Day 3

Question 1

Q1-A 50 y/o man presents with chest pain, shortness of breath (SOB), palpitations, and ankle edema for the past month (mo), with worsening of symptoms over 2 days. Physical examination (P/E) finds tachycardia, normal BP, JVD, and lower limb edema. ECG (EKG) reveals an atrial rate of 380/min, irregular QRS, and no clear P-wave with baseline. What’s the most appropriate next step of treatment (Tx)?

A-Aspirin 
B-Warfarin for 3 weeks 
C-Metoprolol 
D-Digoxin 
E-Electric cardioversion (50-100j)

Answer 1

Ans: D. Digoxin is the best initial treatment (TX) for this patient with heart failure (HF) + atrial fibrillation. Warfarin (to prolong PT) +/aspirin should be added for 3 weeks before cardioversion and be continued until normal (Nl) sinus rhythm has been maintained for at least 4 weeks, to prevent embolism. “C” is good for acute Atrial-fib rate control, but should be used cautiously with heart failure. “E” is indicated if the patient is unstable.

Question 2

Q2-A72 year man presents with 4-hour history of acute ischemia of left leg. Examination reveals signs of acute ischemia with no evidence of gangrene. There is no neurological deficiet. Arteiogram shows occlusion of distal femoral artery by thrombosis. What is the management?

A-Femoral popliteal bypass
B-Femoral distal bypass
C-Percutaneos baloon angioplasty
D-Femoral femoral crosover graft
E-Intraarterial tPA infusion

Answer 2

Ans: E

Question 3

Q3-Low TSH, Low T3, Low T4, Low TRH (thyroid releasing hormone). Which is this condition?

A-Primary hypothyroidism
B-Secondary hypothyroidism
C-Tertiary hypothyroidism
D-Quaternary hypothyroidism

Answer 3

Ans: C. This case is - Tertiary hypothyroidism
Primary Hypothyroidism-TSH high, T3, T4 low
Secondary Hypothyroidism-Low T3, T4 and TSH
Tertiary Hypothyroidism-LowT3, T4, TSH and TRH

Question 4

Q4-A 50 year man presented with painless hematuria. He is hypertensive but the rest of the examination is unremarkable. What is the most likely diagnosis?

A-Polycystic kidneys
B-Cancer bladder
C-Cancer prostate
D-TTP (Throbotic thrombocytopenia purpura)
E-HUS (Hemolytic uremic syndrome)

Answer 4

Ans: B. Bladder cancer characteristically causesblood in the urine, which may be visible or detectable only by microscope. Blood in the urine is the most common symptom in bladder cancer, and is painless. Visible blood in the urine may be of only short duration, and a urine test may be required to confirm non visible blood. Between 80–90% of people with bladder cancer initially presented with visible blood.[12]Blood in the urine may also be caused by other conditions, such as bladder or ureteric stones, infection, kidney disease, kidney cancers or vascular malformations, though these conditions (exceptkidney cancers) would typically be painful.

Question 5

Q5-The way to determine the accuracy of occult blood test for 11,000 old patients is by measuring:

A-Sensitivity
B-Specificity
C-Positive predictive value
D-Negative predictive value

Answer 5

Ans: A

Question 6

Q6-Patient came with hypertension, KUB shows small left kidney, arteriography shows renal artery stenosis, what the best next investigation?

A-Renal biopsy
B-Renal CT scans
C-Renal barium
D-Retrograde pyelography

Answer 6

Ans: B

Question 7

Q7-The way to differentiate between low iron level from iron deficiency anemia and anemia of chronic disease is?

A-S.Ferritin
B-S.TIBC
C-Serum Iron
D-Serum Transferrin

Answer 7

Ans: A.Iron Deficiency Anemia-LOW FERRITIN

It’s defined as reduced RBC and Hb with hypochromic cells, MCV < 80, and low levels of stored iron in the body. It’s usually caused by an increased blood loss (No.1 cause by GI bleeding in male and by menstrual loss in female). It is difficult for the body to increase the iron absorption quickly at blood loss because it’s strictly regulated. Other causes include poor oral intake, malabsorption, hemolysis, etc.
Essentials of diagnosis 1. History of the above anemic symptoms, +/- brittle nails, “spoon” nails, glossitis, and pica. 2. Lab tests: A low serum ferritin < 10 ng/mL is very specific and sensitive for Fe-deficient anemia as the most common diagnostic test. Serum Fe, MCV and reticulocyte count are low. TIBC and RDW are increased. Blood smear shows microcytic, hypochromic RBC (“doughnut cells”, The most specific test is bone marrow (BM) biopsy for Prussian blue iron staining, but rarely used.
Treatment
1. Oral ferrous sulfate tablets are the most common treatment. Parenteral iron is used in patient with malabsorption, intolerance to oral therapy, or very high requirements.
2. Blood transfusion is the most effective treatment for severe or urgent anemia caused by blood loss.

Question 8

Q8-Elderly patient complaining of urination during night and describe when he feels the bladder is full and need to wake up to urinate, he suddenly urinates on the bed this is?

A-Urgency incontinence
B-Urge incontinence
C-Stress incontinence
D-Flow incontinence

Answer 8

Ans: B. Urge incontinenceis a common form ofincontinence. You have an urgent desire to pass urine and sometimes urine leaks before you have time to get to the toilet. It is usually due to an overactive bladder. Treatment with bladder retraining often cures the problem. Medication may also be advised to relax the bladder.

Stress at time of physiological pressure, Folw often present without urge to urinate.

Question 9

Q9-A 3.9 kg male infant whose Apgar scores were 9 and 10 at 1 and 5 minutes, respectively, after delivery is brought in by his parents because his eyes are red. The delivery was without any complications and both mother and child are in no acute distress.
What is the most likely diagnosis at 1 day, at 2 to 7 days, and at >7 days?

A-Chemical irritation
B-Neisseria gonorrhoeae
C-Chlamydia trachomatis
D-Herpes simplex
E-All of the above

Answer 9

Ans: E. To diagnose the cause of conjunctivitis in the newborn, you must consider when the redness and irritation begins.
At 1 day, the most likely cause of the conjunctivitis is chemical irritation.
From days 2 to 7, the most likely cause is Neisseria gonorrhoeae.
Conjunctivitis after more than 7 days post delivery is most likely due to Chlamydia trachomatis.
Conjunctivitis after 3 weeks or more is most likely due to herpes infection.

Treatment In the delivery room, all newborns must be given 2 types of antibiotic drops in each eye to prevent ophthalmia neonatorum. This condition can be attributed most commonly to Neisseria gonorrhoeae or Chlamydia trachomatis. Use: Erythromycin ointment or tetracycline ointment, Silver nitrate solution

Question 10

Q10-A 23-year-old woman complains of difficulty falling asleep and worsening
Anxiety that began 2 months earlier after she was involved in a minor biking accident (bike vs car) in which she did not suffer any injuries. Since the accident, she has refused to participate in any outdoor activities.What is her most likely diagnosis?

A-Adjustment disorder
B-Major depression
C-Agarophobia
D-Generalised Anxiety disorder

Answer 10

Ans: A. Adjustment disorder, which consists of emotional and behavioral symptoms that develop in response to an identifiable stressor, lasts >1month and <6 months, and doesnot have five or more symptoms of major depressive disorder.

Question 11

Q11-A lady presents with itching around the breast and greenish foul smelling discharge from thenipple. She had a similar episode before. What is the most likely dIagnosis?

A-Duct papilloma
B-Duct ectasia
C-Breast abscess
D-Periductal mastitis
E-Mammary duct fistula

Answer 11

Ans: B. Duct ectasia of the breast,mammary duct ectasiaorplasma cell mastitisis a condition in which occurs when a milk duct beneath the nipple widens, the duct walls thicken and the duct fills with fluid. This is the most common cause of greenish discharge.[1]Mammary duct ectasia can mimic breast cancer. It is a disorder of peri- or post-menopausal age.
Duct ectasia syndromeis a synonym fornonpuerperal mastitis, but the term has also been occasionally used to describe special cases of fibrocystic diseases or mastalgia or as awastebasketdefinition of benign breast disease.
Correlation of duct widening with the “classical” symptoms of duct ectasia syndrome is unclear. However, duct widening was recently very strongly correlated with noncyclic breast pain

Question 12

Q12-The most important factor for smoker to quit is?

A-Patient’s desire
B-Give nicotine pills
C-Give programmed plan
D-Change life style

Answer 12

Ans: A. Nicotine Cigarette smoking and chronic nicotine intoxication has been associated with increased risks of COPD, CAD, stroke, peripheral vascular disease, multiple malignancies, etc., and is the leading preventable cause of mortality. Intoxication: Restlessness, insomnia, anxiety, arrhythmia. Treatment: Smokers should be managed with a combination of behavioral support and medication therapy. Firstline medicines for smoking cessation include nicotine replacement therapy, varenicline, and bupropion. Withdrawal: Irritability, headache, anxiety, weight gain, bradycardia, and distractibility

Question 13

Q13-A 38-year’s woman, 10 days’ post partum presents to GP with History of passing blood clots per vagina since yesterday. Examination showed BP 90/40mm of hg. Pulse-110/min, T 38C, Uterus tender on palpation and fundus 2 cm above umbilicus. Blood clots+++.Choose single most likely diagnosis?

A-Abruption of placenta secondary to pre eclempsia
B-Secondary PPH
C-Primary PPH
D-Concealed hemorrhage
E-Retained placenta

Answer 13

Ans: B. Secondary PPH.its defined as abnormal or excessive bleeding from birth canal between 24 hours to 12 weeks postnatally.

Question 14

Q14-A 71-year old woman presents to accident and emergency with pain in the right knee. This has been ongoing for the past five months but she is now finding it
Difficult to walk. Pain is usually worse after exertion. On examination, the right
Knee is swollen. There is a reduced range of active movement and palpable crepitus. What are the most likely findings on x-ray?

A-Increased joint space, subchondral sclerosis, bone cysts and osteophytes
B-Increased joint space, soft tissue swelling and peri-articular osteopenia
C-Normal x-ray
D-Reduced joint space, subchondral sclerosis, bone cysts and osteophytes
E-Reduced joint space, soft tissue swelling and peri-articular osteopenia

Answer 14

Ans: D The case in this question is describing a patient with osteoarthritis. Reduced
joint space, subchondral sclerosis, bone cysts and osteophytes (D) are theradiographical features of osteoarthritis. Reduced joint space, soft tissue swelling and peri-articular osteopenia (E) are the radiographical features ofrheumatoid arthritis. It is likely that the woman in this case will have x-raychanges, thus making normal x–ray (C) an incorrect option. However, it is important to note that the radiographical changes of osteoarthritis may notcorrelate with the clinical features. The joint space in osteoarthritis isreduced, making options (A) and (B) incorrect.

Question 15

Q15-The same patient has no response after both NST and vibroacoustic stimulation, and BPP (by real-time ultrasound) is done with a score of 5. What’s the best next step now?

A-Labor induction 
B-IV steroid 
C-CST 
D-C-section 
E-Reassurance

Answer 15

Ans: B. The fetus is in worrisome conditions and mother’s GA is < 34 weeks, thus you should speed up delivery first by IV steroid, followed by labor induction or C-section in 24-48 hours.

Question 16

Q16- A patient at 34 weeks of GA comes to the physician and presents regular painful contraction every 2 min with the Os 5 cm. Two hours later, the Os is still 5 cm, and she feels less abdominal pain but tired. Her vital signs are stable and FHR is 125 bpm. What’s the best next step?

A-Acceleration of labor with oxytocin 
B-IV fluid + steroid 
C-Test of fetal lung maturity 
D-Vacuum induction 
E-C-section

Answer 16

Ans: E. It’s an active phase rest (#1 cause is cephalopelvic disproportion), and requires a prompt C-section since 34 weeks GA makes the fetus viable (with enough lung maturity). Oxytocin, vacuum, and forceps deliveries are forbidden in this condition

Question 17

Q17-A 25-year female complains of intermittent pain in her fingers. She describes episodes ofnumbness and burning of the fingers. She wears gloves whenever she leaves the house. What is the most probable diagnosis?

A-Kawasaki disease
B-Takayasu arteritis
C-Buerger’s disease
D-Raynaud’s phenomenon

Answer 17

Ans: D. Raynaud syndrome, also known asRaynaud’s phenomenon, is amedical conditionin whichspasm of arteriescause episodes of reducedblood flow. Typically, the fingers, and less commonly the toes, are involved.Rarely, the nose, ears, or lips are affected. The episodes result in the affected part turningwhiteand thenblue. Often,numbnessor pain occurs. As blood flow returns, the area turns red and burns. The episodes typically last minutes, but can last several hours.
Episodes are often triggered by cold or emotional stress. The two main types are primary Raynaud’s, when the cause is unknown, and secondary Raynaud’s, which occurs as a result of another condition. Secondary Raynaud’s can occur due to aconnective-tissue disorder, such assclerodermaorlupus, injuries to the hands,prolonged vibration, smoking, thyroid problems, and certain medications, such asbirth control pills. Diagnosis is typically based on the symptoms.
The primary treatment is avoiding the cold.Other measures include the discontinuation of nicotine orstimulantuse.Medications for treatment of cases that do not improve includecalcium channel blockersandiloprost. Little evidence supportsalternative medicine. Severe disease may rarely be complicated byskin soresorgangrene

Question 18

Q18-Female developed extreme fear from zoo, park, sporting events; the fear prevented her from going out:

A-Agoraphobia
B-Social phobia
C-Schizophrenia
D-Hypochondriasis

Answer 18

Ans: A.Phobic (Anxiety) Disorder
It’s defined as irrational fear and avoidance of objects and situations. Subtypes include:
1. Agoraphobia: Fear or avoidance of places from which escape would be difficult in the event of panic conditions (public places, crowds, outside alone, etc.). It occurs more in females and often leads to severe restrictions on the individual’s travel and daily routine.
2. Social phobia: Fear of humiliation or embarrassment in either general or specific social situations (e.g., at public speaking, “stage fright”).
3. Specific phobia: Fear or avoidance of objects or situations other than agoraphobia or social phobia, such as animals or insects, natural environments (e.g., storms), injury (e.g., injections, blood), and situations (e.g., heights, darkness).
Treatment
1. CBT: Very effective for phobia, combined with systematic desensitization and assertiveness training.
2. Pharmacotherapy: A benzodiazepine (lorazepam) or SSRI (sertraline) is effective on social phobias, and a betaR blocker is effective on performance anxiety (“stage fright”).

Question 19

Q19-A 36- year woman has recently spent a lot of money on buying clothes. She goes out almost everynight with her friends. She believes that she knows better than her friends, so she should choose the restaurant for eating out. She gave history of having low mood at 12 year of age. What is the likely diagnosis?

A-Mania
B-Depression
C-Bipolar affective disorder
D-Borderline personality disorder
E-Dysthymia

Answer 19

Ans: C. Bipolar Affective Disorder, also know as Manic Depression, is a medical diagnosis characterized by wide mood alterations, with periods of both depression and mania. A person experiencing depression or mania may have intense mood swings and changes in thinking and behaviour. Bipolar means sharing two poles (high and low) and Affective Disorder means a disorder having to do with mood. In most cases, the high pole is experienced as mania and the low pole experienced as depression.
What Causes Bipolar Affective Disorder?
Any person can develop Bipolar Affective Disorder; however, studies indicate that highly creative, sensitive people, people tending to be perfectionists and high achievers, have a higher prevalence of bipolar affective disorder. Biological factors seem to play a major role in producing Bipolar Affective Disorder. A person’s personality make-up and/or stresses in the environment (for example, death of a loved one, separation, divorce, etc.) may also play a part in bringing on depressive or manic states.

Question 20

Q20-A 12 y/o boy is given 6 months of medical Tx for a chronic disease. He runs out of the drug and comes to refill his prescription. P/E finds generally pale and dry skin with scratching tracks, and decreased pain sensation. CBC reveals a microcytic, normochromic anemia. What’s the most likely vitamin deficiency?

A-B1 
B-B2 
C-B3 
D-B5 
E-B6

Answer 20

Ans: E.“DNA”—dermatitis, neuritis, and anemia, mostly due to prolonged INH use for TB. B1 deficiency (Def): “HEN”—heart failure, encephalopathy, and neuritis. B2 deficiency: “ACC”—angular stomatitis, cheilosis, and corneal vascularization. B3 deficiency: “DDD”—dermatitis, diarrhea, and dementia. B5 deficiency: Rare.

Question 21

Q21-Patient with history of Hypertension for 5 years on thiazide came to Emergency Room at midnight screaming holding his Left foot, on examination patient afebrile, left foot tender, erythema, swollen. big toe most tender and painful, no other joint involvement.what is likely diagnosis?

A-Cellulitis
B-Gouty arthritis
C-Septic arthritis
D-Rhumatoid arthritis

Answer 21

Ans: B. Thiazide diuretic in chronic use can cause hyperuracemia, which presents as a gouty pain as deposit of urate crystal in joint mainly lower limb

Question 22

Q22-24-year-old lady, pregnant 25 weeks, exposed to rubella virus since 3 days, never vaccinated against rubella, mumps or measles, what’s the best thing to do:

A-Give Immunoglobulin
B-Vaccine of rubella
C-Do nothing /reasurance
D-Terminate the pregnancy

Answer 22

Ans: C

Question 23

Q23-A 64-year-old man suffers an anterior myocardial infarction. A few hours later, his pulse rate is noted to be 46/minute and his blood pressure 94/59 mm Hg. He is short of breath and has slight central chest pain. The monitor showed sinus bradycardia. What would be your choice of management?

A-Insertion of temporary pacing wire
B-Intravenous isoprenaline
C-Intravenous atropine
D-Intravenous adrenaline
E-Oral salbutamol

Answer 23

Ans: C Transient vagal activation resulting in sinus bradycardia is common after myocardial infarction and may be symptomatic, as in this case, with hypotension and probably reduced cardiac output. It usually responds to one or more doses of atropine (C). Pacing (A) is unnecessary unless heart block is also present, while stimulant drugs (B, D and E) are not only ineffective in this situation but also dangerous, as they increase the risk ofventricular arrhythmias.

Question 24

Q24-A 55 y/o man complains of 3 months of cough, fatigue, muscle weakness, decreased urine output, and mood lability. He has a 10year history of “moderate” alcohol use and smoking. P/E finds hypertension, cutaneous striae, and truncal obesity. CXR shows evidence of chronic bronchitis. Blood tests reveal increased glucose, ACTH, and cortisol levels, and decreased Na and K levels. Urinary WBC, RBC, and protein are (-). The most appropriate next step is

A- 24-hour free urinary cortisol collection
B-high-dose dexamethasone suppression test
C-chest CT scan
D-aldosterone level test
E-adrenal CT scan

Answer 24

Ans: A.Because this patient is having Cushing’s syndrome and suspected with ectopic malignancy due to increased cortisol and glucose, the 24-hour urine-cortisol can be used as a screening test to replace the low-dose dexamethasone suppression test, which will only inhibit benign hypercortisolism, not the malignant.

Question 25

Q25-A 3 y/o boy had fever, headache, polyuria, and dysuria for the past 3 days. His mother gave him amoxicillin and aspirin for the past 2 days. Now he has started to vomit and has become combative and confused. P/E finds T = 40oC, delirium, tachycardia, hypotension,
jaundice, hepatosplenomegaly, and renal tenderness. Urine analysis (U/A) shows WBC and protein. Blood tests show increased WBC with bands, hypoglycemia, and normal LFTs. What’s the most appropriate test to determine the original pathologic condition?

A-Blood culture (C/S) 
B-Blood ammonia levels 
C-Liver biopsy 
D-Urine culture 
E-Urinary reducing substances

Answer 25

Ans: E. This is most likely a case of galactosemia complicated by E. coli pyelonephritis and sepsis. The original condition can be screened by testing reducing substances for galactosemia in the urine and confirmed by specific RBC GALT activity. Blood culture/sensitivity (C/S) is important to guide Tx of the infection. Reye syndrome is associated with recent aspirin use or viral infection in children, with similar symptom but mostly with elevated LFTs and blood ammonia levels; definitive Dx is by liver biopsy.