensivecrisis.Shecomplained of palpitations and apprehension. Past medical history is insignificant. In the hospital, her blood pressure is labile and poorly responding to antihypertensives. The patient’s drug screen was negative, and initial laboratory investigations were as follows: hematocrit: 49% (normal: 37-48), glucose: 8.9 mmol/L and calcium: 2.7 mmol/L (normal: 2.2-2.67). What is the most likely diagnosis? A. Renal artery stenosis B. Pheochromocytoma C. Essential hypertension D. Type 1 diabetes mellitus E. Anxiety attack

Answer 107

B. Pheochromocytoma Note: Polycythemia secondary to pheochromocytoma can occur due to increased release of erythropoietin while hyperglycemia can be induced by high catecholamines levels. Hypercalcemia in the setting of pheochromocytoma occurs either due to ectopic release of calcitonin or parathyroid hormone-related protein, catecholamine-induced parathyroid hormone release or as part of MEN 2A syndrome: pheochromocytoma, parathyroid hyperplasia and medullary thyroid carcinoma.

Question 108

A 61-year-old male patient is a known case of COPD on longterm oxygen therapy, diuretics and bronchodilators. He was admitted to the ward with an acute exacerbation that was infective in origin. On examination, the patient was in respiratory distress and expectorating purulent sputum. An arterial blood gas analysis and serum electrolyte measurement were performed and came back as follows: pH: 7.31 (normal: 7.35-7.45) Sodium: 146 mmol/L (normal: 135-145) PCO2: 55 mmHg (normal: 35-45) Potassium: 3.3 mmol/L (normal: 3.5-5) HCO3: 41mmol/L (normal: 22- 26). Chloride: 102 mmol/L (normal: 98-106) PO2: 66mmHg (normal: 80-100) a. Mixed respiratory acidosis and metabolic alkalosis b. Mixed metabolic acidosis and respiratory alkalosis c. Uncompensated metabolic acidosis d. Uncompensated respiratory acidosis e. Compensated results

Answer 108

a. Mixed respiratory acidosis and metabolic alkalosis Note: Patients with acute exacerbation of COPD who are concomitantly on diuretics are one famous example where mixed respiratory acidosis and metabolic alkalosis coexist. Respiratory acidosis is caused by CO2 retention, i.e. type 2 respiratory failure, while metabolic alkalosis is caused by excessive use of diuretics. To find out whether the increase in bicarbonate is a compensatory mechanism or due to coexisting metabolic alkalosis, the following formula can be used to calculate the expected compensatory increase in bicarbonate in patients with chronic respiratory acidosis: HCO3 = (PCO2 - 40)/5 + 24. The expected bicarbonate level in this patient would be 27 mmol/L. Hence, a value of 41 suggests the presence of metabolic alkalosis as well.

Question 109

A 17-year-old female was noted to have profuse prolonged bleeding after a dental extraction. She recalls having a similar presentation when she was younger. Investigations revealed the presence of isolated prolongation of prothrombin time. What coagulation factor is this patient deficient for? a. Factor VII b. Factor VIII c. Factor IX d. Factor X e. Factor XI

Answer 109

a. Factor VII

Question 110

A 16-year-old epileptic patient was managed with gabapentin for years. The doctor made the decision to add lamotrigine to the patient’s anticonvulsant regimen three weeks back. The patient presents now with widespread erythematous rash, fever, lymphadenopathy and hepatomegaly. Laboratory tests show elevated liver enzymes. Which of the following is also expected to be found in this patient? A. Lymphopenia B. Eosinophilia C. Neutropenia D. Lymphopenia and neutropenia

Answer 110

B. Eosinophilia Note: Drug reaction with eosinophilia and systemic symptoms (DRESS) or drug hypersensitivity syndrome is commonly caused by aromatic anticonvulsants, e.g. lamotrigine and carbamazepine. Treatment is with oral steroids. Precipitant medications should be avoided in the future with sodium valproate being a suitable alternative in epileptic patients.

Question 111

A 31-year-old male patient underwent splenectomy for immune thrombocytopenia. The patient has refused to receive any vaccinations. What is this patient at risk of developing? A. Bronchiectasis B. Epiglottitis C. Tuberculosis D. Candidiasis E. Malignancy

Answer 111

A. Bronchiectasis Note: Splenectomized patients are at increased risk of infections with encapsulated bacteria due to loss of splenic macrophages needed for bacterial phagocytosis. Therefore, these patient should be vaccinated with pneumococcal, Hemophilus influenzae type b and meningococcal vaccines. Infections with streptococcus pneumoniae are the most common and deadly, and in unvaccinated individuals, they can result in recurrent bacterial pneumonias, predisposing to bronchiectasis.1

Question 112

A 45-year-old male patient complains of low back pain and morning stiffness. Peripheral joints were not affected. He was later diagnosed with psoriatic arthritis. What is the best treatment option for this patient? * TNF inhibitors * Methotrexate * Sulfasalazine * Plaquenil * Azathioprine

Answer 112

* TNF inhibitors Note: DMARDs, including MTX, are clearly ineffective for treating axial arthropathy and are better reserved for patients with peripheral arthritis. On the other hand, TNF inhibitors improve signs and symptoms of inflammation in both peripheral and axial joints as well as in periarticular tissues such as the entheses.

Question 113

A 23-year-old woman with history of type 1 diabetes mellitus is on rapid- acting insulin three times a day before meals and glargine at night. She comes to her diabetologist on a follow-up visit with a diary of blood glucose readings at different times of the day as shown below. Breakfast: 9.1 Lunch: 8.6 Dinner: 6.9 Bedtime: 6.4 How should the doctor further manage this patient based on her readings? A. Increase the dose of rapid-acting insulin B. Add an intermediate-acting insulin C. Increase the dose of glargine D. Decrease the dose of glargine E. No need for dose adjustment

Answer 113

C. Increase the dose of glargine

Question 114

A 69-year-old gentleman was found to have an impressively enlarged spleen. His complete blood count shows marked leukocytosis and the smear shows populations of white blood cells at different stages of maturation. Which of the following accurately relates to chronic myeloid leukemia? a. Tyrosine kinase inhibitors are the treatment of choice and markedly improve survival b. The underlying chromosomal translocation is t (14; 18) c. The associated anemia is usually hypochromic microcytic d. It is mostly associated with a rapid course and poor prognosis e. It is commonly associated with lymphadenopathy and bone pains

Answer 114

a. Tyrosine kinase inhibitors are the treatment of choice and markedly improve survival

Question 115

2)A 23 years old female reports history of fainting .She had two attacks within the last week while in the shower. Whenever she regain consciousness,she says she finds her self slightly confused and nauseous and had vomited once.She reports no other symptoms between the attacks .Physical examination is unremarkable with normal vital signs and chest examination.An ECG was performed and was normal upon presentation. The patient is very worried about her fainting attacks and of experiencing additional ones. What is the most appropriate next step in the management of this patient? A)perform tilt test B)Reassure the patient of the benign course C) Arrange for Holter monitoring D)Do exercise test

Answer 115

C) Arrange for Holter monitoring

Question 116

What treatment modality has been shown to be effective in reducing complications when used in the initial management of acute spinal cord compression? A. Loop diuretics B. Mannitol C. Intravenous steroids D. Sodium nitroprusside E. Acetazolamide

Answer 116

C. Intravenous steroids Note: Steroid treatment initiated in the early hours after acute spinal cord compression is aimed at reducing the extent of permanent paralysis during the rest of the patient's life. This is achieved by minimizing the consequences of secondary spinal injury, including cord edema. High- dose methylprednisolone is the only pharmacologic agent shown to have efficacy when administered within eight hours of injury.

Question 117

A 41-year-old woman has a history of Hashimoto’s thyroiditis on medications. She now complains of fatigue and malaise. Thyroid function tests were ordered and came back within normal limits. Liver biochemistry came back as follows: ALT 518 U/L (normal: 0-35), AST 423 U/L (normal: 0-35), alkaline phosphatase 134 U/L (36-92), total bilirubin 25 μmol/L (normal: 5.1-20.5), direct bilirubin 6 μmol/L (normal: 0-5.1). Which of the following serological markers is this patient likely to have? * Anti-smooth muscle antibodies * Anti-mitochondrial antibodies * Cytoplasmic anti-neutrophil cytoplasmic antibodies (c-ANCA) * Anti-Saccharomyces cerevisiae antibodies * Perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA)

Answer 117

* Anti-smooth muscle antibodies Note: Autoimmune hepatitis can coexist with other autoimmune diseases, like pernicious anemia, Hashimoto’s thyroiditis and celiac disease. Antibodies recognized in the sera of these patients include anti- nuclear, anti-smooth muscle (anti-actin), anti-liver/kidney microsomal (anti-LKM1) and possibly, anti-soluble liver antigen antibodies.

Question 118

8)A 17 year old female teenager presented to the clinic with symptoms of shortness of breath particularly when she is involved in physical activity.Chest auscultation reveals an ejection systolic murmur in the left lower sternal border and a loud pulmonary component of the second heart sound.Chest X-ray shows enlarged pulmonary arteries along with prominent pulmonary vasculature. What is expected to be found in Echocardiography? A)Right atrial and ventricular dilatation B)Decreased cross sectional area of pulmonary valve C)Right to left shunt D) Hypertrophic left ventricle E)Large defect in the interventricular septum

Answer 118

A)Right atrial and ventricular dilatation Note:This scenario describes a case of atrial septal defect Left to right shunting eventually dilates the right heart with increased flow through the pulmonary valve creating a plethoric picture of the lung fields on X-ray.

Question 119

A 66-year-old male patient reports symptoms of dysphagia and heartburn. He initially had difficulty swallowing food but is now starting to suffer with liquids as well. His weight has dramatically decreased over the past few months. He did not experience any episodes of hematemesis. What should be done next to this patient? * Upper endoscopy * Start him on a trial of PPIs * 24-hour intraluminal pH monitoring * Advise lifestyle modifications * Pneumatic dilatation

Answer 119

* Upper endoscopy

Question 120

A 32-year-old woman developed skin lesions on her face after going to a beauty salon. On examination, multiple firm papules 1 to 2 mm in size were noted on the face. On close inspection, they were found to be umbilicated in the center. What is the diagnosis in this patient? A. Molluscum contagiosum B. Herpessimplex C. Planewarts D. Acneiform eruption

Answer 120

A. Molluscum contagiosum

Question 121

What is the most common cause of adult bacterial meningitis? A. Hemophilus influenzae type b B. Streptococcus pneumoniae C. Neisseria meningitidis D. Listeria monocytogenes E. Staphylococcus aureus

Answer 121

B. Streptococcus pneumoniae

Question 122

A 58-year-old gentleman was referred to the gastroenterology clinic with symptoms of dyspepsia and epigastric pain. He was scheduled for an upper endoscopy where a biopsy from the gastric mucosa was taken. Histological assessment confirmed the diagnosis of mucosa- associated lymphoid tissue lymphoma (MALToma). Further workup showed no metastasis. How should this patient be managed? * Eradication of Helicobacter pylori * Surgical resection of the tumor * Chemotherapy * Radiation therapy * Total gastrectomy

Answer 122

* Eradication of Helicobacter pylori

Question 123

A 22-year-old patient has a longterm history of fatigue and breathlessness. His hemoglobin was found to be 8.1 g/dL with a low MCV. The patient is not on regular transfusions. On examination, the patient has splenomegaly and frontal bossing. Hemoglobin electrophoresis shows high HbF and high HbA2. What is the diagnosis in this patient? a. Alpha thalassemia trait b. Beta thalassemia intermedia c. Hereditary spherocytosis d. Sickle cell anemia e. Alpha thalassemia major

Answer 123

b. Beta thalassemia intermedia Note: Thalassemia intermedia signifies patients who are moderately symptomatic with a satisfactory hemoglobin (7-10 g/dL) and do not require regular transfusions. This can result from the presence of a combination of β and ⍺ thalassemia, reducing the chain imbalance and disease severity. However, the decreased synthesis of normal chains is attempted to be overcome by the overproduction and ẟ chains, increasing levels of HbF and HbA2, respectively.

Question 124

A 66-year-old man with longterm history of diabetes mellitus was found to have 4+ protein in his urine. Renal function tests came back as follows: creatinine 823 μmol/L (normal: 44-110), blood urea nitrogen 24 mmol/L (normal: 2.8-8.1). Hemoglobin was 9.1 mg/dL. His blood pressure was measured to be 151/89 mmHg. What medication should this patient be started on? a. Angiotensin receptor blockers b. Angiotensin converting enzyme inhibitors c. Calcium channel blockers d. Thiazide diuretics e. Spirolactone

Answer 124

a. Angiotensin receptor blockers Note: As per the guidelines of the American diabetes association on hypertension management in adults with diabetes mellitus, patients with type 2 diabetes, hypertension, macroalbuminuria (> 3 g/day) and renal insufficiency are strongly considered to be started on angiotensin receptor blockers. ACE inhibitors can be alternatively used in cases of microalbuminuria, and in type 1 diabetics with any degree of albuminuria. However, since ACE inhibitors are classically known to be used for renoprotection in hypertensive diabetics, this question has been taken care of by the Department of Medicine.

Question 125

A 64-year-old patient was admitted to the ICU with pneumonia. One day after, the patient deteriorated and went on to develop septic shock. Which of the following is used to monitor the kidneys’ function on a daily basis? a. Serum creatinine b. 24-hour urine collection c. Estimated GFR d. Fractional excretion of electrolytes e. Inulin clearance

Answer 125

a. Serum creatinine

Question 126

A 45-year-old male patient was admitted to the medical ward with a productive cough, fever and pleuritic chest pain. A chest x-ray was done and showed an evidence of lobar consolid n in the right lung. The patient was started on IV antibiotics for pneumonia and has improved thereafter. atioTwo days later, the patient became febrile again with chest pain and shortness of breath. Chest x-ray showed the presence of pleural effusion. How should this patient be managed? a. Do an ultrasound and perform thoracocentesis if the amount of pleural fluid is significant b. Continue the same management and observe the patient for 48 hours before changing the antibiotics c. Change the antibiotics and evaluate the patient in 48 hours d. Stop intravenous fluids e. No need to do anything as this effusion is self-limiting

Answer 126

a. Do an ultrasound and perform thoracocentesis if the amount of pleural fluid is significant Note: Parapneumonic pleural effusion (PPE) may not develop until after antibiotic treatment has been started with symptoms taking several days to manifest. It represents a self-limited inflammatory response to pneumonia and is often related to rapid killing of bacteria, and hence, they do not necessarily indicate that the antibiotic is ineffective. Uncomplicated PPE would eventually resolve on antibiotics alone; however, uncomplicated PPE that separates the lung from the chest wall by >10 mm requires therapeutic thoracocentesis. In contrast, complicated PPE (positive gram stain and culture), PPE occupying >50% of the hemithorax, loculated effusion, pH <7.2 and empyema necessitate drainage with tube thoracotomy.

Question 127

A 71-year-old male patient was brought to the ER with fever and productive cough of purulent sputum. On initial assessment, the patient was confused, feverish and tachypnic with a respiratory rate of 33/min. His blood pressure was 88/61 mmHg. A chest x-ray was performed and showed a lobar infiltrate. How should this patient be managed? a. He should be admitted to the intensive care unit (ICU) b. He should be admitted to the medical ward c. He can be managed on an outpatient basis d. He can be managed in the ER then discharged when stabilized e. He can be immediately discharged home with no further management

Answer 127

a. He should be admitted to the intensive care unit (ICU) Note: CURB-65 criteria are a severity-of-illness score that can be calculated to determine the severity of pneumonia and the appropriate treatment setting. It includes five variables: confusion (C), urea >7 mmol/L (U), respiratory rate ≥30/min (R), blood pressure, systolic ≤90 mmHg or diastolic ≤60 mmHg (B), and age ≥65 years. This patient has a score of 4 and hence, should unhesitatingly be admitted to the ICU.

Question 128

A 67-year-old lady has 20-year history of diabetes mellitus. When inspected, the patient was found to have a Charcot joint. What is expected to be found on the examination of the lower limb of this patient? A. Pitting edema and increased circumference B. Hyperpigmentation and a venous ulcer C. Ankle deformity and distal sensory loss D. Pes cavus and muscle atrophy E. Hypermobile ankle and hyperextensible skin

Answer 128

C. Ankle deformity and distal sensory loss

Question 129

A 34-year-old male patient was found to have a single tender ulcer on the prepuce of the penis associated with painful unilateral inguinal lymphadenopathy. What is the likely diagnosis in this patient? A. Chancroid B. Chancre C. Lymphogranulomavenereum D. Granuloma inguinale E. Herpes simplex

Answer 129

A. Chancroid

Question 130

Regarding the patient in the previous scenario, what finding would be present on histological examination? * Necrotizing non-caseating granulomas * Granulomatous reaction with caseation * Dermoepidermal junction inflammatory infiltrate and hyperkeratosis * Fibrinoid necrosis * Congo-red positive deposits

Answer 130

* Necrotizing non-caseating granulomas

Question 131

A 23-year-old male patient was brought to the emergency room after sustaining a head trauma in a road traffic accident. The patient was found to have a serum sodium of 149 mmol/L (normal: 135-145) and a markedly increased urine output. Which of the following is the likely cause of this patient’s hypernatremia? a. Diabetes insipidus b. Hypovolemic shock c. Severe vomiting d. Syndrome of inappropriate ADH secretion (SIADH) e. Water restriction

Answer 131

a. Diabetes insipidus Head trauma, hemorrhage and pituitary bleeding may reduce the level of ADH leading to central DI.

Question 132

19)A 40 year old man is rejected from applying to the military. He reports six month history of central heaviness and dyspnea as well as syncopal attacks in the past month. His past medical history is significant for a heart murmur that was discovered 15 years back.Shown on his chest x-ray .Which of the following is expected finding during auscultation of the chest? A)Eiection click in the apex B)Wide and fixed splitting of S2 C)Early diastolic murmur at right sternal border D)Soft pulmonary component of $2 E)Pansvstolic murmur at the left sternal border

Answer 132

A)Eiection click in the apex Note:The chest X-ray finding demonstrated above is post stenotic dilatation of the ascending aorta, which intern suggests a diagnosis of valvular AS .Given the young age at which the murmur was detected ,the likely cause of this patient's AS is the presence of congenital bicuspid aortic valve .A systolic ejection click is the most common abnormal sound detected and is best heard in the apex.

Question 133

A young nurse presented to the ER with dizziness and diaphoresis. On initial assessment, she was disoriented with a heart rate of 108/min. Initial investigations showed a random blood sugar reading of 2.8 mmol/L. The patient was not a case of diabetes mellitus but her sister is a known case of type 1 since childhood. Further workup shows high serum insulin and low C-peptide levels. What is the likely cause of this patient’s presentation? A. Factitious insulin use B. Factitious sulphonylurea use C. Starvation ketoacidosis D. Alcohol intoxication E. Insulinoma

Answer 133

A. Factitious insulin use Note: Factitious hypoglycemia due to exogenous insulin administration is accompanied by the presence of low serum C-peptide levels since insulin preparations lack the C- peptide. On the contrary, sulphonylureas stimulate the release of endogenous insulin, increasing levels of C-peptide in the blood. The latter is also found in insulinoma.

Question 134

A 16-year-old male patient was admitted with a vaso-occlusive crisis complicating his hemoglobinopathy. Which of the following is true regarding sickle cell trait? a. Patients have abnormalities in their urinary concentrating ability b. Patients have a reduced life expectancy c. Patients require to be on long-term transfusion d. Patients are at an increased risk of thrombosis e. It occurs due to substitution of methionine for glutamic acid

Answer 134

a. Patients have abnormalities in their urinary concentrating ability Note: The hypoxic, acidotic and hyperosmolar environment of the inner renal medulla promotes sickling of RBCs with subsequent ischemia and impairment of solute reabsorption by the ascending limb of the loop of Henle, impairing urinary concentrating ability in patients with sickle cell trait. This phenomenon is termed isosthenuria.

Question 135

A 43-year-old male patient presents with recent onset of hemoptysis. He also reports dyspnea that is occasionally accompanied by malaise. Endoscopic examination of the nose reveals the presence on a nasal ulcer. A chest x-ray was done and is shown below. Which of the following serological markers will likely be present in this patient? * C-antineutrophil cytoplasmic antibodies * Anti-smooth muscle antibodies * Anti-dsDNA antibodies * Anti-saccharomyces cerevisiae antibodies * Anti-cyclic citrullinated antibodies

Answer 135

* C-antineutrophil cytoplasmic antibodies Note: Typical radiologic pulmonary findings of granulomatosis with polyangiitis include: multiple migratory nodular infiltrates with frequent cavitation, ground-glass opacities of pulmonary hemorrhage, reticulonodular infiltrates and airway stenosis or ulceration.

Question 136

A 23-year-old male patient presents with severe flank pain and hematuria. X-ray KUB was done and came back unremarkable. Intravenous pyelography showed mild hydronephrosis and a ureteric filling defect. What type of ureteric stone is this most likely to be? a. Uric acid stone b. Cysteine stone c. Calcium oxalate stone d. Calcium carbonate stone e. Magnesium-ammonium-phosphate stone

Answer 136

a. Uric acid stone

Question 137

A 48-year-old man has a history of alcoholic cirrhosis. He comes for an elective upper endoscopy that confirmed the presence of grade 3 esophageal varices. What medication should this patient be started on? * Beta blockers * Somatostatin * Terlipressin * Proton pump inhibitors * Lactulose

Answer 137

* Beta blockers Note: Initiation of non-selective beta blockers, e.g. propranolol or carvedilol, in patients with esophageal varices not presenting with acute hemorrhage has a substantial prophylactic value. They reduce the portal venous pressure by means of cardiac output reduction (β1 blockade) and reduced splanchnic arterial vasodilation (β2 blockade).

Question 138

A 45-year-old lady complains of difficulty swallowing and chest discomfort for six weeks. She noticed that she has been losing weight as well despite her unaffected appetite. She underwent a barium study and is shown below. What is the most likely diagnosis in this patient? * Achalasia * Esophageal carcinoma * Systemic sclerosis * Diffuse esophageal spasm * Pyloric stenosis

Answer 138

* Achalasia

Question 139

14)A 31vear old man develops a recent onset of viral illness. His previous symptoms were followed by retrosternal chest pain that radiated to the back and a low grade fever. Few days after his last presentation ,the patient was brought to the causality upon deterioration of his condition.On examination, the patient's heart rate was 113/min and BP was 85/63.His JVP was raised and heart sound could barely be heard. What is the most appropriate management of this patient? A)Pericardiocentesis B)Establishing a pericardial window C)Initiate a broad spectrum antibiotics D)Insersion of intraaortic ballon bump E)Administration of intravenous fluid and reassessment

Answer 139

A)Pericardiocentesis Note:A case of cardiac tamponade, immediate pericardiocentesis should follow.

Question 140

A 32-year-old man reports recent history of upper respiratory tract infection and symptoms of sinusitis that he had for the past week as well as his children. On examination, the patient has pharyngeal erythema and cervical lymphadenopathy. He also looked mildly jaundiced with total bilirubin of 36 μmol/L (normal: 5.1-20.5). His children had similar findings on examination. What is recommended regarding this patient’s management? * Reassurance of the benign course * Lymph node biopsy * Abdominal ultrasound * CT of the chest and abdomen * Lung biopsy

Answer 140

* Reassurance of the benign course Note: Gilbert syndrome is the most common familial unconjugated hyperbilirubinemia. It is often detected incidentally with a raised bilirubin, especially upon fasting or during mild illness. Once the diagnosis is established, further investigations are not required and reassurance of the benign course is sufficient.

Question 141

A 22-year-old female patient is a known case of ulcerative colitis on steroids. She presented to the clinic complaining of uncontrolled symptoms. She reports increased bowel habits and rectal bleeding. It was decided to start her on 6-mercaptopurine to control her symptoms. One week later, she presents to the ER with severe epigastric abdominal pain that radiates to the back. Her WBC count was found to be 3.5 x109 (normal: 4 - 10 x109). Which of the following is the likely explanation for her recent presentation? * Acute pancreatitis due to 6-mercaptopurine * Acute pancreatitis due to steroids * Intra-abdominal abscess due to neutropenia * Fulminant toxic megacolon * Small bowel obstruction due to stricture formation

Answer 141

* Acute pancreatitis due to 6-mercaptopurine Note: Thiopurine-induced acute pancreatitis is a documented adverse effect that follows initiation of azathioprine or its metabolite 6- mercaptopurine. The involved mechanism has been postulated to be immune-mediated in nature. The timing of acute pancreatitis in this patient was such that it could not be attributed to steroids.

Question 142

A 71-year-old female was brought to the ER after developing an episode of massive lower gastrointestinal bleeding, which happened to be painless and accompanied by dizziness. On examination, the patient looked confused, was tachycardic and had orthostatic hypotension. What is the most likely cause of this patient’s bleeding event? * Diverticulosis * Colorectal adenocarcinoma * Vascular malformation * Internal hemorrhoids * Ischemic colitis

Answer 142

* Diverticulosis Note: The most common cause of lower gastrointestinal bleeding remains to be colonic diverticulosis, comprising about 30% of cases requiring hospitalization. It typically affects the elderly, is painless in nature, massive in amount and resolves spontaneously.

Question 143

A 35-year-old lady comes to her physician and is planning to get pregnant soon. She is a known case of SLE that is well controlled on steroids and plaquenil. How would this patient be further counseled? * Continue both drugs * Discontinue both drugs * Stop steroids and continue plaquenil * Stop plaquenil and continue steroids

Answer 143

* Discontinue both drugs Note: Low-dose steroids and antimalarials are safe to continue in pregnant patients with SLE.

Question 144

18)A 12 vear old male child has history of recurrent throat infections he now presents with joint pain and myalgia as well as fever. Laboratory tests reveal an elevated ESR and high WBC.ECG shows a prolonged PR interval. Echocardiography shows regurgitant aortic valve .What is true regarding this patient's condition? A)Penecillin prophylaxis should be administered until the age 40 B)The aortic valve is most commonly affected in his condition C)Modified Dukes criteria are used to diagnose his condition D)It is associated with chronic but not acute cardiac complications E)Penicillin should be given for 10 years to prevent long term sequelae

Answer 144

A)Penecillin prophylaxis should be administered until the age 40 Note: Secondary prophylaxis for rheumatic fever with penicillin should be ensued in patients with well documented history of rheumatic fever and those with evidence of rheumatic heart disease to minimize long term cardiac sequelae of the condition and should be initiated as soon as the diagnosis is established.Patient with carditis and residual heart disease,i.e.clinical or echocardiographic persistent valvular disaese,should be medicated for 10 years or until age of 40 whichever is longer; in those with carditis but no residual heart disase, for 10 years or until age 21 ;in those with no carditis whatever, for 5 years or until age 21 .An intramuscular injection of pencillin G benzathine four -weekly is recommended regimen.

Question 145

A 32-year-old male patient complains of back stiffness and low back pain. What is the best imaging modality used to detect findings of ankylosing spondylitis? * MRI of the sacroiliac joints * Lumbosacral x-ray * Bone scan * CT scan of the pelvis * X-ray of the cervical spine

Answer 145

* MRI of the sacroiliac joints Note: MRI is the most useful imaging tool for detecting sacroiliitis and is capable of documenting inflammation long before damage becomes visible on x-ray.

Question 146

A 23-year-old female patient develops a bilateral headache that is throbbing in character, photophobia and malaise. On examination, the patient had nuchal rigidity. A lumbar puncture was performed and CSF analysis came back as follows: lymphocytic pleocytosis, slightly elevated protein level, and normal glucose level. Opening pressure was mildly increased. What is the likely diagnosis? A. Viral meningitis B. Migraine headache C. Subarachnoid hemorrhage D. Idiopathic intracranial hypertension E. Multiple sclerosis

Answer 146

A. Viral meningitis

Question 147

A 26-year-old male patient is a known case of epilepsy on anti-epileptics. Routine laboratory investigations showed a hematological abnormality. His blood smear is shown below. What is the likely diagnosis? a. Vitamin B12 deficiency b. Secondary polycythemia c. Drug hypersensitivity syndrome d. Leukomoid reaction e. Immune thrombocytopenia

Answer 147

a. Vitamin B12 deficiency

Question 148

What is the most common cause of status epilepticus? A. Alcohol withdrawal B. Central nervous system infection C. Cryptogenic D. Noncompliance to anti-epileptic medications E. Hypoxic brain injury

Answer 148

D. Noncompliance to anti-epileptic medications

Question 149

According to the most recent guidelines for thrombolytic treatment of stroke, what is the time window from the onset of symptoms that allows administration of tPA for ischemic stroke? A. 3 to 4.5 hours B. 1 to 2hours C. 2 to 3hours D. 4.5 to 6 hours E. 6 to 12 hours

Answer 149

A. 3 to 4.5 hours

Question 150

A 45-year-old patient presents with a swollen, tender knee joint and fever. Aspiration of the synovial fluid was done and showed turbid fluid with a markedly high neutrophil count. It was negative for crystals. What is the most common causative organism of this patient’s presentation? * Staphylococcus aureus * Salmonella entertidis * Neisseria gonorrhoeae * Group B streptococci * Mycobacterium tuberculosis

Answer 150

* Staphylococcus aureus

Question 151

A young male patient presents to the ER with a seizure. He is known to have developed previous similar episodes. How to differentiate between psychogenic seizures and epileptic seizures? A. Measure serum prolactin B. Perform a brain MRI C. Document family history of epilepsy D No requirement for intubation E. Episodes occur in isolation

Answer 151

Note: Serum prolactin level increases shortly after a generalized epileptic seizure but not after a psychogenic non-epileptic seizure. However, it can only be of value to distinguish between the two in the setting of isolated seizures as opposed to status epilepticus.