2012 - 7th Flashcards by Fajer e

A previously healthy nursing male presented with weakness and tremor. He had no ophthalmopathy or pretibial myxedema. His free T4 was elevated and thyroid scan showed diffuse decreased uptake. The thyroid gland was not palpable. What is the diagnosis?
A. Subacute thyroidits
B. Factitious hyperthyroidism
C. Grave’s disease
D. Thyroid adenoma
E. Thyroid carcinoma

B. Factitious hyperthyroidism

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a 32-year-old female presenting with a four day history of fever & epigastric pain. Her labs showed Hct 28%, platelets 15x10^3, LDH 833, and her blood smear showed schistocytes. What is the pathophysiology of this disease?
a. Deficiency in ADAMTS 13
b. Autoimmune destruction of platelets
c. Deficiency of G6PD

a. Deficiency in ADAMTS 13

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An elderly patient presenting with chest pain, diaphoresis & shortness of breath. On examination; he had bilateral pulmonary crepitations & S3 gallop. His systolic blood pressure was 70 mmHg. Patient received inotropes after which his systolic blood pressure became 80
mmHg
What your next step?
Alincrease the dose of inotrones
B) Intra-aortic balloon pump and stenting
C) Coronary angiography and emergent graft bypass

B) Intra-aortic balloon pump and stenting

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A middle aged patient complaining of abdominal pain, discomfort and constipation. His pain is relieved by defecation. Colonoscopy was done and showed normal mucosa with multiple diverticula in the sigmoid. What is your diagnosis?
A) Irritable bowel syndrome B) Celiac disease
C) Chronic diverticulitus
D) Constipation

A) Irritable bowel syndrome
Bloating, constipation and abdominal pain that is relieved by defecating is IBS. IBS is associated with a normal colon on colonoscopy.

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36-year-old presented with right joint knee pain, fever & swelling. What is the most important single investigation?
CBC
Culture
ESR
synovial fluid examination
synovial biopsy

synovial fluid examination

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A Male patient with history of prostate cancer 1 year ago presented with back pain and paresthesia of both lower limbs. Which of the following is indicative acute cord compression?
A) Sensory level
B) Hyperreflexia C) Clonus
D) Weakness

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.

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Patient with low grade fever 37.8, with shortness of breath and dry cough, bilateral knee and elbow pain and tender nodules on the shins. CXR showed bilateral hilar lymphadenopathy What is the stage of sarcoidosis?
a. 0
b. 1
c. 2
d. 3
e. 4

b. 1

Staging of sarcoidosis is based on CXR findings. Bilateral hilar lymphadenopathy without parenchymal infiltrates corresponds to Stage 1.

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A 35-year-old woman came complaining of ptosis and diplopia. Her symptoms are worse at the end of the day. On examination she looks fatigued. The doctor diagnosed her with myasthenia gravis. Where in the nervous system is the problem?
A) Presynaptic membrane B) Postsynaptic membrane C) Nerve Plexus
D) Nerve roots
E) Peripheralnerves

B) Postsynaptic membrane
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.

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A 40-year-old female who has a long history of watery diarrhea diagnosed as “irritable bowel syndrome” and infertility. she presented 3 months ago with abnormal liver enzymes: AST 83 (N=3-35 IU/L), ALT 64 (N=3-36 IU/L) and normal bilirubin, albumin, ALP, and INR. CBC shows normal leukocytes but Hb 100mg/L and MCV was 67 (microcytic anemia). Hepatitis A, B, and C serology were all negative. She came to you now and repeat tests confirm abnormal liver enzymes and iron deficiency anemia. What is your next step?
A) Obtain a liver biopsy
B) Check for anti-transglutaminase IgA and IgG
C) CT Abdomen
D) Alfa fetoprotein
E) Repeat hepatitis serology

B) Check for anti-transglutaminase IgA and IgG – celiac disease: watery diarrhea and the anemia, which is due to nutritional deficiency.

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What measures activity in systemic lupus erythematosus?
A. C3/C4 level
B. dDNA

A. C3/C4 level

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25-year-old female known case of epilepsy and was on three antiepileptic drugs, presented to the ER with status epilepticus. What is the most common cause of status epilepticus?
A) stopping medications & non-compliance
B) Psychogenic seizure C) Refractory epilepsy

A) stopping medications & non-compliance

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A 56-year-old male whose father and brother are diabetics, presented with polydypsia polyuria and nocturia. He came to the GP to check if he has diabetes. What is diagnostic of diabetes:
A. HbA1C 6.1%
B. Fasting blood glucose of7.2
C. 11.1 after one hour of 75g oral glucose (OGTT) D) Urinalysis showing microalbuminuria
D. Random blood glucose of 10.5

B. Fasting blood glucose of7.2

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A 50-year-old female presented with weakness, lethargy & muscle cramps & constipation. Her blood pressure was 220/110. She was started on thiazide, verapamil & nimodipine at the polyclinic and then referred to the hospital. When she went to the hospital her blood pressure was 190/90. Labs were conducted and all were normal except K+ = 3.1 mmol/L she claims that she has been taking her durgs properly. What is the cause of her hypertension? What is your diagnosis?
A. Pheochromocytoma
B. Conns
C. Essential hypertension
D. Coarctation

B. Conns

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A patient was brought by her husband who says she has been feeling “unwell” lately. On examination, she has a fever of 38 C, atrial fibrillation, and is agitated. The husband mentions that she has a thyroid disease.
Which of the following drugs should not be administered initially?
A. Lugol’s iodine
B. Propylthiouracil
C. Hydrocortisone
D. Carbimazole

A. Lugol’s iodine

Note: Iodine solutions given at least 1 hour after antithyroid drugs to avoid exacerbation
of thyroid storm due to increased iodine uptake.

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A 19-year-old boy presented with vomiting and abdominal pain. He was already diagnosed with diabetes type 1 and takes 20 units of insulin glargine at bedtime and short acting insulin 8 units before meals. He was drinking alcohol heavily the night before. BG= 35 PH=7 urine Ketones 4+ What is the next step and his management?
A. let him start feeding
B. Start IV fluid normal saline 0.9% + insulin + K

B. Start IV fluid normal saline 0.9% + insulin + K

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A 38-year-old male presented with history of nausea and constipation for 6 months. Vital signs: HR=80 bpm, BP 138/86. ECG showed shortened QT segment. Stool was positive for fecal occult blood. Upper GI endoscopy revealed multiple 1 cm diameter of multiple gastric antral ulcers. Which of the following is expected to be found in this patient?
A) Elevated TSH
B) Elevated Calcium
C) Elevated thyroxine
D) Low serum gastrin
E) Elevated serum glucose

B) Elevated Calcium
Elevated calcium is associated with constipation and shortened QT segment on ECG.

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A 83-year-old male came with 2 day history of LLQ abdominal pain that is constant and not relieved by position or defecation. He has a fever of 38C. A palpable mass is felt in the LLQ with no rebound tenderness. WBC are 14x10^5. All other labs are normal. CXR is normal and no air under diaphragm.
What is your next step in diagnosis?
A) Double contrast barium enema
B) Colonoscopy with terminal ileoscopy
C) Contrast CT of abdomen and pelvis
D) Small bowel follow through
E) Capsule endoscopy

C) Contrast CT of abdomen and pelvis
Old age, LLQ abdominal pain, fever, and elevated WBCs are indicative of diverticulitis. The test of choice to diagnose diverticulitis is contrast CT of abdomen and pelvis.

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This is a blood smear of a patient:
What’s your diagnosis?
a. Iron deficiency anemia
b. Megaloblastic anemia
c. Thalassemia
d. Lead poisoning

c. Thalassemia

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A 24-year-old female with multiple sclerosis, deficiency of which vitamin is going to cause worsening of her condition?
A) Vitamin A
B) Vitamin B
C) Vitamin C
D) Vitamin D
E) Vitamin E

D) Vitamin D

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A patient who had Crohns disease and went through multiple surgeries for intestinal obstruction had bleeding at a surgical site. He was stabilized intra- operatively with bovine thrombin at the bleeding site. Patient was doing well until day 8 when he was found to have high PT and APTT. His blood smear was normal and mixing studies did not correct the abnormality. What is the underlying cause?
a. liver disease
b. factor inhibitor
c. Hemophilia
d. vitamin k deficiency

b. factor inhibitor

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A 50-year-old multigravida presented with dyspnea on exertion, paroxysmal nocturnal dyspnea & lower limb edema and abdominal distention 2 weeks after delivery.
Echocardiography showed dilated poorly contractile left ventricle. EF was 20%. Which arterial pulse does this patient have?
A) Pulsus alternans
B) Pulsus parvus et tardus
C) Pulsus biseferians
D) Pulsus paradoxus
E) Pulsus bigeminus

A) Pulsus alternans

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What is the best management in term of importance in obstructive sleep apnea?
a. Family history of OSA
b. A CT scan of chest
c. ENT consultation
d. Methacholine challenge test
e. Spirometry

c. ENT consultation

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Patient presents with sharp central chest pain radiating to shoulder and left arm aggravated by deep breathing and relieved with sitting up. His BP is 107/76 and heart rate is
113. Physical exam is unremarkable except for the tachycardia. ECG done shows ST elevation in all leads except aVR. On the third day patient becomes hypotensive with raised JVP, what is the management?
A) notropes
B) Emergent pericardiocentesis
C) Penicillin and saline
D) Anticoagulation
E) Cardiac angiography and stenting

B) Emergent pericardiocentesis

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A woman is known to have orthopnea, ascites and lower limb edema for years. Her CXR is given below:
What would be the finding in this patient?
A) Pulsus alternans
B) Paradoxical splitting of S2
C) Pericardial rub
D) High JVP
E) S3 Gallop

D) High JVP

Pericardial calcification >constrictive pericarditis.
Signs and symptoms of constrictive pericarditis:
1)dyspnea, fatigue, palpitation.
2) Abdominal pain.
3)May mimic CHF (especially right sided heart failure).
4)Increased JVP ‚Kussmaul’s sign(paradoxical increase in jvp with inspiration), Friedreich’s sign(prominent y descent).
5)BP usually normal (and no pulsus paradoxus).
6) Pericardial Knock.

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A patient is a known case of diabetes controlled on metformin. He is admitted as a case of stroke. You decide to admit him. His random blood sugar is 22. What will you do for the management of his blood glucose levels? A. Continue oral metformin B. Stop metformin and start glucose insulin potassium infusion (GIK) C. Stop metformin and start s.c. intermediate insulin twice daily D. Stop metformin and start insulin infusion

D. Stop metformin and start insulin infusion Note: to manage inpatient hyperglycemia we use (basal-bolus + sliding scale insulin SSI) strategy. I will summarize this strategy into steps: 1. Calculate total daily dose TDD which is usually 0.5 Unit/Kg except for 3 conditions “if Cr>1.5 / GFR<60 , age >65, BG <10 mmol/l” we use 0.3 units/Kg instead of 0.5 2. Divide TDD into 50% basal (long acting) given at night before sleep and 50% nutritional insulin (rapid acting) before each meal or use mix (intermediate with short acting insulin e.g. Novolin) twice a day “that’s why answer C is wrong” 3. For SSI, take 5% of TDD this is the number of unit you will administer for every 2.2 mmol/l increase in BG e.g. TDD=50, 5% of 50= 2.5 (round the number down to the nearest whole number in this case 2) so you will add 2 units of insulin for every 2.2 increase in BG. If the patient is eating all or most of each meal: Administer as short-acting insulin (or rapid-acting insulin) before each meal and at bedtime. If the patient is not eating (NPO): Administer as short-acting insulin every 6 hours 4. Adjust as needed (hypoglycemia: reduce 20% of basal insulin and/or 2 unit from SSI) (persistent BG> 7.8 with no episodes of hypoglycemia: increase Basal by 20% and/or increase SSI by 2 units

A 55-year-old patient who is a known case of hypertension, diabetes mellitus & hyperlipidemia and history of smoking came complaining of repeated attacks of syncope. An echo was done and revealed a severely calcified tricuspid aortic valve with high mean pressure gradient along with LVH and EF55%. What is the most appropriate next step? A) Request surgeon opinion for aortic valve replacement B) Follow up the patient C) Arrange for coronary angiography before sending the patient for valve replacement Surgery

C) Arrange for coronary angiography before sending the patient for valve replacement Surgery

A 25-year-old man presenting with hematuria post exercise. On further questioning, he had a history of hematuria accompanying illness and infection. What is the likely underlying cause? a. IgA nephropathy b. Alports c. Post infectious GN

a. IgA nephropathy

A 71-year-old male patient was admitted to ICU with pneumonia. The patient was improving but on day 3 in his hospital stay his labs showed ab isolated platelet count. Which of the following could explain this finding? a. Aminoglycoside mediated effect b. Albumin infusion c. High dose prednisolone d. Enoxaparin for VTE prophylaxis e. Dilutional effect of IV fluids

d. Enoxaparin for VTE prophylaxis

An Adult with sickle cell disease had a peripheral blood smear done. The most likely cause is: a. Autosplenectomy b. Hemolysis c. Chronic hepatitis B infection d. Folate deficiency e. Vitamin B12 deficiency

a. Autosplenectomy

A young patient on soluble insulin before meals who complains of hypoglycemia after exercising. His HBA1c was 6.5%. What is the advantage of rapid-acting insulin over soluble insulin? A. Reduces the number of hypoglycemic attacks B. Reduces post-prandial blood sugar C. Has a significant effect in reducing HBA1c D. Prevents the long term complications of diabetes E. Longer duration of action

A. Reduces the number of hypoglycemic attacks

A 60-year-old male with history of a heart attack 1 year ago presented with chest pain, diaphoresis, elevated JVP & S3 gallop. On examination, he had a faint pansystolic murmur on the apex. Initially his BP was within the normal range. The patient was given nitrates then his blood pressure dropped to 90/60. ECG showed ST elevation in leads L1,2,L3, aVF. What's the patient's diagnosis? A) Aortic dissection B) Acute mitral regurgitation C) Hypertensive crisis D) Inferior wall & right ventricular infarct

D) Inferior wall & right ventricular infarct

A 20 year old medical student just completed his riveting hematology rotation and decides to do a coagulation profile test. It shows high PTT with normal PT. Prolonged incubation resulted in shortening of PTT. What is the cause? a. Vitamin K deficiency b. Mishandling of blood sample c. Hemophilia A d. Prekallikrein deficiency

d. Prekallikrein deficiency

Which of the following is the most specific test to detect Rheumatoid arthritis? A. Anti-cyclic citrullinated peptide antibody. B. Rheumatoid factor C. ANA

A. Anti-cyclic citrullinated peptide antibody. (from dr.mona msd, using anti- CCP has a sensitivity of 80%)

A 60- year-old male with macrocytosis with RBCs being round not oval and with lipid vacuoles. He has normal LFTs but elevated GGT, bone marrow exam showed ringed sideroblasts. What is the diagnosis? a. Excess alcohol b. Megaloblastic anemia c. Myeloproliferative disorder d. Hemochromatosis

a. Excess alcohol

A 25-year-old woman who presented with a 2 week history of headache, nausea, tinnitus & visual problems. On examination, the patient was found to have papilledema and 6th cranial nerve palsy. She mentions that she has been taking a new medication. Which vitamin would be in this medication that would result in this condition? A) Vitamin A B) Vitamin B C) Vitamin C D) Vitamin D E) Vitamin K

A) Vitamin A Vit A (retinoids) excess causes idiopathic intracranial hypertension (IIH)

All of the following are seen in bone marrow examination of megaloblastic anemia, except: a.Giant metamyelocytes b. Nuclear cytoplasmic asynchrony of developing erythroid cells c. Absent stainable iron d. Hypersegmented megakaryocytes e. Hypersegmented neutrophils

c. Absent stainable iron

A 25-year-old with history of malaise weight loss and fatigue. He is being worked up for an immunodeficiency. He had the BCG vaccine at birth and his PPD shows 4mm after 48 hours. How would you interpret this response? A. Negative result due to T-cell abnormality B. Negative result due to B cell abnormality C. Negative result due to Complement abnormality D. Normal skin reaction

A. Negative result due to T-cell abnormality

Which of the following scenarios indicate fulminant liver failure? A) A patient with paracetamol overdose with ALT 20,000 and INR 1.4 B) A 20-year-old lady with HBV surface antigen and ALT 1,200 2 weeks ag. Presenting now with ALT 700 & INR 4 & drowsiness C) A known cirrhotic patient who stopped his medications 4 months ago because of depression who comes now with astrexis and confusion of 5 days D) A 70-year-old with alcoholic cirrhosis presenting with variceal hemorrhage E) A 20-year-old IV drug user presenting with confusion. ALT 220, INR 1.1

B) A 20-year-old lady with HBV surface antigen and ALT 1,200 2 weeks ag. Presenting now with ALT 700 & INR 4 & drowsiness Hepatic failure is characterized by encephalopathy (drowsiness) and coagulopathy (INR 4).

Which of the following scenarios would have a high risk of osteoporosis? A. A 38-year-old white lady marathon runner. B. A 48 years old Asian lady with hyperthyroidism and her weight is 43 Kg C. A 47-year-old black lady with sarcoidosis D. A 36 year-old black with 2 children E. A 19-year-old white lady with binge eating and her weight is 68 Kg

B. A 48 years old Asian lady with hyperthyroidism and her weight is 43 Kg Note: Thyroid hormone affects the rate of bone replacement. Too much thyroid hormone (i.e. thyroxine) in your body speeds the rate at which bone is lost. If this happens too fast the osteoblasts may not be able to replace the bone loss quickly enough.

30-year-old female, who has a persistent cough of 5-6 months duration. She had no nasal symptoms & no obvious triggers. She does not complain of heart burn. The cough gets worse mainly at night. The patient mentions that she is exposed to passive smoking & she has pets, a dog and a cat, for the past 5 years. She works as a clerk and has a sedentary lifestyle. What is the best intervention for this patient? a. Trial inhaled steroids b. Trial oral steroids c. Trial of anti-reflux medications d. Trial of antihistamines e. Trial of cough suppressants

a. Trial inhaled steroids This patient has persistent asthma (not intermittent) and so needs a trial of long-term intervention as well as a SABA/ or ICS-Formeterol to be taken as needed (but not mentioned in these answer options). Inhaled steroids are preferred over oral due to fewer systemic side effects.

A 19-year-old male, with persistent sputum that ranges from clear to yellow to sometime green and purulent. He had previous 2 episodes of hemoptysis. He has had multiple chest infections. Now he is presenting with worsening symptoms. On examination he had bilateral diffuse rhonchi and localized crepitations in the left lower lobe. What would be the finding in CXR? a. Cystic lesions with thickening of bronchial walls b. Normal c. Alveolar infiltrates d. Obliteration of the left costophrenic angle

a. Cystic lesions with thickening of bronchial walls b FYI: Rhonchi are sounds are caused by movement of fluid and secretions in larger airways, and are cleared with coughing. This patient has bronchiectasis most probably due to cystic fibrosis (hints: purulent sputum, hemoptysis, and recurrent chest infections. The cardinal finding of later stages of cystic fibrosis is the presence of bronchial wall thickening. These begin as cylindrical and progress through varicoid to cystic forms. However this is found clearly on CT and CXR can usually be normal in a lot of cases. Hopefully in the exam the question would be clearer.

A 24-year-old male who presented with a 2-day history of pus discharge from the urethra. He reports having unprotected sex 1 week back. His CBC and chemistry profile are normal. What is the most likely diagnosis? a. Urinary tract infection b. Gonoccocal urethritis c. Syphilis d. Herpes simplex

b. Gonoccocal urethritis Giving a history of pus discharge and unprotected sex are clues for urethritis in young, sexually active male.

A 34-year-old woman complaining of 8 months history of epigastric pain, previously healthy with no associated symptoms. Her Physical examination was unremarkable. What is the most likely cause? A) Duodenal ulcer B) Gastric ulcer C) Gastritis D) Non-ulcer dyspepsia

D) Non-ulcer dyspepsia This case had no associated symptoms. Both peptic ulcer disease and gastritis are associated with epigastric pain as well as other symptoms.

A 27-year-old man complains of fever, urethritis and arthralgia. On examination he has a swollen ankle joint and pustular rash of the dorsum of the hand. What is the diagnosis? A. Gonococcal arthritis B. Staphylococcus arthritis C. Viral arthritis D. Rheumatic fever

A. Gonococcal arthritis

A 25-year-old male presented with recurrent painful scrotal and oral ulcers since 18 years old. He also had red eyes, joint pains & red papules and pustules over his trunk. What is your diagnosis? Bechet’s Sweets syndrome Reiters syndrome Recurrent HSV infection Recurrent erythematosus dermatitis.

Bechet’s

Which antihypertensive is not used in asthma patient? A) Propranolol B) ACEI C) CCB D) Thiazide

A) Propranolol B blockers are contraindicated in asthmatics because of their potential causing bronchospasm.

70 year presented to the casualty with sudden onset of retrosternal chest pain, dyspnea, and sweating. He was diagnosed with STEMI. He hater devolved ventricular fibrillation and passed away in spite of DC shock. What is the most likely atherosclerosis site on autopsy? A) Right coronary artery B) Left anterior descending artery C) Circumflex artery D) Marginal actuate artery

B) Left anterior descending artery

Which of these may slow the rate of deterioration in a patient with COPD? a. LABAs b. SABAs c. Inhaled muscarinic antagonists d. Corticosteroids e. Smoking cessation

e. Smoking cessation Smoking cessation, along with home oxygen therapy, are the only 2 interventions shown to improve survival.

24-year-old female several episodes of wheezing and cough that resolves spontaneously. Every time she goes to the GP spirometry is normal. What’s the best way to diagnose her when she’s asymptomatic? a. CT b. Peak flow c. Methacholine challenge test d. Spirometry pre and post bronchodilator e. Skin allergy test

. Methacholine challenge test The methacholine challenge test (bronchoprovocation test) is useful when asthma is suspected but PFTs are nondiagnostic or inconclusive.

A 19-year-old female known case of sickle cell disease on hydroxyurea, folic acid, and tramadol for pain. She was for generalized boney aches. She was hydrated and started on IV morphine. Within minutes of starting the morphine, she developed severe itching all over her body. On examination, she was fully conscious and talking, vitally stable, chest was clear and no urticarial or angioedema was detected. She and her parents are worried that she is allergic to morphine and it will affect her treatment. Which is correct? A. This is a type 2 hypersensitivity reaction B. This is a mixed 2 and 3 hypersensitivity reaction C. Antihistamines will not relieve her condition D. Pruritus is a known side effect of opioids and it is not an allergy mediated reaction E. All opioids should be withdrawn and formal skin prick testing performed to identify a suitable opioid for this patient

D. Pruritus is a known side effect of opioids and it is not an allergy mediated reaction

A 40 old patient with DM2 US came for an annual checkup. He was found to have hepatomegaly and US showed enlarged liver with echogenicity. He is an occasional social drinker. He has a BMI of 38. AST high, ALT high, Bilirubin normal, Albumin normal What’s the diagnosis? A) Hemochromatosis B) Alcoholic liver disease C) Cirrhosis D) Non-alcoholic steatohepatitis

D) Non-alcoholic steatohepatitis NASH: Risk factors: metabolic syndrome ie. DM2. Patients are asymptomatic; therefore it is usually picked up on an annual checkup. Liver biochemistry shows elevated AST/ALT.

A woman with recurrent complaint of bloating, abdominal pain that is relieved by defecating, and diarrhea with passage of soft mucoid stool with no blood. What is likely seen in her colonoscopy? A) Circumferential small bowel inflammation with skip lesions B) Continuous mucosal ulceration C) Normal colon

C) Normal colon Bloating and abdominal pain that is relieved by defecating is IBS which is associated with a normal colon on colonoscopy.

28-vear old male previouslv healthy presenting with rever and sharo chest pain for 3 davs duration. One week ago, ne had symptoms of cold, cough & body aches. His physical examination was unremarkable with BP 130/80, HR 120 and temperature 38.3 C. ECG is given below: How would you manage this patient? A) Beta blocker B) PCI C) NSAIDS D) Clopidogrel

C) NSAIDS

A 84-year-old nonsmoker male came with a history of shortness of breath on exertion and chronic cough. Whenever he exercises, he develops mild intermittent non-productive cough. He has bilateral basal fine crackles and CXR shows infiltrates and opacities in the lower zones. What is the best test for diagnosis? a. Chest CT with contrast b. Chest CT without contrast c. Chest CT with high resolution d. Bronchoscopy

c. Chest CT with high resolution HRCT (High Resolution CT) is the test of choice. Bronchoscopy is also a diagnostic test, but it is not always performed.

A 64-year-old obese male presented with dyspnea, lower limb edema and abdominal distention. He drinks alcohol occasionally. His LFTs were normal. Serum albumin was 37 g/L. Ascitic tap was performed: ascetic albumin: 17 g/L total protein 35 g/LWBCs: 350mm 12% neutrophils. Which of the following is a possible cause? A) TB peritonitis B) Metastatic peritonitis C) Pancreatic ascites D) Perforated viscus E) Heart failure

ANSWER: E) Heart failure Dyspnea, lower limb edema and abdominal distention are manifestations of heart failure. SAAG = Serum albumin – Ascitic albumin, SAAG in this stem is > 11.1, therefore indicating a transudate cause. Also, ascitic fluid total protein is used to differentiate the causes of ascites if ascitic or serum albumin is not given, ascitic total protein > 25 is indicative of heart failure. A) Requires elevated lymphocytes B) Requires cytology C) Requires elevated pancreatic enzymes (Amylase and lipase)

What is the most common type of aura seen with migraine headaches? A) Auditory aura B) Sensory aura C) Visual aura

C) Visual aura MSD Raed Behbehani ‘Neuro-ophthalmologic Causes of Headache’ Migraine: photophobia + visual aura

A 53-year-old male who is a heavy smoker with chronic cough, presented with fatigue and lethargy. His lab investigations showed Na 123 mmol/L Serum osmolarity 270 mOsm (NR: 290-325) Urine osmolarity 450 mOsm (NR: 200- 1000) Blood glucose 6 mmol/L . Choose the correct statement: A. His condition is mostly due to diabetes insipidus B. The underlying cause is probably lung cancer C. Rapid correction of his hyponatremia will result in cerebral edema D. Fanconi syndrome is possible in this patient.

B. The underlying cause is probably lung cancer Note: hyponatremia with low serum osmolarity could be either (RTA, Addison’s, hypothyroidism, or SIDAH) giving that the patient is smoker with history of chronic cough raised the suspicion of lung cancer probably small cell carcinoma which characterized with ectopic ADH secretion.

A 30-year-old diabetic presented with polydipsia and polyuria of 4 month duration. His dad was diabetic since he was 13. He had hyperpigmentation on the back of his neck. A. MODY B. Diabetes mellitus type I C. Diabetes mellitus type II D. Cushing’s syndrome E. Drug-induced diabetes

C. Diabetes mellitus type II Note: the patient showed symptoms of hyperglycemia together with 2 risk factors which are 1) having a first degree relative with diabetes and 2) having “acanthosis nigricans’. Adults aged 20 to 39 with acanthosis nigricans were 4.2 times more likely to have at least two diabetes risk factors as were those without the condition.Acanthosis nigricans can be used to rapidly identify those patients with multiple risk factors for type 2 diabetes mellitus.

A 28-year-old male was found unconscious by his family. Upon taking history from his relatives, he was not known to have any medical problems. They noticed during the past six months that he didn’t go to work and was being aggressive towards his wife and children. In the ER, the patient was drowsy and only responded to painful stimuli. His heart rate was 60. His blood pressure was 90/60. He didn’t have any localizing neurological symptoms. On examination. He had multiple injection marks on his anterior cubital area. The next management step to perform is: A) ECG B) ABG C) CXR D) Serum electrolytes E) CT head

A 22-year-old female presented with a painful vesicular rash that was confined to her right upper back. What is the causative organism? a. Herpes simplex b. Herpes zoster c. EBV d. CMV e. Coxsackievirus

b. Herpes zoster

A patient gave birth to a baby with rash and complete heart block. What antibodies would be positive in the mother? A. Anti-dsDNA B. AntiRo/ AntiLa SS C. ANA D. Anti-CCP

B. AntiRo/ AntiLa SS ( Anti-Ro/SSA and anti-La/SSB are associated with an increased risk of neonatal lupus which is characterized by rash and heart block)

A 60-year-old diabetic patient on hypoglycemic agents and glargine. He injected his insulin in the morning and developed sweating and tachycardia. He was found comatosed with increased reflexes on the right side and a smell of alcohol on his breath at 1:30 pm. What is the most likely diagnosis? A. CVA B. Delirium tremens C. Hypoglycemia D. DKA E. Seizure

C. Hypoglycemia Note: Hypoglycemia symptoms include sweating, trembling, dizziness, inability to concentrate, and nausea. Severe hypoglycemia can lead to confusion, convulsions, coma, and death.

What test would help the physician to differentiate central from obstructive OSA? a. Arterial CO b. Arterial oxygen c. ECG d. Nasal airflow e. Thoraco-abdominal movement

e. Thoraco-abdominal movement Obstructive sleep apnea differs from central in which there is effort to breathe but the patient is unable to do that due to upper airway obstruction.

A young man developed anaphylactic reaction, post transfusion. What packed cells you would use in the future a. Washed RBCs b. WBC free RBC c. Frozen RBCs d. CMV negative RBC’s

a. Washed RBCs

Which of the following is true regarding asthma: a. Enhancement of FEV1 equals to or > 20% after bronchodilator b. If there is no wheezing this is not asthma c. It might be complicated with bronchiectasis d. No role of anti-histamines in management e. If there was no response to ICS the first choice of add on montelukast

a. Enhancement of FEV1 equals to or > 20% after bronchodilator A is not a perfect answer because the increase should be by at least 12% (not 20%) after bronchodilators. However all the other answers are wrong and therefore eliminated.

A 18-year-old female presented with jerky movements and inability to walk. She had a soft S1 and a pansystolic murmur. Laboratory tests reveal an elevated ESR and high white blood cell count. She was successfully treated with steroids, penicillin, and haloperidol. What is the next step for this patient? A) Monthly IM penicillin until she's 40 BOra penicillin for 4 weeks C) No follow up

A) Monthly IM penicillin until she's 40

In heparin induced thrombocytopenia, heparin-PF4 antibodies immunoassay IS performed. Which is true regarding diagnosis with this immunoassay? a. Heparin-PF4 antibodies immunoassay has no role b. Patients will develop heparin-PF4 antibodies only if they have clinically evident severe thrombocytopenia c. Heparin-PF4 antibodies immunoassay has a high negative predictive value d. Patients with detectable heparin-PF4 antibodies are 60-80% more likely to develop clinical disease e. Patients with seroconversion after an initially negative test are more likely to develop clinically prevalent disease

d. Patients with detectable heparin-PF4 antibodies are 60-80% more likely to develop clinical disease

A 57-year-old male with long standing diabetes complaining of a long history of abdominal fullness, intermittent nausea and bloating. On physical examination a splash is heard over the stomach on auscultation while moving the patient. What is the diagnosis? A) Peptic ulcer disease B) Gallstone C) Gastroparesis D) Irritable bowel syndrome

C) Gastroparesis

A 34-year-old lady with history of dry cough of 2 months duration. Her chest X-ray showed bilateral hilar lymphadenopathy and lung function tests showed a restrictive pattern with low DLCO. What is the best next step for diagnosis? a. Calcium levels b. Bronchoscopy with transbronchial biopsy c. Measurement of ACE levels d. Thoracoscopy with lung biopsy

b. Bronchoscopy with transbronchial biopsy Next confirmatory test of choice is bronchoscopy.

a 55-year-old male with multiple episodes o loss o consciousness and body stiftness for 2 days period. He had head lacerations because of the fall. On examination HR was 38 and a prominent wave in IVe was detected. He was also tound to have an ejection systolic murmur ir the right upper sternal border. ECG is given below What is the next step in management? A) Urgent echo B) coronary angiography C) Temporary pacemaker D) CT head E) Electroencephalogram

C) Temporary pacemaker

A 55-year-old-man who presented with massive splenomegaly. CD 19/22/103 were positive. Monoclonal B cells with bright kappa positivity. Total leukocytes 3.3 What the Diagnosis? a. B cells Prolymphocytic leukemia b. Hairy T-cell leukemia ( a typo in the exam itself, it should be hairy cell leukemia) c. Mantle cell leukemia d. Diffuse large B-cell lymphoma

b. Hairy T-cell leukemia ( a typo in the exam itself, it should be hairy cell leukemia)

8-year-old with a known history of peanut allergy presented after eating a cake with peanuts. He had edema on his face and lips with urticaria, He was conscious and coherent, on examination: BP 95/64 Pulse 107 BPM,regular RR 22 SpO2 93% On chest auscultation he had mild scattered wheezes􏰁 After ABC what would you do? A. Give him IV corticosteroids If no response give him IM epinephrine B. Give him IV antihistamine If no response give him IM epinephrine C. Even though he is conscious and stable he should receive IM epinephrine D. Anaphylactic shock is type 3 hypersensitivity reaction E. Anaphylaxis is mediated by prostaglandin and cytokines release from mast cells

C. Even though he is conscious and stable he should receive IM epinephrine

A patient with sickle cell anemia changed her physician. Her new physician ordered a CBC and found macrocytosis. What is the most likely explanation for her macrocytosis? a. iron deficiency b. Folate deficiency c. B12 deficiency d. Hydroxyurea e. Infection

d. Hydroxyurea

A 74-year-old male patient with diabetes mellitus developed stage 5 diabetic nephropathy. He has retinal hemorrhages treated with laser photocoagulation 2 years ago and had coronary artery stenting for 2 vessels 3 months ago. What is true regarding renal replacement therapy for this patient? a. Renal transplantation is better than dialysis given his medical status b. Hemodialysis is better because of his cardiovascular status c. Peritoneal dialysis is better because it does not require anticoagulation d. Hemodialysis will increase his serum glucose more than peritoneal dialysis

a. Renal transplantation is better than dialysis given his medical status

A 67-year-Old male presented with Central chest discomfort and fatigue, ECG showed ST elevation MI. Upon transferring him to CCU he developed dizziness and palpitations. He had a weak pulses and a systolic BP of 80 ECG is shown below: What is the proper management? A) IV propanalol B) IV amiodarone C) IV adenosine D) Intra-aortic balloon pump E) DC cardioversion

E) DC cardioversion

A patient with Crohns who underwent multiple surgeries for complications. He presented with an enter-colic fistula and taken to surgery, where multiple adhesions and oozing were found, suspected to be bacterial overgrowth. Which of the following is true regarding bacterial overgrowth? A) It can be confirmed by hydrogen breath test B) High serum folate rules out diagnosis C) The anomaly of defect can be easily corrected

A) It can be confirmed by hydrogen breath test

A 60-year-old man presented with hemoptysis & renal impairment. His urine dip stick showed 4+ protein, RBC 3-5/HPF. kidney biopsy showed crescentic nephritis. The patient was positive for c-ANCA.What is the appropriate management? a. Cyclophosphamide b. Steroids, cyclophosphamide and plasma exchange c. Steroids

b. Steroids, cyclophosphamide and plasma exchange

A 68-year-old male heavy smoker for 50 years, presented with cough and hemoptysis. CXR showed a 4 cm lung mass in the upper right lobe with large lymphadenopathy. Bronchoscopic biopsy showed small blue malignant cell. Immunohistochemistry staining showed a neuroendocrine tumor. What is the main characteristic of this kind of lung cancer? a. It does not respond to chemo and radio b. Early distal metastasis c. Easily respectable if early diagnosed d. Better prognosis compared to other histological types e. Rarely presents with paraneoplastic syndromes

b. Early distal metastasis This is SCLC (small cell lung carcinoma). It commonly metastasizes and is difficult to resect. Its prognosis is usually poor in comparison to other types. It does respond to chemo and radio if it was limited, and chemo alone if extensive.

What’s true about idiopathic pulmonary fibrosis? a. Median survival is 7.5 years b. Prognosis in females is worse than males c. Generally, prognosis is better than cancer d. Prognosis is worse when it’s associated with pulmonary hypertension

d. Prognosis is worse when it’s associated with pulmonary hypertension

A 15-year-old girl with a history of Menorrhagia and easily bleeding from small cuts. APTT is 35 Sec. Bleeding time is prolonged with a normal platelet count. What could be the diagnosis? a. F VIII Deficiency b. vWD c. Platelets function disorder d. F VII deficiency

b. vWD

Q4. A patient has hypertension and DM nephropathy. What do you want his blood pressure to be? A) 130/80 B) 140/90 C) 110/70 D) 150/90 E) 120/70

A) 130/80

A young patient with type 1 diabetes mellitus came with a blood pressure of 90 systolic on lying down. When he stands it drops to 70 systolic. His labs show Na of 131 (low) and potassium (high). His glucose on admission (low). What would you find in such a patient? A. Low urine sodium B. Low renin C. TSH receptor antibodies D. High DHEA E. 21-hydroxylase antibodies

E. 21-hydroxylase antibodies Note: 1) orthostatic hypotension ” Glucocorticoids play an important role in catecholamine-induced vasoconstriction and myocardial contractility.” 2) hyponatremia ”Glucocorticoids inhibit ADH secretion and thereby prevent excessive water retention. With adrenal insufficiency, ADH secretion is disinhibited causing increased reabsorption of free water with subsequent dilution hyponatremia. 3) hypoglycemia “Glucocorticoids inhibit peripheral glucose utilization and increase gluconeogenesis" These are the symptoms of low cortisol level (hyporcortisolism). 21-hydroxlase is an enzyme that is produced predominantly in the adrenal cortex and involved in steroidogenesis. Deficiency of this enzyme is the most common cause of congenital adrenal hyperplasia.

A 63-year-old lady presented with watery diarrhea & has longstanding GI bleeding manifested by melena for which she underwent colonoscopy twice, endoscopy & small bowel follow-through. All found to be normal. What Investigation could reveal the cause? A) Repeat colonscopy B) CT scan C) Capsule endoscopy

C) Capsule endoscopy Wireless capsule endoscopy indication: obscure gastrointestinal bleeding.

Which of the following is the most common paraneoplastic manifestation of small cell lung Carcinoma (SCLC)? a. SIADH b. Hypercalcemia due to PTH secretion c. Distal muscle weakness in the lower limbs

a. SIADH SIADH (Syndrome of inappropriate ADH) is found in approximately 10% of SCLC patients. SCLC patients can also have ectopic ACTH secretion, as well as Eaton Lambert syndrome which presents as proximal muscle weakness. PTH-like hormone secretion and consequent hypercalcemia is most commonly in squamous cell carcinoma (so not SCLC).

A 50 years old male admitted to ICU with huge ischemic stroke. His level of consciousness deteriorated. CT scan showed severe cerebral edema. The quickest effective way to treat this raised intracranial pressure: A) Elevation of the head B) Hyperventilation C) Mannitol D) CSF drainage

B) Hyperventilation Hyperventilation is one known method of rapidly lowering ICP. Cerebral bf dependent on PaCO2. Hyperventilation decreased PaCO2 which subsequently leads to arterial vasoconstriction thus lowering CBF, CBV, and ICP.

A 76- year old male presented to the hospital with watery diarrhea. He had the same presentation 1 month ago and was treated for clostridium difficile with oral metronidazole for 14 days. Investigations showed persistent C.difficle toxin. How would you treat this patient? A) Oral metronidazole 6 weeks B) IV metronidazole 2 weeks C) IV vancomycin 2 weeks D) Oral vancomycin 14 days E) Oral vancomycin 6 weeks

D) Oral vancomycin 14 days Management: 1. Stop antibiotics 2. Oral vancomycin 3. If fulminant and life threatening, use both oral vancomycin and IV metronidazole NEVER USE IV VANCOMYCIN.

A young Male presented with shaking of his hands when he performs tasks. It was aggravated by anxiety. He says that his father and grandfather have the same problem. What is the most likely diagnosis? A) Parkinson's Disease B) Hypothyroidism C) Hyperthyroidism D) Essential Tremor E) MS

D) Essential Tremor Essential tremor is characteristically postural (occurring with voluntary maintenance of a position against gravity) and kinetic (occurring during voluntary movement). It usually resolves when the body part relaxes

A 36-year-old female presented with 3 weeks’ history of perioral numbness, tingling, and carpopedal spasms. Total calcium was found to be 2.00 (N 2.2-2.6) What other lab finding do you expect? A. Low magnesium B. High albumin C. High glucose D. Low sodium

A. Low magnesium

A lady had an in-utero fetal death and during dilation and curettage she developed abruptio placenta with massive vaginal bleeding and from cannula sites. She was given 2 PBRCs and 1 unit platelets and she stabilized. She was doing fine until day 8, when she developed bleeding from the vagina and lower limb purpura. Investigation shows platelets 5X10^9, normal APTT, normal PT, no D- dimers/FDPs. What is the cause? a. DIC b. HIT c. ITP d. Post transfusion purpura

d. Post transfusion purpura

Mrs. Amal is a 32 years old with a history of SLE for 8 years. She had 2 abortions and episode of pulmonary embolism 3 years back. What investigations should be performed to this patient? Anti-dsDNA Abs ANA Anti-B2 globulin Anti-ribonucleoprotein ESR

Anti-B2 globulin Anti-ribonucleoprotein

An old man with splenomegaly and a platelet count of 1150. He had a normal RBC and no other abnormalities. He was found to be positive for calreticulin mutation. What’s the most likely diagnosis? a. Polycythemia rubra vera b. Reactive thrombocythemia c. Essential thrombocythemia

c. Essential thrombocythemia

How to follow the daily renal function of an ICU patient? a. 24-hour urinary clearance b. 24 hour measured GFR c. Estimated GFR d. Serum creatinine

d. Serum creatinine

A 26 years old banker came with bloating, abdominal pain, and weight loss. His labs showed IDA and High ALP.The next appropriate blood test would be: A) Serum iron B) Serum gastrin C) Haptoglobin and retic D) Tissue transglutaminase antibody E) H. pylori serology

D) Tissue transglutaminase antibody

A 55 year old man with 4-5 episodes of gout attacks per year. What will you prescribe him? A. NSAIDs B. Colchicine C. Paracetamol D. Steroids E. Allopurinol

E. Allopurinol

A 36-year-old man presents to the emergency room at 1 AM in the morning, complaining of vomiting approximately 200 mL of bright red blood. Earlier in the evening he was at a party & had consumed excessive amount of alcohol. He had become sick while at the party & had experienced repeated retching & vomiting followed by bleeding. Upper GI endoscopy was done and was unremarkable. The next day patient is vitally stable. What is your management? A) PPI B) Refer for a surgical opinion C) Send home D) Give omeprazole for one month

C) Send home

What is true regarding antibodies? A. IgA and IgM can cross the placenta B. IgM are produced by GI mucous membrane as part of 1st line defense C. IgM are found on circulation forming pentad D. RF is an IgM autoantibody that binds to the Fc portion of IgG and help in the diagnosis of rheumatoid arthritis E. One IgG antibody can bind to a maximum of one antigen

D. RF is an IgM autoantibody that binds to the Fc portion of IgG and help in the diagnosis of rheumatoid arthritis

Mr. Ibrahim, a 45-year-old man came with scaly lesions on the extensor surfaces of his body. He complained of back pain and morning stiffness. Which of the following drugs is best to control his condition? A. Methotrexate B. Anti-TNF C. Imuran D. Dapsone

B. Anti-TNF

A 28-year-old female presented with an asymptomatic thyroid nodule. she denies any hoarseness, dysphasia or obstructive symptoms. TSH is normal. What is the next best step to evaluate this patient? A. Thyroid scan B. CT scan C. T4 level D. Thyroid US

D. Thyroid US

An elderly woman with inability to open jars because of of stiffness in her hands. On examination she had swelling of distal fingers and of the first metacarpophalangeal joint. ESR was normal. What is the diagnosis? A. Gouty arthritis B. RA C. Reactive arthritis D. Osteoarthritis

D. Osteoarthritis ( in OA the distal interphalangeal are most likely affected)

A 25-year-old post-graduate, found to have a heart murmur after pre-employment check-up. She's asymptotic and exercises regularly. On physical examination she was well fit, normal VP with prominent A waves, normal blood pressure. Rest of examination is unremarkable except for a systolic thrill and murmur over the precordium. Her chest x-rays showed: How would you manage this condition? A) Device closure for PDA B) Aortic value replacement C) Balloon pulmonary valvuloplasty D) Tricuspid valve repair E) Closure of VSD

C) Balloon pulmonary valvuloplasty

65-year-old man was put on hydralazine for hypertension presents now with a low- grade fever, chest pain and joint pain. On examination he has pericardial rub. His chest X-ray showed bilateral pleural effusion. What is the most probable diagnosis? A. Polymyositis B. Reactive arthritis C. Lupus D. Polymyalgia Rheumatica

C. Lupus

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 PMN B) High glucose C) Low lymphocytes D) High protein E) gram positive organism

D) High protein

An African male who is a known case of sickle cell anemia presented with generalized body aches and body pain. CBC was done and showed Hgb 85 g/L (NR: 140-180) MCV: normal. What is the management of the patients’ current condition? a. Hydration and analgesia b. Chelation with deferroxamine c. Blood transfusion d. Exchange transfusion

a. Hydration and analgesia

A 54-year-old female patient previously healthy had a CBC which showed a platelet count of 41x10^3/ml (NR:150-400X10^3). Otherwise her CBC was normal with a normal coagulation profile. Which of the following is a possible cause for the patients’ low platelet count? a. Adverse reaction to a new antibiotic b. Antiphospholipid syndrome c. Lymphoproliferative disorder d. Myelodysplastic syndrome

a. Adverse reaction to a new antibiotic

A 26-year-old woman presented with history of increased fatigability especially at the end of the day. She could not keep her eyes open. The doctor wanted to use the most sensitive test for myasthenia gravis. What is this test? A) Anti-acteylcholine antibodies B) EMG C) Single fiber EMG D) LP

C) Single fiber EMG Single-fiber EMG (SFEMG) is a highly sensitive test for ocular myasthenia gravis (OMG)

A 25-year-old male mechanic presented with acute weakness & difficulty urinating after carrying a heavy object, MRI was done & showed a herniated disc. How would you initially treat this patient? A) IVIG B) isotonic saline C) Mannitol D) IV steroids

D) IV 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.

A 55-year-old male with a history of smoking 2 packs of cigarette per-day and a family history of CVA in a young age presented with right sided hemiparesis and dysphasia. What is the appropriate window for thrombolysis according to the new guidelines? A) 6-8 B) 3-4.5 C) 2-4 D) 6-12

B) 3-4.5

A 25-year-old male complains of dizziness when lifting heavy objects. his blood pressure was 130/100. He has a family history of hypertension & has a sibling who recently passed away due cardiac condition. Physical examination revealed Normal HR with a double pulse and a jerky ejection systolic murmur. Echo showed left ventricular hypertrophy and asymmetrical thickening of the intraventricular septum. What will you give for the patient's symptoms? A) ACEI B) BB C) calcium channel blocker

B) BB

A 70-year-old man was brought by his son for frequent falls. On examination he had shuffling gait, bradykinesia, resting tremor, and rigidity. The doctor gave him a treatment for which he improved dramatically. what is the medication? A) beta blocker B) Calcium channel blocker C) GABA agonist D) Levodopa

D) Levodopa

A 20-year-old lady came complaining of palpitations and chest pain especially during exam season. On general examination, the patient has wide AP diameter and she is well-built & tall. On examination she had a mid-systolic click with a late systolic murmur. ECG showed ventricular ectopic beats. Echo showed echo showed prolapsed anterior mitral leaflet and mild mitral regurgitation & EF was 64%. In terms of management, what will you do for this patient? A) Reassure patient of benign prognosis B) Beta blockers (It should be A according to dr salman alotabi?)

B) Beta blockers

A female with history of metastatic breast cancer treated with chemotherapy and radiation. Presented to with limited active shoulder abduction at 45 degrees and painful internal and external rotation. What is the cause? A. Rotator cuff tear B. Adhesive capsulitis C. Biceps tendinitis

B. Adhesive capsulitis

A Patient with type 1 diabetes displays typical hypoglycemia unawareness. What is true regarding hypoglycemic unawareness? A. Selective beta blockers are an important cause of hypoglycemic unawareness B. In diabetes mellitus type 1, glucagon response to hypoglycemia parallels insulin release contributing to hypoglycemic unawareness C. Recurrent hypoglycemia is not significant in a patient with coronary artery disease D. Alcohol accelerates gluconeogenesis causing hypoglycemia unawareness E. Recurrent asymptomatic hypoglycemia has no effect on higher cognitive function

B. In diabetes mellitus type 1, glucagon response to hypoglycemia parallels insulin release contributing to hypoglycemic unawareness Note: Insulin-dependent individuals with diabetes are at risk for a severe hypoglycemic event that may predispose them to several repeat episodes during which the normal counter regulatory mechanisms that protect against hypoglycemia fail to be activated. This state of hypoglycemia unawareness is characterized by a failure of glucagon release, preventing mobilization of endogenous glucose stores from the liver. Hypoglycemia unawareness characterized by the onset of neuroglycopenia before the appearance of autonomic warning symptoms. Neurogenic/autonomic Increased sympathetic activity: tremor, pallor, anxiety, tachycardia, sweating, and palpitations Increased parasympathetic activity: hunger, paresthesias, nausea, and vomiting Neuroglycopenic Agitation, confusion, behavioral changes Fatigue Seizure, focal neurological signs Somnolence → obtundation → stupor → coma → death

A 52-year-old male patient with hyperkalemia of 6.1 and oliguria How would you manage him? a. Loop diuretic b. Mannitol c. Glucose and insulin d. Calcium carbonate e. Normalsaline

c. Glucose and insulin

A 60-year-old man previously well and healthy presented with a 6-week history of loss of vision. He was investigated and plasma glucose was 12.9 mmol/L. What is the cause of his visual change? A. Cataract B. Maculopathy C. Osmotic eye changes D. Proliferative diabetic retinopathy E. Retinal vein thrombosis

D. Proliferative diabetic retinopathy Note: Diabetic retinopathy is classified into non-proliferative diabetic retinopathy, proliferative diabetic retinopathy, and diabetic maculopathy. Loss of vision is typically insidious and occurs in most patients 20–30 years after the onset of DM, but acute loss of vision may occasionally occur as a result of retinal detachment, vitreous hemorrhage, or macular edema

A 50-year-old male presenting with a 2-month history of weakness upon going up stairs and brushing his hair. He also complains of constipation. He had s nerve conduction study, which showed the presence of bilateral carpal tunnel syndrome. What is the cause of his presentation? A. Polymyositis B. Dermatomyositis C. Hypothyroidism myopathy

C. Hypothyroidism myopathy

A 25-year old female with type 1 diabetes mellitus on insulin and diabetic nephropathy. Her glucose levels are high and uncontrolled despite taking insulin 3 times daily. A year later, she came for a follow up. She now has good control with persistent hypoglycemic attacks despite being on the same dose of insulin & same diet. What is the reason behind her hypoglycemia? A. Increase in the synthesis of insulin by B-cells B. Worsening of renal function C. Increased glucose in the urine D. She is taking steroids

B. Worsening of renal function Note: CKD may increase the risk of hypoglycemia. With reduced GFR, kidney gluconeogenesis and clearance of insulin and other glucose-lowering medications are reduced, and the counter-regulatory response to hypoglycemia may be blunted

Which of the following is more likely to develop diabetic nephropathy? a. Type DM 1 for 5 years with 3.5 proteinuria b. Type DM 1 for 10 years with bilateral small kidneys c. Type DM 2 for 5 years with retinopathy d. Type DM 2 for 10 years with hematuria & proteinuria e. Type DM 2 for 10 years with normal RFT & urinalysis, but high HbA1C

c. Type DM 2 for 5 years with retinopathy

A 20-year-old female with a 2-month history of diarrhea and weight loss. On examination she has tenderness in the left lower quadrant. How to differentiate between Crohn’s disease and Ulcerative colitis? A) Bloody diarrhea B) Age C) Erythema nodosum D) Ankylosing spondylitis E) Rectal sparing

E) Rectal sparing

13 years old boy suddenly developed puffy face and ascites with scrotal edema BP was normal Albumin low 9 Serum Creatinine was normal Serum cholesterol was high No other abnormality was detected What would his kidney histology/biopsy show under light and immunofluorescence microscopy? a. No abnormal features b. IgA deposition c. Interstitial deposition of all the antibodies d. Endothelial deposition of monocytes

a. No abnormal features

A 70-year-old patient with pancytopenia for 6 months’ duration. Bone marrow biopsy showed dysplasia of granulocytes, erythrocytes and megakaryocytes. Bone marrow blast cells were less than 5% and peripheral blood smear blast cells were less than 1%. What is the diagnosis? a. Myelodysplastic syndrome with blast cells-1 b. Myelodysplastic syndrome with blast cells-2 c. Myelodysplastic syndrome with multi-lineage dysplastic changes d. AML with dysplastic syndrome e. Myeloproliferative tumor

c. Myelodysplastic syndrome with multi-lineage dysplastic changes

A 64-year-old woman presented with a 3 year history of Raynaud’s phenomenon and telangiectasia and thickening of her fingers and toes. She has positive anti-centromere antibody. Which of the following has the poorest prognosis? A. Dysphagia B. Pulmonary hypertension C. Weight loss D. Digital infarcts

B. Pulmonary hypertension (scleroderma patient)

A 40 years old male has exertional breathlessness and chest pain for the past 6 months. He had an episode of fainting when he hurried to the mosque for prayer. He is known to have a murmur since childhood. CXR is given below: What would echocardiography show? A) Mitral valve stenosis B) Bicusoid aortic valve stenosis C) Left atrial myxoma D) Hypertrophic cardiomyopathy E) Pulmonary valve stenosis

B) Bicusoid aortic valve stenosis

A 38 year old female presented with easy bruising, petechial and purpura on the trunk and extremities. This was her first presentation and she had no significant past medical history. Labs showed normal cbc. APTT, and PT with platelets count of 7000. What the likely pathophysiology? a. Reaction to steroids b. ITP c. Myelodysplastic syndrome

b. ITP

A patient presenting with significant proteinuria. He had increased free serum lambda light chains and kidney biopsy showed apple-green birefringence of congo red stain under polarized ligh. What is the diagnosis? a. SLE b. FSGN c. Amyloidosis d. Hepatitis C

c. Amyloidosis

pregnant lady comes to the emergency room with a sudden onset of headache in the occipital area. She had signs of meningeal irritation & examination showed bilateral papilledema. What is the most important thing to rule out in this patient? A) Cerebral venous thrombosis B) Meningitis

A) Cerebral venous thrombosis

Which virus causes deterioration in a patient with renal transplant and on immunosuppressive therapy? a. Hepatitis B b. Polyoma virus c. Adenovirus d. Influenza virus

b. Polyoma virus Polyoma virus associated- nephropathy under immunosuppression occurs in up to 10% of all kidney transplant patients. Treatment is difficult usually by antiviral drugs and reduction of immunosuppression.

A 60-year-old hypertensive male has a creatinine of 148 (upper limit was 120) underwent cardiac angiography with contrast to evaluate his ACS. His creatinine became 450. What is true regarding contrast induced renal injury? a. Urine eisinophilia b. Protinuria c. Can be avoided by good hydration d. Cannot be reversed

c. Can be avoided by good hydration

An 18-year-old man presented with intermittent diarrhea, right iliac fossa pain & an oral ulcer as well as perianal discharge. It was associated with lower back pain and stiffness especially in the morning. How will you manage this patient? A) Antibiotics B) Azathioprine C) Infliximab D) Steroids E) Mesalazine

C) Infliximab

A 20-year-old patient with potassium of 1.9. Which of the following is correct? a. You could find U wave on the ECG b. Treat with IV calcium gluconate c. Side effect of spironolactone d. Associated with metabolic acidosis e. Counteracted by loop diuretic

a. You could find U wave on the ECG

A woman in her second trimester of pregnancy. What is the most sensitive method for measuring renal function in this patient? a. Serum creatinine b. 24-hour urine calculation of GFR c. DMSA scan d. Urine microalbumin

b. 24-hour urine calculation of GFR the most sensitive method for measuring renal function is GFR even in pregnancy so if the doctor does not mention serum uric acid in the options choose GFR.

Acute tubular necrosis is the commonest cause of renal failure in: a. aminoglycoside toxicity b. NSAIDs

a. aminoglycoside toxicity According to the MSD: the most common cause of AKI in clinical practice is aminoglycoside

A 35-year-old man came with acute left knee swelling. Aspiration revealed purulent fluid and WBC > 50,000/mm3. Which of the following is the most common organism for this condition? A. Staphylococcus aureus B. Staph epidermidis C. Hemophillus influenza D. Group b streptococcus

A. Staphylococcus aureus ( it indicate septic arthritis and the most common organism is staph aureus)

A 22-year-old lady came to the hospital with fidgety movement of both of her hands. She did not have urinary incontinence. Her sister has a history of epilepsy. How would you differentiate between true and psychogenic seizures?

A) Serum prolactin levels. 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.

A 25-year-old female came with red painful nodules over shins, fever, and complaints of arthralgia. Her labs showed: Mild leukocytosis & High ESR. She had a history of sore throat one month ago. CXR was done & it was normal. She had a negative tuberculin test. What is the most likely diagnosis? A. Erythema nodosum B. Pyoderma gangrenosum

A. Erythema nodosum

A female patient who has systemic lupus erythematosus and was controlled on plaquenil and prednisolone. She came to consult you about her medications now that she is 3 weeks pregnant. What would you recommend? A. Stop plaquenil and continue steroids B. Continue both plaquenil and steroids C. Stop steroids and continue plaquenil D. Stop both

B. Continue both plaquenil and steroids

What is the correct clinical scenario to describe hyperemesis gravidarum? A. Nausea and vomiting are not correlated with the level of maternal B-HCG B. Symptoms resolved in 20 weeks’ gestation in 91% of cases C. Symptoms usually start in 3rd trimester. D. Multiparous smoker women have worse symptoms.

B. Symptoms resolved in 20 weeks’ gestation in 91% of cases

A 50-year-old healthy gentleman presented to the polyclinic for a routine checkup, physical exam was unremarkable. Labs were all normal except for uric acid levels of 530. What is your line of management? A. Allopurinol B. Colchicine C. Do nothing D. Paracetamol E. Refer to a dietician

E. Refer to a dietician ( maybe because he eat a lot of red meat (healthy) which can increase the uric acid , we can’t diagnose it as gout by the first time)

28-year old male asthmatic patient who is on inhaled corticosteroids and short acting beta agonist. He came complaining of nocturnal wheezing and he has been using salbutamol puffs three times per week. FEV1 was 60% predicted. What is the best add-on therapy to control the patients’ symptoms? a. LABA b. 2 weeks’ oral steroids c. Increase inhaled corticosteroids d. Add ipratropium bromide 4 times daily e. Add omalizumab

a. LABA

A 28-year-old woman was diagnosed with Graves’ disease 8 months ago and started on radio-iodine treatment 2 months after diagnosis. She now presents with weight gain and menorrhagia. Her TSH is 12. Levothyroxine 75 mcg is initiated and she is put on calcium and vitamin supplements. what is true regarding her management? A. Serum TSH should be checked every 2-3 weeks for response B. Calcium carbonate is recommended one hour after levothyroxine C. Measuring anti-TSH receptor ab levels during pregnancy is recommended D. Levothyroxine is stopped once TSH normalizes

C. Measuring anti-TSH receptor ab levels during pregnancy is recommended Note: Anti-TPOAb and anti-TgAb should be measured in pregnant women with possible hypothyroidism to determine whether Hashimoto thyroiditis is the cause. Often, measuring TPOAb levels is sufficient because results are usually positive in patients with Hashimoto thyroiditis

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? A) Surgical resection of the tumor B) Chemotherapy C) Radiation therapy D) Total gastrectomy E) Testing and eradication of Helicobacter pylori

E) Testing and eradication of Helicobacter pylori H. pylori causes dyspepsia and epigastric pain. A complication of H pylori is MALTOMA, which can be treated by simply eradicating H pylori.

An 18-year-old female presented with breathlessness & audible wheezing. She is a known asthmatic and has allergies. Her PEFR was found to be 60% The test that will provide the most important clinical information about her disease is: a. Maximal respiratory pressures. b. Spirometry c. Oximetry d. 6-minute walk test

b. Spirometry

A 40-year-old diabetic presented with acute ascending paralysis of both lower limbs. Tendon reflexes were absent. An LP was performed and results showed normal cell count but high protein levels. What is your diagnosis? A) Diabetic amyotrophy B) Peripheral neuropathy C) Gulliane-barre syndrome D) Autonomic neuropathy

C) Gulliane-barre syndrom

A 55-year-Old man Diabetic on metformin was found to have a blood pressure of 150/92, on further Assessment, he has been complaining of nocturia and had microalbuminuria What is the best management? A. Advice life style changes B. start him on alpha blockers Start him on ACEI C. Start him on hydrochlorothiazide D. Start him on CCB

C. Start him on hydrochlorothiazide Note: microalbuminuria is the first sign of diabetic nephropathy. ACEI is the first line management for diabetic nephropathy

A 55-year-old man who has exertional dyspnea & paroxysmal nocturnal dyspnea. He came to the hospital with symptoms of TIA that resolved once he arrived. He has a past medical history of sore throat and joint pain when he was in school. In addition to his anti-failure medications, what would you prescribe him? A) Aspirin B) Warfarin C) Digoxin

B) Warfarin

Patient with colon cancer who had bowel resection now coming with watery diarrhea. What will you give this patient? A) Cholestyramine B) Probiotics

A) Cholestyramine Cholestyramine is a bile acid sequestrant that is generally considered as the first-line treatment for bile acid diarrhea

A 40-year-old presented with itchy red well-demarcated lesions on his axilla and groin. fungal examination was negative. Wood lamp showed coral-red appearance. A. Erythrasma B. Erysipelas C. Tineaversicolor D. Tinea capitis

A. Erythrasma

Patient diagnosed presented with acute gouty arthritis attack with history of duodenal ulcers on upper GI endoscopy. How will you manage him? A. Intra-articular steroids B. Naproxen C. Paracetamol & tramadol D. Allopurinol

A. Intra-articular steroids ( because the patient has ulcer we cannot give NSAIDS its contraindicated so we give it intra-articular, also we never give allopurinol in acute gouty its contraindicated)