101-150 Flashcards by Amnah Qaw

A 55-year-old man with Liver cirrhosis is admited to the hospital with a massive upper gastrointestnal (GI) bleeding. In additon to volume restoraton, which intravenous medicaton is recommended before upper GI endoscopy?
A. Vitamin K
B. Octreotde
C. Propranolol
D. Vasopressin

B. Octreotde

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A 28-year-old woman is evaluated because of recurrent lower abdominal pain and diarrhea for the last 6 months. She also reported having occasional joint pains and a 3 kg weight loss. She received treatment with antbiotcs, dietary restrictons, and antspasmodics without improvement. Barium series showed thickening of the terminal ileum and few strictures in the jejunum (see lab results). Test Result Normal Values Hb 94 130-170 g/. (Male) 120-160 g/L (Female) ESR 85 2-10 mm/h (Male) 3-15 mm/h (Female) Which of the following is expected feature on physical examinaton?
A. Nail pitng
B. Splenomegaly
C. Perianal diseases
D. Erythema marginatum

C. Perianal diseases

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A 56-year-old man presents to the Gastroenterology Clinic with frequent heartburn. He had upper GI endoscopy and biopsy, which revealed Barret’s esophagus with low dysplasia. Which of the following is the best inital opton in management?
A. Esophageal resecton
B. Pantoprazole
C. Ranitdine
D. Sucralfate

B. Pantoprazole

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A 60-year-old man with diabetes presented with progressive ascites, fever and weight loss for 2- months. Paracentesis revealed low serum-ascites albumin gradient (SAAG). Which of the following is the most likely diagnosis?
A. Liver cirrhosis
B. Peritoneal tuberculosis
C. Veno-occlusive disease
D. Restrictve cardiomyopathy

B. Peritoneal tuberculosis

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A 44-year-old man with HBV cirrhosis presents with increasing abdominal girth, lower limb edema, and 10 kg weight gain over the last 3 months. On examinaton, he has jaundice and moderate ascites (see lab resuits and report). Test Result Normal Values Sodium 132 134-146 mmol/L Potassium 3.8 3.5-5.1 mmol/L Creatnine 65 44-115 mol/L Albumin 30 34-56 g/L
Total bilirubin 25 3.5-16.5 mol/L Ascetc fuid analysis: showed an albumin level of 12 g/L and neutrophil count of 180/ul. In additon to salt-restricted diet, what is the best next step in management?
A. Trans-jugular Intrahepatc Portosystemic shunt
B. Furosemide and spironolactone
C. Large-volume paracentesis
D. Terlipressin and albumin

B. Furosemide and spironolactone

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In a patent with ulceratve colits, which of the following is associated with increased risk of colorectal cancer?
A. Colits limited to the most distal 15 cm of colon
B. Disease of three-year duraton
C. Primary sclerosing cholangits
D. Mild infammaton

C. Primary sclerosing cholangits

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A previously healthy 22-year-old woman reports 3-month history of frequent bloody bowel movements with mucus and occasional right hip pain. She has had no history of contact with sick patent and no recent intake of drugs. Physical examinaton fndings are within normal except for gross blood on rectal examinaton (see lab results and report). Test Result Normal Values Hb 110 130-170 g/L. (Male) 120-160 q/L (Female) MCV 72 80-95 f Stool analysis: Shows many RBCs and few WBCs. Which of the following is the most likely diagnosis?
A. Internal haemorrhoids
B. Ulcerative colits
C. Infectous colits
D. Celiac disease

B. Ulcerative colits

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A 20-year-old woman with no previous medical illnesses, presented with 7-day history of increasing jaundice, nausea, vomitng and right sided upper abdominal pain (see lab results). Test Result Normal Values Total bilirubin 26 3.5-16.5 umol/L Aspartate aminotransferase 700 12-40 IU/L Alanine aminotransferase 1650 5-40 IU/L Alkaline phosphatase 126 39-117 IU/L Which of the following tests has the greatest prognostc value?
A. Bilirubin
B. Albumin
C. Prothrombin time
D. Alanine aminotransferase

C. Prothrombin time

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A 28-year-old woman presents with right lower quadrant abdominal pain, loose bowel motons, and weight loss for 3 months. Colonoscopy and biopsy of the terminal ileum demonstrated non- caseatng granulomas. Which of the following is the most likely diagnosis?
A. Pseudomembranous colits
B. Intestnal tuberculosis
C. Crohn’s disease
D. Celiac disease

C. Crohn’s disease

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A 25-year-old woman presents with abdominal pain, bloatng and weight loss. Physical examinaton is unremarkable except for BMI 18% (see lab results and report), Test Result Normal Values Hb 90 130-170 g/L. (Male) 120-160 g/L (Female) MCV 70 80-95 f Calcium 2.05 2.15-2.62 mol/L Phosphate, inorganic 0.79 0.82-1.51 mmol/L Tissue transglutaminase antbody: Positve. Which of the following is the best management?
A. Glucocortcoids
B. Gluten free diet
C. Metronidazole
D. Ciprofoxacin

B. Gluten free diet

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A 56-year-old man presents with epigastric pain, bloatng and weight loss. Gastroscopy showed antral mass and biopsy is taken (see reports). Helicobacter pylori breath test: Positve. Biopsy report: Mucosa-Associated Lymphoid Tissue lymphoma (MALToma). Which of the following is the next step in management?
A. Eradication therapy for H. Pylori
B. Referral for gastrectomy
C. Chemotherapy
D. Radiotherapy

A. Eradication therapy for H. Pylori

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A young woman who is known to have pan ulceratve colits is admited for a severe relapse. Since there was no response to medical treatment, surgery is decided. The patent is very sceptcal about surgery and requested more informaton. What is the appropriate way to address her concerns?
A. Tell her that she will die if surgery is not performed
B. Discard her concerns as unfounded and push her for surgery
C. Inform her that surgery will leave her with a colostomy bag
D. Agree on another meetng with the surgeon and the gastroenterologist

D. Agree on another meetng with the surgeon and the gastroenterologist

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A 52-year-old man, who has been medically treated as peptc ulcer for a long tme, underwent upper endoscopy, which showed a malignant ulcer. During the visit, he started blaming his primary physician and wanted to fle a complaint. Which of the following is the most appropriate response?
A. Agree that it is his right to do so
B. Take a neutral stand in this issue
C. Inform him that his doctor did what he could do
D. Tell him that he should blame himself not his doctor

A. Agree that it is his right to do so

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A married man, who had a trip to Thailand 2 months ago, is complaining of recurrent diarrhoea and weight loss. He underwent HIV testng which came reactve. However, he requested not to tell anyone including his wife. Which of the following is the best response?
A. Disclose the result to his employer
B. Request the social worker to inform his wife
C. Report to the infection control unit in the hospital
D. Respect his request not to disclose the result to anyone

C. Report to the infection control unit in the hospital

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A 60-year-old man presented with high-grade fever and lef pleuritc chest pain. On examinaton, he has early clubbing and evidence of moderate pleural efusion in the lef side of the chest. Pleural fuid analysis revealed pH of 7,0. Which of the following is the most likely diagnosis?
A. Empyema
B. Chylothorax
C. Parapneumonic efusion
D. Tuberculous pleural efusion

A. Empyema

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A 65-year-old man with diabetes and hypertension is admited with extensive anterior ST elevaton myocardial infarcton (STEMI). had successful angioplasty and stentng to lef anterior descending artery. Aspirin, clopidogrel, bisoprolol and enalapril were started (see lab results). Test Result Normal Values Cholesterol (HDL) 1.0 > 1.03 mmol/L Cholesterol (LDL) 3.36 <3.36 mmol/L Total Cholesterol 5.0 <5.1 mmol/L Triglycendes 2.2 <2.16 mmol/L Which of the following is recommended?
A. No additonal medicaton is indicated
B. Atorvastatin
C. Fenofbrate
D. Niacin

B. Atorvastatin

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A 55-year-old man with diabetes presented to the Cardiology Clinic with vague chest pain with exerton for 2 months (see report). Electrocardiogram: Normal. Which of the following is the most appropriate next step in management?
A. Assurance
B. Exercise ECG testing
C. Coronary angiogram
D. Adenosine myocardial perfusion imaging

B. Exercise ECG testing

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A 60-year-old man with poorly controlled hypertension presents with exertonal dyspnea and occasional paroxysmal nocturnal dyspnea. No chest pain or palpitaton. On examinaton, he is comfortable at rest; the JVP is 3 cm above sternal border, loud A2 and lef ventricular $4, no murmur (see reports). Blood pressure 160/100 mmH Heart rate 76 /min Respiratory rate 18 /min Oxygen saturaton 95 % Electrocardiogram: Shows sinus rhythm and lef ventricular hypertrophy.
Echocardiogram: Normal cardiac chambers size, concentric lef ventricular hypertrophy and normal lef ventricular ejecton fracton. Which of the following is the most likely diagnosis?
A. Left ventricular diastolic dysfunction
B. Restrictve cardiomyopathy
C. Silent myocardial ischemia
D. Constrictve pericardits

A. Left ventricular diastolic dysfunction

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A 30-year-old man is found to have cardiomegaly on chest X-ray during pre-employment check- up. He denies chest pain, dyspnea, orthopnea or PND. Physical examinaton unremarkable (see reports). Blood pressure 120/80 mg Heart rate 76 /min Respiratory rate 18 /min Electrocardiogram: Normal. Echocardiogram: Dilated lef ventricle with ejecton fracton of 40%. Which of the following is the best management?
A. Digoxin
B. Lisinopril
C. Furosemide
D. Echocardiogram in 6 months

B. Lisinopril

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A 45-year-old man with previous history of rheumatc heart disease presents with worsening dyspnea, orthopnea and PND. Physical examinaton shows holosystolic murmur in the apex and bibasilar crackles on lung auscultaton. His symptoms improved with furosemide, spironolactone, enalapril and carvedilol (see report). Echocardiogram: Showed mildly dilated lef ventricle, LVEF 45% and severe rheumatc mitral regurgitaton. Which of the following is the best next step in management?
A. Digoxin
B. Losartan
C. Follow-up in 6 months
D. Mitral valve replacement

D. Mitral valve replacement

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A 70-year-old man is found to have ejecton systolic murmur in the aortc area during routne medical check-up. He denied symptoms of dyspnea, chest pain or syncope. Physical examinaton revealed slow raising carotd pulsaton; normal JVP and normal lung auscultaton (see reports). Blood pressure 110/70 mmHg Heart rate 76 /min Respiratory rate 18 /min Electrocardiogram: Normal sinus rhythm with LVH. Echocardiogram: Shows concentric LVH, normal ejecton fracton and severely stenosed aortc valve. Which of the following is the next step in management?
A. Aortic valve replacement
B. Follow-up in 6 months
C. Furosemide
D. Enalapril

B. Follow-up in 6 months

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A 30-year-old woman with history of rheumatc heart disease since childhood presented with exertonal dyspnea and occasional paroxysmal nocturnal dyspnea. Physical examinaton showed JVP of 5 cm above sternal angle, loud S1, loud P2 and mid diastolic rumbling murmur in the apex. Fine basal crackles are present on lung auscultaton. Which of the following is the most likely diagnosis?
A. Mitral stenosis
B. Aortic stenosis
C. Tricuspid stenosis
D. Pulmonary stenosis

A. Mitral stenosis

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A 60-year-old man presents with abdominal distension dyspnea and orthopnea. The JVP is markedly elevated and fails to descend during inspiraton. Lower limbs showed massive pitng edema up to the thighs. Heart sounds are normal. There are bibasilar crackles on lung auscultaton. Abdominal examinaton showed hepatomegaly and positve shifing dullness (see report). Echocardiogram: Both atria are dilated. Lef and right ventricles are normal in size and LVEF is 60%. No valve lesions. Which of the following has the highest diagnostc value?
A. Holter monitor
B. Cardiac CT scan
C. Coronary angiogram
D. Exercise ECG testng

B. Cardiac CT scan

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An 18-year-old boy presents with recurrent syncope with exercise. Physical examinaton showed normal JVP, jerky carotd pulsatons and thrustng apex. There is an ejecton systolic murmur, which is best heard in the lef parasternal area that increases in intensity with standing and reduced during handgrip (see report). Blood pressure 110/70 mmHg Heart rate 76 /min Electrocardiogram: Shows lef ventricular hypertrophy. Which of the following is the most likely diagnosis?
A. Aortc stenosis
B. Pulmonary stenosis
C. Ventricular septal Defect
D. Hypertrophic obstructive cardiomyopathy

D. Hypertrophic obstructive cardiomyopathy

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A young man with diagnosis of hypertrophic cardiomyopathy presented with recurrent exertonal chest pain and syncope. Which of the following is the best management? A. Nifedipine B. Metoprolol C. Hydralazine D. Nitroglycerine

B. Metoprolol

A 65-year-old woman with diabetes and hypertension, presented with retrosternal chest pain at rest for 3 hours. Physical examinaton is normal except for $4 gallop (see lab result and report). Blood pressure 110/70 mmHg, Heart rate 76 /min, Oxygen saturaton 95 % Test Result Normal Values Troponin 10 < 0.2 pg/L Electrocardiogram: T-wave inversion in leads V2-V5. Which of the following is the most likely diagnosis? A. Stable angina B. Unstable angina C. Elevaton myocardial infarcton D. Non ST elevaton myocardial infarcton

D. Non ST elevaton myocardial infarcton

A 60-year-old man with diabetes and hypertension is admited to the Coronary Care Unit with diagnosis of unstable angina. Physical examinaton is normal except for S4 gallop. Aspirin, bisoprolol, enoxaparn, atorvastatn and nitrate are started (see lab result and reports). Blood pressure 110/70 mmHg, Heart rate 76 /min Respiratory rate 18 /min Test Result Normal Values Troponin .001 < 0.2 pg/L Electrocardiogram: Showed ST depression in leads II, III, AVF. Echocardiogram: Normal. What additonal medicaton is indicated? A. Clopidogrel B. Candesartan C. Streptokinase D. Spironolactone

A. Clopidogrel

A 30-year-old man presents with burning retrosternal chest pain associated with dyspnea. His history is signifcant only for common cold 2 weeks ago (see image). Which of the following clinical signs is likely to be present? A. Murmur B. Pericardial rub C. Cannon a-wave D. Fourth heart sound

B. Pericardial rub

A 70-year-old man presents with dyspnea, fatigue and pre-syncope. On examinaton, the JVP showed Cannon a-wave and variatons in the intensity of the frst heart sound (see image). Which of the following is the defnitve treatment? A. Implantable cardioverter defibrillator B. Permanent pacemaker C. Oral theophylline D. Oral metoprolol

B. Permanent pacemaker

A 64-year-old woman with advanced breast cancer complains of dyspnea on exerton. On examinaton, her systolic blood pressure is noted to markedly decrease during inspiraton. Heart sounds are distant to auscultaton. Chest is clear (see report). Blood pressure 95/65 mmH, Heart rate 100 /min, Respiratory rate 24 /min, Temperature 36.6 °C, Oxygen saturaton 95 % Chest x-ray: Marked cardiomegaly with clear lung felds. Which of the following is the most likely diagnosis? A. Hypertrophic obstructve cardiomyopathy B. Restrictive cardiomyopathy C. Dilated cardiomyopathy D. Cardiac tamponade

D. Cardiac tamponade

A 65-year-old woman with diabetes and hypercholesterolemia presents to the Emergency Department with chest tghtness associated with sweatng and nausea of 4-hour duraton. Physical examinaton showed elevated JVP, which increases further during inspiraton, S4 gallop and clear lung felds on chest auscultaton. Aspirin and clopidogrel were given. Results of cardiac enzymes are pending (see image). Blood pressure 90/55 mmH Heart rate 76 /min Respiratory rate 18 /min Oxygen saturaton 95 % Which of the following immediate acton should be taken? A. Chest X-ray B. Echocardiogram C. Coronary CT angiogram D. ECG with right chest leads

D. ECG with right chest leads

A 25-year-old woman presented with dyspnea and cyanosis. Physical examinaton revealed elevated JVP with predominant a-wave and lef parasternal heave. There is an ejecton systolic murmur best heard in the lef second intercostal space that increases in intensity during inspiraton. An ejecton click is also heard in the same area Blood pressure 110/70 mmHg Heart rate 76 /min Respiratory rate 20 /min Which of the following is the most likely diagnosis? A. Aortc stenosis B. Coarctaton of aorta C. Ventricular septal defect D. Congenital pulmonary stenosis

D. Congenital pulmonary stenosis

A 70-year-old man is admited for stomach resecton for gastric cancer. On the 4TH postoperatve day. the patent developed retrosternal chest pain accompanied with dyspnea and perfuse sweatng. Physical examinaton is remarkable only for S4. Aspirin, clopidogrel and nitrate were administered (see report) Blood pressure 110/70 mmHg, Heart rate 76 /min, Respiratory rate 18 /min, Temperature 36.6 °C Oxygen saturaton 95 % Electrocardiogram: Shows ST elevaton in leads V2-V5. Which of the following is the most appropriate step in management? A. Thrombolytc therapy B. Primary angioplasty C. Abciximab D. Warfarin

B. Primary angioplasty

A 70-year-old man with hypertension, diabetes and aortc sclerosis discovered to have atrial fbrillaton on routne health check-up. He denies dyspnea, chest pain or palpitatons. Which of the following drugs is recommended to prevent systemic embolization? A. Aspirin B. Warfarin C. Clopidogrel D. Rivaroxaban

B. Warfarin

A 22-year-old woman presents with retrosternal burning chest pain, which is worse during breathing and coughing. Precordial auscultaton showed an added sound of 3 components; systolic, diastolic and presystolic (see image). Which of the following is the best inital treatment? A. Tissue plasminogen actvator B. Enoxaparin C. Ibuprofen D. Prednisone

C. Ibuprofen

In a patent with heart failure due to dilated cardiomyopathy presentng with fast atrial fbrillaton, which of the following drugs is the most appropriate to control the heart rate? A. Digoxin B. Diltazem C. Ivabradine D. Propranolol

A. Digoxin

A 40-year-old man is admited with palpitatons of 4-hour duraton. He had similar atack a month ago but did not seek medical advice. His inital electrocardiogram showed atrial fbrillaton with controlled ventricular rate. He subsequently converted to sinus rhythm. Which of the following drugs is the most appropriate to maintain sinus rhythm? A. Digoxin B. Bisoprolol C. Verapamil D. Amiodarone

D. Amiodarone

An 18-year-old girl is recently diagnosed to have rheumatc fever with cardits. Echocardiogram showed mild mitral stenosis with mild regurgitaton. To what age the rheumatc fever prophylaxis is recommended? A. 40 B. 28 C. 23 D. 21

A. 40

Which of the following is an absolute contraindicaton for thrombolvtc therapy? A. Pregnancy B. Intracranial hemorrhage 2 years ago C. Cardiopulmonary resuscitaton for 10 min D. Blood pressure at presentaton of 180/110 mmH

B. Intracranial hemorrhage 2 years ago

A 28-year-old woman presents to the Cardiology Outpatent Department with recurrent palpitatons for the last 6 months. She describes the palpitatons as fast heartbeat, which starts and ends suddenly. Each atack lasts 5-10 min. No associated chest pain, dyspnea, syncope or presyncope (see lab result and report). Test Result Normal Values Hb 132 130-170 g/L (Male) 120-160 g/L (Female) Thyroid-Stmulatng Hormone 3.8 0.4 - 5.0 jU/mL. Electrocardiogram: Normal sinus rhythm with rate of 70/min. Which of the following is the best next investgaton? A. Exercise ECG testing B. Electrophysiology C. Echocardiogram D. Holter monitor

D. Holter monitor

An elderly patent is admited with diagnosis of unstable angina. He is known to have atrial fbrillaton and taking warfarin. The atending resident administered heparin but did not check the INR, which came back as 6.8. The patent developed bleeding from the gums and hematuria. His son is upset, and he requests an explanaton. Which of the following is the most appropriate response? A. Say that you are sorry for what happened and request him to calm down B. Apologize and reassure him that you will start an investigation C. Tell him that this is an expected side efect of the drug D. Inform him that the situaton is under control

B. Apologize and reassure him that you will start an investigation

A 60-year-old man with hypertension and diabetes undergone coronary angiogram, which showed 3-vessel disease requiring coronary bypass surgery. The patent refused surgery. Being the resident with the team, what is the appropriate communicaton tool to be used? A. Use the SPIKES protocol B. Tell the son to speak to the patent C. Respect autonomy and contnue medical treatment D. Apply the counselling in the presence of the consultant

D. Apply the counselling in the presence of the consultant

A patent who presented with heart failure had an echocardiogram, which showed severe rheumatc mitral regurgitaton requiring valve replacement. He is waitng to know the result. Which of the following is the most appropriate way to break the news? A. Avoid asking him about what he already knows B. Tell him all the details from the beginning C. Express more sympathy than empathy D. Deliver the informaton in small steps

D. Deliver the informaton in small steps

A 53-year-old widow with dilated cardiomyopathy presented to the Cardiology Clinic with decompensated heart failure. She lives alone, has no insurance and cannot aford the cost of medicatons. During counselling, which of the following is the most appropriate plan? A. Arrange for a charity organizaton to help her fnancially B. Involve the social worker and the hospital support system C. Refer her to the Emergency Department D. Advise her to avoid salt and stop smoking

B. Involve the social worker and the hospital support system

A 79-year-old man with multple co-morbidites is hospitalized for dissectng aneurysm and needs urgent surgery. He lives alone and he has no writen will or advanced directve. His conditon is very critcal in the ICU. What is the best way to arrange the consent for surgery? A. The atending medical team should sign the consent form B. The social worker is asked to complete the consent form C. Proceed for emergency and delay the consent D. Request a court decision

A. The atending medical team should sign the consent form

A 38-year-old man presented to the Emergency Department with 5-day history of fever and a productve cough (see lab results and reports) Blood pressure 100/65 mHg Temperature 39 °C Test Result Normal Values WBC 12 4.5-10.5 x 109/L ESR 26 2-10 mm/h (Male) 3-15 mm/h (Female) Chest X-ray: Right middle lobe infltrate. Sputum culture: Pending. Which of the following is the most appropriate immediate therapy? A. Moxifoxacin 400mg IV once daily B. Cefazidime 1 gm IV every 8 hours C. Meropenem 1 gm IV every 8 hours D. Piperacillin /Tazobactam 4.5 gm every 6 hours

A. Moxifoxacin 400mg IV once daily

A 27-year-old man presented to the Emergency Department with 2-days history of confusion and 5-hours history of seizures. Positve history of multple unprotected sexual contact for the last 6 years. On examinaton, he was disoriented to tme; place and person (see lab results and report. Temperature 39 °C Test Result Normal Values WBC 1.3 4.5-10.5 x 109/L Serum Cryptococcal Antgen: Positve. Which of the following is the most appropriate diagnostc test? A. HIV serology B. CSF toxoplasma PCR C. CSF culture for syphilis D. Herpes Simplex Polymerase chain reacton (PCR)

A. HIV serology

A 22-year-old man recently diagnosed with HIV presented to the clinic for counselling. Whom should he disclose his HIV status to? A. Wife B. Parents C. Brother D. Employer

A. Wife

A 53-year-old man recently diagnosed with HIV came to the clinic for counselling. Who should be ofered HIV testng? A. Parents B. Ex-wife C. 28-year-old son D. Ofce colleagues

B. Ex-wife

A 69-year-old man known to have diabetes mellitus, presented to Emergency department with 4-day history of productve cough and tachypnea. On examinaton, oriented to tme place and person. Chest exam revealed right lower lobe crepitaton (see lab results and report). Respiratory rate 23 /min Temperature 38.5 °C Test Result Normal Values WBC 12 4.5-10.5 x 109/L Urea 5 2.75-7.4 mmol/L Chest X-Ray: Right lower lobe intltrate. Which of the following is the most appropriate management approach? A. Admit to general ward and start IV antbiotcs B. Admit to Intensive care unit and start IV antbiotcs C. Start oral antbiotcs and observe in Emergency Room for 24 hours D. Start oral antbiotcs and see in outpatent clinic in 7-days

A. Admit to general ward and start IV antbiotcs

A 70-year-old woman known to have hypertension on medicaton. Presented to the Emergency Department with 4-days history of productve cough, shortness of breath and tachypnea. Chest exam, right lobe zone crepitaton. Temperature 38.5 °C Which of the following is the most appropriate next diagnostc test to confrm the diagnosis? A. Chest X-ray B. Elevated WBC C. Sputum culture D. Echocardiogram

A. Chest X-ray

A 54-year-old man known to have diabetes and hypertension presented to Emergency Department with 9-days history of cough, headache, shortness of breath and fever. Cough was productve of white sputum, which has become yellowish lately. On chest examinaton, wheezing, and right side crepitaton (see lab results and reports). Temperature 38 °C Test Result Normal Values Retculocyte 8 0.2-1.2 % WBC 12 4.5-10.5 x 109/L Cold agglutnin ttre: 1:256 Chest X-Ray: Bilateral shadowing both lungs with more density on the right middle lobe. Which of the following is the most likely diagnosis? A. Bronchial asthma exacerbaton B. Streptococcal pneumonia C. Atypical pneumonia D. Exacerbaton of heart failure

C. Atypical pneumonia

A 28-year-old woman referred to the clinic with 3-weeks history of generalized fatgability, malaise, arthralgia, back pain and fever. Positve history of raw milk ingeston. Abdominal examinaton, mild hepato-splenomegaly (see lab results and report). Temperature 39 °C Test Result Normal Values Hb 10.5 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 120 150-400 x 109/L Blood culture: Gram negatve cocco-bacilli. Which of the following is the frst line in treatment opton? A. Doxycycline and clindamycin B. Doxycycline and streptomycin C. Ciprofoxacin and trimethoprim sulfamethoxazole D. Rifampin and trimethoprim sulfamethoxazole

B. Doxycycline and streptomycin

A 28-year-old woman referred to the clinic with 3-week history of generalized fatgability. malaise, arthralgia, back pain and fever. Positve history of raw milk ingeston. Abdominal examinaton, mild hepato-splenomegaly (see lab results and reports). Temperature 38.5 °C Test Result Normal Values Hb 10.5 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 120 150-400 x 109/L Blood culture: Gram negatve cocco-bacilli MRI of the back: Sacroiliac joint spondylits. Which of the following is the optmal duraton of therapy? A. 3 weeks B. 6 weeks C. 12 weeks D. 24 weeks

C. 12 weeks

A 45-year-old housemaid from Southeast Asia, recently came to Saudi Arabia, presented to the Emergency Department with 2-weeks history of productve cough and shortness of breath. Positve history of hemoptysis. Chest exam showed right upper zone crepitatons (see lab results and report. Temperature 38.5 °C Test Result Normal Values WBC 14 4.5-10.5 x 109/L ESR 73 2-10 mm/h (Male) 3-15 mm/h (Female) Chest X-Ray: Right upper lobe infltrate and cavitaton. Which of the following is the most appropriate next step? A. IV cefriaxone B. Bronchoscopy C. Sputum for acid fast bacilli D. Isoniazid, rifampin, pyrazinamide and ethambutol

C. Sputum for acid fast bacilli

A 45-year-old man admited to the hospital with history of productve cough and shortness of breath. He was found to have cavitatory pulmonary tuberculosis (TB. He was started on 4 ant- TB drugs. Few days later, he notced that the urine color is red. Detailed history revealed family history of urethral stones (see lab resuits). Test Result Normal Values Hb 11 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 110 150-400 x 109/L Which of the following is the most likely cause of his new symptom? A. Urethral stones B. Renal tuberculosis C. Medication side effect D. Hematological abnormalites related to TB

C. Medication side effect

A 45-year-old man admited to the hospital with history of productve cough and shortness of breath. He was found to have positve acid fast bacilli (AFB) in sputum. He was started on isoniazid, rifampin, pyrazinamide and ethambutol. He came back to the clinic for follow up afer 3- weeks. Cough was beter and no other symptoms (see lab results) Admission lab results: Test Result Normal Values Total bilirubin 5 3.5-16.5 mol/L Aspartate aminotransferase 28 12-40 IU/L Alanine aminotransferase 32 5-40 IU/L ESR 75 2-10 mm/h (Male) 3-15 mm/h (Female) Follow-up lab results: Test Result Normal Values Total bilirubin 0.7 3.5-16.5 mol/L Aspartate aminotransferase 75 12-40 IU/L Alanine aminotransferase 80 5-40 IU/L ESR 35 2-10 mm/h (Male) 3-15 mm/h (Female) Sputum AB Negatve Which of the following is the best management approach? A. Continue ant-TB and repeat LFT in 1 week B. Stop all ant-TB and repeat LFT in 1 weeks C. Stop pyrazinamide and repeat LFT in 2 weeks D. Stop isoniazid and rifampin and repeat LFT in 2 weeks

A. Continue ant-TB and repeat LFT in 1 week

A 60-year-old man known to have hypertension and post aortc valve replacement on lisinopril 20 mg. amlodipine 5 mg and warfarin 3 mg once daily. He was admited to the hospital with history of productve cough and shortness of breath, and was found to have positve acid fast bacilli (AFB) in sputum. First line four ant-TB drugs were started. Which of the following regarding medicatons should be done? A. Lisinopril dose needs to be decreased B. Amlodipine needs to be stopped C. Warfarin needs to be increased D. Rifampin should be stopped

C. Warfarin needs to be increased

A 60-year-old man from India presented to the Emergency Department with headache and low- grade fever for 3-weeks. The headache became worse over the last 2-days and was associated with vomitng. In the emergency room, he developed generalized seizures (see lab results and reports), Test Result Normal Values WBC 19 4.5-10.5 x 109/L Pressure 280 200-250 mmH20 (Male) 300-400 mmH20 (Female) Cells 380 0-3 /ML Total protein (Men) 3 0.22-0.33 g/L Glucose 1.2 2.50-3.89 mmol/L CSF diferental WBC count: 73% lymphocytes and 13 % neutrophils. CSF culture: Pending. Which of the following is the most likely diagnosis? A. Neurocystcercosis B. Tuberculous meningits C. Bacterial meningits D. Viral meningits

B. Tuberculous meningits

A 53-year-old woman known diabetc, hypertensive and cardiac arrhythmia on amiodarone, presented to Emergency Department with 3-days history of progressive redness and pain on her right leg. Examinaton showed a sharply demarcated red lesion, which was tender with no ulcer, Temperature 38.8 °C. Which of the following is the most likely diagnosis? A. Erysipelas B. Erythema nodosum C. Side efect of Amiodarone D. Necrobiosis lipodica diabetcorum

A. Erysipelas

A 53-year-old woman known diabetc presented to the Emergency Department with 5-days history of progressive redness and pain on her right thigh. On examinaton, right thigh showed 15 cm red lesion, which was tender with no uicer (see report). Temperature 38.3 °C Ultrasound: Showed infammatory changes and 10 x 8 cm deep abscess collecton. Which of the following is the best management approach? A. Admit to ward and start IV antibiotics B. Admit to ICU and start IV antbiotcs C. Discharge home on oral antbiotcs with 1-week follow up D. Admit to ward, start IV antbiotcs, and surgical consultaton

D. Admit to ward, start IV antbiotcs, and surgical consultaton

A 53-year-old woman recently returned from Egypt, known diabetc, presented to the Emergency Department with 3-days history of progressive redness and pain on her right shin. Positve history of allergy to penicillin. On examinaton, right leg has red lesion, which was tender with no ulcer. She was started on oral antbiotcs. Next day she complained of abdominal pain, watery diarrhoea and fever. Temperature 37.8 °C Which of the following is the most likely diagnosis? A. Worsening of diabetc gastroparesis B. Allergy to antbiotc C. Clostridium difcile infection D. Salmonellosis

C. Clostridium difcile infection

A 63-year-old woman known diabetc for the last 20-years on insulin, presented to the Emergency Department with 3-days history of right knee pain and swelling. Right knee examinaton revealed, red, swollen and tender with severely limited range of movement. Other joints were normal (see lab result and report). Temperature 39 °C Test Result Normal Values WBC 17 4.5-10.5 × 109/L Synovial fuid: WBC: 55.000 Crystals: Pending Culture: Negatve Which of the following is the most likely diagnosis? A. Charcot joint B. Septic arthritis C. Gout arthrits D. Pseudo-gout arthrits

B. Septic arthritis

A 32-year-old man presents to the Emergency Department with 3-days history of generalized body aches, sore throat, runny nose, productve cough and shortness of breath. Chest exam shows right lung crepitatons. The patent was admited and according to the results of throat swab was started on oseltamivir (see report). Temperature 39 °C. Chest X-Ray: Right middle lobe infltrate. Which of the following isolaton precautons should be considered? A. Contact B. Standard C. Airborne D. Droplet

D. Droplet

A 33-year-old woman presents with headache and myalgia for 5 days. 2 days ago, she started to have fever and notced a skin rash on her face. She returned from Jeddah 10-days ago (see lab resuits). Test Result Normal Values Hb 8 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 80 150-400 x 109/L Which of the following is the most appropriate next step in management? A. Steroid B. IV antviral C. IV antbiotcs D. Supportive management

D. Supportive management

A 27-year-old soldier going to a military mission at the Southern border of Saudi Arabia. His medical history is insignifcant apart from a positve history of depression, which is controlled by medicaton. He came for counselling regarding malaria preventon. Which of the following is the best malaria chemoprophylaxis regimen? A. Atovaquone-proguanil B. Doxycycline C. Mefoquine D. Chloroquine

A. Atovaquone-proguanil

A 30-year-old man presents to the Emergency Department with history of fever and headache. He recently came from a trip to Sudan, where he stayed there for 10-days. Abdominal examinaton, palpable spleen 3 cm below costal margin (see lab results). Temperature 40 °C Test Result Normal Values Hb 9 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 90 150-400 x 109/L Aspartate aminotransferase 88 12-40 IU/L Alanine aminotransferase 94 5-40 IU/L Which of the following is the frst line treatment opton? A. Quinine B. Mefoquine C. Chloroquine D. Artemisinin based combinaton therapy

D. Artemisinin based combinaton therapy

A 45-year-old man, heavy smoker, presents to the Emergency Department with 5-days history of fever and skin rash and 3-days of dyspnea and dry cough. Skin examinaton shows vesicular lesions over the truck and extremites, some of the lesions were crusted. Chest examinaton shows bilateral crepitaton's (see report). Respiratory rate 28/min Temperature 39 °C Oxygen saturaton 82 % Chest X-Ray: Difuse bilateral infltrate. Which of the following is the most appropriate intravenous treatment opton? A. Cefriaxone and azithromycin B. Acyclovir C. Steroids D. Furosemide

B. Acyclovir

A 22-year-old man recently returned from Umrah, presents to Emergency Department with 1- day history of fever and headache. Upon arrival to the Emergency Department, he started to have seizures on the right extremites. On examinaton, positve Kering sign (see lab results and report). Temperature 39 °C Test Result Normal Values Cells 380 0-3 /pL Total protein (Men) 1.2 0.22-0.33 g/L CSF analysis: WBC diferental count: 87% neutrophils and 5% lymphocytes. Which of the following is the most appropriate intravenous treatment opton? A. Cefriaxone, vancomycin and steroid B. Cefriaxone and vancomycin C. Cefriaxone and IV acyclovir D. Acyclovir and steroid

A. Cefriaxone, vancomycin and steroid

A 22-year-old man presents to Emergency Department with 4-days history of fever, headache and confusion. On examinaton, Kemig's sign is present (see lab results and reports). Temperature 39 °C Test Result Normal Values Cells 380 0-3 /pL Total protein (Men) 0.8 0.22-0.33 g/L Glucose 3.7 2.50-3.89 mmol/L CSF analysis: WBC diferental count: 5% neutrophil and 90% lymphocytes. CSF Culture: Pending. Which of the following is the most appropriate intravenous treatment opton? A. Cefriaxone, vancomycin and steroid B. Cefriaxone and vancomycin C. Cefriaxone D. Acyclovir

D. Acyclovir

A 22-year-old man recently returned from Hal, presents to Emergency Department with 1-day history of fever and headache. On examinaton, Kerig's sign is present. Skin examinaton showed petechial rash on extremites and trunk (see lab results and report). Temperature 39 °C Test Result Normal Values Cells 380 0-3 /pL Total protein (Men) 0.9 0.22-0.33 g/L Glucose 1.2 2.50-3.89 mmol/L CSF analysis: WBC diferental: 87% neutrophils and 5% lymphocytes. Which of the following isolaton precautons should be considered? A. Contact B. Droplet C. Standard D. Airborne

B. Droplet

A 27-year-old man recently returned from Umrah. Presents to Emergency Department with 1- day history of fever and headache. On examinaton, positve Kernig's sign and petechial rash on extremites and trunk. He was isolated and started on antbiotcs (see lab results and report). Temperature 39 °C Test Result Normal Values Cells 380 0-3 /pL Total protein (Men) 0.9 0.22-0.33 g/L Glucose 1.2 2.50-3.89 mmol/L CSF analysis: WBC diferental 87 % neutrophil and 5 % lymphocytes. How many hours afer startng antbiotcs should isolaton be discontnued? A. 12 B. 24 C. 48 D. 72

B. 24

A 64-year-old diabetc woman was recently started on hemo-dialysis through a femoral central line. During dialysis, the nurse notces that she is shivering. Detailed history reveals a 3-day history of fever. On examinaton, central line site was red with pus discharge. Which of the following is the most appropriate management approach? A. Withdraw blood culture and start IV antbiotcs B. Start IV antbiotcs and hold dialysis for 3 days C. Withdraw blood culture, change the line and resume dialysis D. Withdraw blood culture, start antbiotcs and remove the line

D. Withdraw blood culture, start antibiotics and remove the line

A 64-year-old diabetc woman is receiving hemo-dialysis through a femoral central line. She develops line sepsis. Blood culture grows MRSA (methicillin resistant staphylococcus aureus). She was started on IV vancomycin 1000 mg every 72 hours (to be infused over 20 min). Immediately afer startng vancomycin, she started to have fushing, redness and itching over the face, neck and trunk. Which of the following is the most appropriate management approach? A. Stop vancomycin and label her allergic to vancomycin B. Contnue vancomycin but a lower dose C. Continue vancomycin but slower infusion rate D. Change vancomycin to cefazolin 1000 mg every 24 hours

C. Continue vancomycin but slower infusion rate

A 38-year-old woman came for routne follow up 2-months afer delivery. She has no symptoms and her baby is well and lactatng normally. Upon reviewing her labs, a positve urine culture: >100,000 fu/ml E. coli was notced which was sensitve to trimethoprim/sulfamethoxazole, ciprofoxacin, and nitrofurantoin. Which of the following is the best treatment option? A. Oral ciprofoxacin B. Oral nitrofurantoin C. Oral trimethoprim/sulfamethoxazole D. No treatment needed

D. No treatment needed

A 38-year-old woman, 28-weeks pregnant came for routne follow up. She has no symptoms and her pregnancy is all well. Upon reviewing her labs, a positve urine culture: > 100,000 fu/mi E.coli was found which was sensitve to ciprofoxacin, nitrofurantoin, trimethoprim/sulfamethoxazole and cefriaxone Which of the following is the best treatment opton? A. Oral ciprofoxacin B. Oral nitrofurantoin C. Oral trimethoprim/sulfamethoxazole D. No treatment needed

B. Oral nitrofurantoin

A 45-year-old diabetc woman presented to Emergency Department with fever, fank pain and dysuria. She is allergic to penicillin. Examinaton shows fank tenderness (see lab result and report). Temperature 39 °C Test Result Normal Values WBC 17 4.5-10.5 x 109/L Urine culture: > 100.000 cfu/ml E.coli. Which of the following is absolutely contraindicated? A. Piperacillin tazobactam B. Ciprofoxacin C. Meropenem D. Cefriaxone

A. Piperacillin tazobactam

A 45-year-old woman presented to Emergency Department with fever, fank pain and dysuria (see lab result and report). Test Result Normal Values WBC 14 4.5-10.5 x 109/L Urine culture: > 100,000 cfu/mi E.coll Which of the following is the best empirical treatment opton? A. Piperacillin tazobactam B. Nitrofurantoin C. Meropenem D. Cefriaxone

D. Cefriaxone

A 48-year-old diabetc woman presented to Emergency Department with dysuria (see lab result and report). Test Result Normal Values WBC 14 4.5-10.5 x 109/L Creatnine 230 44-115 mol/L Urine culture: > 100,000 cfu/ml E.coli Which of the following medicatons is contraindicated? A. Nitrofurantoin B. Ciprofaxacin C. Piperacillin tazobactam D. Trimethoprim / sulfamethoxazole

A. Nitrofurantoin

A 62-year-old man presented with 2-weeks history of tredness, dyspnea and 5-days history of fever. No previous surgical history. Cardiac exam shows pan-systolic murmur at the apex. Hands exam shows splinter hemorrhage on nails. Temperature 38.8 °C Which of the following is the most likely causatve organism? A. Staphylococcus epidermidis B. Enterococcus species C. Klebsiella pneumoniae D. Streptococcus species

D. Streptococcus species

A 58-year-old man presented with 2-weeks history of tredness, dyspnea and 5-days history of fever. No previous surgical history. Cardiac exam shows pan systolic murmur at the apex. Hands exam shows splinter hemorrhage on nails Temperature 38.5 °C Which of the following is the most appropriate empirical therapy? A. Cefriaxone B. Gentamicin C. Piperacillin tazobactam D. Cefriaxone and vancomycin

D. Cefriaxone and vancomycin

A 24-year-old woman is 10-weeks pregnant. She has dysuria and is diagnosed with a urinary tract infecton. Which of the following antbiotcs is contraindicated? A. Nitrofurantoin B. Ciprofoxacin C. Amoxacillin D. Cefriaxone

B. Ciprofoxacin

A 22-year-old woman presented to the clinic with 2-months history of polyarthralgia, skin rash, mucosal ulcers and fatgue. Her clinical examinatons revealed malar rash over her face and actve arthnits at several joints (see lab results). Test Result Normal Values Hb 100 130-170 g/L. (Male) 120-160 g/L (Female) Platelets count 100 150-400 x 109/L WBC 3 4.5-10.5 x 109/L ESR 35 2-10 mm/h (Male) 3-15 mm/h (Female) Lupus antcoagulant positve negatve Urea 5 2.75-7.4 mmol/L Creatnine 78 44-115 mol/L C-reactve peptde 5 <8.2 mg/L Complement C3 0.3 0.7-1.5 g/L Complement C4 0.13 0.15-0.45 g/L Which of the following test obtained at this visit is most likely to confrm the diagnosis? A. Ant-Ro (SSA) antbodies B. Antinuclear antbodies (ANA) C. Ant-double-stranded DNA (ant-DNA) D. Ant- ribonucleoprotein (RNP) antbodies

B. Antinuclear antbodies (ANA)

A 30-year-old woman presented to the clinic with polyarthralgia, malar rash and mucosal ulceratons for 2-months. Examinaton revealed actve malar rash and arthrits afectng several joints. She has positve ant-nuclear antbody with high tter (see lab results). Test Result Normal Values Hb 110 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 280 150-400 x 109/L WBC 10 4.5-10.5 x 109/L ESR 65 2-10 mm/h (Male) 3-15 mm/h (Female) Urea 4 2.75-7.4 mmol/L Creatnine 60 44-115 mol/L Appearance clear clear Protein absent absent Leukocytes 2 0-3 per high power feld Erythrocytes 0 0-2 per high power feld Complement C3 0.6 0.7-1.5 g/L Complement C4 0.13 0.15-0.45 g/L Alkaline phosphatase 50 39-117 TU/L Alanine aminotransferase 18 5-40 IU/L Aspartate aminotransferase 20 12-40 IU/L Which of the following is the best treatment opton at this tme? A. Hydroxychloroquine and methotrexate B. Hydroxychloroquine and azathioprine C. Hydroxychloroquine and cyclophosphamide D. Hydroxychloroquine and mycophenolate mofetl

A. Hydroxychloroquine and methotrexate

A 30-year-old woman presented to the clinic with polyarthralgia, malar rash and mucosal ulceratons for 2-months. Examinaton revealed actve malar rash and arthrits afectng several joints. She has positve ant-nuclear antbody with high tter (see lab results). Test Result Normal Values Hb 100 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 90 150-400 × 109/L WBC 3.5 4.5-10.5 x 109/L ESR 60 2-10 mm/h (Male) 3-15 mm/h (Female) Urea 5 2.75-7.4 mmol/L Creatnine 150 44-115 mol/L Protein 1200 0-150 mg/24 hr Complement C3 0.4 0.7-1.5 g/L Complement C4 0.1 0.15-0.45 g/L Which of the following is the best high dose treatment opton at this tme? A. Steroid and mycophenolate mofetl B. Steroid and hydroxychloroquine C. Steroid and methotrexate D. Steroid and cyclosporine

A. Steroid and mycophenolate mofetl

A 50-year-old man with actve rheumatoid arthrits presented to the clinic complaining of polyarthralgia and signifcant early morning stfness. His current treatments are methotrexate, prednisone and hydroxychioroquine. Examinaton revealed actve arthrits at several joints (see lab results). Test Result Normal Values Hb 160 130-170 g/L (Male) 120-160 q/L (Female) Platelets count 500 150-400 x 109/L WBC 10 4.5-10.5 x 109/L ESR 80 2-10 mm/h (Male) 3-15 mm/h (Female) Urea 5 2.75-7.4 mmol/L Creatnine 75 44-115 mol/L C-reactve peptde 18 <8.2 mg/L Rheumatoid factor 600 <58 kIU/L Aspartate aminotransferase 37 12-40 IU/L Alanine aminotransferase 35 5-40 IU/L Albumin 50 34-56 g/L Which of the following is the most appropriate additonal treatment opton? A. Azathloprine B. Adalimumab C. Cyclosporine D. Mycophenolate mofetl

B. Adalimumab

A 38-year-old man presented to the clinic complaining of recurrent painful swelling afectng right knee and lef ankle for 6-months despite using non-steroidal ant-infammatory drugs. His past history revealed urinary tract infecton 2-weeks prior to onset of his joint pain. On examinaton, he has actve arthrits at right knee and lef ankle (see lab results). Test Result Normal Values Hb 160 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 450 150-400 x 109/L WBC 12 4.5-10.5 x 109/L ESR 65 2-10 mm/h (Male) 3-15 mm/h (Female) Urea 4 2.75-7.4 mmol/L Creatnine 100 44-115 mol/1. C-reactve peptde 20 <8.2 mg/L Rheumatold factor 13 <58 kJU/L Color clear clear or light yellow Protein absent absent Nitrite absent absent Leukocytes 2 0-3 per high power feld Which of the following is the most appropriate treatment? A. Sulfasalazine B. Methotrexate C. Azithromycin D. Cyclosporine

A. Sulfasalazine

A 30-year-old woman with systemic lupus erythematosus is complaining of arthralgia and skin rash for 3 months. Examinaton revealed actve arthrits at two small joints of right hand and malar rash over her face (see lab results). Test Result Normal Values Hb 110 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 190 150-400 x 109/L WBC 6 4.5-10.5 x 109/L ESR 35 2-10 mm/h (Male) 3-15 mm/h (Female) Urea 5 2.75-7.4 mmol/L Creatnine 65 44-115 mol/L Which of the following advice should be presented to the patent about hydroxychloroquine? A. Interferes with mycophenolate mofetl B. Should be stopped during pregnancy C. Should be stopped during lactaton D. Efficacy is reduced by smoking

D. Efficacy is reduced by smoking

A 50-year-old woman presented to the clinic with polyarthralgia afectng distal and proximal interphalangeal joints bilaterally for 3-years. She does not have signifcant early morning stfness. Clinical examinaton revealed no actve arthrits but there was non-tender hard nodules over some distal interphalangeal (see lab results). Test Result Normal Values Hb 140 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 190 150-400 × 109/L WBC 11 4.5-10.5 x 109/L ESR 15 2-10 mm/h (Male) 3-15 mm/h (Female) C-reactve peptde 5 <8.2 mg/L Rheumatoid factor 30 <58 klU/L Urea 4 2.75-7.4 mmol/L Creatnine 75 44-115 mol/L Which of the following is the most likely rheumatological disease? A. Seronegatve rheumatoid arthrits B. Hand osteoarthrits C. Polyartcular gout D. Reactve arthrits

B. Hand osteoarthrits

A 53-year-old woman presented to the clinic with polyarthralgia afectng distal and proximal interphalangeal joints bilaterally for 3-years. She does not have signifcant early morning stfness. Clinical examinaton revealed no actve arthrits (see lab results). Test Result Normal Values Hb 140 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 200 150-400 × 109/L WBC 8 4.5-10.5 x 109/L ESR 12 2-10 mm/h (Male) 3-15 mm/h (Female) Urea 4 2.75-7.4 mmol/L Creatnine 75 44-115 umol/L C-reactve peptde 5 <8.2 mg/L Which of the following is the best management opton at this stage? A. Methotrexate therapy B. Surgical interventon C. Weight loss D. Finger splints

D. Finger splints

A 65-year-old man presented to the clinic with 3-year history of progressive worsening of bilateral knee pain and stfness that occurs at rest and at night. He has no history of trauma. Paracetamol and ibuprofen resulted in mild improvements of his joint pain. Upon examinaton, there is no warmth, erythema or efusion and there is no compromise in joints stability (see lab results). Blood pressure 140/90 mmHg Temperature 36.6 °C Weight 90 kg Height 160 cm Test Result Normal Values Hb 125 130-170 g/L. (Male) 120-160 g/L (Female) Platelets count 300 150-400 × 109/L WBC 9 4.5-10.5 x 109/L ESR 15 2-10 mm/h (Male) 3-15 mm/h (Female) Blood urea nitrogen 9 2.8 to 8.9 mmol/L Creatnine 115 44-115 mol/L C-reactve peptde 6 <8.2 mg/L Which of the following is the most appropriate next investgaton? A. MRI of knee joints B. Bone scintgraphy C. Ultrasonography for knee joints D. Standing plain radiography of knee joints

D. Standing plain radiography of knee joints

A 30-year-old man presented to the clinic with lef knee pain for one month. 3 months ago, he had an episode of right knee actve arthrits that was aspirated and then improved. Synovial fuid aspiraton showed leukocyte count 40,000/cu mm, and negatve cultures. Clinical examinaton revealed a swollen and tender lef knee only. He has not had rashes or eye symptoms. Knee radiographs are normal (see lab results). Test Result Normal Values Hb 140 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 450 150-400 x 109/L WBC 10 4.5-10.5 x 109/L ESR 55 2-10 mm/h (Male) 3-15 mm/h (Female) Urea 4 2.75-7.4 mmol/L Creatnine 85 44-115 mol/L C-reactve peptde 16 <8.2 mg/L Rheumatoid factor 35 <58 kIU/L Which of the following is the most appropriate inital treatment? A. Ibuprofen B. Methotrexate C. Infiximab D. Amoxicillin

A. Ibuprofen

A 23-year-old woman with systemic lupus erythematosus (SLE) presented to the clinic with a 3- month history of lower-extremity swelling and shortness of breath. She has not had chest pain, palpitatons, or fevers. On physical examinaton, she has jugular venous distenton and engorgement with inspiraton. Heart sounds are distant; a prominent early diastolic sound without gallops or murmurs is heard. Breath sounds are normal. Abdominal examinaton reveals shifing dullness. Pitng edema to the level of the knees is noted (see lab results). Blood pressure 110/70 mmHg Heart rate 95 /min Respiratory rate 25 /min Temperature 36.6 °C Oxygen saturaton 90 % Test Result Normal Values Hb 90 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 450 150-400 x 109/L WBC 3 4.5-10.5 x 109/L Creatnine 150 44-115 mol/L Albumin 28 34-56 g/L Complement C3 0.5 0.7-1.5 g/. Complement C4 0.1 0.15-0,45 g/L. Aspartate aminotransferase 100 12-40 IU/L Alanine aminotransferase 94 5-40 IU/L Which of the following SLE associaton most likely explains the current conditon? A. Constrictive pericardits B. Myocardial infarcton C. Liver failure D. Renal failure

A. Constrictive pericardits

A 30-year-old woman with systemic lupus erythematosus presented to Emergency Department with seizures and fatgue for 2-days. No history of fever or skin rash. Musculoskeletal and neurologic examinatons are normal. She has negatve septc workup. Brain MRI revealed multple hyperintense lesions (see lab results). Blood pressure 120/70 mmg Temperature 37.2 °C Oxygen saturaton 95 % Test Result Normal Values Hb 110 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 200 150-400 x 109/L WBC 6 4.5-10.5 x 109/L ESR 35 2-10 mm/h (Male) 3-15 mm/h (Female) APTT 30 30-40 sec INR 1 0.8-1.2 Lupus antcoagulant negatve negatve Urea 6 2.75-7.4 mmol/L Creatnine 100 44-115 mol/L Pressure 300 200-250 mmH20 (Male) 300-400 mmH2O (Female) Cells 20 0-3 /pL Total protein (Women) 0.65 0. 15-0.45 g/L Ant SS antbodies 35 negatve Complement C3 0.5 0.7-1.5 g/L. Complement C4 0.1 0.15-0.45 g/L. Which of the following is the most appropriate treatment in additon to cortcosteroids? A. Cyclophosphamide B. Azathioprine C. Phenytoin D. Heparin

A. Cyclophosphamide

A 50-year-old man presented to the clinic with a 15-year history of multple joints pain with daily signifcant moming stfness that lasts for 3 hours. He has been admited 3 tmes during the last year to the local hospital for treatment of bacterial pneumonia. Physical examinaton reveals multple rheumatoid nodules and an enlarged spleen. He has actve arthrits afectng multple metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints symmetrically. Hands x- ray show severe erosive disease of the MCP and PIP joints. Bone marrow aspiraton and biopsy reveals an excess of immature forms and maturaton arrest with normal diferental (see lab results). Test Result Normal Values Hb 90 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 100 150-400 x 109/L WBC 2 4.5-10.5 x 109/L ESR 80 2-10 mm/h (Male) 3-15 mm/h (Female) Rheumatoid factor 400 <58 klU/L Which of the following is the most likely diagnosis? A. Systemic lupus erythematosus B. Feltys syndrome C. Lymphoma D. Tuberculosis

B. Feltys syndrome

A 40-year-old man presented to Emergency Department with fever and painful swelling in the lef knee for 2 days. 2 weeks ago, he had watery, non-bloody diarrhea and abdominal pain for 5- days afer eatng from a restaurant. On physical examinaton, lef knee is warm and tender, with a moderate efusion. The right wrist is mildly swollen and tender. The lef achilles tendon is mildly tender and swollen at its inserton into the calcaneus. Blood, stool and synovial cultures are negatve. However, testng for Clostridium difcile toxin is positve (see lab results). Blood pressure 140/90 mmHg Heart rate 76 /min Temperature 38.5 °C Test Result Normal Values ESR 75 2-10 mm/h (Male) 3-15 mm/h (Female) WBC 18 4.5-10.5 x 109/L. Creatnine 110 44-115 mol/L Uric acid 260 200-410 mol/L (Male) 140-360 mol/L (Female) C-reactve peptde 20 <8.2 mg/L Rheumatoid factor 35 <58 klU/L Which of the following is the most likely arthrits? A. Septic B. Gonococcal C. Reactive D. Peripheral associated with infammatory bowel disease

C. Reactive

A 32-year-old woman smoker presented to the clinic with 6-months history of polyarthraigia, malar rash and fatgue. Examinaton revealed actve malar rash over her face and lower limb pitng edema up to the knees. She has positve antnuclear antbody with high tter (1:1280). She is started on hydroxychloroquine and mycophenolate mofetl (see lab results). Test Result Normal Values Hb 110 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 200 150-400 x 109/L WBC 3.5 4.5-10.5 x 109/L ESR 45 2-10 mm/h (Male) 3-15 mm/h (Female) Urea 5 2.75-7.4 mmol/L Creatnine 75 44-115 mol/L 24 hr urine protein 750 0.8-14 mg/di (Male) 2.5-11 mg/dl (Female) Complement C3 0.4 0.7-1.5 g/L Complement C4 0.1 0.15-0.45 g/L Which of the following non-pharmacological interventon would be most important at this tme? A. Weight loss B. Smoking cessation C. Low protein diet D. Reduce physical actvites

B. Smoking cessation

A 27-year-old man with systemic lupus erythematosus (SLE) is seen in the clinic because of worsening fatgue and exertonal shortness of breath. He has had no fevers, arthrits, ulcers, rash, chest pain or palpitatons. His current treatments are hydroxychloroquine and mycophenolate mofetl. Systemic examinaton is unremarkable (see lab results). Blood pressure 130/70 mmHg Respiratory rate 18 /min Temperature 37.3 °C Test Result Normal Values Hb 78 130-170 g/L (Male) 120-160 g/L (Female) Retculocyte 7 0.2-1.2 % Platelets count 300 150-400 x 109/L WBC 6 4.5-10.5 x 109/L Creatnine 85 44-115 mol/L Haptoglobin 0.2 0.9-1.4 g/L Iron 11 11.7-31.8 molL (Male) 9-30.4 umol/L (Female) Ferritn 500 20-300 g/L. (Male) 20-120 pg/L (Female) Lactate dehydrogenase 1200 60-160 IU/L Which of the following anemias is most likely associated with SLE at this stage? A. Anaemia of chronic disease B. Iron defciency C. Hemolytic D. Pernicious

C. Hemolytic

A 55-year-old man with rheumatoid arthrits for 6-years on methotrexate 15 mg weekly and prednisone 5 mg daily presented to the Emergency Department with a 2-day history of lef knee pain and swelling. On examinaton, lef knee is swollen, red, warm and tender. Lef knee aspiraton revealed high white blood cells 35000 cells/mm and the culture is pending (see lab results). Blood pressure 105/70 mmHg Heart rate 96 /min Temperature 39 °C Oxygen saturaton 97 % Test Result Normal Values Hb 125 130-170 g/I (Male) 120-160 g/L (Female) Platelets count 450 150-400 x 109/L WBC 18 4.5-10.5 x 109/L ESR 80 2-10 mm/h (Male) 3-15 mm/h (Female) C-reactve peptde 28 <8.2 mg/L Rheumatoid factor 600 <58 klU/L Which of the following is the most appropriate immediate management? A. Intravenous antibiotics B. Intravenous high dose steroids C. Intra-artcular steroid injecton D. Oral non-steroidal ant-infammatory drugs

A. Intravenous antibiotics

A 65-year-old-woman presented to the clinic with a 5-day history of pain and swelling in the lef knee. Her pain aggravated by walking and relieved by rest. No history of small joints involvement or signifcant morning stfness. On examinaton, lef knee is swollen but not warm or erythematous. Lef knee X-ray shows osteophytes and joint space narrowing. Joint aspiraton reveals 280 leukocytes/mm (see lab results). Blood pressure 140/80 mmHg Temperature 36.6 °C BMI 35 kg/m2 Test Result Normal Values Hb 125 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 300 150-400 x 109/L WBC 11.5 4.5-10.5 x 109/L ESR 8 2-10 mm/h (Male) 3-15 mm/h (Female) Which of the following is the most likely arthrits? A. Osteoarthritis B. Rheumatoid C. Gouty D. Septic

A. Osteoarthritis

A 35-year-old man with rheumatoid arthrits for 6 months on methotrexate 20 mg weekly and ibuprofen daily presented to the clinic with increasing joint pain in both hands and feet associated with morning stfness for 2-hours. On examinaton, he shows signs of actve arthrits at both wrists. Hand X-rays show erosions at multple joints (see lab results). Test Result Normal Values Hb 120 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 450 150-400 x 109/L WBC 8 4.5-10.5 x 109/L ESR 60 2-10 mm/h (Male) 3-15 mm/h (Female) C-reactve peptde 18 <8.2 mg/L Rheumatoid factor 500 <58 klU/L Which of the following is the most appropriate additonal treatment? A. Adalimumab B. Azathioprine C. Cyclophosphamide D. Hydroxychloroquine

A. Adalimumab

A 28-year-old woman presented to the clinic with 2-month history of pain and swelling in the hand joints with morning stfness for 2-hours. She is 3-months postpartum, and taking care of her infant. On examinaton, she has actve arthrits at second and fourth proximal and metacarpophalangeal joints and both wrists (see lab results). Test Result Normal Values Hb 120 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 450 150-400 x 109/L WBC 6 4.5-10.5 x 109/L ESR 70 2-10 mm/h (Male) 3-15 mm/h (Female) C-reactve peptde 18 <8.2 mg/L Which of the following is the most likely diagnosis? A. Viral arthritis B. Reactive arthritis C. Polyartcular gout D. Rheumatoid arthritis

D. Rheumatoid arthritis

A 75-year-old man presented to the clinic with a 5-year history of right knee pain that worsens with walking and is relieved with rest. Paracetamol 1 gm 3 tmes a day resulted in mild improvements. He also has hypertension, diabetes mellitus and chronic kidney diseases. On examinaton, his right knee is mildly swollen but not tender or warm with signifcant limitaton of his fexion movements. Right knee radiography shows osteophytes and signifcant joint space narrowing (see lab results). Test Result Normal Values ESR 8 2-10 mm/h (Male) 3-15 mm/h (Female) Urea 8.5 2.75-7.4 mmol/L Creatnine 190 44-115 mol/L Which of the following is the most appropriate treatment? A. Celecoxib B. Ibuprofen C. Tramadol D. Prednisone

C. Tramadol

A 30-year-old woman presented to the clinic with 4-month history of muitple joint pain and morning stfness for 2-hours. On examinaton, she has actve arthrits at multple small joints of both hands and feet. Hands radiography show erosions at several small joints of both hands (see lab results). Test Result Normal Values Hb 110 130-170 g/L. (Male) 120-160 g/L (Female) Platelets count 450 150-400 x 109/L WBC 10 4.5-10.5 x 109/L ESR 65 2-10 mm/h (Male) 3-15 mm/h (Female) Urea 4 2.75-7.4 mmol/L Creatnine 67 44-115 mol/L C-reactve peptde 25 <8.2 mg/L Rheumatoid factor 450 <58 klU/L Which of the following is the most appropriate management? A. Prednisone 60 mg daily B. Hydroxychloroquine 400 mg daily C. Indomethacin, 25 mg three tmes daily D. Hydroxychloroquine 400 mg daily and methotrexate 15 mg weekly

D. Hydroxychloroquine 400 mg daily and methotrexate 15 mg weekly

A 28-year-old man with systemic lupus erythematosus presented to the clinic with a 1-month history of joint pain and moring stfness. He has no current history of skin rash or other systemic features. His current treatment consists of hydroxychloroquine 400 mg daily. On examinaton, he has actve arthrits at both wrist joints and second proximal interphalengeal joint of both hands (see lab results). Test Result Normal Values Hb 125 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 220 150-400 x 109/L WBC 5 4.5-10.5 x 109/L ESR 55 2-10 mm/h (Male) 3-15 mm/h (Female) Urea 4.5 2.75-7.4 mmol/L Creatnine 78 44-115 mol/L C-reactve peptde 12 <8.2 mg/L Complement C3 0.9 0.7-1.5 g/L Complement C4 0.1 0.15-0.45 g/L Which of the following agents should be added to control the arthrits? A. Methotrexate B. Sulfasalazine C. Azathioprine D. Cyclosporine

A. Methotrexate

A 67-year-old man comes to the clinic complaining that he has a tremor in the right hand. It is best displayed when he reaches for a pen and is manifested easily in the fnger-to-nose test. In which of the following locatons is the lesion? A. Left basal ganglia B. Right cerebellum C. Left motor cortex D. Left cerebellum

B. Right cerebellum

A 72-year-old woman with Parkinson's disease, complaining of a very annoying tremor of the dominant right hand. She is not on any medicaton. She states that her tremor is the only feature that disturbs her functoning. Which of the medicatons would be most likely to improve her tremor? A. Procyclidine B. Amitriptyline C. Bromocriptne D. Carbidopa/levodopa

A. Procyclidine

A 69-year-old man comes to the clinic complaining of increasing fatgue and drowsiness and difculty to arouse. History reveals he was in a vacaton 2 weeks ago. Although he admits to taking several falls, he is unaware of any head injury. Neurological examinaton showed no lateralizing or focal fndings. Head and scalp examinatons are negatve for focal tenderness and deformity. Plain X-ray of the skull is negatve (see lab results). Test Result Normal Values RBC 5.1 4.7-6.1 x 1012/L (Male) 4.2-5.4 x 1012/L (Female) Hb 132 130-170 g/L (Male) 120-160 g/L (Female) HCT 0.40 0.42-0.52 (Male) 0.37-0.48 (Female) MCH 30 28-33 pg/cell MCHC 322 320-360 g/L MCV 88 80-95 f Retculocyte 0.9 0.2-1.2 % Platelets count 200 150-400 x 109/L WBC 5.5 4.5-10.5 x 109/L Neutrophils 50 40-60% Eosinophils 2 1-4 % Basophils 0.8 0.5-1 % Lymphocytes 32 20-40 % Monocytes 4.1 2-8 % Calcium 2.3 2.15-2.62 mmol/L Calcium ionized 1.2 1.1-1.3 mmol/L Magnesium 0.8 0.7-1.2 mol/L Thyroid-Stmulatng Hormone 4.4 0.4 - 5.0 p/mL Thyroxine (T4 free serum) 12 8.5 - 15.2 pmol/L Sodium 136 134-146 mmol/L Potassium 4.2 3.5-5.1 mmol/L Which of the following is the most likely diagnosis? A. Stroke B. Acute bacterial meningits C. Post-concussion syndrome D. Chronic sub-dural hematoma

D. Chronic sub-dural hematoma

A 73-year-old diabetc man presents with right-sided weakness. The weakness is equal in the right face, arm and leg. Sensaton, speech and comprehension are intact. Which of the following arteries is afected? A. Vertebral artery B. Mid-basilar artery C. Anterior cerebral artery D. Penetrating branch, middle cerebral artery

D. Penetrating branch, middle cerebral artery

A 70-year-old man complains of a sudden severe headache while bending down to pick up his keys this morning. He describes it as the worst headache he has ever had; he says it was like being hit on the back of the neck. Which of the following is the most likely diagnosis? A. Meningitis B. Cluster headache C. Tension headache D. Sub-arachnoid hemorrhage

D. Sub-arachnoid hemorrhage

A 48-year-old woman has a 2-year history of a slowly progressive bilateral tremor. The tremor interferes with her writng and eatng. She has recently noted head bobbing and a change in her voice. Which of the following would be an appropriate frst-line medicaton for her problem? A. Carbidopa/levodopa B. Alprazolam C. Propranolol D. Olanzapine

C. Propranolol

A 45-year-old man presents with a sudden onset of unilateral peripheral facial nerve weakness 1 hour ago. He has no medical illness and not on any medicaton. Which of the following is most likely to shorten his symptoms? A. Antviral therapy B. Thrombolytc therapy C. Corticosteroids therapy D. Hyperbaric oxygen therapy

C. Corticosteroids therapy

A 36-year-old woman presented with 2-year history of recurrent headaches. These headaches occur 3 to 4 tmes per month and last 12 to 24 hours. The headaches are usually located over the right or lef frontal sinuses. This partcular headache has lasted 2 days now, and she has some nausea associated with it. The patent has been using an over-the counter analgesic-decongestant combinaton without signifcant relief. Neurological examinaton is within normal limits. The optc fundi are normal, Blood pressure 110/70 mmHg Heart rate 76 /min Temperature 36.6 °C What is the appropriate next step to determine the etology of this headache? A. MRI scan of the brain B. CT scan of the paranasal sinuses C. Erythrocyte sedimentaton rate D. Careful history and physical examination

D. Careful history and physical examination

A 31-year-old man complains of persistent watery diarrhea and has notced some weight loss. He returned 5 weeks ago from Egypt. He submits a stool sample that came back negatve. Which of the following is the most likely diagnosis? A. Giardiasis B. Shigellosis C. Amoebiasis D. Ulceratve colits

A. Giardiasis

A 62-year-old woman presents with dysphagia. Her symptoms were frst notced a few months ago and have steadily worsened. Initally she had difculty swallowing solids but over recent weeks has also been having difculty swallowing liquids. She lost 5 Kg over 5 weeks. On examinaton, she looks thin and slightly pale. Which of the following is the most likely diagnosis? A. Achalasia B. Pharyngeal pouch C. Oesophageal cancer D. Gastro-oesophageal refux disease

C. Oesophageal cancer

A 24-year-old woman is diagnosed with celiac disease Which of the following foods should she avoid? A. Rice B. Barley C. Maize D. Potatoes

B. Barley

A 40-year-old woman brought to Emergency Room with severe colicky right upper quadrant pain. The pain started afer eatng fsh and chips for lunch. By the tme she is seen, an hour later, the pain has setled and she is otherwise asymptomatc. Clinical examinaton is unremarkable. Which of the following is the most likely cause of her symptoms? A. Acute cholecystts B. Gastroenterits C. Renal colic D. Biliary colic

D. Biliary colic

A 21-year-old woman presents with a 3-months history of upper abdominal pain. The discomfort and bloatng becomes worse by eatng. There is no diarrhea or constpaton and her appette is good. Clinical examinaton of her abdomen is normal. Helicobacter test is negatve and other blood tests are all normal, Which of the following is the most likely diagnosis? A. Irritable bowel syndrome B. Functional dyspepsia C. Celiac disease D. Crohn's disease

B. Functional dyspepsia

A 25-year-old woman presented with episodic abdominal pain and altered bowel habits that have been present intermitently for the past year. The pain is "crampy." and moderate to severe. Defecaton brings some relief, but she sometmes must pass several loose, watery stools before the pain resolves. She occasionally notes mucus in her stool and sometmes feels that evacuaton is incomplete even though she is unable to pass more stool. Her body weight is stable. Abdominal examinaton are normal. Which of the following is the most appropriate test to establish diagnosis? A. Helicobacter pylori test B. Celiac disease testing C. Thyroid functon test D. CT abdomen

B. Celiac disease testing

A 42-year-old man with no medical problems presents with a 2-day history of profuse bloody diarrhea, severe abdominal cramping and fever. He has recently returned from a week-long trip to Indonesia. His stool culture is positve for Campylobacter. Which of the following is the most appropriate treatment? A. Metronidazole B. Ciprofoxacin C. Azithromycin D. Amoxicillin

C. Azithromycin

A 34-year-old woman presents with a 4-week history of retrosternal burning pain. The pain is ofen worse following eatng. Her past medical history includes depression and she is on escitalopram 10 mg OD. Clinical examinaton is unremarkable. Which of the following is the most likely diagnosis? A. Pericardits B. Pneumothorax C. Myocardial infarcton D. Gastro-oesophageal reflux disease

D. Gastro-oesophageal reflux disease

A 38-year-old woman with a history of chronic abdominal pain and diarrhea develops tender red nodules on her shins. The fndings are most consistent with which of the following? A. Celiac disease B. Crohn's disease C. Divertcular disease D. Irritable bowel syndrome

B. Crohn's disease

A 38-year-old woman presented with a 7-weeks of frequent, loose and bloody bowel movements that associated with campy abdominal and rectal pain. She has family history of crohn's disease. Stool analysis is negatve (see lab results). Blood pressure 110/70 mmH, Heart rate 76 /min, Temperature 36.6 °C Test Result Normal Values RBC 9.2 4.7-6.1 × 1012/L (Male) 4.2-5.4 x 1012/L (Female) Hb 111 130-170 g/L (Male) 120-160 g/L (Female) HCT 0.41 0.42-0.52 (Male) 0.37-0.48 (Female) MCH 27 28-33 pg/cell MCHC 330 320-360 g/L MCV 77 80-95 f1 Platelets count 220 150-400 x 109/L C-reactve peptde 22 <8.2 mg/L Which of the following is the most appropriate next step in establishing diagnosis? A. Anorectal manometry B. Upper GI endoscopy C. Celiac disease testng D. Measurement of fecal calprotectn

B. Upper GI endoscopy

A 28-year-old man with 4-months history of non-specifc crampy abdominal pain and diarrhea alternate with constpaton that is not related to any specifc food. He has no history of food allergy. No history of weight loss. Blood pressure 110/70 mmH, Heart rate 76 /min, Temperature 36.6 °C, BMI 23 kg/m2 Which of the following is the most likely diagnosis? A. Irritable bowel syndrome B. Lactose intolerance C. Colonic cancer D. Crohn's disease

A. Irritable bowel syndrome

A 34-year-old man previously healthy brought a laboratory results for hepatts B virus from a private clinic (see lab results). Test Result HBAg Negatve HBeAg Negatve Ant- HBsAg Positve Ant-HBc IgG Negatve What is the clinical state the laboratory results indicate? A. Previous Hepatitis B infection B. Acute Hepatitis B infection C. Chronic Hepatitis B infection D. Previous hepatitis B immunization

D. Previous hepatitis B immunization

A 31-year-old woman presented to the Emergency Room with mild acute cholecystts. She was started on intravenous fuids and empiric antbiotcs. Which of the following is the most appropriate next step? A. Endoscopic retrograde cholangiopancreatography B. Laparoscopic cholecystectomy within 72 hours C. Cholecystectomy afer 3 months D. No more interventon needed

B. Laparoscopic cholecystectomy within 72 hours

A 34-year woman presented with recurrent biliary colic for 5 months. Liver functon test is within normal limits. Liver ultrasound shows cholelithiasis. Which of the following procedures is the most appropriate? A. Cholecystectomy B. Upper Gi endoscopy C. Gall bladder lithotripsy D. Endoscopic retrograde cholangiopancreatography

A. Cholecystectomy

A 29-year-old man presented with painless jaundice afer resoluton of upper respiratory tract viral infecton, otherwise he is asymptomatc. Clinical abdominal examinaton is unremarkable. Peripheral blood smear is normal (see lab results). Test Result Normal Values RBC 5.1 4.7-6.1 x 1012/L (Male) 4.2-5.4 x 1012/L. (Female) Hb 133 130-170 g/L. (Male) 120-160 g/L (Female) MCV 88 80-95 f Retculocyte 0.21 0.2-1.2 % Platelets count 220 150-400 x 109/L WBC 5.2 4.5-10.5 x 109/L Alkaline phosphatase 41 39-117 1U/L Alanine aminotransferase 12 5-40 IU/L Aspartate aminotransferase 20 12-40 IU/L Indirect bilirubin 18 3.2-12.1 mol/L Direct bilirubin 1.51 1.5-6.5 mol/L Total bilirubin 19.51 3.5-16.5 mol/L HCT 0.44 0.42-0.52 (Male) 0.37-0.48 (Female) Which of the following is the most likely cause of his jaundice? A. Hemolytic anemia B. Fatty liver disease C. Gilbert syndrome D. Common bile duct obstruction

C. Gilbert syndrome

A 39-year-old man with asymptomatc hereditary hemochromatosis presented to the clinic for a check-up (see lab results). Test Result Normal Values Alkaline phosphatase 42 39-117 IU/L Alanine aminotransferase 20 5-40 IU/L Aspartate aminotransferase 22 12-40 IU/L Ferritn 860 20-300 g/L (Male) 20-120 pg/L (Female) Which of the following is the most appropriate management? A. Give penicillamine B. Referral to upper GI endoscopy C. Repeat the serum ferritn afer 6 month D. Initiate regular therapeutic phlebotomy

D. Initiate regular therapeutic phlebotomy

A 52-year-old man develops sudden severe retrosternal chest pain that radiates to his back. Within minutes, he became unconscious. He is a heavy smoker and has history of hypertension. Blood pressure 85/56 mmHg Heart rate 92 /min. Which of the following is the most likely diagnosis? A. Vasovagal atacks B. Pulmonary embolism C. Tear in the aortc intma D. Acute myocardial infarcton

C. Tear in the aortc intma

A 23-year-old man is brought to the hospital afer an episode of collapse. He states that on a few occasions while playing football he has had some chest pain, breathlessness and felt as he was going to faint. Last night during training, he collapsed and blacked out for a few seconds. Clinical examinaton revealed a harsh ejecton systolic murmur with a palpable systolic thrill at the lef steal edge; and a prominent jerky carotd pulse. Which of the following is the most likely diagnosis? A. Hypertrophic obstructive cardiomyopathy B. Wolf-parkinson-white syndrome C. Brugada syndrome D. Long QT syndrome

A. Hypertrophic obstructive cardiomyopathy

A 68-year-old man is seen for a follow-up. He has longstanding breathlessness and symptoms of cardiac failure. The ECG confrmed a diagnosis of heart failure due to lef ventricular dysfuncton. His currently on enalopril 10 mg OD, simvastatn 40 mg OD, furosemide 40 mg OD and omeprazole 20 mg OD. Examinaton revealed that the chest is clear and heart sounds are normal. There is no peripheral edema. Blood pressure 125/83 mmHg, Heart rate 76 /min. Which of the following is the most appropriate next step in the management at this stage? A. Add in digoxin B. Add in losartan C. Add in bisoprolol D. No additonal medicaton indicated

C. Add in bisoprolol

A 78-year-old man diagnosed with heart failure due to lef ventricular dysfuncton. His currently on aspirin 75 mg OD, simvastatn 40 mg OD and furosemide 40 mg OD. On examinaton, heart sounds are normal, his chest is clear and there is no peripheral edema. Which of the following is the most appropriate drug therapy to initate at this stage? A. Digoxin B. Enalopril C. Hydralazine D. Spironolactone

B. Enalopril

A 55-year-old man presents with a 3-month history of exertonal chest pain. He has previous history of myocardial infarcton. Which of the following is modifable risk factors in the treatment of ischemic heart disease? A. Family history B. Smoking C. Gender D. BMI

B. Smoking

A 78-year-old woman presents with exertonal syncope. On clinical examinaton, she has a slow rising carotd pulse and a loud ejecton systolic murmur at the upper right sternal edge, radiatng to the carotds. Which of the following is the most likely cause of these fndings? A. Mitral stenosis B. Aortic stenosis C. Mitral valve prolapse D. Tricuspid regurgitaton

B. Aortic stenosis

A 43-year-old healthy man concerned about heart disease. Which of the following is the most important risk factor of ischemic heart disease? A. BMI of 31.2 kg/m2 B. Waist circumference of 103 cm C. Blood pressure of 132/82 mmHg D. 2 separate fasting plasma glucose of 8.2 and 8.3 mmol/L.

D. 2 separate fasting plasma glucose of 8.2 and 8.3 mmol/L.

A 72-year-old man presented with an episode of right-sided weakness that lasted 10 minutes and fully resolved and he is clinical stable. He has no other medical illness. On clinical examinaton, he is in atrial fbrillaton. Blood pressure 110/70 mmHg, Heart rate 95 /min, Temperature 36.6 °C. Which of the following is the most appropriate next step in the management? A. Aspirin B. Warfarin, INR range 3-4 C. Warfarin, INR range 2-3 D. No additonal drug treatment

C. Warfarin, INR range 2-3

A 58-year-old man comes to the clinic for a follow-up. He has been discharged afer an acute inferior myocardial infarcton. He is diabetc type 2, on metormin 1g BD, aspirin 75 mg. atorvastatn 10 mg OD and lisinopril 10 mg OD. Examinaton revealed bilateral basal crackles on auscultaton of the chest. Blood pressure 148/88 mmH, Heart rate 76 /min, BMI 24 kg/m2 Which of the following is the most appropriate medicaton to add to his regime? A. Bisoprolol B. Amlodipine C. Losartan D. Warfarin

A. Bisoprolol

A 61-year-old woman comes to the clinic complaining of palpitatons. She has also notced some weight loss over the last 2 months. On clinical examinaton, she has an irregularly irregular pulse and a fne tremor. Her ECG shows atrial fbrillaton. Which of the following is the next most appropriate investgaton to do? A. Carotid Ultrasound B. Thyroid function tests C. Exercise tolerance test D. 24 hours ECG monitoring

B. Thyroid function tests

A 66-year-old man comes for follow-up. He has shortness of breath on exercise, which have increased over the past few months. He became unable to walk more than 200-300 meters on the corridor and cannot climb the stairs easily. He has history of hypertension and currently on amlodipine 5 mg OD and indapamide 2.5 mg OD. On examinaton, he has bilateral basal crackles and mild pitng ankle edema (see lab results). Blood pressure 188/96 mmH Heart rate 79 /min Test Result Normal Values Hb 133 130-170 g/L (Male) 120-160 g/L (Female) Sodium 138 134-146 mmol/L Potassium 4.2 3.5-5.1 mmol/L Creatnine 133 44-115 mol/L Which of the following is the most appropriate next therapy? A. Spironolactone B. Furosemide C. Bisoprolol D. Lisinopril

D. Lisinopril

A 66-year-old man presents with a diastolic murmur best heard at the lef steal edge. On examinaton, the apex beat is displaced outwards. Which conditon typically presents with these fndings? A. Coarctation of the aorta B. Aortic regurgitation C. Mitral regurgitation D. Aortic stenosis

B. Aortic regurgitation

A 64-year-old man is diagnosed with persistent atrial fbrillaton. His past medical history includes hypertension and type 2 diabetes. He has no contraindicatons to any antthrombotc treatments. What antthrombotc treatment should be considered frst line for this patent? A. Aspirin and Clopidogrel B. Clopidogrel C. Warfarin D. Aspirin

C. Warfarin

A 77-year-old woman comes to the clinic for a check-up. She has an irregular pulse when the nurse checked her vitals. An ECG has confrmed persistent atrial fbrillaton .She is completely asymptomatc. She has a past medical history of migraine and asthma and on salbutamol PRN for asthma and PRN ibuprofen for her migraines. Other clinical examinaton is normal. Blood pressure 138/85 mmg, Heart rate 88 /min. What antthrombotc treatment should be considered frst line in this patent? A. Aspirin B. Clopidogrel C. Aspirin and dipyridamole D. Oral anticoagulation

D. Oral anticoagulation

A 63-year-old smoker man presents with pain in his lef leg, which is exacerbated by exercise and relieved by rest. Examinaton revealed weak pulses in the lef leg compared to the right. The ankle brachial pressure Index is 0.84. Which of the following is the most likely diagnosis? A. Peripheral arterial disease with critical ischemia B. Normal peripheral arterial disease C. Peripheral arterial disease D. Incompressible vessels

C. Peripheral arterial disease

A 62-year-old man presents with a 3-month history of epigastric pain afer eatng and intermitent heartburn between meals. He has lost weight but does not have any nausea or vomitng. He has not notced any change in bowel habit and has not passed any blood or melena stools. He has no past medical history. He quit smoking 2 years ago. What is the most appropriate management strategy? A. Routine ultrasound of the abdomen B. Urgent referral for upper Gl endoscopy C. An oral proton pump inhibitor for 4 weeks D. Blood testing for helicobacter pylori infection

B. Urgent referral for upper Gl endoscopy

A 29-year-old man is seen in the pre-employment clinic for routne exam, He is asymptomatc. Physical examinaton revealed a systolic murmur that heard at the apex. The murmur is augmented with sustained handgrip and reduced with Valsalva manoeuvre. Which of the following is the most likely cause for this murmur? A. Mitral regurgitation B. Aortic regurgitation C. Mitral stenosis D. Aortic stenosis

A. Mitral regurgitation

A 38-year-old man presents to the clinic complaining of severe epigastric pain that is worse afer eatng. He describes the pain as burning in nature with mild improvement with antacid therapy. Physical examinaton is unremarkable (see lab results). Test Result Normal Values Hb 120 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 450 150-400 x 109/L WBC 10 4.5-10.5 x 109/L Urea 8.5 2.75-7.4 mmol/L Creatnine 65 44-115 mol/L What is the most appropriate test to establish the diagnosis? A. CT scan of the abdomen B. upper endoscopy C. Barium swallow D. H. pylori antbody

B. upper endoscopy

A 29-year-old man who is smoker for 5 years had appendectomy 2 years ago. He came to the clinic to discuss with you his risk to develop Crohn's disease because his brother has Crohn's disease that difcult to be controlled. Which of the following increase the risk for the development of Crohn's disease? A. Being male B. Cigarette smoking C. No known risk factors D. History of appendectomy

B. Cigarette smoking

A 30-year-old woman presents to the Emergency Department with 2-days history of severe abdominal pain that radiated to the back, which is associated with nausea and vomitng. On examinaton, she has normal vital signs with tender epigastrium but without rebound (see lab results). Test Result Normal Values Platelets count 450 150-400 x 109/L WBC 14 4.5-10.5 x 109/L Alanine aminotransferase 80 5-40 IU/L Aspartate aminotransferase 65 12-40 IU/L Amylase 800 24-151 IU/L Lipase 750 0-160 IU/L HCT 49 0.42-0.52 (Male) 0.37-0.48 (Female) Which of the following predict a poor prognosis for this patent? A. Hematocrit > 44% B. Lipase > 500 IU/L C. Amylase > 600 IU/L D. Albumin > 3.5 g/di

A. Hematocrit > 44%

A 30-year-old man with 3 years history of intermitent abdominal pain, bloatng and diarrhoea is seen in the clinic. Which of the following complains is highly suggestve of irritable bowel syndrome? A. Diarrhea that alternate with Constipation B. Undiagnosed food partcles in the stool C. Blood streak mixed with stool D. Diarrhoea at night

A. Diarrhea that alternate with Constipation

A 35-year-old woman with rheumatoid arthrits who maintained on methotrexate 15 mg weekly. She is currently on remission. 4 months ago, her liver functon tests were normal but the most recent liver functon tests are shown (see lab results). Test Result Normal Values Aspartate aminotransferase 300 12-40 IU/L Alanine aminotransferase 280 5-40 IU/L Albumin 30 34-56 g/L What is the most appropriate acton to be done for her abnormal liver functon tests? A. Do ultrasound for the liver B. Start glucocortcoids C. Stop methotrexate D. Order liver biopsy

C. Stop methotrexate

A 55-year-old man with chronic hepatts C present to the clinic for regular follow-up. His examinaton reveals a palpable right upper quadrant mass. CT scan of his abdomen shows a large 6*6 cm mass in the right lobe of the liver. A mass biopsy confrms the diagnosis of hepatocellular carcinoma. What is the most appropriate management steps at this stage? A. Start chemotherapy B. Start radiotherapy C. Referral for palliatve medicine D. Referral for surgical resection

D. Referral for surgical resection

A 30-year-old asymptomatc woman presents to the clinic as pre-employment screening. Her examinatons are unremarkable. Her laboratory tests revealed, positve HbsAg, ant-HBc (IgG) and ant- HBe but negatve ant-HBs and HBeAg. Which of the following statements is the most accurate? A. She has acute hepatitis B B. She has chronic hepatitis B C. She has received hepatitis B vaccine D. She has been exposed to hepatitis B but now in recovery period

B. She has chronic hepatitis B

A 65-year-old man presents to the clinic with progressive exertonal shortness of breath that associated with syncope. His examinatons show a mid-systolic murmur at right upper sternal boarder that radiates to carotds. Chest x-ray shows cardiomegaly. ECG reveals lef ventricular hypertrophy. Which of the following is the most appropriate management? A. Start anthypertensive with tght control of his blood pressure B. Surgical valvular replacement C. Start vasodilators D. Start diuretcs

B. Surgical valvular replacement

A 28-year-old man presents to the Emergency Department with sudden onset of chest pain that reduced with sitng forward associated with shortness of breath class II. No history of fever. Examinatons reveal a normal heart sound with fricton rub. His cardiac enzymes are within normal range. ECG shows difuse ST segment elevaton. Blood pressure 130/70 mmH Heart rate 90 /min Respiratory rate 24 /min Temperature 37.9 °C Oxygen saturaton 95 % What is the most appropriate treatment for this patent? A. Start antbiotcs B. Start corticosteroids C. Start anticoagulation D. Start non steroid ant-infammatory drug

D. Start non steroid ant-infammatory drug

A 55-year-old man with congestve heart failure on multple treatments came to the clinic for follow up. The physician discussed with him the importance of compliance and the efect of the treatments on his life. Which of the following medicatons is associated with reduced mortality rate in congestve heart failure? A. Digoxin therapy B. Diuretc therapies C. antcoagulaton therapies D. Angiotensin-convertng enzyme (ACE) inhibitors

D. Angiotensin-convertng enzyme (ACE) inhibitors

A 50-year-old man presents to the clinic with chronic history of productve cough and shortness of breath. A diagnosis of chronic obstructve pulmonary disease (COPD) is suspected. Pulmonary functon test is ordered. Which of the following pulmonary functon tests is most likely to represent COPD? A. Increased total lung capacity (TLC), decreased vital capacity (VC), decreased FEV1/FVC ratio B. Increased total lung capacity (TLC), decreased vital capacity (VC), increased FEV1/FVC ratio C. Decreased total lung capacity (TLC), increased vital capacity (VC), decreased FEV1/FVC ratio D. Increased total lung capacity (TLC), normal vital capacity (VC), decreased FEV1/FVC rato.

A. Increased total lung capacity (TLC), decreased vital capacity (VC), decreased FEV1/FVC ratio

A 35-year-old-man presented to the Emergency Department with 5-day history of fever, shortness of breath and productve cough. Lung examinaton reveals duliness to percussion to approximately half of the lung feld on the right and his breath sounds are markedly diminished. Chest radiography, shows right lower and middle lobes consolidaton with moderate pleural efusion. Which of the following would indicate the need for tube thoracostomy? A. Pleural fuid glucose below 60 mg/di B. Pleural fuid PH more than 7.20 C. Pleural fuid with more than 90% polymorphonucleocytes (PMNs) D. Pleural fuid/ serum protein less than 0.4

A. Pleural fuid glucose below 60 mg/di

A 36-year-old man presents to Emergency Department with 5-day history of fever, productve cough and shortness of breath. On examinaton, he is febrile with temperature 38.5 C and his lung examinaton reveals dullness to percussion with markedly diminished breath sound over half of the lung feld on the right side. Chest radiography shows right lower and middle lobes consolidaton and moderate pleural efusion. Which of the following is the most appropriate management? A. Start azithromycin and cefriaxone B. Start azithromycin, cefriaxone and oseltamivir C. Start azithromycin, cefriaxone and do thoracocentesis D. Start azithromycin, cefriaxone and do CT scan of the chest

C. Start azithromycin, cefriaxone and do thoracocentesis

A 36-year-old man presents to Emergency Department with 4-week history of low-grade fever, non- productve cough and shortness of breath. On examinaton, he is febrile with temperature 37.9 °C and his lung examinaton reveals duliness to percussion with markedly diminished breath sound over half of the lung feld on the right side. A diagnosis of tuberculous pleural efusion is suspected. Chest radiography shows moderate pleural efusion (see lab results). Test Result Normal Values Leukocytes 4500 <1000/pL Total Protein 6 10-20 g/L Glucose 1.6 >2.2 mmol/L LDH 650 <200/UL Which of the following tests is the most sensitve to establish the diagnosis? A. Positive pleural fluid AB culture B. Exudative pleural fluid with lymphocytosis C. Pleural fuid with very low glucose concentraton D. Pleural fuid adenosine deaminase more than 45 IU/L

D. Pleural fuid adenosine deaminase more than 45 IU/L

A patent with a diagnosis of advanced chronic obstructve pulmonary disease (COPD) who is discussing with his doctor the therapeutc benefts of diferent therapies on his survival rate Which of the following therapies is most likely to improve his survival? A. Theophylline B. Corticosteroids C. Mucolytcs D. Oxygen

D. Oxygen

A 25-year-old man presents to the Emergency Department with progressive shortness of breath, non- productve cough and wheezes for 1 day. On examinatons, he has obvious difculty in breathing and his lungs show with difuse wheezes but no crackles. Blood pressure 120/70 mmHg, Heart rate 100 /min, Respiratory rate 28 /min, Temperature 36.6 °C, Oxygen saturaton 93 % Which of the following is the most efectve inital treatment at this tme? A. Epinephrine B. Inhaled steroids C. Inhaled B2 agonists D. Intravenous magnesium

C. Inhaled B2 agonists

A 25-year-old woman non-smoker presents to Emergency Department with sudden onset of severe chest pain and shortness of breath. Her past medical history is signifcant for caesarean secton 4 days ago. Her examinatons show a distressed woman with oxygen saturaton 92% but otherwise unremarkable. Chest radiography is unremarkable. Which of the following is the most appropriate management? A. Start warfarin B. Start thrombolytc drugs C. Start low molecular heparin D. Insert inferior vena caval flter

C. Start low molecular heparin

A 65-year-old man presents to the Emergency Department with exertonal syncope and progressive shortness of breath. Clinical examinaton reveals fne crackles at both lung bases and mid-systolic murmur at right upper sternal boarder that radiated to carotds. Chest radiography demonstrated clear evidence of pulmonary edema. Which of the following statements about the assessment and diagnosis is the most accurate? A. The murmur will be augmented by standing position B. The main treatment for symptomatic patient is diuretics C. Electrocardiogram (ECG) will show right bundle branch block (RBBB) D. Presence of symptoms of congestive heart failure are poor prognosis

D. Presence of symptoms of congestive heart failure are poor prognosis

A 38-year-old man who is smoker for several years presents to the clinic with progressive shortness of breath. Pulmonary functon test (PFT) done which results in the following parameters: forced expiratoy volume (FEV1/forced vital capacity (FVC) rato < 0.7 with minimal improvement afer bronchodilators low difusing capacity for carbon monoxide (DLCO). Which of the following is the most likely diagnosis? A. Emphysema B. Bronchial asthma C. Chronic bronchits D. Interstitial lung disease

A. Emphysema

A 48-year-old woman is seen in the clinic because of recurrent severe nocturnal chest pain for several months that rapidly resolved with sublingual nitrate. She had a normal cardiac catheterizaton and positve ergonovine echocardiography testng. She does not want to use multple medicatons and she accept to use only one drug as a long-term maintenance therapy. Which of the following drugs is the best strategy for long-term management of this patent? A. Lisinopril B. Carvedilol C. Nifedipine D. Aspirin

C. Nifedipine

A 28-year-old woman has 2-week history of jaundice and an 11-month history of progressive fatgue and arthralgia. She is not on any regular medicaton and does not drink alcohol. Her examinaton reveals hepatosplenomegaly. Viral hepatts screening tests are negatve (see lab results). Test Result Normal Values Hb 10 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 120 150-400 x 109/L WBC 7 4.5-10.5 x 109/L INR 1.5 0.8-1.2 Total bilirubin 26 3.5-16.5 mol/L Aspartate aminotransferase 920 12-40 IU/L Alanine aminotransferase 890 5-40 IU/L Alkaline phosphatase 160 39-117 1U/L Albumin 30 34-56 g/L Which of the following is the most likely diagnosis? A. Hepatocellular carcinoma B. Autoimmune hepatitis C. Primary biliary cirrhosis D. Acute cholangits

B. Autoimmune hepatitis

A 34-year-old man presents to the clinic with symptoms of gastrosophageal refux disease that not responding well to esomeprazole 20 mg once a day. Despite mild improvement in his symptoms, he contnues to wake up with an acid taste in the middle of the night. He has not had difculty swallowing. He confrms that he takes the medicaton properly. Physical examinaton is unremarkable. His laboratory investgaton are within normal range. Which of the following is the most appropriate management for this patent? A. Switch to pantoprazole B. Perform upper endoscopy C. Add amoxicillin and clarithromycin D. Increase the dose of esomeprazole

D. Increase the dose of esomeprazole

A 35-year-old nurse is seen in the clinic afer a recent routne screening for viral hepatts infecton. She was found to have positve antbody to hepatts C virus (HCV). Her medical history is unremarkable; she has not used illicit drugs or had any history of blood transfusions She currently feels well and takes no medicatons. Vital signs and physical examinaton are normal. Laboratory studies reveal a positve CV antbody test, but HCV RNA testng is negatve (see lab results). Test Result Normal Values Hb 120 130-170 q/L (Male) 120-160 g/L (Female) Platelets count 300 150-400 x 109/L WBC 8 4.5-10.5 x 109/L Aspartate aminotransferase 26 12-40 IU/L Alanine aminotransferase 30 5-40 IU/L Alkaline phosphatase 80 39-117 IU/L Gamma glutamy/transferase 25 6 to 37 IU/L Which of the following is the most appropriate acton to be done? A. No further testing B. Perform liver ultrasound C. Repeat HCV antibody testing D. Perform serial alanine aminotransferase monitoring

A. No further testing

A 40-year-old man is evaluated in the Emergency Department for several episodes of hematemesis. He has no previous similar episodes. His history is unremarkable. He takes no medicatons. There is no jaundice or other signs of chronic liver disease. Abdominal examinaton reveals no tenderness, guarding, or rebound (see lab results). Blood pressure 105/65 mmHg Heart rate 110 /min Temperature 36.8 °C Test Result Normal Values Hb 95 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 250 150-400 x 109/L WBC 12 4.5-10.5 x 109/L Prothrombin tme 11 10-13 sec Alanine aminotransferase 30 5-40 IU/L Alkaline phosphatase 26 39-117 IU/L Blood urea nitrogen 14 2.8 to 8.9 mmol/L Creatnine 88 44-115 mol/L Which of the following is the most likely cause of his gastrointestnal bleeding? A. Erosive gastrits B. Peptic ulcer disease C. Oesophageal varices D. Mallory-Weiss tear

B. Peptic ulcer disease

A 45-year-old man with a diagnosis of gastrosophageal refux disease who is taking a maximum dose of pantoprazole for several weeks presents to the clinic with heartburn that is minimally improved with treatment. The patent verifed that he is taking the medicaton 30 minutes before meals. He takes no other medicatons. His physical examinaton is unremarkable. Upper endoscopy fndings are normal. Which of the following is the most appropriate next step in the management? A. Repeat endoscopy B. Barium esophagogram C. Esophageal manometry D. Ambulatory pH impedance monitoring

D. Ambulatory pH impedance monitoring

A 50-year-old man presents to the Emergency Department with acute onset of abdominal pain, nausea and vomitng. Abdominal examinaton shows tenderness and guarding at the epigastrium. CT scan of the abdomen reveals fuid around the pancreas. He was admited and started on intravenous fuids; analgesics and nasogastric sucton (see lab results). Test Result Normal Values Hb 120 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 190 150-400 x 109/L WBC 18 4.5-10.5 x 109/L Aspartate aminotransferase 55 12-40 IU/L Alanine aminotransferase 65 5-40 IU/L Lactate dehydrogenase 6 1.4-3.56 mol/L Amylase 850 24-151 IU/L Lipase 900 0-160 IU/L Which of the following is the most appropriate next step in the management? A. Add imipenem B. Add pantoprazole C. Add methyiprednisolone D. Urgent surgical consultaton

A. Add imipenem

A 32-year-old man is evaluated for a 10-month history of fatgue and diarrhoea. He has a good appette but has unintentonally signifcant weight loss over the past 10 weeks. He has not had blood in the stool, melena, or other obvious source of blood loss. His systemic examinatons are unremarkable. Stool is negatve for occult blood (see lab results). Blood pressure 110/70 mmHg Heart rate 80 /min Respiratory rate 16 /min Temperature 36.6 °C BMI 18 kg/m2 Test Result Normal Values Hb 109 130-170 g/ (Male) 120-160 g/L (Female) MCH 20 28-33 pg/cell MCV 70 80-95 f1 Platelets count 455 150-400 x 109/L WBC 8 4.5-10.5 x 109/L Aspartate aminotransferase 30 12-40 IU/L Alanine aminotransferase 26 5-40 IU/L Albumin 32 34-56 g/L Total bilirubin 10 3.5-16.5 pmol/L Which of the following is the best treatment? A. Loperamide (ant-diarrhoea agent) B. Metronidazole (antbiotc drug) C. Mebendazole (ant-parasitc drug) D. Gluten-free diet

D. Gluten-free diet

A 55-year-old woman with a chronic obstructve pulmonary disease (COPD) on combinaton of long- actng B2-agonist and inhaled glucocortcoid and albuterol as needed presents to the clinic with worsening of her symptoms. On physical examinaton, there is no jugular venous distenton. Pulmonary examinaton reveals decreased breath sounds. Bilateral lower extremity edema is noted to a level above the ankles. Echocardiogram is normal apart of high mean pulmonary artery pressure, 52 mmH (see lab results). Blood pressure 125/75 mmH Heart rate 84 /min Respiratory rate 20 /min Temperature 36.6 °C Oxygen saturaton 86 % BMI 30 kg/m2 Test Result Normal Values ABG PCO2 7.5 4.7-6.0 kPa pH 7.6 7.36-7.45 ABG PO2 8.6 10.6-14.2 kPa Which of the following is the most appropriate treatment at this tme? A. Start mucolytcs B. Start oral diuretics C. Start oral prednisone D. Start oxygen therapy

D. Start oxygen therapy

A 66-year-old woman is evaluated for a 6-week history of increasing dyspnea and right-sided pleuritc chest pain with occasional cough. She has lost signifcant body weight in the last 3 months. She has no other medical problems and takes no medicatons. Her physical examinaton reveals dullness to percussion and decreased breath sounds over both lower lung zones. A 4-cm right breast mass is palpated. Chest radiograph demonstrates bilateral pleural efusions but no evidence of infltrate or pulmonary vascular congeston. Thoracentesis is performed. Pleural fuid Gram stain is negatve (see lab results). Test Result Normal Values Total Protein 40 10-20 g/L Fluid Protein/Serum Protein 0.67 <0.5 Glucose 3.5 >2.2 mmol/L LDH 350 <200/UL Total Proteins 60 60-84 g/L Lactate dehydrogenase 125 60-160 IU/L Leukocytes 3600 <1000/pL Which of the following is the most appropriate statement about the diagnosis? A. Exudative pleural effusion due to malignancy B. Transudatve pleural efusion due to malignancy C. Exudatve pleural efusion due to heart failure D. Transudatve pleural efusion due to empyema

A. Exudative pleural effusion due to malignancy

A 28-year-old woman with bronchial asthma that controlled on budesonide and albuterol inhalers is evaluated in the clinic as she is 6 weeks pregnant. Her symptoms are well controlled on the treatment. However, symptoms usually fare in fall and she treats these symptoms with an add-on oral leukotriene inhibitor. She currently has no asthma symptoms. On examinaton, vital signs are normal. The lungs show good air entry and no wheezes. She is so concern about the safety of medicatons during pregnancy. What is the best informaton to be delivered to her with regard to medicaton safety? A. Continue the current treatments as they are safe during pregnancy B. Stop budesonide and continue albuterol inhaler C. Stop albuterol and contnue budesonide inhaler D. Switch to as-needed albuterol therapy

A. Continue the current treatments as they are safe during pregnancy

A 26-year-old man presents to the clinic with shortness of breath and occasional wheeze that occurs several tmes per week. He develops signifcant shortness of breath when playing football. He notes that it takes several minutes to recover his breath when this occurs. He also notes coughing during exercise as well. He takes no medicatons. On physical examinaton, vital signs are normal. Mild nasal congeston is noted. His systemic examinatons are unremarkable. A chest radiograph is normal. Spirometry fndings are within normal parameters. Which of the following is the most appropriate next step in assessment? A. Repeat spirometry B. Clinical observaton C. Methacholine challenge test D. Helical (spiral) computed tomography (CT) for the chest

C. Methacholine challenge test

A 31-year-old woman is evaluated because of daily wheezing and breathlessness that limit her actvites several tmes a week. Medical history is otherwise unremarkable. She has never smoked. She is diagnosed with moderate persistent asthma. In additon to a short-actng 32-agonist, which of the following is the most appropriate treatment? A. Add a low-dose inhaled corticosteroid and long-acting B2-agonist B. Add a low-dose inhaled corticosteroid C. Add a leukotriene antagonist D. Add thiophylline

A. Add a low-dose inhaled corticosteroid and long-acting B2-agonist

A 66-year-old woman with severe COPD is admited with 4 days of dyspnoea and cough. She is alert, in moderate respiratory distress, and has an oxygen saturaton of 93% on 3 L/min supplemental oxygen. A chest radiography demonstrates no consolidaton. She receives intensive bronchodilator therapy and systemic steroids (see lab results). Test Result Normal Values ABG PCO2 8.8 4.7-6.0 kPa pH 7.28 7.36-7.45 ABG PO2 9.9 10.6-14.2 kPa Which of the following is the best next step in the management? A. Non-invasive ventilation B. Increase supplemental oxygen C. Decrease supplemental oxygen D. Intubaton and mechanical ventlaton

A. Non-invasive ventilation

A 58-year-old woman with acute onset shortness of breath and pleuritc chest pain. She is diagnosed with pulmonary embolism. Which of the following is an indicaton to do thrombophilia workup? A. Age above 55 years B. Being on oral contraceptive pills C. Has a history of connectve tssue disease D. Has negatve family history of thrombosis

B. Being on oral contraceptive pills

A 32-year-old man is evaluated in the clinic because of an abnormal chest computerised tomography (CT) scan that revealed a small lung lesion (7 mm) without any other abnormalites. He is non-smoker and he is asymptomatc. Physical examinaton shows no lymphadenopathy and normal lung examinatons (see lab results). Test Result Normal Values Hb 140 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 300 150-400 x 109/L WBC 8 4.5-10.5 x 109/L ESR 11 2-10 mm/h (Male) 3-15 mm/h (Female) Calcium 2.25 2.15-2.62 mol/L Which of the following is the most appropriate procedure to do next? A. Repeat CT scan within 3-6 months B. Pulmonary functon test C. Biopsy of this lesion D. PET scan

A. Repeat CT scan within 3-6 months

A 60-year-old man is evaluated in the clinic for cardiac risk assessment. He is asymptomatc and physically actve. He has never smoked. He has no chronic health issues and takes no medicatons. His physical examinatons are normal. Cardiovascular risk calculaton using the Pooled Cohort Equatons predicts a 6.5% risk of a myocardial infarcton in the next 10 years that indicate an intermediate risk of myocardial infarcton. Which of the following investgatons should be done next? A. Cardiac CT angiography B. Stress echocardiography C. High-sensitvity C-reactve protein D. Cardiac magnetc resonance (CMR) imaging

C. High-sensitvity C-reactve protein

A 58-year-old woman with hypertension and type 2 diabetes mellitus presents to the clinic for routne follow-up. She has no symptoms. Medicatons are hydrochlorothiazide, losartan, atorvastatn, and metormin. Cardiac examinaton shows a grade 2/6 diastolic murmur heard best over the apex. Peripheral pulses are normal. Electrocardiogram shows sinus rhythm with nonspecifc ST changes. Blood pressure 160/80 mmH Heart rate 78 /min Respiratory rate 18 /min Temperature 36.6 °C Oxygen saturaton 96 % Which of the following is the most appropriate test to perform next? A. Transthoracic echocardiography B. Cardiac CT angiography C. Transesophageal echocardiography D. No further testng

A. Transthoracic echocardiography

A 55-year-old woman presents to the clinic for her regular follow-up. 6 months ago, she presented to Emergency Department with palpitatons and dyspnea and diagnosed to have atrial fbrillaton. She is currently asymptomatc with no palpitatons. Her medical history is also signifcant for a transient ischemic atack and hypertension. Her medicatons are warfarin, metoprolol and candesartan, Her physical examinaton is unremarkable. Her most recent electrocardiogram shows normal sinus rhythm. which of the following is the most appropriate management? A. Continue warfarin B. Discontnue warfarin C. Continue warfarin and start aspirin D. Discontinue warfarin and start clopidogrel

A. Continue warfarin

A 68-year-old man presented to the Emergency Department with progressive exertonal dyspnoea, orthopnea and dry cough for 7 days. His medical history is signifcant for hypertension. Physical examinaton reveals raised central venous pressure, fne crackles at lung bases and hepatomegaly. His extremity examinaton reveals bilateral pitng edema. Echocardiogram shows a lef ventricular ejecton fracton of 60% and normal valves. Chest radiograph shows evidence of pulmonary edema (see lab results). Blood pressure 160/85 mmHg Heart rate 86 /min Respiratory rate 18 /min Test Result Normal Values Sodium 140 134-146 mmol/L Potassium 4 3.5-5.1 mmol/L Urea 6 2.75-7.4 mmol/L Creatnine 88 44-115 mol/L Brain natriuretc peptde 900 0-300 ng/L Which of the following is the most appropriate next step in the management? A. Start calcium channel blocker agent B. Start B-Blocker agent C. Start spironolactone D. Start furosemide

D. Start furosemide