2013 - 5th Flashcards
1
Q
A young male patient was brought to the casualty with abdominal pain, nausea and vomiting. The patient looked very ill and dehydrated. Earlier that day, he passed large amounts of urine and was feeling unusually thirsty too. His blood glucose was found to be very high, pH was 7.23 and urine was positive for ketones. A diagnosis of diabetic ketoacidosis complicating undiagnosed case of type 1 diabetes mellitus was confirmed. Which of the following would be the initial step in managing this patient?
A. Infusion of normal saline and insulin immediately
B. Wait for the ICU setting to give insulin
C. Administration of Ringer’s lactate and subcutaneous insulin
D. Administer insulin first then check the fluid levels
E. Wait for electrolyte results then administer insulin and NS
A
E. Wait for electrolyte results then administer insulin and NS
Note: K level should be < 4 replace if low or administer NS first because the patient is dehydrated.
2
Q
A 17 years old patient had back pain then developed grouped vesicular lesions on her trunk that was confined to a dermatome, what is the causative agent?
A. Herpes Zoster Virus
B. Herpes Simplex Virus
A
A. Herpes Zoster Virus
3
Q
A women with idiopathic intracranial hypertension came to the hospital to do LP. what is the most common complication of LP?
A. headache
B. epidural hematoma
C. transtentorial herniation
D. infection
A
A. headache
4
Q
A 28 years old engineer who was previously healthy. he had hypopigmentation spots on unexposed area of his trunks and body. What is the most likely cause?
A. Mycosis fungoides
B. Chemical leukoderma
C. Hansen’s disease
D. Pityriasis versicolor
E. Early vitiligo
A
D. Pityriasis versicolor (not sure)
5
Q
Scenario describing Cushing syndrome. what is the best initial test?
A. Serum cortisol
B. dexamethasone suppression test
A
B. dexamethasone suppression test
6
Q
what is the most sensitive indicator of contrast-induced nephropathy?
a. urine output < 600
b. hematuria
c. rising creatinine > 26 in 24 hours
A
c. rising creatinine > 26 in 24 hours
7
Q
A 36-year-old obese female complains of frequent headaches, tinnitus, and visual obscurations. On neurological examination, fundoscopy reveals papilledema. She also had signs of sixth cranial nerve palsy. What is the likely diagnosis according to this patient’s presentation?
A
Idiopathic intracranial hypertension
MSD Raed ‘headaches’
Idiopathic Intracranial Hypertension
* Headache, pain in the neck and shoulders and upper back. * Worse with the morning and with coughing/straining.
* Pulsatile tinnitus.
* Transient visual obscurations.
* Diplopia ( Abducens Nerve Palsy )
8
Q
A young lady experienced chest tightness and wheezes upon exposure to dust. she came to ER with O2 saturation 92%. on examination she had bilateral rhonchi. what will the spirometry most likely show? what is true about her condition?
a. obstructive pattern significantly reversible with bronchodilator
b. normal spirometry
c. obstructive pattern largely irreversible with bronchodilator
A
a. obstructive pattern significantly reversible with bronchodilator
Allergic asthma presents this way clinically and will have a reversible obstructive pattern on PFT.
9
Q
49-year-old woman has a history of joint pain and morning stiffness for four months. Examination reveals swelling of the wrists and MCPs. Which of the following can be used to monitor the activity of rheumatoid arthritis?
A. C-RP
B. Rheumatoid factor
C. Complement levels
A
A. C-RP ( CRP is useful to detect the disease activity and the respond to therapy however RF is not useful for the activity its more used in the prognosis of the disease, these information are from the MSD of dr. mona)
10
Q
A 25-year-old man presented with one month history of right sided chest pain with progressive shortness of breath and dry cough. He now has a fever as well. Upon examination, his right chest had increased vocal resonance, dullness on percussion and normal breath sounds compared to the left side. What is the most likely diagnosis?
a. left pneumothorax
b. Right consolidation
c. Right effusion
d. Left effusion
e. Right collapse
A
b. Right consolidation
Consolidation due to pneumonia usually will reveal these physical examination findings. The other diagnoses don’t fit with the findings.
11
Q
Which results would be a cause of established essential hypertension rather than secondary hypertension in a young lady?
a. Bilateral renal cysts
b. LowK
c. pH 7.4
d. Hypercalcemia
e. Hypernatremia
A
c. pH 7.4
According to AMBOSS: in secondary HTN pt will have metabolic alkalosis and low K. so all the options are for secondary expect C.
12
Q
A 30 year old female who is a known case of systemic lupus erythematosus, presented with polyarthralgia, palor and jaundice. Which of the following tests confirms the diagnosis?
A. Direct Coombs test
B. Bone Morrow Aspiration
C. Osmotic fragility test
A
A. Direct Coombs test (SLE can cause autoimmune hemolytic anemia which will be diagnosed by positive direct coombs test)
13
Q
A 65 years old man with with melena. He had 4 upper endoscopies, 3 colonoscopies, and barium follow through that all turned out to be negative. what is the best next step ?
A. CT of abdomen
B. Mesentric angiography
C. CT-angiograpy with intravenoues heparin
D. Wireless capsule endoscopy
E. Repeat colonscopy
A
D. Wireless capsule endoscopy
Wireless capsule endoscopy indication: obscure gastrointestinal bleeding, meaning that it is used as an investigation tool when the site/cause of bleeding is unknown.
14
Q
A 48-year-old woman with alcoholic cirrhosis is evaluated because of increasing ascites and a right-sided pleural effusion. Her liver disease is classified as Child-Pugh Class B. She has no history of encephalopathy. The ascites is being managed by dietary sodium restriction and administration of furosemide and spironolactone but has required large-volume para-centesis approximately every 10 days. Paracentesis shows low-protein ascetic fluid and a serum-ascites gradient of 1.5. Previous attempts to increase her diuretic dosage resulted in orthostasis and azotemia and have only partially reduced the volume of ascites.
On physical examination, she has tense ascites but no pedal edema. Which of the following is most appropriate at this time?
A. TIPS
B. Portocaval shunt
C. Peritoneocaval shunt
D. Repeat Abdominal paracentesis
E. Chest tube draining the ascites and pleurodesis
A
A. TIPS
Management of ascites:
1. Medications; diuretics: spironolactone, and if the response is poor furosemide is added.
2. If resistant to medical therapy, paracentesis is done.
3. If resistant/refractory ascites, TIPS is done as a last resort
15
Q
elderly patient with atrial fibrillation presented with severe peri-umbilical pain, no guarding or tenderness , what is the investigation you want to order?
A. CT of abdomen
B. Mesenteric angiography
C. laporotomy
A
B. Mesenteric angiography
ACUTE MESENTERIC ISCHEMIA:
Caused by compromised blood supply, usually an emboli due to a cardiac origin (A Fib). Therefore mesenteric angiography is the definitive diagnostic method.
Patients usually present with severe abdominal pain that is disproportionate to physical findings.
16
Q
A 63 years old hypertensive male had a stroke. After which, he couldn’t read but he could write and speech was intact. he also had right homonymous hemianopia. where is the lesion?
A. Left heschl’s gyrus
B. Left visual cortex
C. Corpus Collusum
D. Corpus Callosum and left visual cortex
E. Broca area
A
D. Corpus Callosum and left visual cortex
• Lesions of the left heschl’s gyrus produce problems of speech perception with difficulty in discriminating speech.
• Broca’s area function is speech production and language comprehension.
• Left visual area explains only the right homonymous hemianopia.
• Lesions in corpus callosum causes inability to read with intact speech and writing abilities.
17
Q
Young male, sudden left sided chest pain. Upon examination, the trachea deviated to the right and there was hyper-resonance, decreased breath sounds in his left side.
a. left pneumothorax
b. Right pneumothorax
c. Left effusion
d. lung collapse
A
a. left pneumothorax
Pneumothorax will show hyperresonance on percussion, decreased breath sounds on auscultation, and tracheal deviation to the opposite side.
18
Q
A 58 year old obese female presented with pain in her left knee associated with morning stiffness that lasted 15 minutes. What is the most likely diagnosis?
A
Osteoarthritis
19
Q
You were about to prescribe PPI to a lady. She was worried about the side effects. Which of the folowing nutrients require acid for absorption?
A. Vit B12, Vit C, Vit E
B. iron, Vit B12, Vit E
C. iron, Vit B12, Calcium
D. Vit B12, Vit C, Vit B12
A
C. iron, Vit B12, Calcium
PPIs are given to lower the acidity, therefore any nutrients that require acidity for absorption will be affected.
20
Q
What is the quickest way to decrease cerebral edema?
A. Mannitol
B. Hyperventilation
C. Head elevation
A
B. Hyperventilation
Hyperventilation causes cerebral vasoconstriction, which reduces cerebral blood flow and volume to decrease the oxygen supply in both normal and injured areas. Hyperventilation decreases the intracranial pressure and relaxes the brain.
21
Q
A 24 year old man presented with weakness and fatigue. On physical examination, he was found to have postural hypotension and raised JVP. Provided are his lab results: PO2: 12.8 Kpa (normal); PCO2: 24 mmHg; HCO3: 15 mmHg; pH: 7.28; Na: 135; Urine Na: 9; Glucose: 5; Urea: 7; Chloride: 115 (high); S-osmolality: 308; K: 3.8. What is the diagnosis?
a. Lactic acidosis
b. Ethanol intoxication
c. Renal failure
d. Renal tubular acidosis
e. Diarrhea
A
e. Diarrhea
Reminder of plasma anion gap: (Na + K) – (HCO3 + Cl), normal anion gap with signs of dehydration -> diarrhea
22
Q
Vogelstien model, Which of the following gene is responsible for the transformation of adenoma into carcinoma?
A. p53 mutation
B. activation of kras oncogene
C. DCC mutation
D. APC mutation
E. DNA methylation
A
A. p53 mutation
23
Q
a known hypertensive diabetic smoker presented with compressing chest pain and diaphoresis. his ECG was given and he has anterior MI. what murmur would you hear on auscultation?
A. pansystolic murmur at the apex
B. ejection systolic murmur
C. mid-diastolic murmur
D. early diastolic murmur
A
A. pansystolic murmur at the apex
MI -> rupture chordae tendineae -> Mitral regurgitation -> Pan systolic murmur.
A pan systolic murmur at left lower sternal border- > Tricuspid regurgitation.
24
Q
A 34-year-old male presented with backache and spinal deformity with kyphosis. He also reports SOB on exertion and palpitations. His BP is 160/50. A murmur was heard on auscultation. Which of the following is likely to be present in this patient?
A. Aortic regurgitation
B. Mitral regurgitation
C. Mitral stenosis
D. Mitral valve prolapse
A
A. Aortic regurgitation
-Backache and spinal deformity with kyphosis are features of ankylosing spondylitis,and it is one of the etiologies of Aortic regurgitation.
-160/50=wide pulse pressure ,which is one of the physical signs that is found in AR.
25
patient with mildly elevated liver enzymes. her BMI= 31 . she has no other complaints. what is the diagnosis?
A. NASH
B. Wilson's disease
C. Autoimmune hepatitis
A. NASH
BMI > 30 = obese and mildly elevated enzymes is associated with NASH. Nothing indicates defective copper metabolism, therefore answer is not Wilson. For AIH, liver enzymes are greatly elevated due to inflammation that leads to hepatocellular injury.
26
what is the antidote of Unfractionated heparin ?
protamine sulfate
27
A 15-year-old, previously healthy, school student presents with sudden onset of dyspnea and orthopnea. She gave a history of 'flu' like illness one week prior to the presentation. Examination revealed bilateral basal crepitations. Echocardiogram showed dilated poorly contracting left ventricle. The most likely additional finding on examination will be?
A. Normal jugular venous pressure
B. Pulsus paradoxus
C. S3 galop at the apex
D. Single second sound
E. Pericardial rub
C. S3 galop at the apex
- Dilated left ventricles means there is systolic dysfunction, and since the patient is young it is most probably dilated cardiomyopathy.
- Systolic dysfunction= S3 galop
- History of flu like illness could mean that the dilated cardiomyopathy resulted from an infectious agent.
- Most commonly associated infectious disease with dilated cardiac myopathy are: Viral(coxsackie B,HIV), Chagas disease, Lyme disease, Rickettsial disease, Acute rheumatic fever, and toxoplasmosis.
- Bilateral basal crepitation indicates pulmonary edema that resulted from left ventricular failure.
- B is incorrect, Pulsus paradoxus is not found in patient with dilated cardiomyopathy, but it is rather found in:
1) Cardiac tamponade
2) Cardiogenic shock
3) Pulmonary embolism (large)
4) Tension pneumothorax
5) Severe obstructive pulmonary disease
6) Constrictive pericarditis-rarely
28
Lacunar stroke causes pure motor hemeparesis. A lesion in which of the following areas is least likely to be associated with pure motor hemeparesis?
A. anterior limb of internal capsule
B. posterior limb of internal capsule
C. infarction of cerebral peduncle
D. infarction of basis pontis
E. infarction of medullary pyramid
A. anterior limb of internal capsule
29
A 60 year old female presented with painless left sided visual loss, he described it as "descending curtain". A diagnosis of amaursis fugax (transient monocular visual loss) was made. What is the most common cause of this condition?
A. Ipsilateral Internal carotid artery atherosclerosis
B. Ophthalmic artery spasm
C. Hypotension
D. Migraine with aura
A. Ipsilateral Internal carotid artery atherosclerosis
30
Which of the folowing is used to lower potassium in patients with hyperkalemia?
a. Calcium gluconate
b. Glucose
c. Insulin
d. Salmetrol
c. Insulin (dr. Wael)
d. Salmetrol (dr. Kamel)
I think we have to give dextrose with the insulin.
According to UpToDate: the first line treatment in hyperkalemia: calcium gluconate if we have ECG changes, second line: insulin, third: sodium bicarb (but in case of metabolic acidosis it is controversial -> fluid overload with hypernatremia and metabolic alkalosis -> heart failure and CKD), third: B2 agonist, in nonacute cases , the effect last for 2 hrs.
31
A 30 year old female with sickle cell anemia developed anemia, thrombocytopenia, and leukopenia. On examination, she had tender splenomegaly. What is the most likely cause?
a. Autosplenectomy
b. Splenic sequestration crisis
c. TTP
b. Splenic sequestration crisis
32
A patient presented with recurrent boils on different parts of his body. He is not known to be diabetic or on any immunosuppressive agents. What is the most likely diagnosis?
A. Hidradenitis suppurative
B. Erythema induratum
C. Recurrent furunculosis
C. Recurrent furunculosis
33
A 25 year old female with more than 5-year history of rheumatoid arthritis has high Rheumatoid Factor and high Anti-CCP. Which of the folowing is an extra articular manifestation in RA?
Pleural effusion
34
A diabetic patient hospitalized for an anterior MI. During his hospital stay, he developed breathlessness and chest pain that is aggravated by lying down and relived by standing or leaning forward. What is the diagnosis?
Pericarditis
- Pain that is aggravated by lying down and relived by standing or leaning forward is defined as pleuritic pain.
- Pericarditis can occur post MI in two different clinical situation:
1) Acute: by direct extension of myocardial inflammation, 1-7 days post MI.
2) Dresser syndrome: Auto-immune reaction, 2-8 weeks post MI.
35
A patient with asthma on maximum doses of inhaled corticosteroids (fluticasone) and LABA. Despite this, his symptoms are uncontrolled and he still gets frequent exacerbation attacks. What is the correct statement about management for this patient?
a. Montelukast, a leukotriene receptor antagonist, is to be added.
b. Theophylline, a methylxanthine drug with wide therapeutic index, is to be added.
c. Omalizumab, a monoclonal antibody against IL-2, might benefit him.
d. Lebrikizumab, a monoclonal antibody against IgE, might benefit him.
a. Montelukast, a leukotriene receptor antagonist, is to be added
From Batch 2013: “The descriptions of all other choices are wrong. Omalizumab is an anti-IgE. Lebrikizumab is anti-IL-13.”
Comment: According to the latest GINA guidelines for treating asthma, I would have chosen Omalizumab ONLY if its definition was written correctly in the exam. The guidelines state that if a patient’s severity is “severe persistent”, he should be on medium/or high dose inhaled steroids, LABA, and an add-on like anti-IgE (Omalizumab) or anti-IL5/5R. He is already on high dose steroids and LABA so what’s left is the omalizumab. Leukotriene receptor antagonists are used in the previous severities along with a low or medium dose steroid, NOT high dose.
الله أعلم In the end ):
36
A 70 year old man who used to work as a constructor worker in shipyard. He presented with progressive shortness of breath. pulmonary function test showed restrictive lung pattern and normal DLCO. what will you find on his CXR?
a. calcified pleural plaques
b. cavity in the upper lung
c. Diaphragmatic plaque
a. calcified pleural plaques
Pleural plaques = pathognomonic for prior asbestos exposure, which is found in shipyards, construction sites, and car mechanics. (asbestosis)
37
A patient with a history of rheumatic fever. he had exertional dyspnea and palpitation. On auscultation a murmur is heard. What does the patient have?
A. Aortic regurgitation
B. Mitral regurgitation
C. Aortic stenosis
D. Mitral stenosis
B. Mitral regurgitation
The previous figure shows the hemodynamics of mitral regurgitation:
During systolic contraction blood regurgitates from the left ventricle into the left atrium across incompetent mitral valve resulting in audible holosystolic murmur between S1 and S2 .The portion of the left ventricle and diastolic volume that regurgitates into the left atrial myocardium increases left atrial pressure resulting in tall V-wave (in the JVP)
38
A 45 year old male presented with shortness of breath and cough productive of yellow sputum which has started insidiously. He is known to have hypertension and type 2 diabetes mellitus. Chest x-ray was normal. Results of his pulmonary function tests are provided.
FEV1/FVC 60% FEV1 60% FVC 110% (probably a typo) RV 125% TLC 120% DLCO 60%
What is the diagnosis?
a. Emphysema
b. Chronic bronchitis
c. Acute bronchitis
a. Emphysema
39
Which of the following is a typical finding in diabetic ketoacidosis?
A. Low HCO3
40
A man presented with symmetrical joint pain in the proximal interphalangeal, metacarpal joints, and carpometacarpal joint with swelling. he has negative RF. what is the best thing you want to do next for this patient?
A. Consult a rheumatologist to confirm the diagnosis
B. Serology for ANA
C. Treat as general non-RA pain with prednisolone
A. Consult a rheumatologist to confirm the diagnosis
41
A 20 year old patient presented with headache, photophobia, nausea and vomiting. Fundoscopy showed papilledema. Which of the following indicates a red flag?
A. Age
B. Photophobia
C. Papilledema
C. Papilledema
MSD Dr Suhail ‘headaches’
Red flags for secondary headaches SNOOP4 Systemic signs and symptoms
Neurological finding in examination
Older than 50 y/o
Postural headache
Precipitation of headache with valsava Progression of headache
Presence of papilledema
42
A young lady with joint pain. labs showed positive anti-histone antibody.her medication includes hydralazine. what is the most appropriate management?
Discontinue hydralazine ( one of the drugs that induces lupus)
43
A female presented with a few-day history of fever, jaundice, and purpura all over her body. According to her family, she has been confused lately. Labs showed
low HB, low platelets, and high LDH. Coagulation profile was normal. What is the best treatment modality?
a. Observation
b. Plasma exchange
c. Fresh frozen plasma
d. Packed red blood cells
e. Prednisone
b. Plasma exchange
44
A 38-year-old female was referred to a rheumatologist with active rheumatoid arthritis in more than 20 joints. What is the best treatment?
A. Imuran
B. Plaquenil
C. Methotrexate
D. Cyclophosphamide
E. Aminoslalicylic acid
C. Methotrexate
45
A patient underwent coronary angiography. Which of the following would you expect to find in contrast-induced nephropathy?
a. proteinuria > 2.6
b. hematuria
c. small kidneys
d. eosinophiluria
e. increased urine osmolarity
e. increased urine osmolarity
Dr. Wael said this is the correct answer for this Q (not hematuria)
46
A 52-year-old man developed an erythematous scaly rash and polyarticular joint pain (Psoriasis). His heels are painful. What musculoskeletal manifestation is he likely to have?
A. Enthesitis
B. Proximal myopathy
C. Palpable osteophytes
D. Subcutaneous nodules
A. Enthesitis (enthesitis, dactylitis, arthritis mutilans are musculoskeletal manifestation of psoriasis)
47
An elderly man presented with LUQ pain and splenomegaly. Below are his CBC and PBS results.
Hb: Low; Platelets: High; WBCs: High (mostly neutrophils) - PBS: Promyelocyts, myelocytes, metamyelocytes, band cells, segmented forms, and 3% eosinophils. Which of the following can be used to treat this condition?
a. Hydroxyurea
b. Tyrosine Kinase inhibitor - Imatinib
c. JAK 2 inhibitor – Ruxolitinib
b. Tyrosine Kinase inhibitor - Imatinib
Note: The scenario indicates CML
48
Which of the following conditions increases DLCO?
a. Pulmonary HTN
b. Polycythemia
c. COPD
b. Polycythemia
When pulmonary blood flow is increased, the diffusing capacity will consequently increase as well. The opposite is also true (anemia = low DLCO)
49
A patient presented with recent history of Jaundice and right upper queadrant pain. which of the following would be the most cost-effective to diagnose viral hepatitis in this patient?
A. HAV IgM, HBSAg, Anti-HCV
B. HAV IgM, HBsAg, HBc IgM, and Anti-HCV
B. HAV IgM, HBsAg, HBc IgM, and anti-HCV
(other options were not including HAV IgM so we excluded them)
50
A 32-year-old lady who is pregnant in the second trimester was found to have a high blood
pressure on a regular follow-up. What drug should be used to manage her condition?
a. Methyldopa
b. Angiotensin converting enzymeinhibitor
c. Beta-Blocker
a. Methyldopa
51
A young female who is taking a drug for depression presented to your clinic with respiratory symptoms. This is her flow-volume loop. What is the most likely diagnosis?
a. Asthma
b. Löffler syndrome
c. ILD
d. Vocal cord dysfunction
e. COPD
d. Vocal cord dysfunction
(**The loop shows variable upper airway obstruction with truncation of
the inspiratory limb.)
Vocal cord dysfunction manifests as an upper airway obstruction. This would show as a flattened inspiratory limb.
52
What substance plays a role in the pathophysiology of migraine headaches?
A. Serotonin
B. Histamine
C. Acetylcholine
Serotonin
53
A 55 year old man with alcoholic cirrhosis presents with increasing ascites that is not responding to diuretics. An ascitic fluid aspiration is performed and the fluid analysis results are as follows:
A. Acute portal vein thrombosis
B. Hepatocellular cancer with peritoneal metastases
C. Spontaneous bacterial peritonitis
D. Tuberculous peritonitis
E. Pancreatic ascites
answer: C. Spontaneous bacterial peritonitis Neutrophil count > 250 cells/mm3 = SBP
B. Hepatocellular cancer with peritoneal metastases Cytology is required
C. Spontaneous bacterial peritonitis Neutrophil count > 250 cells/mm3 = SBP
D. Tuberculous peritonitis Elevated lymphocytes
E. Pancreatic ascites Elevated amylase (pancreatic enzymes)
54
A 44 yr old female presented with left pleuritic chest pain and shortness of breath of 1 hour duration. Also swollen painful legs of few days duration. Previous records show that the patient had DVT 7 years ago and was treated with heparin and developed HIT. what is the best initial management?
a. LMW heparin
b. unfractioned heparin
c. warfarin
d. aspirin and clopidogrel
e. factor Xa inhibitor
e. factor Xa inhibitor
Note: the first line treatment for HIT is factor Xa inhibitor
55
scenario describing ILD. how to confirm?
a. bronchoscopy with biopsy
b. HRCT
b. HRCT
56
An old lady presented with vomiting for 1 week. Now she she has persistent epigastric pain. Her creatinine level is 200 and urine sodium was 12. What is the next step for management?
A. IV normal saline and antibiotics
B. PPI and endoscopy
C. Upper endoscopy
D. CT scan with contrast to identify the source of her pain
A. IV normal saline and antibiotics
Read the stem of the question carefully, keep an eye to whether the question is asking for the next or the best management. Vomiting for 1 week in a old lady would most probably lead to dehydration and volume depletion, which is supported by her creatinine levels and the urine sodium. Therefore the next step is to rehydrate by IV saline (think ABCs).
57
A 15 year old girl presented with involuntary chorea movements. She had recurrent rheumatic fever episodes. What might the workup of this patient reveal?
A. Chronic arthritis
B. Involvement of spinal joints
C. Erythema nodosum
D. High ASO titer
D. High ASO titer
-An involuntary chorea movement in a patient with recurrent rheumatic fever -› Sydenham chorea.
-Sydenham chorea is neurological disorder of childhood resulting from infection by group A beta-hemolytic streptococcus, the bacterium that causes rheumatic fever.
-Answer A is incorrect because the type of arthritis in rheumatic fever is acute (less than 6 weeks) not chronic.
-Spinal joints is not involved in rheumatic fever, and the most commonly involved joints are the knees, ankles, elbows, and wrists.
-Answer C is incorrect, rheumatic fever is associated with erythema marginatum and subcutaneous nodules.
58
Regarding the paraneoplastic syndromes, which of the following malignancies is most likely to be associated with hypercalcemia?
a. Small cell carcinoma
b. Large cell carcinoma
c. Adenocarcinoma
d. Squamous cell carcinoma
d. Squamous cell carcinoma
Squamous cell carcinoma is commonly associated with PTH-like hormone secretion resulting in hypercalcemia. REMEMBER:
59
A 50-year-old alcoholic man with history of cirrhosis presents to the casualty with an episode of hematemesis. On physical examination, he is alert and oriented. His blood pressure was 112/70 and heart rate was 89/ min. The patient received IV octreotide and was planned for an upper endoscopy. What should be done to this patient at this point?
A. Administer IV antibiotics
B. Sengstaken-blakemore tube
C. TIPS
A. Administer IV antibiotics
How to approach upper GI bleed (stepwise):
1) if varices → iv octreotide & iv antibiotics, if PUD → iv ppi
2) Esophageal banding
3) if banding fails, insert a Sengstaken-blakemore tube
4) followed by emergent TIPS
5) to prevent further bleeding, give beta blockers
60
A 14 years old boy with known bleeding disorder presented with severe pain in both legs. examination revealed splenomegaly. what is the diagnosis?
a. sickle with thalassemia
b. Sickle trait
c. sickle SS
d. Sickle SC
e. Thalassemia major
a. sickle with thalassemia
Note: The blood film of a patient with sickle cell/ beta thalassemia compound heterozygosity shows sickle cells, boat-shaped cells, target cells, nucleated red cells, anisocytosis, poikilocytosis.
61
A 36 year old hypertensive presented with hematuria and proteinuria. Immunofluoroscence showed granular deposits. He had normal complement levels. What is the likely diagnosis?
a. IgA nephropathy
b. Membranoproliferative glomerulonephritis
c. Lupus nephritis
d. Cryoglobulinemia
a. IgA nephropathy
62
A 43 year-old heavy smoker male presented with exertional chest pain relieved by rest for three years. While he was sleeping, he experienced a sudden chest pain and heaviness that waked him up from sleep. Next day he came to the ER, his ECG showed ST depression while his cardiac enzymes were normal. What is the most probable cause of his pain?
A. Stable angina
B. Stable angina with severe drop in BP
C. Unstable angina
D. Prinzmetal's angina
E. Myocardial infarction
C. Unstable angina
-The answer is not D, because the hallmark of Prinzmetal's is transient ST segment elevation (not depression) on ECG during chest pain, and coronary angiography is the definitive test to diagnose it.
-Since there is ECG changes so it is not stable angina.
-One of the criteria to diagnose MI that there should be a rise/fall in serum markers, and since the cardiac enzymes were normal so it is not MI.
How to differentiate between unstable angina and MI:
1) Unstable angina is clinically defined by any of the following:
– accelerated pattern of pain: increased frequency, increased duration, decreased threshold of exertion, decreased response of treatment.
– angina at rest.
– new onset angina.
– angina post MI or post procedure (PCI, CABG).
2) MI (STEMI/NSTEMI) is defined by evidence of myocardial necrosis and is diagnosed by raise/fall of serum markers plus any one of:
– symptoms of ischemia (chest/upper extremity/mandibular/epigastric discomfort, and dyspnea).
– ECG changes (ST-T changes, new BBB, or pathological Q waves).
– image evidence (myocardial loss of variability, wall motion abnormality, or intracoronary thrombus).
– if biomarker changes are unattainable, cardiac symptoms combined with ECG changes is sufficient.
• NSTEMI meets the criteria for MI without ST elevation or BBB.
• STEMI meets the criteria for MI characterized by ST elevation or new BBB.
63
A typical scenario of a COPD patient. Which of the following makes the diagnosis of emphysema more likely?
a. High TLC
b. Irreversibility after bronchodilator
c. Low DLCO
d. High RV & FVC
c. Low DLCO
In emphysema, the lung has lost alveoli, thus resulting in a lower surface area available for diffusion.
64
These findings were obtained from a patient who was admitted to the ICU with septic shock
WBC: 40 (high); Hb:105 (low); Platelets: 25 (low); PT: 20 (high)
APTT: 60 (high); TT: 20 (high); D-dimer: 4000 (high); FDP: 1.1 (high)
What is the most appropriate management for this patient?
a. Treat the underlying infection
b. Fresh frozen plasma infusion
c. Anticoagulation with heparin
d. Packed RBC transfusion
e. Platelet transfusion
a. Treat the underlying infection
Note: The only effective treatment for DIC is treating the underlying condition. FFP/cryoprecipitate ... etc. are administered if the patient presented with bleeding. There’s lack of consensus regarding the cut-off point below which platelets should be transfused to a non-bleeding patient.
65
A 62 year old man complains of bilateral knee pain for a few months which is worse with activity and movement. It is associated with stiffness that lasts less than 30 minutes. Which of the following is the most essential diagnostic measure?
X-ray ( suspecting osteoarthritis)
66
A 45 year old female, who underwent subtotal thyroidectomy for hyperthyroidism,
is on levothyroxine. Her TSH level was high. Which of the following must be done?
A. Increase levothyroxine dose
67
A patient presented with acneiform eruptions. What is the best diagnostic method?
A. Skin biopsy
B. Pus culture and sensitivity
C. Patch tests
D. KOH scrape
B. Pus culture and sensitivity
A. Skin biopsy (another possibility)
68
A 53 years old female, who is a known case of hypothyroidism and depression, experienced occasional sweating and feeling warmth for 8 months. She is stable on levothyroxine drugs since years. Which of the following hormone will point toward the diagnosis?
A. TSH
B. FSH
C. free T4
D. urine catecholamines
E. B-HCG
B. FSH
Note: She's in her premenopausal period
69
A patient presented with recurrent headaches associated with tearing and rhinorrhea lasting 10 minutes each. This pain was relieved by using Indomethacin. What is the most likely diagnosis?
A. Cluster headache
B. Paroxysmal hemicrania
C. migraine headache
D. trigeminal neuralgia
E. occipital neuralgia
B. Paroxysmal hemicrania
MSD Raed ‘headaches’
Parxoysmal hemicranias
* Occurring in brief episodes lasting 2–30 minutes at least 5 times a day.
70
A 71-year-old woman, known CKD patient, has a history of back pain. Spine imaging showed a compression fracture in the thoracic spine. Further investigations showed a low serum calcium level, borderline-low serum phosphate level (1; while lower limit of normal is 0.9), high parathyroid hormone level and high alkaline phosphatase. Which of the following would be the likely management of this condition?
a. Calcium carbonate and noncalcium phosphate binders
b. Calcium carbonate and alpha Vitamin D
c. Vitamin D
d. Parathyroidectemy
b. Calcium carbonate and alpha Vitamin D
71
A 60-year-old Kuwaiti man with low Hb, low MCH, and high RDW. FOBT +ve. What is the most likely cause of his underlying condition?
a. IDA due to GI blood loss
72
A truck driver presented with daytime sleepiness. He was recently involved in 2 car accidents. What would be an appropriate investigation?
Overnight sleep study
To evaluate for obstructive sleep apnea.
73
A 25 year old female presented with malar rash, oral ulcers and arthralgia. Which of the following is likely to be found in the patient?
ANA ( suspecting SLE)
74
A patient presented with painless lymphadenopathy. He also had weight loss and night sweats. Pictures were provided.
a. Hodgkin’s lymphoma
b. NonHodgkin's disease
c. infectious mononucleosis
d. thyroid cancer
a. Hodgkin’s lymphoma
75
A 21-year-old male complains of dyspnea on exertion and occasionally, chest pain and dizziness. He has a sibling who recently passed away due to a non-investigated cardiac condition. Physical examination revealed a jerky pulse and an ejection systolic murmur. What is the likely diagnosis?
Hypertrophic cardiomyopathy
-HOCM is caused by a genetic defect involving one of the cardiac sacromeric proteins ,and it is associated with autosomal dominant inheritance ->that explain why his brother passed away.
-Jerky pulse is a pulse with a brisk or sharp upstroke that literally taps against the palpating fingers.The pulse volume is not increased.
So,Jerky pulse=rapid upstroke/normal downstroke/normal volume,and it is seen typically in HCM.
-During auscultation two murmurs can be heard:
1)Eiection systolic murmur due to left ventricular outflow obstruction.
2)Pan systolic murmur due to dysfunctional mitral regurgitation >this is found in asymmetrical septal hypertrophy with obstruction(one of the types of HCM).
76
A 35 year old female teacher, diagnosed with migraine 10 years ago. She persistently sees silver starts in the sky before she develops the headache. What is the most common aura in migraine?
A. Motor
B. Visual
C. speech
D. Auditory
B. Visual
MSD Raed Behbehani ‘Neuro-ophthalmologic Causes of Headache’ Migraine: photophobia + visual aura
77
64-year-old obese lady complains of pain in her left knee and morning stiffness that lasts about 15 minutes. What would the plain radiograph of her knee most probably show?
A. subchondral sclerosis
B. symmetricaljoint space narrowing
C. increased joint space
D. Osteophyte
E. osteopenia
D. Osteophyte (OA suspicion)
78
young female, symptoms of right sided HF and Left sided HF, raised JVP, she had a history of abnormal jerky movements when she was in school. Pulse irregularly irregular with a heart rate of 98. What would the auscultation reveal?
A. pre-systolic murmur at the apex
B. long mid diastolic murmur at the apex
C. S3 gallop
D. ejection click
B. long mid diastolic murmur at the apex
-History of abnormal jerky movements -›Sydenham chorea -> Rheumatic fever.
-The most common cause of mitral stenosis is rheumatic fever.
-Atrial fibrillation can be found in patient with rheumatic heart disease(irregularly irregular).
79
A couple with thalassemia trait. Which of the following is true?
a. 25% chance to have a child with thalassemia major
80
What will you give for Acute attack of migraine with photophobia and phonophobia ?
A. Sumatriptan
B. Propranlol
C. valporic acid
D. topiramate
A. Sumatriptan
MSD Dr Jassem ‘headaches’
81
A 45-year-old lady has a history of dry cough and occasional shortness of breath. Chest x-ray shows bilateral hilar lymphadenopathy with reticulo-nodular infiltrates of the lung parenchyma. A lung biopsy was taken, and a diagnosis of sarcoidosis was confirmed. What is the biopsy expected to show on histology?
a. Non-necrotizing granuloma and lymphocytosis in a peribronchial and perivascular distribution
b. Chronic interstitial inflammation with widely dispersed granulomas
c. Chronic inflammatory changes with eosinophilic infiltration
d. bronchial infiltration of pigmented macrophages
e. Necrotizing granulomatous vasculitis of small- and medium-sized vessels
a. Non-necrotizing granuloma and lymphocytosis in a peribronchial and perivascular distribution
82
What is the most cost effective modality to diagnose an elderly man with a positive fecal occult blood (FOBT)?
A. Colonoscopy
B. Flexible sigmoidoscopy
C. Barium enema
A. Colonoscopy
Flexible sigmoidoscopy is wrong because a positive result still has to be confirmed by colonoscopy.
A positive FOBT is always followed by a flexible sigmoidoscopy (Dr. waleed alazmi 4th year), however the stem is asking for the most COST EFFECTIVE modality. Therefore to ensure cost effectiveness, a positive FOBT is followed by colonoscopy, which is the gold standard of diagnosis.
83
Which of the following would distinguish diabetic retinopathy from hypertensive retinopathy?
A. Microaneurysms
B. Macular stars
C. Hard exudates
D. Flame-shaped hemorrhages
E. Roth spots
A. Microaneurysms
Note: retinal capillary microaneurysm is usually the first visible sign of diabetic retinopathy.
84
Increased PT otherwise everything normal, which of the following factors is responsible for this condition?
a. VII factor
b. X factor
c. V factor
d. Von wilbrand factor
e. Fibrinogen
a. VII factor
85
A patient presented with anemia and glossitis. Deficiency of which of the following causes this condition?
Vitamin B12
86
A 16 year old girl presented with migraine. The doctor prescribed vitamins. Which of the following vitamins is used for migraine?
A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin B6
E. Vitamin B9
B. Vitamin B2
87
Who would most likely benefit from DVT prophylaxis?
a. 19 y/o male investigating for infertility
b. 20 y/o women having tooth extraction
c. a man who has follicular tonsillitis
d. 30 y/o Women who has just delivered by c section
e. 40 y/o man who has family history of VT and want to travel to Dubai by airplane
e. 40 y/o man who has family history of VT and want to travel to Dubai by airplane
88
A 33-year-old woman with a known history of systems lupus erythematous presents with recent onset of fatigue, dizziness, pallor and jaundice. She has polyartharlgia as well. Laboratory investigations revealed a low hemoglobin level. Which of the following tests is appropriate to confirm the cause of her presentation?
A. Direct Coombs test
B. Bone marrow aspiration
C. Osmotic fragility test
A. Direct Coombs test
89
A patient complains of fever and left knee pain. On examination, his knee was swollen,
red, and warm. Which of the Following is the most essential diagnostic measure?
Synovial fluid aspiration ( suspecting septic arthritis)
90
A 34-year-old Caucasian female presented with non-specific musculoskeletal symptoms, fatigue, and mild RUQ pain. Her labs showed (AST=353, ALT=267, ALP=220, bilirubin=60). Ultrasound of the liver showed mild enlargement and echogenicity. A biopsy was taken and is shown below. Based on the previous scenario, what is the best treatment option for this patient?
A) gradual weight reduction
B) ursodeoxycholic acid
C) prednisone
D) piglitazone
E) methotrexate
C) Prednisone
AUTOIMMUNE HEPATITIS - MSD DR WALEED ALAZMI
– Clinical presentation: Symptoms are commonly nonspecific fatigue and mild right upper quadrant discomfort.
– Lab work: Characteristic pattern is hepatocellular injury rather than cholestasis, therefore raised LFTs is seen.
– Management: prednisone.
91
A women who has mitral stenosis and Atrial fibrillation underwent valve replacement and she got St. Jude prosthetic valve. what is the best anticoagulation?
A. warfarin
B. aspirin
C. clopidogrel
D. dabigatran
A. warfarin
92
A child took ampicillin for 3 days for his illness. he came with a creatinine of 200 (it was description of acute renal failure) no microscopic hematuria, no edema. what would you do?
a. give normal saline
b. nothing, it is just post-strept glomerulonephritis
c. give steroids
c. give steroids
This is from Dr.Salman Alotaibe
93
A patient on oral hypoglycemic agents and glargine. He injected insulin in the morning and developed sweating, tachycardia. He was found comatosed with increased reflexes in his right leg and smell of alcohol breath at 1:30 pm. What is the most likely condition?
A. Hypoglycemia
B. CVA
C. Delirium tremens
D. DKA
B. CVA
(Confirmed by Dr. Jasem Alhashel)
This is a repeated question for years and the answer is NOT hypoglycemia.
The patient presented with UNILATERAL increased reflexes and the only cause of this presentation could only be a brain infarct. Yes the patient could also be hypoglycemic and in theory that could cause a brain infarction but it would have to be extremely severe/repeated hypoglycemia attacks and she presented a whole day later. Additionally, the fact that she experienced palpitations could explain why the stroke occurred.
94
A 65 year old man complains of headache and temporal tenderness. He also reported jaw pain while eating. How can the diagnosis be confirmed?
A. Temporal artery biopsy
B. ESR
C. Angiography
D. CT scan of the head
A. Temporal artery biopsy
MSD Raed ‘Headaches’
Giant-cell arteritis:New onset of headache (temporal) , acute or transient loss of vision, jaw claudication, weight loss, fever, and myalgias. Diagnosed by temporal artery biopsy.
95
Which of the following is used to monitor the glucose levels over 2 to 4 months?
A. Hba1C
96
A 70 years old patient presented with jaundice and palpable non-tender gall bladder. what is the diagnosis?
A. pancreatic cancer
B. gallstones
C. gastric cancer
D. hepatitis
E. esophageal cancer
A. pancreatic cancer
Courvoisier sign or Courvoisier-Terrier sign states that in a patient with painless jaundice and an enlarged gallbladder (or right upper quadrant mass), the cause is unlikely to be gallstones and therefore presumes the cause to be an obstructing pancreatic or biliary neoplasm until proven otherwise. Also the old age in the stem makes cancer more relevant.
97
A patient who consumes cocaine developed hematuria. Urine dipstick showed blood but microscopy shows 2 RBC/HPF. Which of the following must be checked to confirm the diagnosis?
Urine myoglobin
Cocaine toxicity can cause rhabdomyolysis.
98
A 50 year old patient presents with facial fullness, plethora, cough, and venous distention in the neck. What is your diagnosis?
a. SVC syndrome
99
A 15 year old female presented with fever and pain and swelling in ankles and knees. She has a history of recurrent sore throat. Positive ESR & ASO. She was treated with penicillin and steroids. What is she more likely to develop in the future?
A. Aortic valve disease
B. Mitral valve disease
C. Tricuspid valve disease
B. Mitral valve disease
The previous scenario meets the criteria of rheumatic fever, and the mitral valve is the most commonly affected valve (mostly MS).
100
A 20-year-old thin tall male who has cardiomegaly, long extremities and fingers, and hyperextensibility. What would you find on auscultation?
A. Early diastolic murmur at upper right and left sternal borders
B. Pansystolic murmur at the left sternal border
C. Mid-diastolic murmur at the apex
A. Early diastolic murmur at upper right and left sternal borders
First:
- Early diastolic murmur at upper right and left eternal borders → Aortic regurgitation.
- Pan systolic murmur at the left sterna border → Tricuspid regurgitation.
- Mid diastolic murmur at the apex → Mitral stenosis.
- Pan systolic murmur at apex → Mitral regurgitation.
- Mid systolic click and mid to late systolic murmur at apex → Mitral valve prolapse
Second:
A thin tall male → think Marfan's syndrome, it can cause MVP, MR, and AR.
So, the only answer that is related to Marfan's syndrome is A.
101
where would you most likely find Howell-Jolly body?
a. splenectomy
b. myelodysplastic syndrome
c. hereditary spherocytosis
a. splenectomy
102
A patient was on amoxicillin when she developed colicky abdominal pain and diarrhea. Colonoscopy showed white exudates and pseudomembranes. Which of the following will be used to treat the patient?
Oral Vancomycin
White exudates and pseudomembrane are seen in pseudomembranous colitis, which is caused by c. difficle.
Management: 1. Stop antibiotics 2. Oral vancomycin 3. If fulminant and life threatening, use both oral vancomycin and IV metronidazole
NEVER USE IV VANCOMYCIN.
103
A 35-year-old female presented with chronic abdominal pain for the past 5 years. She stated that the pain is all over her abdomen and is intermittent. It is usually associated with episodes of constipation, and relieved by defecation. She denied any rectal bleeding and her weight is stable over the past few years. Her laboratory tests were all within normal range. Upper endoscopy and colonoscopy were done one year ago and were normal. Which of the following measures is most appropriate at present time?
Reassurance
Intermittent diffuse abdominal pain that is associated with episodes of constipation and relieved by defecation indicates IBS. Therefore reassurance is most appropriate.
104
A 20 year old presented with nausea and vomiting. His father was diagnosed with diabetes type 1 at 13 years old. On examination you found dark colored skin on his neck. What does he have?
A. Type2DM
B. Type1DM
C. MODY
A. Type2DM
Note: MODY doesn’t cause acanthosis nigricans
105
An elderly woman has knee pain while kneeling during her prayer, what is the next step in investigation?
A. x-ray
B. synovial fluid
A. x-ray ( start with non-invasive first)
106
A patient with purpura, easy bruising, and gingival bleeding. Her platelet count was 4x10^9. Otherwise her labs were normal. what is the diagnosis?
a. ITP
b. observe and reassess
a. ITP
107
A patient with heart failure, what is the benefit of using ACE inhibitor?
it improves survival
108
A patient with complains of chronic pancreatitis (see x-ray) , how will you treat this patient?
Pancreatic enzyme supplements
Calcified pancreas on x-ray= chronic pancreatitis
Therefore treatment is enzyme supplements, since the pancreas is calcified and is no longer viable to produce the required enzymes.
109
What is the pathophysiology of the X-ray finding of Rheumatoid arthritis?
Pannus formation
110
A patient with a 5 year history of SLE, and many abortions. She presented with hemiparesis. What diagnostic investigation is important to determine her therapy?
A. anti-dsDNA
B. anticardiolipin A
B. anticardiolipin A
(as mentioned before, here we’re suspecting antiphospholipid syndrome so we check the antiphospholipid antibodies one of them is antiocardiolipin)
111
A patient with anterolateral thigh numbness and increased sensitivity to touch. what is the condition?
A. meralgia parasthetica
B. diabetic neuropathy
C. Vitamin B12 deficiency
A. meralgia parasthetica
112
A 47 years old patient with goat was prescribed Allopurinol. After taking his drug, he developed generalized desquamation of his skin, difficulty to swallow or eat, and oral ulcers. Which of the following is true regarding this condition?
A. Type 2 hypersensitivity
B. IV immunoglobulin has been show to greatly benefit these patients
C. Despite how severe it is, mortality is less than 10%
D. This condition causes conjunctivitis, GI hemorrhage, and ATN
D. This condition causes conjunctivitis, GI hemorrhage, and ATN
(In Toxic Epidermal Necrolysis (TEN), IVIg have not been proven to greatly benefit)
113
A 25-year old previously healthy man presents with fever, central chest pain and breathless of two-week duration. Examination revealed raised JVP and a leathery scratchy noise on auscultation of the precordium. Which of the following is the most likely finding on his evaluation?
A. Weak pulse during inspiration and strong pulse during expiration
B. A prominent "V" wave in JVP waveform
C. Loud first and second heart sounds on auscultation of the heart
C. Calcification around the heart on his chest X-ray
D. 'ST' elevation, "T' wave inversion and 'Q' waves in the chest leads of ECG
A. Weak pulse during inspiration and strong pulse during expiration
- Leathery scratchy noise= pericardial friction rib, which can be heard in acute pericarditis.
- Acute pericarditis can be diagnosed by a triad of (chest pain, friction rib, ECG changes that include diffuse ST elevation, and depressed PR segment).
- But, acute pericarditis by itself does not cause elevated JVP unless it was complicated by cardiac tamponade, restrictive pericarditis, or pericardial effusion.
- Rule out constrictive pericarditis because pericardial rub is not heard in constrictive pericarditis.
- There is no answer that is relevant to pericardial effusion, so rule it out.
- Only left with cardiac tamponade, which is characterized by: Hypotension / Increased JVP / Tachycardia / Pulsus paradoxus
- So the correct answer is A which describes the pulsus paradoxus.
- Answer D is incorrect for acute pericarditis, because the ECG changes that are found in pericarditis are:
1) ST elevation in most ECG leads with concavity upwards.
2) T wave inversion occurs after ST segment returns to base line (unlike in acute MI, where the ST segment is concave downwards and there is some amount of T wave inversion accompanying the ST elevation).
3) PR segment depression caused by inflammation of the atrial wall.
114
A 70-year-old male presented with chest pain, exertional dyspea, and syncopal episodes. On auscultation, a musical murmur was heard all over the precordium, what is the mostlikely diagnosis ?
A. Calcific aortic stenosis of the elderly
B. Rheumatic heart disease
A. Calcific aortic stenosis of the elderly
115
A 23 year old asthmatic male came to your clinic because of multiple SOBs and wheezing. He was previously prescribed for LABA, ICS, and albuterol. However, he wasn't compliant to his medications because of the adverse effects. Which of the following statements is true?
a. 10 % of patients get addicted to albuterol
b. ICS doesn’t cause difference in height between children who are taking it and who are not
c. ICS doesn’t cause weight gain
d. ICS causes mouth ulcers
e. ICS causes deactivation of tuberculosis
e. ICS causes deactivation of tuberculosis
116
A patient presented with loss of pain and temperature on the right side of the body and left side of the face. He also complained of dysphagia, hoarseness, and hiccups. On examination, the uvula and palate were deviated towards the right side. This presentation is compatible with Wallenberg syndrome. Which of the following arteries is affected in this patient?
A. Right PICA
B. Right AICA
C. Left AICA
D. basilar artery
E. Left vertebral artery
E. Left vertebral artery
Wallenberg syndrome causes **ipsilateral cranial nerve symptoms** and **contralateral spinothalamic tract symptoms** >> blockage of either **left vertebral artery** or **left posterior inferior cerebellar artery (PICA)**
117
Someone who was vomiting for several days. What is the most probable metabolic profile ?
a. Hypochloramic alkalosis
b. Hyperchloramic acidosis
c. Hypokalemic acidosis
d. Hyperkalemic alkalosis
e. none of the above
a. Hypochloramic alkalosis
118
A patient presented with hematuria and a sudden increase in creatinine, which was normal a few weeks ago. He has granular immunoglobulin deposits under immunoflorescene.Complement levels were low. What is the most likely diagnosis?
a. Goodpasture's syndrome
b. Granulomatosis with polyangiitis
c. IgA nephropathy
d. Cryoglobulinemia
d. Cryoglobulinemia
119
Elderly patient who is an ex-smoker with 40 packs-year history of smoking. He stopped smoking 10 years ago. he has long standing history of COPD for 20 years, he used to have 1st degree clubbing, he is compliant to his COPD medications and inhalers. He came to the clinic recently with shortness of breath mainly and worsening clubbing. On examination the clubbing was 3rd degree. what is the diagnosis?
a. acute exacerbation of COPD
b. bronchiectasis
c. idiopathic pulmonary fibrosis
d. bronchogenic carcinoma
d. bronchogenic carcinoma
– A is eliminated because COPD doesn’t present with clubbing.
– Bronchiectasis is eliminated because it doesn’t fit with the patient’s symptoms.
– IPF and bronchogenic carcinoma can both present with clubbing.
• However, it is more appropriate to choose the latter because the patient is a significant ex-smoker. There is a linear relationship between pack-years and risk of lung cancer. Even if the patient is an ex-smoker, his risk gets reduced gradually over time BUT is still not equal to a non-smoker’s risk.
120
FEV1/FVC 110% / FEV1 84% / FVC 76% / TLC 60% / DLCO 60%
What is the likely pattern?
a. restrictive pattern due to pulmonary parenchymal disease
b. restrictive pattern due to chest wall deformity
c. restrictive pattern due to neuromuscular disease
a. restrictive pattern due to pulmonary parenchymal disease
121
A patient presented with severe unilateral headache, associated with tearing and nasal congestion. He was diagnosed with cluster headache. what is the duration of cluster headaches?
A. 1til 30 minutes
B. 15 til 180 minutes
C. 30 til 180 minutes
D. 4 til 72 hours
B → Dr. Suhail
C → Dr. Jassem & Kumar
122
A women presented with diarrhea and weight loss. Anti-endomysial Ab for celiac sprue was negative. Endoscopy showed notched duodenum and villous atrophy. what is the reason for the negative test?
A. IgA deficiency
B. IgG deficiency
C. dermatitis herpitiformis
A. IgA deficiency
Celiac investigation: Serum antibodies
False negatives occur in IgA deficiency (2% of celiac patients), therefore IgG based tests should be used.
Dermatitis herpitiformis is a dermatological manifestation of celiac.
123
Patient is on hypothyroidism treatment. she has postural hypotension. low sodium, high potassium.low calcium. they give Na in urine also. she has no pedal edema What is the diagnosis ?
a. SIADH
b. Adrenal insufficiency
b. Adrenal insufficiency
Autoimmune polyendocrine syndrome; autosomal dominant syndrome characterized by adrenal insufficiency, autoimmune thyroiditis, and DM 1. In primary adrenal insufficiency the pt will have hypoaldosteronism -> hypotension (hypotonic hypotension). Also, they have low Na and Ca, and high K+
124
A patient with sensory symptoms neck and shoulder pain. he also noticed tingling and loss of sensation in the fourth and fifth fingers of his hand . What is the most likely diagnosis ?
A. C5 radiculopathy
B. C6 radiculopathy
C. C7 radiculopathy
D. C8 radiculopathy
E. T1 radiculopathy
D. C8 radiculopathy
125
A patient has numbness and tingling thumb and index. there was atrophy of the thenar eminence. Tinel sign was positive. what is the diagnosis?
A. Carpal tunnel syndrome
B. de-Quervain tenosynovitis
A. Carpal tunnel syndrome
126
A 51-year-old lady with 10 year history of rheumatoid arthritis is scheduled for surgery to remove her gallbladder. Which of the following measures is compulsory before endotracheal
intubation?
A. Chest x-ray
B. X-ray of the cervical spine
C. X-ray of lumbar spine
B. X-ray of the cervical spine (always before intubation we should take an x-
ray of the cervical spine)
127
A young male with sudden chest pain, fever, and sweating for 2 weeks. After that he came to the hospital, what will be the first investigation that you would order in the ER?
a. Chest X-ray
b. Sputum cultures
c. Blood cultures
d. Bronchoscopy
e. colonoscopy
a. Chest X-ray
Initial test of choice to rule out pneumothorax and pneumonia.
128
A patient presented with signs and symptoms of hyperthyroidism. What will the labs show?
A. High T4 and T3 with low TSH
129
Young female diagnosed with schizophrenia, she takes Haloperidol. came to the clinic with bilateral colorless breast discharged, decreased lipido, amenorrhea. Whats the cause?
A. Hyperprolactinemia caused by haloperidole
B. PCOS
C. She is hallucinating
D. Malingering
E. breast cancer
A. Hyperprolactinemia caused by haloperidole
130
A 28-year-old female reports history of joint pain in her hands and feet. Which of the following favors inflammatory polyarthritis?
A. Low-grade fever
B. Morning stiffness less than 30 minutes
A. Low-grade fever
131
A young girl presents with DKA (pH=7.12) and low HCO3. what is the next step in the management of this patient?
A. give ringers lactate with subcutaneous insulin
B. IV bolus Potassium chloride
C. NaHco3
D. give normal saline 1L over 2 hours
D. give normal saline 1L over 2 hours
132
A patient who undergoes chemotherapy for lymphoma, which of the following is likely to be found?
Hyperuricemia
133
A female was found to have multiple kidney stones. She also reported a history of passing stones during urination. She also complains of body aches and constipation. Laboratory investigations showed high calcium and low phosphate levels. What investigation would further confirm the diagnosis?
A. Intact PTH level
134
A women started to have headache recently. upon questioning her, she admitted the use of medication for the last three months. she was diagnosed with idiopathic intracranial hypertension. which of theses drugs is most likely to cause headache for her?
A. vitamin A for acne
B. folate
C. iron
D. multivitamin
E. omega 3
A. vitamin A for acne
Vit A (retinoids) excess causes idiopathic intracranial hypertension (IIH)
135
A 34 years old female with tighted skin and digital ulcers. She was diagnosed with hypertension, what is the best drug for her ?
A. Thiazide
B. Hydralazine
C. Methyldopa
D. B blcoker
E. Lisinopril
E. Lisinopril
(scleroderma patient with hypertension we treat with ACE inhibitors)
136
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 and had consumed excessive amount of alcohol. He had become sick while at the party and had experienced repeated retching and vomiting but no hematemesis. There was no past history of indigestion or gastrointestinal bleeding but his father and grandfather both died from a gastric carcinoma. Physical examination revealed pallor but no other abnormality. What is the most likely cause of his hematemesis?
A. Esophageal varices.
B. Acute alcoholic gastritis
C. Mallory-Weiss syndrome
D. Bleeding duodenal ulcer
E. Gastric carcinoma
C. Mallory-Weiss syndrome.
A mucosal tear at (or just below) the gastroesophageal junction as a result of forceful vomiting or retching. It usually occurs after repeated episodes of vomiting. It is most commonly associated with binge drinking in alcoholics.
137
A patient was admitted to the hospital. On day 3, he developed fever and shortness of breath with cough. what is the cause?
a. hospital acquired pneumonia
b. community acquired pneumonia
c. ventilator associated pneumonia
a. hospital acquired pneumonia
138
A 65-year-old patient presented with fatigue, lymphadenopathy and recurrent infections. His peripheral blood smear showed mature lymphocytes and smudge cells.
What is the most likely diagnosis?
a. AML
b. ALL
c. ET
d. CLL
d. CLL
139
A patient presented with recurrent infections, sinusitis, and productive cough. The sputum he coughed is green in color with foul smell and great in amount.
Chest x-ray showed prominent broncho-alveolar markings. Which of the flowing is
diagnostic?
a. High-resolution CT
b. Sputum culture
a. High-resolution CT
HRCT is the imaging test of choice for bronchiectasis
140
pregnant lady with frothy sputum. What is the mechanism of breathlessness in this patient?
a. pulmonary HTN
b. increased pulmonary capillary pressure
c. increased alveolar oncotic pressure
b. increased pulmonary capillary pressure
An increases in pulmonary capillary pressure causes increased fluid flux out of the capillaries and into the interstitium, inducing pulmonary edema.
141
A scenario describing rheumatoid arthritis. what is the technique that is used in the lab to detect rheumatoid factor?
A. Nephelometry
B. flow cytometry
C. ELISA
D. Immunofluorescence
E. something has Ab mentioned in it
A. Nephelometry
142
A 50 years old female complained of mild muscle weakness and polyuria. Her BP 140/98 High Na, low K, high HCO3 & Ca, what test is most appropriate for diagnosis ?
A. urinary catecholamine
B. aldosterone level
C. cortisol level
D. aldosterone to renin ratio
E. plasma renin
D. aldosterone to renin ratio
143
Woman with HbA1c of 7.2 obese and has joint pain (osteoarthritis) she tried losing weight for the past 6 months but she couldn't. How can you manage her condition?
A. give NSAID for knee pain
B. lose more weight
C. give Metformin
D. thalazidomide
E. start insulin
C. give Metformin
Note: this is a diagnosis of diabetes, HbA1C >6.5, obesity is a RF. Fist line treatment for diabetic patient is metformin
144
Which of the following is less likely to be found in Parkinson?
A. asymmetrical tremor
B. tremor made worse with mental tasks
C. tremor better with movement
D. decrease swinging of the arm
E. early gait instability
E. early gait instability
(gait instability is a late sign)
