51-100

Question 1

A 38-year-old woman has fever and headache for 2 days. Peripheral smear done (see image and lab results). Heart rate 110 /min Temperature 38.9 °C Test Result Normal Values Hb 112 130-170 g/L (Male) 120-160 g/L (Female) Retculocyte 3.2 0.2-1.2 % Platelets count 123 150-400 x 109/L Fibrinogen 1.1 2-4 g/L APTT 68 30-40 sec INR 1.8 0.8-1.2 Prothrombin tme 24 10-13 sec Direct bilirubin 24.5 1.5-6.5 mol/L Total bilirubin 48.3 3.5-16.5 mol/L Lactate dehydrogenase 390 60-160 IU/L Which of the following is the most likely diagnosis?
A. Immune thrombocytopenia (ITP)
B. Heparin induced thrombocytopenia (HIT)
C. Thrombotc thrombocytopenic purpura (TTP)
D. Disseminated intravascular coagulopathy (DIC)

Answer 1

D. Disseminated intravascular coagulopathy (DIC)

Question 2

A 62-year-old woman has atrial fbrillaton for which she has started on warfarin. Few weeks afer, she fell down and developed a subdural hematoma that requires evacuaton (see lab result). Test Result Normal Values INR 3.9 0.8-1.2 Which of the following is the most appropriate management?
A. Vitamin K
B. Fresh frozen plasma
C. Actvated factor VII (fviia)
D. Fresh frozen plasma and vitamin K

Answer 2

D. Fresh frozen plasma and vitamin K

Question 3

An 18-year-old-boy is receiving chemotherapy for acute lymphoblastc leukemia. On day 17 of chemotherapy, he has fever. He has no focus of infecton (see lab results). Heart rate 110 /min, Temperature 38.9 °C, Test Result Normal Values Platelets count 25 150-400 x 109/L WBC 0.6 4.5-10.5 x 109/L Neutrophils 60 40-60% Lymphocytes 20 20-40 % Which of the following is the most appropriate management?
A. Send blood, urine, sputum cultures
B. Send blood, urine, sputum cultures and start paracetamol
C. Send blood, urine, sputum cultures and start oral broad spectrum antbiotcs
D. Send blood, urine, sputum cultures and start intravenous broad spectrum antbiotcs

Answer 3

D. Send blood, urine, sputum cultures and start intravenous broad spectrum antbiotcs

Question 4

A 43-year-old-woman has fever, night sweats and weight loss. She has lost 12 Kg in the last 3 month (unintentonal). She had no contact with a tuberculosis patent. On examinaton, she has bilateral cervical lymph nodes, largest 3 cm X2 cm. There is also inguinal lymphadenopathy and the spleen is palpable 3 fngers below the costal margin. Which of the following is the most appropriate next step in management?
A. Fine needle aspiraton of the lymph node
B. Excisional biopsy of the lymph node
C. Bone marrow biopsy
D. Splenectomy

Answer 4

B. Excisional biopsy of the lymph node

Question 5

A 63-year-old man has chronic lymphocytc leukemia started on chemotherapy. His inital lymphocyte count was 73,000. 2 days afer chemotherapy, he presents with fatgue and dry mouth (see lab results). Test Result Normal Values WBC 5.7 4.5-10.5 x 109/L Lymphocytes 60 20-40 % Potassium 5.5 3.5-5.1 mmol/L Phosphate, inorganic 1.48 0.82-1.51 mmol/L Creatnine 139 44-115 mol/L Uric acid 620 200-410 umol/L (Male) 140-360 mol/L (Female) Which of the following electrolyte abnormality is associated with the above conditon?
A. Hypocalcimia
B. Hypercalcimia
C. Hyponatremia
D. Hypernatremia

Answer 5

A. Hypocalcimia

Question 6

A 65-year-old man presented with 6-month symptoms of Parkinsonism, early dementa. fuctuatons in cogniton and visual hallucinatons. Which of the following is the most likely diagnosis?
A. Parkinson disease
B. Alzheimer disease
C. Cortcobasal syndrome
D. Dementia with Lewy bodies

Answer 6

D. Dementia with Lewy bodies

Question 7

A 65-year-old man presented with 6-month symptoms of Parkinsonism, early dementa. fuctuatons in cogniton and visual hallucinatons. Which of the following is the most likely diagnosis?
A. Parkinson disease
B. Alzheimer disease
C. Cortcobasal syndrome
D. Dementia with Lewy bodies

Answer 7

D. Dementia with Lewy bodies

Question 8

An 81-year-old man with memory loss and difculty recognizing his grandsons. He has no cardiovascular risk factors. Which of the following is the most common cause of his cognitve impairment?
A. Alcohol-induced encephalopathy
B. Parkinson’s associated dementa
C. Mult-infarct dementa
D. Alzheimer’s disease

Answer 8

D. Alzheimer’s disease

Question 9

A 65-year-old man who is asymptomatc and has no known allergies is seen for a general examinaton. What is the best approach for pneumococcus immunizaton?
A. PPSV23
B. PCV13 followed by PPSV23
C. PPSV23 followed by PCV13
D. No evidence supports vaccinatng this patent

Answer 9

B. PCV13 followed by PPSV23

Question 10

A 64-year-old man presents to the clinic afer having frst episode of right knee pain for 2 weeks duraton. He asks for a medicine to relieve his pain. He does not have any other symptoms apart from epigastric burning. He has no history of injury to the knee. Examinaton of knee is normal. Which is the most appropriate analgesic for this patent at this stage?
A. Aspirin
B. Codeine
C. Ibuprofen
D. Paracetamol

Answer 10

D. Paracetamol

Question 11

An 82-year-old woman at long term nursing facility who wears hearing aids and is found to have bilateral cerumen impacton, a Weber test that lateralizes to the right. and a bilaterally positve Rinne test. Which of the following is the most likely explanation?
A. Right-sided acoustc neuroma
B. Prebycusis that is greater on the right
C. Conductve hearing loss that is greater on the right
D. Chronic serous otts media that is greater on the lef

Answer 11

B. Prebycusis that is greater on the right

Question 12

A 91-year-old man with poor performance status, dementa, and multple medical problems who has been diagnosed with an adenocarcinoma of an unknown primary site and has upper abdominal lymphadenopathy, liver lesions, and pulmonary nodules. Which of the following is the most appropriate management?
A. Exploratory laparotomy with biliary bypass procedure
B. Excisional biopsy to identfy the primary site
C. Palliatve systematc chemotherapy
D. Comfort care

Answer 12

D. Comfort care

Question 13

A 79-year-old man comes to the clinic for a follow-up. He has a 1-year history of progressive memory impairment and clinical evidence of early Alzheimer dementa. Which of the following is the most appropriate inital diagnostc tests?
A. Brain imaging
B. Lumbar puncture
C. Carotd ultrasound
D. Electroencephalogram

Answer 13

A. Brain imaging

Question 14

An 81-year-old woman reports low back pain that began afer a forceful coughing episode. Lumbar radiographs reveal features of a lumbar compression fracture. Which of the following is the most appropriate inital step in her care?
A. Prescribe nasal calcitonin
B. Prescribe acetaminophen
C. Admit for vertebroplasty
D. Infuse zoledronate

Answer 14

B. Prescribe acetaminophen

Question 15

A 77-year-old woman with stage 3 chronic kidney disease and pain from osteoarthrits of the frst carpometacarpal joint. Which of the following is the best inital treatment for her pain?
A. Tendon-release surgery
B. Splintng and occupatonal therapy
C. Ibuprofen 800mg 3 tmes daily with food
D. Glucocortcoid injecton into the frst carpometacarpal joint

Answer 15

B. Splintng and occupatonal therapy

Question 16

Which of the following physical maneuvers is most likely to assist the risk of future falls for a healthy 68-year-old man?
A. Test for nystagmus
B. Get-up-and-go test
C. Test for pulsus paradoxus
D. Lumbar spine fexibility test

Answer 16

B. Get-up-and-go test

Question 17

A 76-year-old man with chronic obstructve pulmonary disease (COPD) comes to the clinic for a follow-up. He is currently taking salmeterol, using albuterol rescue inhaler 2 to 3 tmes per day for the past 3 months. He has been hospitalized for COPD exacerbatons twice in the past 6 months. Which of the following medicatons should be added to the maintenance regimen?
A. Montelukast
B. Prednisone
C. Tiotropium
D. Formoterol

Answer 17

C. Tiotropium

Question 18

A 78-year-old man was admited to hospital with lethargy and back pain. He had a history of type 2 diabetes mellitus and rheumatoid arthrits (see lab results). Test Result Normal Values Calcium 2.72 2.15-2.62 mol/L Creatnine 196 44-115 mol/L Urinary protein: creatnine rato 154 mg/mmol (<30) Which of the following is most likely diagnosis?
A. Primary hyperparathyroidism
B. Membranous nephropathy
C. Diabetc nephropathy
D. Primary amyloidosis

Answer 18

C. Diabetc nephropathy

Question 19

A 75-year-old man with difculty walking and lef-sided leg weaknesses due to osteoarthrits of the hip. In which hand should a cane be used by this patent?
A. Lef hand
B. Right hand
C. Either hand
D. Both hands simultaneously

Answer 19

B. Right hand

Question 20

A 71-year-old man is referred to the Outpatent Clinic for advice on his anthypertensive treatment. He has a history of stroke and longstanding uncontrolled hypertension. 6 blood pressure recordings at home and at his surgery within the past 2 weeks were 188-216/03-112 mmg. His therapy comprised ramipril, atenolol, and amlodipine (see lab results). Test Result Normal Values
Sodium 138 134-146 mmol/L Potassium 2.9 3.5-5.1 mmol/L Urea 8 2.75-7.4 mmol/L Creatnine 88 44-115 mol/L Which of the following is most likely contributng to the treatment failure?
A. Antacids
B. NSAIDs
C. Table salt
D. Pseudoephedrine

Answer 20

B. NSAIDs

Question 21

A 75-year-old man comes to the clinic with hypertension and gradual loss of cognitve functon. He has predominant executve functon impairment (see report). MRI: Reveals difuse periventricular white-mater hyperintensites Which of the following is most likely diagnosis?
A. Alzheimer disease
B. Dementa with Lewy bodies
C. Vascular cognitve impairment
D. Normal pressure hydrocephalus

Answer 21

C. Vascular cognitve impairment

Question 22

A 77-year-old man with a 7-years history of Parkinson disease reports hallucinatons, confusion and worsening motor functon. On physical examinaton, he is kinetc and rigid with no tremor. He has prominent gait disorder and postural instability. Which of the following symptoms is most strongly associated with an increased risk for dementa?
A. Increase irritability
B. Word-fnding difculty
C. Trouble recalling appointment times
D. Difculty reading an artcle in a single sitng

Answer 22

C. Trouble recalling appointment times

Question 23

A son of 78-year-old patent brought a medical report of his father cognitve functon status statng that he has” mild cognitve impairment’. Which of the following is indicatng mild cognitve impairment?
A. Low mood for 2 weeks
B. Localized motor dysfuncton
C. Objective evidence of memory decline
D. Impairment in at least 1 actvity of daily living

Answer 23

C. Objective evidence of memory decline

Question 24

A 78-year-old man presents with a 10-day history of intermitent colicky abdominal pain. The pain is low, central and seems to be worse afer eatng. He has no associated fever or vomitng but does feel nauseated when the pain is present. He says that prior to this episode he had hard stools once or twice a week that were difcult to pass. For the past several days, he has had only watery stools, several tmes a day. On examinaton, there is fullness in his lef lower quadrant with nonspecifc tenderness difusely and no guarding or rebound. A urine dipstck is normal. Which of the following is the most likely diagnosis?
A. Acute colits
B. Constipation
C. Ureteric stone
D. Urinary tract infecton

Answer 24

B. Constipation

Question 25

Which of the following is the best exercise to improve the functon of a 68-year-old woman?
A. Walking
B. Swimming
C. Resistance training
D. Statonary bicycling

Answer 25

C. Resistance training

Question 26

A 72-year-old man complains of difculty in getng up from the chair for the last 3 months. History reveals he has controlled type 2 diabetes and long standing hypertension. Which of the following is the most leading type of injury in this patent?
A. Road trafc accidents
B. Fire-related injuries
C. Gunshot wounds
D. Falls

Answer 26

D. Falls

Question 27

A 48-year-old man presents with central and severe chest pain, which started around 1 hour ago. There is no radiaton of the pain or associated shortness-of-breath. He has had some similar feetng pains over the past 2 weeks but these setled spontaneously afer a few seconds. Which of the following is the most likely diagnosis?
A. Gastro-oesophageal refux disease
B. Myocardial Infarcton
C. Pneumothorax
D. Anxiety

Answer 27

B. Myocardial Infarcton

Question 28

A 64-year-old man, who has hypertension, presents with increasing shortness of breath. His symptoms are worse at night. On examinaton, there is bilateral basal crackles and a third heart sound (S3). Which of the following is the most likely diagnosis?
A. Heart failure
B. Bronchial asthma
C. Pulmonary fbrosis
D. Obstructve sleep apnea

Answer 28

A. Heart failure

Question 29

A 39-year-old man presents with shortness of breath for 2 weeks. The symptoms associated with actvity and relieved by rest. He is otherwise healthy, takes no medicatons and denies chest pain or pressure. Which of the following is the most likely diagnosis?
A. Classical angina
B. Anginal equivalent
C. Musclo-skeletal pain
D. Myocardial infarcton

Answer 29

B. Anginal equivalent

Question 30

A 77-year-old man with poorly controlled hypertension presents with a 6-months history of fatgue and dyspnea on exerton. He denies edema, orthopnea, chest pain and palpitatons. His only medicaton is hydrochlorothiazide (25 mg) once daily. On examinaton, he has a grade 2/6 midsystolic ejecton murmur, which is loudest at the right upper steal border. An S4 is heard at the apex, there is no S3. His lungs are clear and there is no peripheral edema. Which of the following is the most likely diagnosis?
A. Aortc regurgitaton
B. Mitral regurgitaton
C. Aortc stenosis
D. Mitral stenosis

Answer 30

C. Aortc stenosis

Question 31

A 49-year-old smoker man has type 2 diabetes mellitus, morbid obesity and a recent diagnosis of symptomatc peripheral arterial disease. He is started on atorvastatn (Lipitor), ofered a supervised exercise program and discussed smoking cessaton and interventons. Which of the following should be recommended to prevent cardiovascular events?
A. Aspirin
B. Warfarin
C. Atenolol
D. Enoxaparin SC injecton

Answer 31

A. Aspirin

Question 32

A 34-year-old woman with a history of prolonged QT syndrome presents with severe acute bacterial sinusits. Which of the following antbiotcs should be avoided?
A. Amoxicillin
B. Moxifoxacin
C. Clarithromycin
D. Amoxicillin/clavulanate

Answer 32

C. Clarithromycin

Question 33

A 75-year-old man has lung cancer comes to the clinic to manage his back pain. A month ago, his oncologist told him that the prognosis was poor and that he is unlikely to survive for more than a year (see lab result). Test Result Normal Values Calcium ionised 3.2 1.1-1.3 mol/L Which of the following is the most appropriate next step in management?
A. Intrvenous isotonic saline
B. Subcutaneous morphine
C. Oral alendronate
D. Oral furosemide

Answer 33

A. Intrvenous isotonic saline

Question 34

A 68-year-old woman is admited to the hospital with frst episode of acute heart failure. She has a history of hypertension treated with a thiazide diuretc. An echocardiogram reveals no evidence of valvular disease and no segmental wall moton abnormalites. Lef ventricular hypertrophy is noted, and her ejecton fracton is 55%. Which of the following is the most likely cause of her heart failure?
A. Hypertrophic cardiomyopathy
B. Diastolic dysfunction
C. Systolic dysfunction
D. High-output failure

Answer 34

B. Diastolic dysfunction

Question 35

A 76-year-old woman with a history of hypertension and osteoporosis presents to the clinic for preoperatve clearance for an upcoming eye surgery. She complains of progressively worsening fatgue over the past 8 to 10 months. She states she ofen feels dizzy but denies syncope. Her current medicatons include alendronate and hydrochlorothiazide. Which of the following is the most appropriate acton?
A. An exercise treadmill test
B. A 48-hour holter monitor
C. Referral to a cardiologist for evaluation
D. Clearance for eye surgery with no further evaluation

Answer 35

C. Referral to a cardiologist for evaluation

Question 36

A 61-year-old man complains of shortness of breath. He has a history of hypertension, type 2 diabetes and hyperlipidemia. He was a smoker for more than 30 years but he quit 4 years ago. On physical examinaton, he is not in respiratory distress, but he has difuse wheezing bilaterally over lower lobes of his lungs. His cardiac examinaton demonstrates an S4 and distended jugular veins. Which of the following is the best treatment to relieve his symptoms?
A. Antcoagulant therapy
B. Steroid therapy
C. Diuretcs
D. Aspirin

Answer 36

C. Diuretcs

Question 37

A 38-year-old man has episodic chest pain. He states that the pain feels like tghtness, located right behind his sternum, lasts less than 3 minutes and is relieved with rest. He takes no medicatons. He has no family history of coronary disease and has never smoked. His ECG in the ofce is normal. What is the most appropriate test to exclude cardiac ischemia?
A. Cardiac CT
B. Exercise ECG
C. Restng echocardiogram
D. Creatne kinase enzyme

Answer 37

B. Exercise ECG

Question 38

A 55-year-old man has congestve heart failure due to lef ventricular systolic dysfuncton. He has no history of medicatons allergy or interacton, Which of the following is the best frst-line treatment opton?
A. ACE inhibitors and diuretics
B. Hydralazine and B-Blockers
C. B-Blockers and diuretcs
D. Nitrates and -Blockers

Answer 38

A. ACE inhibitors and diuretics

Question 39

A 58-year-old man has chronic atrial fbrillaton. Which of the following is this patent at increased risk for?
A. Acute myocardial infarcton
B. Cerebrovascular accident
C. Sudden cardiac death
D. Ventricular fbrillaton

Answer 39

B. Cerebrovascular accident

Question 40

A 55-year-old man presents to the clinic with history of atrial fbrillaton. What is the drug of choice to prevent complicatons of his conditon?
A. Prophylactic warfarin
B. Prophylactc heparin
C. Prophylactc lidocaine
D. No drug is recommended

Answer 40

A. Prophylactic warfarin

Question 41

A 59-year-old man is admited to the hospital with infero-lateral myocardial infarcton. Which of the following medicatons would improve his survival?
A. Hydrochlorothiazide
B. Metoprolol
C. Morphine
D. Warfarin

Answer 41

B. Metoprolol

Question 42

A 56-year-old man has a low-pitched diastolic rumble heard at the apex, a widened pulse pressure and a grade 3/6 diastolic decrescendo murmur at the lef steal border. Which of the following is the most likely diagnosis?
A. Hypertrophic cardiomyopathy
B. Pulmonic insufciency
C. Aortic regurgitaton
D. Mitral stenosis

Answer 42

C. Aortic regurgitaton

Question 43

A 60-year-old man, with type 2 diabetes, presents with persistent difuse neck pain for the past hour, diaphoresis, shortness of breath, a normal troponin I level, and an electrocardiogram that reveals only nonspecifc ST-segment and T-wave changes. Which of the following is the most appropriate next step in management?
A. Administer oral ibuprofen
B. Recheck the troponin I level in 6 hours
C. Perform a right-sided electrocardiogram
D. Administer aspirin and sublingual nitroglycerin

Answer 43

D. Administer aspirin and sublingual nitroglycerin

Question 44

A 42-year-old man presented with worsening pleuritc, positonal chest pain. Examinaton revealed pericardial rub, a clear lung examinaton, and no evidence of lower-extremity edema ECG shows non-diagnostc fndings. Which of the following is the most appropriate next step for diagnosis?
A. D-dimer testng
B. Exercise stress testng
C. Referral to echo-cardiograph specialist
D. Reassure the patent about insignifcant symptoms

Answer 44

D. Reassure the patent about insignifcant symptoms

Question 45

A 26-year-old woman had 2 episodes of syncope in the past 2 months during micturiton and coughing. Physical examinaton and electrocardiogram are unremarkable. Which of the following is the most appropriate management optons?
A. Transthoracic echocardiogram
B. Reassurance and education
C. Holter monitor
D. Tilt-table test

Answer 45

B. Reassurance and education

Question 46

A 22-year-old woman with vasovagal syncope comes to the clinic. She has a normal physical examinaton and a normal electrocardiogram. Which of the following management approaches is most appropriate?
A. Reassurance and explanaton
B. Echocardiogram
C. Tilt-table study
D. Holter monitor

Answer 46

A. Reassurance and explanaton

Question 47

A 60-year-old man admited to the Emergency Room with 1-day history of hematemesis. He has multple spider angiomata on his chest with bilateral gynecomasta. Abdominal examinaton showed splenomegaly (see lab results). Blood pressure 100/60 mmHg, Heart rate 100 /min, Respiratory rate 18 /min, Temperature 36.6 °C, Oxygen saturaton 95 % Test Result Normal Values Hb 8.5 130-170 g/L (Male)
120-160 g/L (Female) HCT 0.23 0.42-0.52 (Male) 0.37-0.48 (Female) Which of the following is the most appropriate next step in management afer the inital fuid resuscitaton?
A. Blood transfusion
B. Upper GI endoscopy
C. Selectve angiography
D. Nasogastric tube inserton

Answer 47

B. Upper GI endoscopy

Question 48

A 22-year-old man presented with 6-month history of non-bloody diarrhea, recurrent abdominal cramps and weight loss. On examinaton, he looked pale with oral ulcers. Abdominal examinaton showed tender right lower quadrant. Blood pressure 110/70 mmH Heart rate 100 /min Temperature 38.1 °C Which of the following is the most likely diagnosis?
A. Celiac disease
B. Crohn’s disease
C. Ulceratve colits
D. Chronic appendicits

Answer 48

B. Crohn’s disease

Question 49

A 35-year-old wornan presented with chronic vague gastric pain for several years. The pain is revealed by food. Serum immunoglobulin studies for igG against helicobacter pylori was positve. Upper Gl endoscopy showed antral gastrits with small clean bases ulcer at duodenum. The patent was treated for Hi.pylori. Which of the following is the most appropriate test to ensure h pylori eradicaton?
A. Rapid urease test
B. Urea breath test
C. Culture of gastric mucosa
D. Repeat lgA and IgG against H.pylori

Answer 49

B. Urea breath test

Question 50

A 60-year-old man presented with jaundice for 2 months. Physical examinaton revealed a nodular enlarged liver (see report). CT Scan: Showed cirrhotc liver with 2 lesions at right lobe measuring 4 x 5 cm. Which of the following risk factors is strongly associated with this conditon?
A. Afatoxin
B. Lead toxin
C. Wilson disease
D. Hepatts B infecton

Answer 50

D. Hepatts B infecton

Question 51

A 35-year-old man with a 7-year history of ulceratve colits. presented with insidious onset of progressive fatgue, prurits and jaundice. He underwent MRCP, which demonstrates multple short strictures of biliary tree at both intrahepatc and extrahepatc ducts (see lab results). Test Result Normal Values Alkaline phosphatase 785 39-117 IU/L Alanine aminotransferase 60 5-40 IU/L Aspartate aminotransferase 40 12-40 IU/L
Creatnine kinase 34 24-170 IU/L (Female) 24-195 IU/L (Male) Which of the following is the most likely diagnosis?
A. Liver cirrhosis
B. Bile duct atersia
C. Primary biliary cholangits
D. Primary sclerosing cholangitis

Answer 51

D. Primary sclerosing cholangitis

Question 52

A 40-year-old man with a history of hypertriglyceridemia presents to Emergency Room with 4- hour of sever epigastric pain, nausea, and vomitng. The pain was steady and radiate to the back. The patent was in pain and agitated (see lab results and report). Blood pressure 100/70 mmHg Heart rate 110 /min Respiratory rate 23 /min Temperature 38.3 °C Oxygen saturaton 94 % Test Result Normal Values BC 5 4.7-6.1 x 1012/L (Male) 4.2-5.4 x 1012/L (Female) Hb 12 130-170 q/L. (Male) 120-160 g/L (Female) HCT 39 0.42-0.52 (Male) 0.37-0.48 (Female) Platelets count 344 150-400 x 109/L WBC 16 4.5-10.5 x 109/L Alanine aminotransferase 97 5-40 IU/L Aspartate aminotransferase 87 12-40 IU/L Amylase 150 24-151 IU/L Lactate dehydrogenase 169 60-160 IU/L Lipase 30 0-160 IU/L Plain Abdominal X-ray:Showed an air-flled intestnal loop at lef upper quadrant. Which of the following is the most likely diagnosis?
A. Acute pancreatitis
B. Bowel perforaton
C. Mesentric ischemia
D.Divertcular disease

Answer 52

A. Acute pancreatitis

Question 53

A 62-year-old patent known case of chronic hepatts C presented with abdominal pain and swelling. Examinaton showed ascites, abdominal tenderness and peripheral edema. Diagnostc ascitc tap done and revealed a neutrophil count of 400/mm (<250 mm) Blood pressure 110/70 mmHg Heart rate 90 /min Temperature 37.6 °C Which of the following is the appropriate next step in the management?
A. Fluid restriction
B. Oral spironolactone
C. Intravenous antibiotics
D. Therapeutc paracentesis

Answer 53

C. Intravenous antibiotics

Question 54

A 69-year-old man seen in Outpatent Clinic for a routne check-up. No relevant history, apart from occasionally low back pain on non-steroidal ant-infammatory drugs as needed. No chronic medical history. On examinaton, his abdomen was sof with no masses. Rectal examinaton was normal (see lab results). Test Result Normal Values RBC 4 4.7-6.1 x 1012/L (Male) 4.2-5.4 x 1012/L (Female) Hb 8 130-170 g/1. (Male) 120-160 q/L (Female) HCT 38 0.42-0.52 (Male) 0.37-0.48 (Female) MCH 23 28-33 pg/cell MCV 70 80-95 f Platelets count 456 150-400 x 109/L WBC 5 4.5-10.5 x 109/L Which of the following is the most important next step?
A. Sigmoidoscopy
B. Ultrasound abdomen
C. Stool for occult blood
D. Upper and lower Gl endoscopy

Answer 54

D. Upper and lower Gl endoscopy

Question 55

A 34-year-old pregnant woman, known case of chronic hepatts B, comes to the clinic for counselling regarding the risk of hepatts B transmission to her baby (see lab results and report). Test Result Normal Values Alkaline phosphatase 198 39-117 IU/L Alanine aminotransferase 120 5-40 IU/L Aspartate aminotransferase 67 12-40 IU/L Hepatts B viral load: 1 million copies/mi. Which one of the following the baby should receive to reduce the vertcal transmission risk?
A. Hepatts b vaccine
B. Hepatts b immunoglobulin
C. Hepatts b vaccine and immunoglobulin
D. Hepatts b vaccine, immunoglobulin and entecavir

Answer 55

C. Hepatts b vaccine and immunoglobulin

Question 56

A 32-year-old woman 30-week pregnant G1+0+0, presented to the clinic with pruritus and jaundice. There is no fever, abdominal pain, or vomitng. She is not on any medicatons and no chronic medical illness (see lab results). Test Result Normal Values Hb 11 130-170 g/L. (Male) 120-160 g/L (Female) Platelets count 160 150-400 x 109/L WBC 7 4.5-10.5 x 109/L Alkaline phosphatase 700 39-117 IU/L Alanine aminotransferase 79 5-40 IU/L Aspartate aminotransferase 100 12-40 IU/L Which of the following is the most likely diagnosis?
A. Viral hepatts
B. Hellp syndrome
C. Budd chiari syndrome
D. Cholestasis of pregnancy

Answer 56

D. Cholestasis of pregnancy

Question 57

A 47-year-old alcoholic patent presented with 6-week history of weight loss, fever, and right hypochondrum pain (see lab resuit and report). Test Result Normal Values Alpha fetoprotein 120 0-40 ng/mL Abdominal Ultrasound: Showed ascites and focal liver lesion in a cirrhotc liver. Which of the following is the most likely diagnosis?
A. Liver abscess
B. Pancreatc cancer
C. Hydatd liver disease
D. Hepatocelluar carcinoma

Answer 57

D. Hepatocelluar carcinoma

Question 58

A 23-year-old woman was informed that her husband has chronic hepatts B infecton. She was worried that he had transmited the virus to her. She is currently asymptomatc apart from fatque. What is the frst evidence of acute infecton in her case?
A. HBEAg
B. HBsAg
C. Ant-HBc
D. Ant-HBs

Answer 58

B. HBsAg

Question 59

A surgeon was performing a procedure on a patent with chronic hepatts C infecton. He accidentally had a needie stck injury. What is the likelihood of hepatts C transmission?
A. 0.03 %
B. 0.3 %
C. 3 %
D. 30 %

Answer 59

C. 3 %

Question 60

A 16-year-old man presented to the Outpatent Department complaining of diarrhea for 3 years. He was passing 3-4 large volume stool per day, which was foul smelling and contained undigested food but no blood or mucus. He was also complaining of postprandial bloatng and easy fatgability. On examinaton, he looked pale and has no secondary sexual characteristcs BMI 14 kq/m2 Test Result Normal Values Hb 10 130-170 g/L (Male) 120-160 g/L (Female) MCV 70 80-95 f Platelets count 433 150-400 x 109/L Alanine aminotransferase 90 5-40 IU/L Aspartate aminotransferase 60 12-40 IU/L ESR 12 2-10 mm/h (Male) 3-15 mm/h (Female) Which of the following is the most appropriate diagnostic test?
A. Stool for fat content
B. Barium follow through
C. Lactose hydrogen breath test
D. IgA antendomysial antbodies

Answer 60

D. IgA antendomysial antbodies

Question 61

A 24-year-old man presented with 2-month of bloody diarrhea. He passes 3-4 loose motons day associated with blood and mucus. He gave history of lef lower quadrant pain. No fever or weight loss. He underwent sigmoidoscopy, which showed loss of normal vascular patern with erosions up to splenic fexure (see lab results). Test Result Normal Values RBC 5 4.7-6.1 x 1012/L (Male) 4.2-5.4 x 1012/L (Female) Hb 10.9 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 488 150-400 x 109/L WBC 6 4.5-10.5 x 109/L ESR 32 2-10 mm/h (Male) 3-15 mm/h (Female) Consistency LIQUID (sof or tght) Color YELLOW Brown Mucus and blood ++ absent Leukocytes +++ solitary Which of the following is the best treatment option?
A. Mesalamine enema
B. Mesalamine suppository
C. Mesalamine oral and enema
D. Mesalamine oral and suppository

Answer 61

C. Mesalamine oral and enema

Question 62

A 60-year-old man with chronic history of heartbum for several years, presented with occasional hematemesis. Upper I endoscopy revealed intestnal-type metaplasia at the distal esophagus.Which of the following is the most likely diagnosis?
A. Oesophagits
B. Mallory-weiss tear
C. Barrett oesophagus
D. Plummer vinson syndrome

Answer 62

C. Barrett oesophagus

Question 63

A 30-year-old woman with lef-sided ulceratve colits presented to Emergency Room with 7-8 bloody diarrhea /day associated with low-grade fever, abdominal pain and joint pain at her knees. On examinaton, she looks ill and in pain. All stool cultures were negatve. Blood pressure 90/70 mmHg Heart rate 120 /min Respiratory rate 18/min Temperature 37.3 °C Oxygen saturaton 95 % Test Result Normal Values Hb 9 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 456 150-400 x 109/L. WBC 10 4.5-10.5 x 109/L.
ESR 122 2-10 mm/h (Male) 3-15 mm/h (Female) Afer fuid resuscitaton what is the best next step in management?
A. Azathioprine
B. Sulphasalazine
C. Oral budesonide
D. Iv methylprednisolone

Answer 63

D. Iv methylprednisolone

Question 64

A 28-year-old man who was previously healthy, presented to the Emergency Department with 5- days history of right upper quadrant abdominal pain, which was associated with nausea and 2 episodes of vomitng. 2 days later, his family notced yellowish discolouraton of his eyes and skin. No history of alcohol or drug use. On examinaton, he was jaundiced. Abdominal exam showed tender right upper abdomen (see lab results), Test Result Normal Values Alkaline phosphatase 109 39-117 IU/L Alanine aminotransferase 990 5-40 IU/L Aspartate aminotransferase 789 12-40 IU/L Which of the following is the most appropriate next step in diagnosis?
A. Hepatitis A IgG
B. Hepatitis A IgM
C. Hepatitis B antgen
D. Hepatitis C antbodies

Answer 64

B. Hepatitis A IgM

Question 65

A 17-year-old man with no previous medical history, presented with 3-weeks history of bloody diarrhoea. He reported frequent urges to defecate, associated with mild lower abdominal cramps. He had experienced similar atacks in the past, but milder associated with bloatng and loose stool, which was mucus with few blood drops. Abdominal examinaton was sof with mild tenderness at lef lower quadrant but no guarding. Blood pressure 110/70 mmHg Heart rate 76 /min Temperature 36.6 °C Oxygen saturaton 95 % Which of the following is the most likely diagnosis?
A. Divertculits
B. Ischaemic colitis
C. Crohn’s disease
D. Ulceratve colits

Answer 65

D. Ulceratve colits

Question 66

A 20-year-old man with a history of high liver functon test in the past presents, with tremors and dysarthria and dyskinesia. Slit-lamp examinaton reveals a greenish-brown ring at comeoscleral juncton. Which of the following is the most likely diagnosis?
A. Anttrypsin defciency
B. Hepatc hemangioma
C. Hemochromatosis
D. Wilsons disease

Answer 66

D. Wilsons disease

Question 67

A 22-year-old woman with chronic diarrhea and malabsorpton is suspected of having celiac disease, a jejunal biopsy taken. Which of the following histological fnding is expected?
A. Flatened crypts
B. Subtotal villous atrophy
C. Epithelial cells with fat globules
D. Fissures and ulcers penetratng into submucosa

Answer 67

B. Subtotal villous atrophy

Question 68

A 50-year-old man presents with 3-months history of jaundice, arthralgia, increase in skin pigmentaton, and upper abdominal discomfort. He is on oral hypoglycemic medicatons for recently diagnosed diabetes mellitus. His viral hepatts screening was negatve. Examinaton revealed a bronze coloured skin, enlarged liver with span of 15 cm, no splenomegaly, and testcular atrophy. Cardiac examinaton revealed a 3rd heart sound (see lab results). Test Result Normal Values Direct bilirubin 24 1.5-6.5 mol/L Total bilirubin 31 3.5-16.5 umol/L Aspartate aminotransferase 79 12-40 IU/L Alanine aminotransferase 112 5-40 IU/L Alkaline phosphatase 109 39-117 IU/L Random Glucose 7 3.9-5.5 mmol/L Ferritn 400 20-300 g/L. (Male) 20-120 pg/L (Female) Which of the following investgatons is the most appropriate next step?
A. Alpha 1-anttrypsin
B. 24 hours urinary copper
C. Antmitochondrial antbodies
D. Hepatc iron load in liver biopsy

Answer 68

D. Hepatc iron load in liver biopsy

Question 69

A 31-year-old patent came to Emergency Room with 1-day history of melena and dizziness. He has no signifcant medical history and takes no medicatons apart from ibuprofen for dental pain for 5 days. Examinaton revealed cold extremites, and faint peripheral pulses. Per-rectal examinaton revealed maroon coloured stool (see lab results). Blood pressure 90/60 mmHg Heart rate 120 /min Respiratory rate 18 /min Temperature 36.6 °C Oxygen saturaton 95 % Test Result Normal Values RBC 4.3 4.7-6.1 x 1012/L (Male) 4.2-5.4 x 1012/L (Female) Hb 8.7 130-170 g/L. (Male) 120-160 g/L (Female) Platelets count 343 150-400 × 109/L WBC 8 4.5-10.5 x 109/L Which of the following is the most appropriate next step in the management?
A. Normal saline
B. Colloid soluton
C. Blood transfusion
D. Albumin and ringer lactate

Answer 69

A. Normal saline

Question 70

A 25-year-old woman came to the clinic for an advice. She is planning to get pregnant; she is a known case of distal ulceratve colits diagnosed 3 years ago on 3 grams of mesalamine granules. Her last exacerbaton was a year ago required a short course of steroid. Currently she has a 2-3 bowel motons a day, occasionally seen a streaks of blood once every 4-5 weeks. Her latest fecal calprotectn is 90 (normal 0-50). Which one of the following is the most appropriate advice?
A. It is difcult to get pregnant now
B. She can get pregnant as her disease is controlled
C. Her risk of aborton is high and should be counselled
D. It is advisable to postpone the pregnancy for 3 years

Answer 70

B. She can get pregnant as her disease is controlled

Question 71

A 65-year-old man known case of diabetes mellitus and hypertension presents to Emergency Room with 1-day history of vomitng fresh blood and melena. He is taking aspirin 81 mg daily. Afer fuid resuscitaton, he was started on IV PPI. He underwent upper Gl endoscopy, which revealed a 2 cm duodenal ulcer at the bulb with visible vessel seen, endoscopic hemostasis was done using endo clip Which of the following is the recommended duraton for IV PPI post endoscopic management?
A. 24 hours
B. 36 hours
C. 48 hours
D. 72 hours

Answer 71

D. 72 hours

Question 72

A 30-year-old woman a known case of fstulizing crohn’s disease on biological therapy and azathioprine. She is pregnant on her third trimester. Her physician is planning to communicate with her obstetrician prior to her delivery about her delivery method and the vaccinaton of the child. Which of the following is the recommended advice for the child vaccinations?
A. All vaccines can be given safely
B. Live atenuated vaccines are contraindicated
C. All vaccines should be postponed tll 6 months
D. Live atenuated vaccines should be postponed for 12 months

Answer 72

D. Live atenuated vaccines should be postponed for 12 months

Question 73

A 65-year-old man presented with melena and hematemesis. He is a known case of diabetes mellitus, hyperlipidaemia, and he is on aspirin 81 mg, lipitor 20 mg, diamicron 80 mg and warfarin 3 mg a day. Underwent upper Gl endoscopy and showed multple superfcial ulcers at the antrum and duodenal bulb. Which of the following medicatons is most strongly associated with his presentaton?
A. Aspirin
B. Lipitor
C. Warfarin
D. Diamicron

Answer 73

A. Aspirin

Question 74

A 21-year-old patent presented with 4-months history of itchy skin rash over his elbows with abdominal bloatng and diarrhoea. No other medical problems. He has a cousin with similar conditon. He underwent upper and lower I endoscopy. Multple duodenal erosions seen at the 1st and 2nd part with scalloping (see lab results and reports). Test Result Normal Values RBC 4 4.7-6.1 x 1012/L (Male) 4.2-5.4 x 1012/L (Female) Hb 10.9 130-170 g/L. (Male)
120-160 g/L (Female) Alkaline phosphatase 112 39-117 IU/L Alanine aminotransferase 123 5-40 IU/L Aspartate aminotransferase 79 12-40 IU/L Calcium 1.9 2.15-2.62 mmol/L Random Glucose 6 3.9-5.5 mmol/L lleocolonoscopy: Normal. Duodenal biopsy: Showed subtotal villous atrophy. Which of the following is the best treatment option?
A. Oral steroid
B. Iv pantoprazole
C. Start gluten free diet
D. Oral iron tablets and repeat endoscopy in 3 months

Answer 74

C. Start gluten free diet

Question 75

Osteoporosis is one of common extra-intestnal manifestatons of crohn’s disease, which carries a concomitant fracture risk. Which of the following risk factors are more likely to be strongly associated with increase osteoporosis risk in crohn’s disease? A. Age 20-40
B. Premenopausal
C. Long steroid use
D. Extensive colonic involvement

Answer 75

C. Long steroid use

Question 76

A 35-year-old woman with heartburn and regurgitaton for 6 months is referred for evaluaton of chronic GERD symptoms. The patent states that she notes burning in her chest primarily afer meals and occasionally experiences episodes of chest pain. She denies change in weight or lifestyle. She ofen consumes dinner 2 hours before going to bed. Her heartbum occurs mainly during the night. Physical examinaton is normal except for a body mass index (BMI) of 28 kg/m2. A complete blood count and metabolic panel are normal. The patent has been taking omeprazole 20 mg daily. An upper endoscopic examinaton is performed, and the appearance of distal esophagits. Which of the following is the best next step?
A. Add antacid twice/day
B. Ranitdine at bed time
C. Advise her to lose weight
D. Refer her for Nilsson Fundoplicaton

Answer 76

B. Ranitdine at bed time

Question 77

A 32-year-old man came to the clinic for follow-up visit. He is diagnosed of iloecolonic crohn’s disease started on steroid and pentasa for 3 months. He notced perineal pain and discharges for 3 weeks duraton. His abdominal symptoms are well controlled with no abdominal pain or diarrhoea. Examinaton was normal apart from 2 perianal fstula were seen (see lab results and report), Test Result Normal Values RBC 4 4.7-6.1 x 1012/L (Male) 4.2-5.4 x 1012/L. (Female) Hb 11 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 421 150-400 x 109/L WBC 7 4.5-10.5 x 109/L ESR 36 2-10 mm/h (Male)
3-15 mm/h (Female) MRI Pelvis: Confrmed the presence of perianal fstulae. Which of the following is the best next step in management?
A. Methotrexate
B. Azathiporine
C. Budesonide
D. Infiximab

Answer 77

D. Infiximab

Question 78

A 40-year-old healthy man came to the clinic requestng a screening colonoscopy. He is asymptomatc with no family history of colon cancer. Clinical examinaton is unremarkable (see lab results). Test Result Normal Values RBC 4 4.7-6.1 x 1012/L (Male) 4.2-5.4 x 1012/L (Female) Hb 13.3 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 321 150-400 x 109/L WBC 4 4.5-10.5 x 109/L Based on the latest recommendaton from local and internatonal gastroenterology associatons, what is the recommended age of screening colonoscopy for this average risk patents?
A. 45
B. 55
C. 65
D. Order for him now

Answer 78

A. 45

Question 79

A 40-year-old man presented with several months history of dyspepsia. He denies any history of dysphagia, vomitng, or weight lost. He has no signifcant past medical history and not on any medicatons. He received helicopter pylori eradicaton (PPI standard dose, clarithromycin 500mg, and amoxil 1g bid for 10 days) with partal response. Basic routne lab was normal (see reports). Endoscopy: Showed gastric erosions. Biopsy: Showed h pylori organism. Which of the following is the best treatment regimen?
A. Repeat the same regimen for a longer duraton 14 days
B. PPI, nitromidazole 500mg bid, doxacyclin 100mg qid for 14 days
C. PPI, levofoxacin 500mg gid, amoxil 1 g bid, nitromidazole 500mg bid for 14 days
D. PPI, bismuthsubcitrate 300mg qid, tertacycline 500mg id , metronidazole 500mg td for 14 days

Answer 79

D. PPI, bismuthsubcitrate 300mg qid, tertacycline 500mg id , metronidazole 500mg td for 14 days

Question 80

A 45-year-old woman presented with 9-months history of worsening dysphagia for both solid and liquid. Recently she had episodes of ill defned central chest discomfort and nocturnal cough. Clinical examinaton was unremarkable (see lab results). Test Result Normal Values RBC 5 4.7-6.1 x 1012/L (Male) 4.2-5.4 x 1012/L (Female) Hb 11.8 130-170 g/L. (Male) 120-160 g/L (Female) Platelets count 300 150-400 x 109/L WBC 7 4.5-10.5 x 109/L
ESR 13 2-10 mm/h (Male) 3-15 mm/h (Female) Which of the following is the most likely diagnosis?
A. Achalasia
B. Esophageal web
C. Pharyngeal pouch
D. Squamous cancer of esophagus

Answer 80

A. Achalasia

Question 81

A 45-year-old man with several months of worsening dyspepsia. He denies any history of diarrhoea, fever, or weight loss. He has no medical problems. He was prescribed pantoprazole 40 mg daily with no relieve of his symptom (see reports). Upper GI endoscopy: Showed multple antral superfcial ulcers. Biopsy: organism. Revealed mucosa-associated lymphoid tssue (malt) lymphoma with numerous H.pylori CT scan of abdomen and chest: Normal. Which of the following is the best management opton?
A. Chemotherapy
B. Radiotherapy
C. Gastrectomy
D. H.pylori eradicaton

Answer 81

D. H.pylori eradicaton

Question 82

A 45-year-old healthy man recently diagnosed with hepatts C virus (HCV) infecton and was referred to the clinic for initaton of HCV therapy. HCV RNA viral load quanttaton was 2 million I/ml and a Genotype 4, a Liver ultrasound that was normal with no cirrhosis or focal liver lesions (see lab results and report). Test Result Normal Values RBC 5 4.7-6.1 × 1012/L (Male) 4.2-5.4 x 1012/L (Female) Hb 13 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 233 150-400 x 109/L WBC 5 4.5-10.5 x 109/L Alanine aminotransferase 89 5-40 IU/L Aspartate aminotransferase 56 12-40 IU/L Creatnine 100 44-115 umol/L Fibroscan: Showed fbrosis score of F3. Which of the following is the recommended treatment?
A. Entacavir
B. Peg-interferon
C. Ledipasvir/sofosbuvir
D. Observe and repeat lab in 3 months

Answer 82

C. Ledipasvir/sofosbuvir

Question 83

A 50-year-old woman presented with few months history of feeling dizziness when getng out of bed she also feels very warm and fushed. She visited the Emergency Room several tmes with frequent episodes of abdominal cramps and watery diarrhea over the past year. She gave a history of itchy skin. On examinaton, she has a 2/6 systolic murmur at lef lower sternal border, chest examinaton reveals wheezing, abdomen was unremarkable. Laboratory results and stool cultures were normal. Which of the following is the most appropriate next step in diagnosis?
A. Ultrasound abdomen and pelvis
B. Double contrast barium enema
C. Serum lipase and amylase level
D. Urine for 5-hydroxindoleacetc acid

Answer 83

D. Urine for 5-hydroxindoleacetc acid

Question 84

A 30-year-old man presented with 1-day of sever epigastric pain radiatng to the back with vomitng. He gave a history of alcohol drinking occasionally. No other medical problems and not on any medicatons. On examinaton, tender upper abdomen without guarding (see lab results). Blood pressure 98/70 mmHg Heart rate 110 /min Respiratory rate 18 /min Temperature 37.2 °C Test Result Normal Values Hb 11.6 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 311 150-400 × 109/L WBC 13 4.5-10.5 x 109/L Alkaline phosphatase 120 39-117 IU/L Alanine aminotransferase 65 5-40 IU/L Aspartate aminotransferase 89 12-40 IU/L Lipase 770 0-160 IU/L Which of the following is the most appropriate next step?
A. Normal saline
B. Order urgent ercp
C. Broad spectrum antbiotc
D. CT scan of the abdomen with contrast

Answer 84

A. Normal saline

Question 85

A 34-year-old man diagnosed of ileocolonic crohn’s disease on infiximab and azathioprine came to the clinic complaining of perianal pain and discharge with low-grade fever for 3 weeks duratons. He has a 3-4 non-bloody bowel motons /day. He has a perianal induraton and purulent discharge on pressure. Blood pressure 110/70 mmHg Heart rate 76 /min Temperature 37.9 °C Which of the following is the appropriate next step in the patent management?
A. Order MRI pelvis
B. Broad spectrum antbiotcs
C. Swab from the perianal discharge
D. Increase infiximab dose and reduce the frequency

Answer 85

A. Order MRI pelvis

Question 86

A 23-year-old woman complaining of 4-months history of abdominal discomfort with alternatng bowel habit. Recently she gave a history of bloatng and passing mucus with stool and notced increase in bowel motons 3-4/day. The abdominal pain was relieved by defecaton with no nocturnal symptoms. She has no weight loss or fever. She is worried about serous diagnosis as her uncle was diagnosed as colon cancer at the age of 60. Clinically is unremarkable (see lab results). Test Result Normal Values RBC 3.7 4.7-6.1 x 1012/L (Male)
4.2-5.4 x 1012/L (Female) Hb 11 130-170 g/L. (Male) 120-160 g/L. (Female) Platelets count 332 150-400 x 109/L. WBC 5 4.5-10.5 x 109/L ESR 10 2-10 mm/h (Male) 3-15 mm/h (Female) Alanine aminotransferase 34 5-40 IU/L Aspartate aminotransferase 23 12-40 IU/L Amylase 122 24-151 IU/L Which of the following is the most likely diagnosis?
A. Gastroenterits
B. Ulceratve colits
C. Colo-rectal cancer
D. Irritable bowel disease

Answer 86

D. Irritable bowel disease

Question 87

A 62-year-old woman with long standing history of prurits and fatgue presented to the clinic with a 2-months history of jaundice and abdominal swelling. On examinaton, scratch marks seen. She was jaundiced with clubbing of her fngers. Abdominal examinaton revealed splenomegaly with ascites (see lab results and report). Test Result Normal Values RBC 4 4.7-6.1 x 1012/L (Male) 4.2-5.4 x 1012/L (Female) Hb 11 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 102 150-400 x 109/L WBC 3 4.5-10.5 x 109/L INR 1.5 0.8-1.2 Alkaline phosphatase 170 39-117 IU/L Alanine aminotransferase 78 5-40 IU/L Aspartate aminotransferase 112 12-40 IU/L US Abdomen: Showed coarse liver with 3 cm focal lesion at rt lobe. Which of the following is the most appropriate next step?
A. Alpha- fetoprotein
B. Biopsy for the lesion
C. Doppler ultrasound of liver
D. Triphasic CT scan of the abdomen

Answer 87

D. Triphasic CT scan of the abdomen

Question 88

A 34-year-old woman presented with 2-months history of jaundice and upper abdominal discomfort. She is known case of SLE on hydroxycholorquine. She also gave history of prurits and fatgue. Clinical examinaton revealed obesity and hepatomegaly (see lab results and reports), Test Result Normal Values Direct bilirubin 32 1.5-6.5 mol/L Total bilirubin 43 3.5-16.5 mol/L Aspartate aminotransferase 654 12-40 IU/L Alanine aminotransferase 734 5-40 IU/L Alkaline phosphatase 129 39-117 IU/L Gamma glutamyltransferase 60 6 to 37 IU/L
Random Glucose 7 3.9-5.5 mmol/L Globulin 43 21-36 g/L US Abdomen: Showed enlarged liver with bright coarse echogenicity. Viral Hepatts: Negatve. ANA: 1:640 Liver Biopsy: Inter phase hepatts with plasma cells. Which of the following is the most appropriate next step in management?
A. Prednisolone
B. Methotrexate
C. Vitamin e with weight loss
D. Ursodeoxycholic acid

Answer 88

A. Prednisolone

Question 89

A 33-year-old man with 2-years history of heartburn and food regurgitaton, he was taking 40 mg of pantoprazole daily with good response. He stopped it 4 months ago and started to have recurrence of his symptoms and becoming worse. No dysphagia or weight loss or nocturnal symptoms. Clinically was normal. All routne laboratory workup was normal. Which of the following is the best next step in his management?
A. PPI high dose (80 mg)
B. Ranitdine twice a day
C. Resume PPI at the same dose
D. PPI high dose and ranitdine

Answer 89

C. Resume PPI at the same dose

Question 90

A 40-year-old patent presented with chronic constpaton. No alarm symptoms. No other medical problems and not on any medicaton. Examinaton was normal including rectal examinaton. All lab workup, thyroid functon, calcium, and fastng glucose were normal. Stool for occult blood was negatve. Which of the following is the most appropriate treatment?
A. Senna
B. Lactulose
C. Magnesium phosphate
D. Bulking agent (psyllium)

Answer 90

D. Bulking agent (psyllium)

Question 91

A 34-year-old man patent a known case of ulceratve colits on azathioprine 100mg/day and tapering dose of steroid presented to the clinic with 6-7 bloody bowel motons, lower abdomen pain and low grade fever. On abdominal examinaton, there is mild tenderness at lef lower abdomen. Stool culture was negatve. Stool for colostrum difcile toxins was positve (see lab results). Blood pressure 110/70 mmH, Heart rate 100 /min, Temperature 38.4 °C, Oxygen saturaton 95 % Test Result Normal Values RBC 5 4.7-6.1 x 1012/L (Male) 4.2-5.4 x 1012/L (Female) Hb 11 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 456 150-400 x 109/L WBC 16 4.5-10.5 x 109/L ESR 67 2-10 mm/h (Male) 3-15 mm/h (Female) Albumin 29 34-56 g/L Which of the following is the most appropriate treatment?
A. Oral tnidazole
B. IV cefuroxime
C. Oral vancomycin
D. IV metronidazole

Answer 91

C. Oral vancomycin

Question 92

A 34-year-old worn with progressive dysphagia diagnosed as a case of achalasia. She has no medical problem and not on any medicatons. She is clinically unremarkable (see lab results). Test Result Normal Values RBC 4 4.7-6.1 x 1012/L (Male) 4.2-5.4 x 1012/L. (Female) Hb 10 130-170 g/L (Male) 120-160 g/L (Female) Platelets count 455 150-400 x 109/L WBC 9 4.5-10.5 x 109/L Urea 5 2.75-7.4 mmol/L Creatnine 98 44-115 mol/L Which of the following is the best treatment opton?
A. Fundoplicaton
B. Pneumatc dilataton
C. Oral isosorbide dinitrate
D. Botulinum toxin injecton

Answer 92

B. Pneumatc dilataton

Question 93

A 35-year-old woman 9 weeks pregnant presented with a history of palpitatons, heat intolerance and anxiety for several weeks, otherwise she feels well. Her only medicaton is a prenatal vitamin. On physical examinaton, she has warm and moist skin with fne tremor. There is no ophthalmology. Examinaton of the neck shows a difusely enlarged thyroid with an audible bruit. Cardiopulmonary and abdominal examinatons are unremarkable (see lab results). Blood pressure 120/70 mmH Heart rate 115 /min Respiratory rate 18 /min Temperature 36.6 °C Oxygen saturaton 95 % BMI 22 kg/m2 Test Result Normal Values Thyroid-Stmulatng Hormone < 0.01 0.4 - 5.0 yU/mL Triiodothyronine (T3 free serum) 14 3.5 - 6.5 pmol/L Thyroxine (T4 free serum) 35 8.5 - 15.2 pmol/L Which of the following is the most appropriate treatment?
A. Observaton
B. Propylthiouracil
C. Radioactve iodine
D. Thyroidectomy

Answer 93

B. Propylthiouracil

Question 94

A 60-year-old man came for follow-up evaluaton of Cushing syndrome. He presented with new. onset diabetes mellitus and a 15.1-kg weight gain over the last 6 months. Medical history is otherwise unremarkable. He is currently taking no medicatons and has had no exposure to exogenous glucocortcoids in the past year. On physical examinaton, he has facial plethora, central obesity, and bilateral supraclavicular fat pads. There are purple abdominal striae
measuring 1 cm wide and multple ecchymoses on the extremites. Inital laboratory studies as following and a 24-hour urine free cortsol level was greater than 3 tmes the upper limit of normal (see lab results). Blood pressure 165/92 mmHg Heart rate 88 /min Respiratory rate 15 /min Temperature 36.9 °C BMI 29 kg/m2 Test Result Normal Values ACTH < 1 2-11 pmol/L Cortsol 8 a.m. 248 mol/I post 138-635 mol/L 1 mg overnight dexamethasone test Which of the following is the most appropriate next diagnostc test?
A. Inferior petrosal sinus sampling
B. Late night salivary cortsol level
C. CT scan of the adrenal glands
D. MRI pituitary

Answer 94

C. CT scan of the adrenal glands

Question 95

A 33-year-old woman is evaluated in the Emergency Department for the sudden severe headache, vomitng and right eye vision loss she has had mild headaches that come and go over the past 2 years and for amenorrhea for the past 2 years. On physical examinaton, she has loss of vision in her right eye, other cranial nerves are intact. Strength and sensaton in all extremites are normal, as are her speech and gait (see reports). CT of the head: Shows acute pituitary hemorrhage. Pituitary MRI: Shows a 4.1 x 2.5 x 3.2-cm pituitary mass compressing the optc chiasm and the right cavernous sinus with central hemorrhage. Blood pressure 120/65 mmH Heart rate 99 /min Respiratory rate 15 /min Temperature 37 °C BMI 25 kg/m2 Which of the following is the most appropriate immediate management in the Emergency Room?
A. IV hydrocortsone
B. Assess pituitary functon
C. Repeat imaging in 2 weeks
D. Urgent transsphenoidal pituitary decompression

Answer 95

A. IV hydrocortsone

Question 96

A 39-year-old man found to have thyroid nodule during an annual physical examinaton. He has no personal or family history of any chronic medical disease, and he takes no medicatons. On physical examinaton, vital signs are normal. Palpaton of the thyroid reveals lef non-tender thyroid nodule, the remainder of the gland is unremarkable, and there is no palpable cervical lymphadenopathy. Other physical examinaton fndings are normal (see lab results and report). Test Result Normal Values Thyroid-Stmulatng Hormone 1.7 0.4 - 5.0 wU/mL Thyroxine (T4 free serum) 13.5 8.5 - 15.2 pmol/L Ultrasound of the neck: Shows a lef 3-cm hypochoic nodule with internal microcalcifcatons. Which of the following is the most appropriate next step in management?
A. Fine-needle aspiraton of the nodule
B. CT with contrast of the neck
C. Levothyroxine therapy
D. Thyroid scan

Answer 96

A. Fine-needle aspiraton of the nodule

Question 97

A 29-year-old woman is evaluated for a 10-day history of severe neck pain with heat intolerance, palpitatons, and insomnia. Medical history is signifcant only for a viral upper respiratory tract infecton 4 weeks ago. She takes no medicatons. On physical examinaton, she appears anxious and she has sinus tachycardia. There is no proposis or lid lag. Examinaton of the thyroid show a normal-sized tender gland. 24-Hour radioactve iodine 5% (low) uptake (see lab results). Test Result Normal Values Thyroid-Stmulatng Hormone < 0.01 0.4 - 5.0 wU/mL Triiodothyronine Reverse (RT3) 4.8 0.9 - 2.8 mol/L Thyroxine (T4 free serum) 34 8.5 - 15.2 pmol/L Which of the following is the most appropriate treatment?
A. Propranolol
B. Methimazole
C. Propylthiouracil
D. Radioactve iodine

Answer 97

A. Propranolol

Question 98

A 70-year-old woman was admited 1 week ago to the Intensive Care Unite with pneumonia requiring intubaton, intravenous fuids, and dopamine support for her blood pressure. On physical examinaton, her skin is warm and dry, no proposis, examinaton or the neck shows a normal-sized thyroid without nodules. Cardiovascular examinaton reveals regular tachycardia otherwise unremarkable systemic examinaton (see lab results). Blood pressure 90/57 mmH Heart rate 120 /min Respiratory rate 18 /min Temperature 39 °C Test Result Normal Values Thyroid-Stmulatng Hormone 0.1 0.4 - 5.0 U/mL Triiodothyronine (T3 free serum) 2 3.5 - 6.5 pmol/L Thyroxine (T4 free serum) 11 8.5 - 15.2 pmol/L Which of the following is the most likely cause of this patents abnormal thyroid functon?
A. Grave’s disease
B. Subacute thyroidits
C. Hashimoto thyroidits
D. Euthyroid sick syndrome

Answer 98

D. Euthyroid sick syndrome

Question 99

A 49-year-old woman is evaluated because of fatgue and weight gain although she follows a daily diet control and exercises 3 tmes per week for 45 minutes. She has hypercholesterolemia requiring statn therapy. Her mother had hypothyroidism. On physical examinaton, she has dry skin, thyroid gland mildly enlarged with a difusely nodular texture. Laboratory studies are with similar results for TSH and T4 were obtained 4 months ago (see lab results). Blood pressure 143/93 mmHg Heart rate 66 /min BMI 29 kg/m2
Test Result Normal Values Thyroid-Stmulatng Hormone 7.0 0.4 - 5.0 pU/mL. Thyroxine (T4 free serum) 9.5 8.5 - 15.2 pmol/L Thyroid peroxidase antbody (TPOAb) 150 <35 lU/mL Which of the following is the most appropriate next step in management?
A. Thyroid ultrasound
B. Start levothyroxine therapy
C. Repeat serum TSH measurement in 12 months
D. Schedule thyroid radioactve iodine uptake and scan

Answer 99

B. Start levothyroxine therapy

Question 100

A 29-year-old man is evaluated for a diagnosis of hypercalcemia. 5 days ago, he was treated of a kidney stone in the Emergency Department. Physical examinaton is unremarkable (see lab results), Blood pressure 140/79 mmHg, Heart rate 85 /min, Respiratory rate 13 /min, BMI 30 kq/m2 Test Result Normal Values Sodium 139 134-146 mmol/L Potassium 4.0 3.5-5.1 mmol/L Chloride 99 97-108 mmol/L Bicarbonate 23 21-28 mmol/L Calcium 2.95 2.15-2.62 mol/L Phosphate, inorganic 0.76 0.82-1.51 mmol/L Parathyroid hormone (intact PTH levels) 200 1.1-5.3 pmol/L Blood urea nitrogen 9.5 2.8 to 8.9 mmol/L Creatnine 125 44-115 mol/L Which of the following is most likely cause for his hypercalcemia?
A. Milk alkali syndrome
B. Primary hyperparathyroidism
C. Secondary hyperparathyroidism
D. Elevated 1,25-dihydroxyvitamin D levels

Answer 100

B. Primary hyperparathyroidism

Question 101

A 35-year-old woman is evaluated for amenorrhea, weight gain, facial hair, alopecia, difculty walking and easily bruising for the last 6 months. Her medical history is signifcant for psoriasis for which she is using clobetasol cream (topical steroid). On physical examinaton, vital signs all normal, she has round face, hirsutsm, mild facial acne, central obesity, and a few wide purple striae on the back of her arms as well as her psoriatc skin lesions (see lab results). Test Result Normal Values Sodium 139 134-146 mmol/L Potassium 3.5 3.5-5.1 mmol/L Blood urea nitrogen 6.7 2.8 to 8.9 mmol/L Creatnine 96 44-115 mol/L ACTH 1.4 2-11 pmol/ Cortsol 8 a.m. 55 138-635 mol/L Which of the following is the most likely diagnosis?
A. Ectopic adrenacortcotropic hormone producton
B. iatrogenic cushing syndrome
C. Adrenocortcal carcinoma
D. Cushing syndrome

Answer 101

B. iatrogenic cushing syndrome

Question 102

A 17-year-old man is evaluated in the Emergency Department for polyuria, polydipsia, polyphagia and an unintentonal weight loss over the past month. He has abdominal pain and drowsiness for the last 12 hours. His medical and family history are unremarkable. He is not of any medicatons. On physical examinaton, he looks sick with dry mucous membrane, tachypnea, and tachycardia with clear chest auscultaton. Abdominal examinaton shows difuse mild tenderness with normal bowel sounds. Intravenous 0.9% saline is initated. An electrocardiogram shows sinus tachycardia 120/min. Chest radiograph is normal (see lab results). Blood pressure 95/53 mmHg Heart rate 119 /min Respiratory rate 20 /min Temperature 37.2 °C Oxygen saturaton 95 % BMI 19 kg/m2 Test Result Normal Values Sodium 130 134-146 mmol/L Potassium 4.4 3.5-5.1 mmol/L Chloride 96 97-108 mmol/L Bicarbonate 10 21-28 mmol/L Blood urea nitrogen 15 2.8 to 8.9 mmol/L Creatnine 115 44-115 mol/L Random Glucose 25 3.9-5.5 mmol/L ABG HCO3- 10 22-28 mmol/L pH 7.10 7.36-7.45 RBC 5 4.7-6.1 x 1012/L (Male) 4.2-5.4 x 1012/L (Female) Hb 130 130-170 g/L (Male) 120-160 g/L (Female) WBC 14 4.5-10.5 x 109/L Which of the following is the most appropriate next step in the management?
A. Administer intravenous cefriaxone
B. Initate intravenous insulin therapy
C. Administer intravenous potassium chloride
D. Administer intravenous sodium bicarbonate

Answer 102

B. Initate intravenous insulin therapy

Question 103

A 45-year-old man is evaluated for recent onset type 2 diabetes mellitus and hypertension for the last 1 year. On physical examinaton, he has moon like face, dorsocervical fat pad and striae measuring 8 to 12 mm wide are noted on his upper arms and abdomen. Laboratory studies reveals the following as well as 24-Hour urine cortsol excreton which was 5 tmes upper the normal cut value and CT scan of the abdomen with and without contrast reveals a 5-cm right adrenal mass with contrast washout at 10 minutes is 60% (see lab results). Blood pressure 162/93 mmHg, Heart rate 88 /min, Respiratory rate 14 /min, Temperature 36.8 °C, Oxygen saturaton 96 % BMI 30 kg/m2 Test Result Normal Values ACTH 1.3 2-11 pmol/L Cortsol 8 a.m. 1400 138-635 mol/L Which of the following is the most appropriate next step in the management?
A. Chemotherapy
B. Surgical excision
C. Mitotane therapy
D. Radiaton therapy

Answer 103

B. Surgical excision

Question 104

A 54-year-old man presents for follow-up evaluaton afer diagnosed with type 2 diabetes mellitus 12 weeks ago. He was managed with lifestyle modifcatons and he come back with blood glucose log for the past 2 weeks. On physical examinaton, there is no evidence of diabetc retnopathy or peripheral neuropathy. Except for his blood glucose parameters, basic laboratory studies obtained at the tme of her inital diagnosis were normal (see lab results). Blood pressure 124/79 mmHg Heart rate 84 /min Respiratory rate 13 /min Temperature 36.9 °C Oxygen saturaton 95 % BMI 27 kg/m2 Inital test before lifestyle modifcatons: Test Result Normal Values НА 1C 8.5% 4.7-5.6 % Blood glucose log for the past 2 weeks: Test Result preprandial blood glucose 150 to 160 mg/dL. (8.3-8.9 mol/L) 2-hour postprandial blood glucose 190 to 200 mg/dL. (10.5-11.1 mmol/L.) In additon to lifestyle modifcatons, which of the following is the most appropriate inital management?
A. Dapaglifozin
B. Metormin
C. Sitagliptn
D. Glipizide

Answer 104

B. Metormin

Question 105

A 37-year-old man with type 1 diabetes mellitus presents to the ofce with history of prolonged hypoglycemia during intense exercise, despite eatng a meal prior to the actvity. He is using insulin glargine and insulin aspart with meals (see lab result). Test Result Normal Value Н6А1C 7.0 4.7-5.6 % Which of the following is the most appropriate management of this patent’s hypoglycemia on the days that he exercises?
A. Decrease meal-tme insulin aspart dose prior to exercise, contnue insulin glargine dose
B. Increase meal-tme protein prior to exercise, contnue current insulin doses
C. Switch insulin aspart to a sliding-scale regimen, contnue insulin glargine dose
D. Discontnue insulin glargine, contnue insulin aspart dose

Answer 105

A. Decrease meal-tme insulin aspart dose prior to exercise, contnue insulin glargine dose

Question 106

A 60-year-old man is evaluated because of fatgue, constpaton and cold intolerance for the last 8 months. Medical history is signifcant for Hodgkin lymphoma treated with radiaton therapy 3 years ago and there is no family history of thyroid disorders. On physical examinaton, he has dry skin with mild periorbital edema and normal thyroid exam (see lab results). Test Result Normal Values Hb 120 130-170 g/L (Male) 120-160 g/L (Female) Sodium 129 134-146 mmol/L
Thyroid-Stmulatng Hormone 5.0 0.4 - 5.0 U/mL. Which of the following will establish diagnosis of hypothyroidism?
A. Repeat TSH measurement in 4 weeks
B. Free thyroxine (T4) measurement
C. Thyroid ultrasound
D. Thyroid scan

Answer 106

B. Free thyroxine (T4) measurement

Question 107

A 30-year-old woman is admited to the hospital for an electve adrenalectomy for non-ACTH dependent Cushing syndrome confrmed by a contrast-enhanced adrenal CT scan fnding of benign right adrenal adenoma. Which of the following is the most appropriate perioperatve management?
A. Postoperatve mitotane
B. Peri operative hydrocortisone
C. Postoperatve fudrocortsone
D. Preoperatve phenoxybenzamine

Answer 107

B. Perioperatve hydrocortisone

Question 108

A 36-year-old woman is evaluated during her frst prenatal visit for Medical history of hypothyroidism, for which she has taken levothyroxine 125 g/d, for the last 2 years. On physical examinaton, no goiter or cervical lymphadenopathy. Cardiovascular, pulmonary and abdominal examinatons are unremarkable (see lab results). Blood pressure 100/73 mmHg Heart rate 87 /min Respiratory rate 13 /min Temperature 36.5 °C Oxygen saturaton 97 % BMI 23 kg/m2 Test Result Normal Values Thyroid-Stmulatng Hormone 4.4 0.4 - 5.0 jU/mL Thyroxine (T4 free serum) 9.5 8.5 - 15.2 pmol/L Which of the following is the most appropriate treatment of this patent’s hypothyroidism now?
A. Increase levothyroxine dose
B. Contnue levothyroxine dose
C. Decrease levothyroxine dose
D. Discontnue levothyroxine dose

Answer 108

A. Increase levothyroxine dose

Question 109

A 59-year-old man is admited to the hospital for evaluaton of chest pain. His medical history is signifcant for type 2 diabetes mellitus, coronary artery disease, hypertension, and hyperlipidemia. He manages his diabetes as an outpatent with diet, exercise, and metormin. His other medicatons are aspirin, metoprolol, atorvastatn, and sublingual nitroglycerin as needed (see lab results). Test Result Normal Values HbA1C 8.5 4.7-5.6 % Plasma Glucose 9.4-14.9 mmol/L Which of the following is the most appropriate diabetes treatment for this patent while hospitalized?
A. Glipizide
B. Metormin
C. Sliding-scale insulin
D. Basal and prandial insulin

Answer 109

D. Basal and prandial insulin

Question 110

A 23-year-old woman is evaluated afer a recent diagnosis of polycystc ovary syndrome. She is concerned about hirsutsm and irregular menses. She is not planning for pregnancy at this tme and takes no medicatons. On physical examinaton, she has mild hirsutsm and the remaining of her physical examinaton, including pelvic examinaton, are normal. Blood pressure 120/70 mmH Heart rate 76 /min Respiratory rate 15 /min Temperature 36.7 °C BMI 36 kg/m2 Which of the following is the most appropriate treatment?
A. Metormin
B. Spironolactone therapy
C. Combined oral contraceptve pills
D. Levonorgestrel intrauterine system

Answer 110

C. Combined oral contraceptve pills

Question 111

A 61-year-old man with a 20-year history of type 2 diabetes mellitus is evaluated for bilateral burning sensaton in his feet for the last 8 months, which worsens at night. His haemoglobin Ac levels have remained less than 7.0% for the last 1 years but were between 9.0% and 10.0% before adding insulin therapy to metormin 1 years ago. His medical history includes coronary artery disease, non-proliferatve diabetc retnopathy, hypertension, and hyperlipidemia. Medicatons are aspart insulin, glargine, aspirin, metoprolol, atorvastatn, and lisinopril. On physical examinaton, fndings are compatble with distal symmetrical polyneuropathy. Which of the following is the most appropriate management of this patent’s neuropathy?
A. Amitriptyline
B. Physiotherapy
C. Tight blood sugar control
D. Vitamin B12 supplements

Answer 111

A. Amitriptyline

Question 112

A 34-year-old woman is evaluated for history of galactorrhea, worsening fatgue, malaise and irregular excessive menses for the last 5 months. She complains of headaches that occur about 2 to 3 tmes per week. Her physical examinaton is unremarkable. Pregnancy test was negatve (see lab results). Blood pressure 120/86 mmHg Heart rate 62 /min Respiratory rate 13 /min BMI 28 kg/m2 Test Result Normal Values Thyroid-Stmulatng Hormone 16 0.4 - 5.0 pU/mL Thyroxine (T4 free serum) 9.2 8.5 - 15.2 pmol/L Prolactn 1000 < 652 pmol/L (Male) < 870 pmol/L (Female) Human chorionic gonadotropin 0.0 < 5 miU/mL Which of the following is the most appropriate management?
A. Begin cabergoline
B. Begin levothyroxine
C. Order pituitary MRI
D. Observaton and retest thyroid functon test in 6 months

Answer 112

B. Begin levothyroxine

Question 113

A 19-year-old woman is evaluated for management of type 1 diabetes. She was diagnosed 4 months ago afer presentng to the Emergency Department with diabetc ketoacidosis. Her hemoglobin A1c level at the tme of diagnosis was 14.5%. She was discharged from the hospital on a basal and prandial insulin regimen with minor adjustments required as an outpatent. Recently she started to have episodes of both fastng and postprandial hypoglycemia. Medicatons are insulin glargine and insulin apart. Her systemic examinatons are unremarkable (see lab results). Blood pressure 115/77 mmH Heart rate 80 /min BMI 22 kg/m2 Test Result Normal Values НА1С 6.0 4.7-5.6 % Random Glucose 4.5 3.9-5.5 mmol/L Which of the following is the most appropriate management for her hypoglycemia?
A. Decrease insulin glargine, decrease insulin aspart
B. Contnue same doses of insulin glargine and aspart
C. Discontnue insulin glargine, discontnue insulin aspart
D. Discontnue insulin glargine, change insulin aspart to a sliding-scale regimen

Answer 113

A. Decrease insulin glargine, decrease insulin aspart

Question 114

A 44-year-old man is evaluated for an 8-month history of decreased libido and severe erectle dysfuncton, including absence of morning erectons. He and his wife would like to conceive. His medical history is otherwise unremarkable, and he takes no medicatons. On physical examinaton, vital signs are normal with unremarkable clinical examinaton (see lab results and report). Test Result Normal Values Thyroid-Stmulatng Hormone 2.5 0.4 - 5.0 wU/mL Follicle-stmulatng hormone 1.2 5-20 IU/L (Follicular phase) 15-35 IU/L (Mid cycle peak) 5-15 IU/L (Luteal phase) 50-100 IU/L (Postmenopausal women) 5-20 IU/L (men) Testosterone 4.2 10.4-41.6 mol/L (Male) 0.7-2.8 mol/L (Female) Luteinizing hormone 1.0 3-15 U/L (Male) 5-22 U/L (Follicular phase) 5-22 U/L. (Luteal phase) 30-250 U/L (ovulatory phase) > 30 U/L (Postmenopausal) Prolactn 1500 < 652 pmol/L (Male) < 870 pmol/L (Female) MRI of the pituitary: Reveals a 0.8-cm anterior pituitary mass consistent with an adenoma. Which of the following is the most appropriate treatment?
A. Testosterone replacement therapy
B. Clomiphene citrate
C. Cabergoline
D. Sildenafl

Answer 114

C. Cabergoline

Question 115

A 79-year-old man was admited to the Intensive Care Unit with features of septcaemia due to severe urinary tract infecton. His blood tests showed thyroid dysfuncton that was atributed to a non-thyroidal iliness or sick euthyroid state. Which one of the following is the common typical patern of thyroid dysfuncton seen in a sick euthyroid illness?
A. Elevated levels of T3 and T4; low levels of reverse T3
B. Elevated levels of T3, T4, and reverse T3
C. Low levels of T3 and T4; elevated levels of reverse T3
D. Low levels of T3 and T4; normal level of reverse T3

Answer 115

C. Low levels of T3 and T4; elevated levels of reverse T3

Question 116

A 24-year-old man presented to thyroid clinic with a 5-month history of feeling unwell, weight loss, anxiety, and panic atacks. He also complained of redness and gritness of eyes, with painful eye movements. On examinaton, he had bilateral tremors, proposis, and lid retracton, Which one of the following factors is associated with increased risk for the development of severe Grave’s orbitopathy?
A. No response to thionamides
B. Free T4 and T3 levels
C. Male sex
D. Smoking

Answer 116

D. Smoking

Question 117

A 39-year-old man incidentally found to have a 2-cm lef adrenal gland mass while she underwent CT of the abdomen to investgate the cause of her pelvic pain. Which one of the following is the most common cause of an incidentally detected adrenal mass?
A. Sub-clinical cushing’s disease
B. Adrenocortcal carcinoma
C. Non-functonal adenoma
D. Conn’s syndrome

Answer 117

C. Non-functonal adenoma

Question 118

A 40-year-old woman was incidentally detected to have a 13-mm pituitary macro-adenoma on a CT of the head arranged to evaluate cause for her recurrent headaches. Apart from the headaches that she had sufered for the last 8 months, she had no history of any signifcant medical illness and was not on any regular medicatons. Her general physical and systemic examinaton was unremarkable. Which of the following is the most appropriate next step in her management?
A. Anterior pituitary hormone profle
B. Discharge from follow-up
C. Neurosurgical referral
D. Insulin tolerance test

Answer 118

A. Anterior pituitary hormone profle

Question 119

A 25-year-old woman complains of dizziness and feeling light-headed. She is a teacher and most frequently experiences this when she stand up in the class. She has never fainted. She lost 5 kg, but atributes this to eatng healthy food. She has notced a recent scar on the back of her hand, which has started to turn very dark as well as generalized skin hyperpigmentaton. What is the most appropriate investgaton to confrm the diagnosis?
A. Synacthen test ( ACTH stmulaton test)
B. Abdominal ultrasound (US) scan
C. Low-dose dexamethasone test
D. Am cortsol measurement

Answer 119

A. Synacthen test ( ACTH stmulaton test)

Question 120

Dipeptdyl peptdase inhibitors 4 (DPP4) are novel oral hypoglycaemic agents that inhibit the enzyme DPP4 and prevent breakdown of endogenous incretns, which will improve blood sugar control in patents with diabetes mellitus type 2. Which of the following DPP4 inhibitor does not require any dose modifcaton in renal disease?
A. Vildagliptn
B. Linagliptn
C. Saxagliptn
D. Sitagliptn

Answer 120

B. Linagliptn

Question 121

A 50-year-old woman recently diagnosed with papillary thyroid carcinoma. Which of the following is an example of positve communicaton skill while explaining the management opton of her disease?
A. Forgetng to say thank you
B. Ask a patent to repeat your instructons
C. Interrupt a patent when she ask questons
D. Inform patents when you cannot spend any more tme with them

Answer 121

B. Ask a patent to repeat your instructons

Question 122

A 30-year-old woman recently diagnosed with Cushing’s syndrome. which of the following will be considered as negatve communicaton skill while explaining for her the course of her disease?
A. Speaking slowly with clear language
B. Looking directly at a patent when speaking
C. Interrupt a patent when he/she does not understand
D. Encouraging the patent to ask questons

Answer 122

C. Interrupt a patent when he/she does not understand

Question 123

At which estmated GFR level, metormin should be stopped in diabetc patents?
A. GFR between 45-60
B. GFR between 30-45
C. GFR less than 30
D. GFR less than 15

Answer 123

C. GFR less than 30

Question 124

Which of the following osteoporosis treatment has FDA approval to treat malignancy induced hypercalcemia?
A. Denosumab
B. Alendronate
C. Ibandronate
D. Recombinant human 1-34 PTH (teriparatde)

Answer 124

A. Denosumab

Question 125

A 35-year-old pregnant woman with gestatonal age of 30-weeks comes for a follow-up. She was diagnosed to have gestatonal diabetes mellitus (GDM) at week 24, she was maintained on diet control but unfortunately her blood sugar reading between (150-200 mg/di). The physician decided to start insulin but she is totally refusing injectons and she asks about any safe oral medicaton to be used in pregnancy. Which of the following oral hypoglycemic agents has safety data and recommended to be used in pregnancy?
A. Glipizide
B. Sitagliptn
C. Glyburide
D. Rosiglitazone

Answer 125

C. Glyburide

Question 126

A 44-year-old man with a strong family history of type 2 diabetes and cardiovascular disease was recently diagnosed with pre-diabetes. He came for advice regarding healthy eatng paterns and physical actvity that will help him to prevent type 2 diabetes (see lab result). BMI 31 kg/m2 Test Result Normal Values HbA1C 6.1 4.7-5.6 % In helping this individual to achieve and maintain his target weight loss, which of the following is the best advice?
A. Reducing caloric intake
B. Exercising 30 minutes per day on 5 days per week
C. Diet low in protein and relatvely higher in carbohydrates
D. Exercise for at least 30 minutes most days of the week and low carbohydrate diet

Answer 126

D. Exercise for at least 30 minutes most days of the week and low carbohydrate diet

Question 127

A 29-year-old woman comes to the clinic for a follow-up. She is diagnosed with gestatonal diabetes mellitus (GDM) at week 24. She is asking for an advice regarding the best dietary habits she can follow to control her blood sugar and avoid insulin injecton. Which of the following is the best diet opton?
A. Low fat diet
B. Mediterranean diet
C. Low glycemic index diet
D. Energy restricton is not recommended during pregnancy

Answer 127

C. Low glycemic index diet

Question 128

A 62-year-old woman receives a diagnosis of prediabetes based on routne lab work showing mildly elevated glycated hemoglobin (HbA1c. She has had obesity for many years. She eats a diet rich in processed foods. She rarely exercises. Physical exam reveals mildly elevated blood pressure along with trace acanthosis nigricans at the nape of the neck. Blood Pressure 145/87 mmH BMI 30 kg/m2 What advice should be given to reduce her risk of developing diabetes, in additon to increasing her physical actvity to >150 minutes per week?
A. Low glycemic index diet to produce 5-10 % weight loss
B. Low fat diet to produce 5-10 % weight loss
C. Diet is less efectve than metormin to reduce the risk of diabetes
D. Low carbohydrate diets are more likely than low fat diets to prevent diabetes in the long-term

Answer 128

B. Low fat diet to produce 5-10 % weight loss

Question 129

A 40-year-old man comes to the clinic for evaluaton and management of obesity. His obesity is complicated by type 2 diabetes mellitus (T2DM), hypertension, sleep apnea, dyslipidemia, chronic low back pain, osteoarthrits of the knees, and depression. He was prescribed medicatons for these problems but that he is not compliant to treatments. His wife accompanied him to the visit was anxious about his health and she want the doctor to council him for the best solutons he can do. BMI 55 kg/m2 Which of the following is the most appropriate advice will help in treatng this patent?
A. Emphasizing the importance of adherence to his medicatons
B. Referral to an orthopedic surgeon for knee arthroplastes
C. Additon of pharmacotherapy for obesity
D. Referral for bariatric surgery

Answer 129

D. Referral for bariatric surgery

Question 130

A 39-year-old woman with type 1 diabetes for 20 years was married recently; she and her husband want to get pregnant. The woman has hypertension treated with an angiotensin convertng enzyme (ACE) inhibitor and a diuretc with maintenance of blood pressure at 118/80 mmHg. Her insulin doses are all administered through a contnuous insulin infusion pump using insulin aspart. She reported that she would try to become pregnant next month (see lab results). Test Result Normal Values 24 hr urine protein 2000 0.8-14 mg/di (Male) 2.5-11 mg/dI (Female) Creatnine 88 44-115 mol/L HbA1C 8.0 4.7-5.6 % What is the best advice at this moment to control her blood sugar and prevent congenital malformaton?
A. Eliminate snacks and begin to take 3 heavy meals daily
B. Substtute an angiotensin receptor blocker for her ACE inhibitor
C. Her age and risk factors indicate the need to begin taking a statn at this tme
D. Delay concepton untl her HbA1c is as close to normal as possible, if this can be safely achieved

Answer 130

D. Delay concepton untl her HbA1c is as close to normal as possible, if this can be safely achieved

Question 131

A 25-year-old woman pregnant at 15 weeks presents to the clinic complaining of palpitaton, tremor and diarrhea for the last 3 weeks. On examinaton, she looks anxious, she has graves ophthalmopathy and goiter. Other systemic examinaton are unremarkable. Diagnosis of grave’s disease was confrmed but she is refusing to start any treatment while she is pregnant (see lab results). Blood pressure 110/65 mmHg Heart rate 125 /min Respiratory rate 18 /min Temperature 37.6 °C BMI 20 kg/m2 Test Result Normal Values Thyroid-Stmulatng Hormone < 0.01 0.4 - 5.0 U/mL Triiodothyronine (T3 free serum) 10.0 3.5 - 6.5 pmol/L Thyroxine (T4 free serum) 35.0 8.5 - 15.2 pmol/L Which of the following is the most appropriate acton?
A. Agree with her opinion and discharge her from the clinic
B. Call her husband and force her to start the treatment
C. Give her follow up afer 2 months and repeat her thyroid functon test
D. Explain clearly the risk for her and the fetus and try to convince her to start the treatment Immediately

Answer 131

D. Explain clearly the risk for her and the fetus and try to convince her to start the treatment Immediately

Question 132

A 45-year-old man presented to the clinic with large thyroid nodule otherwise asymptomatc, that was proven to be papillary thyroid carcinoma. The physician is planning to send him for total thyroidectomy but the patent is afraid from the surgical complicaton. The treatng physician needs to create a lastng impression at the end of the consultaton. Which of the following is the most appropriate acton?
A. Avoid answering all patent’s questons
B. Patent’s agreement for referral is not required
C. Avoid discussing the serious surgical complicatons
D. Briefy explain the acton plan with possible expected and unexpected outcome

Answer 132

A. Avoid answering all patent’s questons

Question 133

A 22-year-old man developed traumatc paraplegia secondary to a road trafc accident about 8 months ago, requiring prolonged immobilizaton. His general physical and systemic examinaton were unremarkable and intact PTH levels (see lab results). Test Result Normal Values Calcium 2.75 2.15-2.62 mmol/L Phosphate, inorganic 0.9 0.82-1.51 mmol/L Parathyroid hormone 1.0 1.1-5.3 pmol/L Which of the following is the most probable underlying aetology for his hypercalcaemia?
A. Malignancy
B. Immobilization
C. Multple myeloma
D. Primary hyperparathyroidism

Answer 133

B. Immobilization

Question 134

A 40-year-old man was referred to the endocrine clinic with symptoms of reduced libido and lack of energy for the last 10 months. On examinaton, he had normal general physical and systemic examinaton (see lab results and report). BMI 40 kg/m2 Test Result Normal Values Thyroid-Stmulatng Hormone 0.3 0.4 - 5.0 wU/mL. Thyroxine (T4 free serum) 7.5 8.5 - 15.2 pmol/L Follicle-stmulatng hormone 2.5 5-20 IU/L (Follicular phase) 15-35 IU/L (Mid cycle peak) 5-15 IU/L (Luteal phase) 50-100 IU/L (Postmenopausal women) 5-20 IU/L (men) Testosterone 8.0 10.4-41.6 mol/L (Male) 0.7-2.8 nmol/L (Female) Luteinizing hormone 1.3 3-15 U/L (Male) 5-22 U/L (Follicular phase) 5-22 U/L (Luteal phase) 30-250 U/L (ovulatory phase) > 30 U/L (Postmenopausal) Prolactn 450 < 652 pmol/L (Male) < 870 pmol/L (Female) MRI brain: Showed 2.5 cm pituitary adenoma. Which of the following is the most likely diagnosis?
A. Morbid obesity
B. Macroprolactnoma
C. Primary hypothyroidism
D. Non-functoning pituitary adenoma

Answer 134

D. Non-functoning pituitary adenoma

Question 135

An 18-year-old boy was referred to the Endocrine Clinic with features of short height and weight gain. On examinaton, he had increased BMI and central adiposity together with purple striae on lower abdomen (see lab results). Test Result Normal Values ACTH 20 2-11 pmol/L Cortsol 8 a.m. 600 138-635 mol/L
Cortsol 4 p.m. 550 83-441 mol/L Cortsol 1 hr afer cosyntropin > 500 > 498 mol/L Which of the following is the most appropriate next step in his management?
A. Bilateral inferior petrosal sinus sampling
B. CT abdomen and thorax
C. MRI of the pituitary
D. Octreotde scan

Answer 135

C. MRI of the pituitary

Question 136

A 25-year-old man was referred to the Endocrine Clinic with a recent history of fragility fracture. He had no signifcant past medical history and was on no medicaton. On examinaton, he had sparse facial and axillary hair growth. His systemic examinaton was unremarkable. BMI 23 kg/m2 Which of the following investgatons useful in establishing the aetology of his fragility fractures?
A. Calcitonin level
B. DEXA bone densitometry scan
C. Insulin like growth factor (IGF1)
D. Testosterone and gonadotrophin levels

Answer 136

D. Testosterone and gonadotrophin levels

Question 137

A 40-year-old man was incidentally detected to have a benign 2.0-cm right adrenal adenoma on CT of the abdomen, which was done to evaluate his symptom of abdominal pain. On examinaton, he had unremarkable general physical and systemic examinaton. Blood pressure 130/70 mmHg, BMI 26 kq/m2 Which of the following is the most appropriate next step in management?
A. MIBG scan
B. MRI adrenals
C. Surgical referral
D. Dexamethasone suppression test (overnight) and urinary metanephrines

Answer 137

D. Dexamethasone suppression test (overnight) and urinary metanephrines

Question 138

A 35-year-old man was found to have a 5.5-cm lef adrenal mass with irregular borders and a density of > 10 HU on non-contrast CT of the abdomen. On contrast-enhanced CT of the abdomen, there is <30% contrast wash out at 15 minutes. In view of the suspicious radiological features of the mass, the patent was referred to the endocrine surgical team for an electve adrenalectomy. Which of the following investgatons should be done prior to an electve adrenalectomy?
A. 24-hour urinary fractonated metanephrines
B. Aldosterone to plasma renin actvity rato
C. Fine needle aspiraton cytology
D. PET scan

Answer 138

A. 24-hour urinary fractonated metanephrines

Question 139

A 30-year-old woman presents with recurrent atacks of dyspnea and cough when exposed to dust and perfumes. Physical examinaton is normal except for mild expiratory wheeze on lung auscultaton (see report). Spirometry: Reversible bronchospasm. Which of the following is most appropriate to initate at this stage?
A. Inhaled totropium
B. Inhaled salbutamol
C. Inhaled budesonide
D. Montelukast

Answer 139

B. Inhaled salbutamol

Question 140

A 60-year-old man with a history of 20-pack-year smoking presents with exertonal dyspnea and productve cough for 3 months. He had similar atack last year. On examinaton, he has central cyanosis and expiratory wheeze on lung auscultaton (see lab resuits) Test Result Normal Values ABG HCO3- 36 22-28 mmol/L ABG PCO2 7.7 4.7-6.0 kPa рН 7.35 7.36-7.45 ABG P02 8.4 10.6-14.2 kPa Which of the following is the most likely diagnosis?
A. Bronchial asthma
B. Chronic bronchits
C. Pulmonary embolism
D. Intersttal pulmonary fbrosis

Answer 140

B. Chronic bronchits

Question 141

A 70-year-old man heavy smoker, presents with lef sided chest pain and hemoptysis for 2 days. Recently his son has notced change in the quality of his father’s voice. On examinaton, he has early digital clubbing and both of his wrists are painful and tender. Blood pressure 110/70 mmHg Heart rate 85 /min Respiratory rate 22 /min Temperature 36.6 °C Oxygen saturaton 92 % Which of the following is the most likely diagnosis?
A. Tuberculosis
B. Bronchiectasis
C. Pulmonary embolism
D. Bronchogenic carcinoma

Answer 141

D. Bronchogenic carcinoma

Question 142

In a patent with acute asthmatc atack, which of the following is the most recommended tool to assess the response to therapy?
A.Chest radiography
B. Arterial blood gas
C. Pulsus paradoxus
D. Peak fow meter

Answer 142

D. Peak fow meter

Question 143

A 65-year-old smoker is being evaluated for pleural efusion. He has cough, dyspnea and hemoptysis. On examinaton, signs of massive pleural efusion are present on right side but the trachea and apex beat are not shifed. Which of the following explains these clinical fndings?
A. Heart failure
B. Tubercular pleural efusion
C. Efusion due to esophageal rupture
D. Carcinoma, obstructng ipsilateral main bronchus

Answer 143

D. Carcinoma, obstructng ipsilateral main bronchus

Question 144

A 45-year-old man is diagnosed to have pulmonary tuberculosis for which he was started on 4 ant-tuberculous drugs 2 months ago. During routne follow up, his blood work shows hyperuricemia (see lab result). Test Result Normal Values Uric acid 600 200-410 mol/L (Male) 140-360 mol/L (Female) What ant-TB drug is responsible for this fnding?
A. Isoniazid
B. Rifampicin
C. Ethambutol
D. Pyrazinamide

Answer 144

D. Pyrazinamide

Question 145

A 32-year-old man is seen in the clinic for evaluaton of primary infertlity. Past medical history is signifcant for recurrent sinusits. Sperm analysis shows normal number of sperms, but they are immotle (see report). Chest radiography: shows situs inversus. Which of the following is the most likely diagnosis?
A. Cystc fbrosis
B. Kartagener’s syndrome
C. Wegner’s granulomatosis
D. Good pasture’s syndrome

Answer 145

B. Kartagener’s syndrome

Question 146

A 40-year-old man presents to the Emergency Department complaining of progressive dyspnea over 5 days. Past medical history is signifcant for road trafc accident 2 week ago. Lung auscultaton revealed absent breath sounds in the right side (see image and lab results). Blood pressure 100/70 mmH Heart rate 90 /min Respiratory rate 24 /min Temperature 36.6 °C Oxygen saturaton 90 % Test Result Normal Values Hb 90 130-170 g/L (Male) 120-160 g/L (Female) WBC 6 4.5-10.5 x 109/L Which of the following is the most appropriate management?
A. Antbiotcs
B. Antcoagulaton
C. Chest tube inserton
D. Salbutamol nebulizer

Answer 146

C. Chest tube inserton

Question 147

A male farmer with chronic liver disease secondary to repeated infectons of schistosoma mansoni complains of progressive dyspnea. Examinaton revealed elevated JVP, clear lung felds and lef parasternal heave. What is the likely complicaton that has occurred?
A. Bronchiectasis
B. Pulmonary embolism
C. Constrictve pericardits
D. Pulmonary hypertension

Answer 147

D. Pulmonary hypertension

Question 148

A 45-year-old man presents with 5-year history of cough, productve of large volume of sputum associated with dyspnea and hemoptysis. On examinaton, he has clubbing and course crackles in the right base. Which of the following tests has the highest diagnostc value?
A. X-ray chest
B. Bronchoscopy
C. High resoluton CT chest
D. Pulmonary functon tests

Answer 148

C. High resoluton CT chest

Question 149

A 50-year-old woman with pulmonary hypertension is being evaluated for a possibility of chronic thromboembolic disease. Which of the following investgatons has the highest diagnostc value?
A. Echocardiogram
B. Electrocardiography
C. Spiral CT chest with contrast
D. Ventlaton-perfusion lung scan

Answer 149

D. Ventlaton-perfusion lung scan

Question 150

Which of the following drugs is a leukotriene receptor antagonist?
A. Infiximab
B. Tenofovir
C. Montelukast
D. Voriconazole

Answer 150

C. Montelukast

Question 151

According to the World Health Organizaton classifcaton of pulmonary hypertension, which of the following conditons falls under group 3?
A. Portal hypertension
B. Lef ventricular failure
C. Chronic thromboembolic disease
D. Lung fbrosis with chronic hypoxemia

Answer 151

D. Lung fbrosis with chronic hypoxemia

Question 152

A 55-year-old man presents with progressive dyspnea and cough for 6 weeks. He is a heavy smoker. 2 weeks ago, he started having headaches and notced swelling of his face. Physical examinaton reveals prominent non-pulsatng neck veins, pufness of the face and edema of the upper limbs (see report). Chest X-ray: Shows a prominence of the right hilum. Which of the following types of lung cancer is the most commonly associated with this clinical presentaton?
A. Adenocarcinoma of the lung
B. Carcinoid tumor of the lung
C. Squamous cell lung cancer
D. Small cell lung cancer

Answer 152

D. Small cell lung cancer

Question 153

An asymptomatc 60-year-old man, non-smoker presents for a routne annual physical check- up. A chest X-ray showed an opacity, which is less than 3 cm in the lef upper lobe. which of the following is the next best step in the management?
A. Surgical resecton
B. Review old chest X-ray
C. CT chest with IV contrast
D. CT-guided transthoracic needle biopsy

Answer 153

B. Review old chest X-ray

Question 154

A 55-year old man with stable COPD, presents with sudden onset lef-sided pleuritc chest pain and exertonal dyspnea. On examinaton, he is not in distress. the trachea is central and breath sounds are equal in both sides with occasional mild expiratory wheezes (see report). Blood pressure 130/70 mmHg Heart rate 80 /min Respiratory rate 22 /min Temperature 36.6 °C Oxygen saturaton 93 % Chest X-ray: Shows a lef sided pneumothorax measuring 2 cm between the lung and chest wall. Which of the following is the most appropriate next step in management?
A. Needle aspiraton
B. Chest tube inserton
C. Perform pleurodesis
D. Oxygenation and observaton

Answer 154

D. Oxygenation and observaton

Question 155

A 20-year-old woman presents to the Out-Patent Department with mild dyspnea, malaise, low-grade fever and arthralgia. Physical examinaton showed tender erythematous nodules measuring 2-3 cm in both shins. Chest auscultaton revealed fne basal crackles. Which of the following is the next best acton in management?
A. Blood culture
B. Oral steroids
C. Chest X-ray
D. Skin biopsy

Answer 155

C. Chest X-ray

Question 156

Which of the following is the best oxygen delivery system in a patent with Chronic Obstructve Pulmonary Disease?
A. Simple face mask
B. Rebreathing bag
C. Nasal cannula
D. Venturi mask

Answer 156

D. Venturi mask

Question 157

A 65-year-old man known to have COPD presented to the Emergency Department with increasing dyspnea, cough, expectoraton and fever. Inital assessment revealed fully conscious patent with mild distress, central cyanosis and bilateral wheezing on chest auscultaton. The patent was started on high fow oxygen and salbutamol nebulizer but 1 hour later, his level of consciousness is reduced (see lab result) Test Result Normal Values ABG HCO3. 36 22-28 mmol/L ABG PCO2 9 4.7-6.0 kPa pH 7.18 7.36-7.45 ABG PO2 15 10.6-14.2 kPa Which of the following is the best inital step in management?
A. Start mechanical ventlaton
B. Reduce oxygen fow
C. Order brain CT scan
D. Give naloxone

Answer 157

B. Reduce oxygen fow

Question 158

A 30-year-old postpartum woman is admited to the General Ward with diagnosis of right leg DVT. She was started on enoxaparin 80 mg bid, but in the same day of admission, she developed sudden onset dyspnea and right pleuritc chest pain. On examinaton, she was dyspneic and apprehensive. Heart sounds showed loud P2 and lungs were clear to auscultaton (see lab results and report). Blood pressure 125/70 mmHg Heart rate 100 /min Respiratory rate 22 /min Temperature 36.6 °C Oxygen saturaton 95 % Test Result Normal Values ABG HCO3- 22 22-28 mmol/L ABG PCO2 4.2 4.7-6.0 kPa pH 7.48 7.36-7.45 ABG PO2 12 10.6-14.2 kPa Spiral CT chest: Thrombus in the right lower pulmonary artery. Which of the following is the most appropriate step in management?
A. Change enoxaparin to sodium heparin
B. Treat with thrombolytc therapy
C. Continue the same management
D. Perform invasive thrombectomy

Answer 158

C. Continue the same management

Question 159

A 40-year-old man with paraplegia following road trafc accident one year ago is brought to the Emergency Department because of sudden onset dyspnea and chest pain. On examinaton, he is in severe distress and cyanosed. He has lef parasternal heave and loud P2. Chest is clear to auscultaton (see lab results and reports). Blood pressure 80/55 mmHg Heart rate 110 /min Respiratory rate 30 /min Temperature 36.6 °C Oxygen saturaton 86 % Test Result Normal Values ABG HCO3- 22 22-28 mmol/L ABG PCO2 4.2 4.7-6.0 kPa pH 7.4 7.36-7.45 ABG PO2 8.6 10.6-14.2 kPa Echocardiogram: Dilated right ventricle with pulmonary artery pressure of 55 mmHg. Venous Doppler: Confrmed DVT in the lef leg extending to the thigh. Which of the following is the best line of management?
A. Inserton of vena-caval flter
B. Alteplase infusion
C. Enoxaparin
D. Warfarin

Answer 159

B. Alteplase infusion

Question 160

A 50-year-old woman presented with fever, dyspnea and weight loss. Physical examinaton showed evidence of pleural efusion in the lef hemithorax (see report). Pleural fuid analysis: Shows exudatve fuid with high gamma interferon level. Which of the following is the most likely diagnosis?
A. Empyema
B. Mesothelioma
C. Parapneumonic efusion
D. Tuberculous pleural efusion

Answer 160

D. Tuberculous pleural efusion

Question 161

A 55-year-old man with COPD, presented with increasing dyspnea, cough and bilateral lower limb swelling. Physical examinaton showed elevated JVP, hepatomegaly and pitng edema in both lower limbs. Chest auscultaton revealed scatered rhonchi in both sides. Which of the following is the most appropriate next step in management?
A. Spirometry
B. Echocardiogram
C. Venous Doppler of lower limbs
D. High resoluton CT scan of chest

Answer 161

B. Echocardiogram

Question 162

In a patent with COPD and cor pulmonale, which of the following improves survival?
A. Montelukast
B. Inhaled steroids
C. Long term oxygen therapy
D. Long actng beta agonist inhaler

Answer 162

C. Long term oxygen therapy

Question 163

A 30-year-old woman is evaluated for a 6-month history of recurrent dyspnea, cough, and wheezing. She is awakened with asthma symptoms 6-8 nights a month. Her current medicaton is salbutamol inhaler. On examinaton, there are wheezes in both lung felds. Which of the following is the most appropriate next best step in management?
A. Montelukast
B. Long-actng B-agonist
C. Inhaled budesonide/formoterol
D. Inhaled budesonide and inhaled albuterol as needed

Answer 163

C. Inhaled budesonide/formoterol

Question 164

A 30-year-old woman complains of recurrent atacks of sudden onset dyspnea, chest and throat tghtness. Inhaled salbutamol is of litle help; however, her symptoms improves suddenly. On examinaton, she is found to have inspiratory wheeze during dyspnea spells. which of the following is the likely cause of symptoms?
A. Bronchial asthma
B. Endobronchial foreign body
C. Gastrosophageal refux disease
D. Vocal cord dysfuncton syndrome

Answer 164

D. Vocal cord dysfuncton syndrome

Question 165

A 55-year-old obese non-smoker man with hypertension presents with exertonal dyspnea for 2 years. His wife stated that he is uncomfortable while sleeping at night and produces loud snores. Examinaton revealed central cyanosis, sufused conjunctvae and clear chest. BMI 40 kg/m2 Which of the following has the highest diagnostc value?
A. Spirometry
B. Spiral CT chest
C. Polysomnography
D. Methacholine challenge test

Question 166

A 55-year-old obese non-smoker man presents with loud snoring, daytme somnolence and exertonal dyspnea for 4 years. Examinaton revealed central cyanosis: sufused conjunctvae and clear chest (see lab results). BMI 40 kg/m2 Test Result Normal Values ABG HCO3- 38 22-28 mmol/L ABG PCO2 6.9 4.7-6.0 kPa pH 7.38 7.36-7.45 ABG PO2 9 10.6-14.2 ka Which of the following is the best treatment afer polysomnography?
A. Home oxygen by venturi mask
B. Inhaled totropium
C. Home nasal CPAP
D. Oral prednisone

Answer 166

C. Home nasal CPAP

Question 167

A 65-year-old man with idiopathic bronchiectasis presents with persistent cough of large amount of mucoid sputum and dyspnea on exerton. He is compliant with his medicatons, which include azithromycin. Physical examinaton showed fnger clubbing and mild bilateral coarse crackles. Which of the following is the most appropriate treatment opton?
A. Prednisone
B. N-Acetylcystne
C. Saline nebulizer
D. Postural sputum drainage

Answer 167

D. Postural sputum drainage

Question 168

A 60-year-old man known to have COPD refused the advice to stop smoking. What is the best statement should be given to him during a communicaton session?
A. “You beter stop smoking otherwise you will die”
B. ‘We will do everything to help you stop smoking”
C. “We have to talk to your family about this refusal”
D. “If you don’t stop smoking we will stop seeing you in the clinic”

Answer 168

B. ‘We will do everything to help you stop smoking”

Question 169

A 56-year-old man who has chronic productve cough underwent a CT chest, which was consistent with bronchiectasis. He came today to discuss his disease. Which of the following would convey the diagnostc informaton to him?
A. Read to him the CT report
B. Show him the chest X-ray flm
C. Inform him that he has bronchiectasis
D. Tell him that his air tubules are infamed and damaged

Answer 169

C. Inform him that he has bronchiectasis

Question 170

A young patent has poorly controlled asthma and her doctor decided to start her on oral steroids. She is uncomfortable about that decision. When counselling this patent, what is the most important communicaton aspect should be addressed?
A. Her living conditons
B. The patent’s concerns
C. Dealing with her anger
D. The scientfc basis of using steroids

Answer 170

B. The patent’s concerns

Question 171

A 74-year-old man, who smokes for 40 years, underwent a CT chest, which showed a large lung mass.Which of the following is the most appropriate way to break the bad news?
A. Avoid wastng tme and tell him directly that he has lung cancer
B. Inform him that this is nothing to worry about
C. Inform him that he should stop smoking
D. Deliver the informaton in small steps

Answer 171

D. Deliver the informaton in small steps

Question 172

A patent with intersttal lung disease has repeated admissions for pneumonia. His son is worried about antbiotcs induced diarrhoea. Which of the following is the most appropriate way to address this situaton?
A. Tell him that the diarrhea is not serious
B. Stress that the hospital infecton control policy will be implemented
C. Agree with him that the antbiotcs should be stopped
D. Apologize for repeatedly using antbiotcs to treat his father

Answer 172

B. Stress that the hospital infecton control policy will be implemented

Question 173

A 28-year-old man, who is a known drug addict, is found in deep coma and cyanosed. Blood pressure 100/55 mmH Heart rate 55 /min Respiratory rate 8 /min Oxygen saturaton 85 % Which of the following is the most important inital management?
A. Obtain detailed history from the family
B. Mechanical ventlaton
C. Do gastric lavage
D. Brain CT scan

Answer 173

B. Mechanical ventlaton

Question 174

A 53-year-old man with liver cirrhosis presents with several episodes of vomitng of blood and black tarry stool. Blood pressure: Supine 105/60 mmH Sitng 85/50 mmHg Heart rate: Supine 90 /min Sitng 110 /min Which of the following is the most appropriate next step in management?
A. Nasogastric tube placement
B. Urgent upper GI endoscopy
C. Resuscitaton with adequate IV fuids

Answer 174

C. Resuscitaton with adequate IV fuids

Question 175

An elderly man, known to have COPD is brought to Emergency Department with severe respiratory distress, cyanosis and drowsiness. His upper airways were full of secretons (see lab results). Blood pressure 90/60 mmH Heart rate 110 /min Respiratory rate 18 /min Temperature 38.0 °C Oxygen saturaton 74 % Test Result Normal Values
ABG HCO3 36 22-28 mmol/L ABG PCO2 7.99 4.7-6.0 kPa pH 7.24 7.36-7.45 ABG PO2 8.99 10.6-14.2 kPa Which of the following is the best opton in management?
A. Nasal CPAP
B. Mechanical ventlaton
C. Aminophylline infusion
D. Oxygen administraton via face mask

Answer 175

B. Mechanical ventlaton

Question 176

A 40-year-old woman is admited with diagnosis of Guillain Barre Syndrome. Which of the following would be the most appropriate method for monitoring ventlatory impairment?
A. Rapid shallow breathing index
B. Serial arterial blood gas measurements
C. Bedside measurement of vital capacity
D. Contnuous monitoring of oxygen saturaton

Answer 176

C. Bedside measurement of vital capacity

Question 177

A 60-year-old man with diabetes mellitus and ischemic heart disease is admited to the Critcal Care Unit in shock. The following parameters are obtained from pulmonary artery catheterizaton (see table). Pulmonary Artery Catheter Test Result Normal Values Right atrial pressure 2 2-8 mmHg Pulmonary artery pressure 15/3 16-24/5-12 mmHg Wedge pressure 4 5-12 mmHg Cardiac output 2.5 4-6 L/min Systemic vascular resistance 1800 800-1200 dyne/s/cm5 Which of the following is the most likely diagnosis?
A. Cardiogenic shock
B. Septcemic shock
C. Hypovolemic shock
D. Pulmonary embolism

Answer 177

C. Hypovolemic shock

Question 178

A 45-year old man is just admited to the Critcal Care Unit with polytrauma following road trafc accident because of hypotension. He is sedated and mechanically ventlated. His heart sounds are distant with no added sounds. Lung auscultaton showed equal air entry to both sides with no added sounds (see report). Blood pressure 85/55 mmHg Heart rate 110 /min Temperature 36.0 °C Oxygen saturaton 100 % Central venous pressure: Right atrial pressure 15 mmHg Chest radiograph: Cardiomegaly and fractured sternum. Both lungs are normal. Which of the following is the most likely diagnosis?
A. Fat embolism
B. Septcemic shock
C. Hypovolemia due to internal bleeding
D. Cardiac tamponade due to hemopericardium

Answer 178

D. Cardiac tamponade due to hemopericardium

Question 179

A 35-year-old man is evaluated in the Orthopedic Ward because of dyspnea, tachycardia and confusion. The patent had fractured lef femur for which he undergone internal fxaton 2-days ago. He is on enoxaparin as prophylaxis and pain-killer as needed. On examinaton, the heart sounds are normal and there are scatered crepitatons in both lung felds. Petechial rash around the neck and axillae are notced (see lab result and reports). Blood pressure 120/70 mmH Heart rate 110 /min Respiratory rate 26 /min Temperature 37.8 °C Oxygen saturaton 85 % Test Result Normal Values ABG HCO3- 22 22-28 mmol/L ABG PCO2 4.7 4.7-6.0 kPa pH 7.26 7.36-7.45 ABG P02 9.5 10.6-14.2 kPa Chest radiograph:Bilateral difuse alveolar infltrate. Electrocardiogram: Sinus tachycardia. Which of the following is the most likely diagnosis?
A. Pulmonary thromboembolism
B. Fat embolism syndrome
C. Aspiraton pneumonia
D. Septcaemia

Answer 179

B. Fat embolism syndrome

Question 180

A 65-year-old woman with diabetes mellitus and old myocardial infarcton is admited to the Intensive Care Unit with urosepsis and septc shock. Her blood pressure did not respond to fuid challenge for which she is started on norepinephrine infusion. She has hypoxia despite optmizing the ventlator parameters and Fi02 of 100% (see table and report). Pulmonary Artery Catheter Test Result Normal Values Right atrial pressure 3 2-8 mm Hg Pulmonary artery pressure 13/3 16-24/5-12 mm Hg Wedge pressure 5 5-12 mm Hg Cardiac output 4 4-6 L/min Chest X-ray: Bilateral lung infltrate. Which of the following is the most likely cause of the lung infltrate?
A. Adult Respiratory Distress Syndrome
B. Cardiogenic pulmonary edema
C. Pulmonary embolism
D. Volume overload

Answer 180

A. Adult Respiratory Distress Syndrome

Question 181

A 50-year-old man with diabetes and hypertension, presents to the Emergency Department with sudden onset lef sided body weakness for 4 hours. On examinaton, he has lef sided upper motor neuron facial palsy and lef sided hemiparesis. Which of the following is the best next step in management?
A. Aspirin
B. Brain MRI
C. Clopidogrel
D. Brain CT-scan

Answer 181

D. Brain CT-scan

Question 182

A 16-year-old boy presents with a several days history of progressive arm and leg weakness. No diplopia or loss of sphincter control. He has been well except for an upper respiratory infecton 2 weeks ago. On examinaton, his breathing is slow and shallow. His heart rate and blood pressure are fuctuant. There is symmetrical weakness of the face and all four extremites. Deep tendon refexes are absent, and sensatons are intact. Which of the following is the most likely diagnosis?
A. Polymyosits
B. Myasthenia gravis
C. Transverse myelits
D. Guillain-Barre syndrome

Answer 182

D. Guillain-Barre syndrome

Question 183

A 45-year-old man presents with an 8-week history of severe headache. The headaches have occurred at the same tme each day, about 2 a.m. and last around 30 minutes. Headaches are accompanied by lacrimaton and redness of the right eye. Which of the following is the best to prevent this type of headache?
A. Verapamil
B. Propranolol
C. Sumatriptan
D. 100% oxygen

Answer 183

A. Verapamil

Question 184

A 55-year-old man with diabetes and hypertension complains of pain in the right eve and double vision when looking to the lef. On examinaton, there is ptosis, limited adducton, elevaton, and depression of the right eye. The pupils are equal and reactve in both sides. Fundoscopy and other cranial nerve are normal as well as the rest of neurological examinaton of the upper and lower limbs.Which of the following is the most likely cause of these fndings?
A. Posterior communicatng artery aneurism
B. Diabetc third nerve neuropathy
C. Cavernous sinus thrombosis
D. Mid brain tumor

Answer 184

B. Diabetc third nerve neuropathy

Question 185

An 18-year-old boy known to have grand mal epilepsy since childhood is brought to the Emergency Department afer having repeated tonic-clonic seizures at home. He is compliant with his medicaton, which is sodium valproate. In the Emergency Department, he is unconscious and contnuously convulsing. Afer oxygenaton and securing the airway, which of the following intravenous drugs should be administered?
A. Phenytoin
B. Diazepam
C. Thiopental
D. Phenobarbitone

Answer 185

B. Diazepam

Question 186

In a patent with Guillain Barre Syndrome, which of the following is the best treatment opton?
A. Pulse steroid
B. Cyclosporine
C. Plasmapheresis
D. Cyclophosphamide

Answer 186

C. Plasmapheresis

Question 187

A 30-year-old woman presents with pain in the right eye associated progressive visual loss over 2 days. She also reported a numbness in the lef side of the face and weakness in both lower limbs. Physical examinaton revealed reduced visual acuity, loss of direct light refex with preserved indirect light refex in the right eye. Lower limbs examinaton showed weakness, clasp knife rigidity, hyperrefexia in both knee and ankle jerks. There is loss of all modalites of sensaton in both lower limbs. Which of the following has the highest diagnostc value?
A. Electromyography
B. Brain and spine MRI
C. Thoracic spine CT scan
D. Nerve conducton study

Answer 187

B. Brain and spine MRI

Question 188

An 80-year-old man has 2-month history of progressive gait disturbance and incontnence Lately he has been forgetul, confused, and withdrawn. His gait is slow, short-stepped and with tendency to fall backward (see report). Brain CT scan: shows dilated ventricles. Which of the following is the most likely diagnosis?
A. Alzheimer’s disease
B. Creutzfeldt-Jakob disease
C. Fronto-temporal dementa
D. Normal-pressure hydrocephalus

Answer 188

D. Normal-pressure hydrocephalus

Question 189

An elderly patent sustained a major stroke and he is intubated in the intensive Care Unit. However, even he was in a very critcal state, he managed to write in the bed clothes that he wants to die in peace. Few days later, he passed away without resuscitaton according to what he wrote. His son was very angry and said that his father had no mental capacity to decide. What is the most appropriate stand when dealing with this situaton?
A. Find out whether the son is the real next of kin
B. Tell the son that in anyway his father would have never made it
C. Inform the son that the doctors respected the wish of your father
D. Inform the son that we do not resuscitate patents who are brain dead

Answer 189

A. Find out whether the son is the real next of kin

Question 190

A young woman is diagnosed to have multple sclerosis. She went through an emotonal breakdown during breaking bad news. Which of the following is the most appropriate way to express empathy?
A. *I share you your feelings and will support you”
B. “Pull yourself up and follow our instructons”
C. “I am very sorry for what happened”
D. “Do not worry, you will be fne”

Answer 190

A. *I share you your feelings and will support you”

Question 191

A 60-year-old man presents with low-grade fever, insomnia and progressive abdominal distenton with vague abdominal pain. Physical examinaton reveals fapping tremor and moderate ascites. Ascitc fuid analysis showed high SAAG and neutrophil count of 350 cells/L. Which of the following is the most appropriate management?
A. Intravenous antbiotc
B. Total paracentesis
C. Syrup lactulose
D. Oral diuretc

Answer 191

A. Intravenous antbiotc