1. fever 102f , abdominal rash , abdominal pain , hepatosplenomegaly?

kalaazar or malaria
Kalaazar

2. INH caused peripheral neuritis ( in glucose 6 phosphate deficiency patients ) can be treated by
using
A. Riboflavin
B. Thiamine
C. Pyridoxine
D. Folic acid

3. All these are anti-coagulant except?

a- Warfarin.
b- Ancord.
c- Heparin.
d- Dipyridamole

4. What is the most sensitive test for breast mass ?

1-U/S
2-FNAC
3-Mammography
4-Clinical exam

5. hip dislocation can be ruled out if there is

a. free movement
b. normal xray
c. u/s
e. clinical examination

6. Woman complain of clear breast discharge on examination no mass head ct scan showed pituitary
mass what is the cause of discharge
A. High tsh
B. high fsh
C. high prolactin
D. acth

7. Pregnant lady, 8 weeks gestation, came with History of bleeding for the last 12 hours with lower
abdominal pain & she passed tissue. On examination the internal Os was 1cm dilated. The diagnosis
is:
a) Complete abortion
b) Incomplete abortion
c) Missed abortion
d) Molar pregnancy
e) Threatened abortion

8. 2 years old child is having rectal temp of 39 C but child is happy having no any complaint and
plays well what is next step?
A. Broad spectrum antibiotics
B. LP
C. Blood culture
D. Observation
E. Admit the patient

9. which of the following is assocaited with the worst prognosis in pancreatitis?

a. elevated amylase
b. elevated lipase

c. intensity of pain
d. low calcium
e. c.reactive proteinn rising.

10. A 50 yr old male is brought to the E.R after being rescued frm motor vehical acident.on
examination, there is sever deformatity of his rit thigh & he is experiencing excruciating pain.His past
medicl hx is signficnt for an extensive history of opiod drug abuse for whch he spent two years in
rehabilitation.he has not use any drugs since the completion of his rehabilitation program.
Whch of the folowing is the mst appropriate choice of analgesic in this patient?
A) intravenous morphine
B) oral ibuprofen
C) oral ketorolac
D) oral hydrocodone
E) oral methadone
F) observation

11. Worst single finding predicting high cardiac risk in preoperative patients.
A) MI
2) Jugular venous distension
3) Arrhythmias
4) Decreased ef

12. A known case of nephrotic syndrome presented to you for routine check up.You ordered urine
analysis and found a droplet that resembles Maltese cross.This is most likely because of
A) hyperlipidemia

B) proteinuria
C) hyperlipiduria
D) hematuria

13. Treatment of hypernatremia bex of Nephrogenic DI

A) IVF
2) vasopression
3) NSAIDs
4) none of the above

14. A patient presented with sudden onset of confusion ,lethargy and forgetfullness,,he was
witnessed to have a seizure like activity..
his u/osmolality is 45mEq/l and serum Na is 122mEq/L..on further evaluation u found an elevated
ADH level.What ll b most appropriate next step
A) RFTs
B) hypertonic saline with diuretic
C) hypertonic saline without diuretic
D) IV Conivaptan

its SIADH,,,,Na level is extremly low it means its severe form of disease with sevre symptoms,,,emergency Rx of
SIADH is D...its only given in hospital no oral form is available,

15. drugs cause postural hypotention

a-frusamide
b-nitrates
c-acei
d BB

16. A modern family doctor is expected to see malignancy in children every

a. 2yrs
b. 3yrs
c. 4yrs
d. 5yrs
e. non of above

17. sickle cell trait parents. the risk of their baby is

a. 5%
b. 10%
c. 15%
d. 20%
e. 25%

18. Psychiatry patient whom swallowed a small pin 5 hours ago, came to the hospital and showed an
X-ray which showed pins in the small intestine and no free air what will be the action?
a) Admit and do a CT scan or MRI
b) Investigations only to CT and MRI
c) Give laxatives
d) Admit and do surgery to remove the pins

19. 5y child healthy, no chest or any other complain. On exam. He has grade 2 ejection systolc
murmur at left sternal border. Murmur changes with position. No other extra sounds. What is best
next step in management??
A. 12lead ecg
B. Echocardiogram
C. Holter monitor
D. Observation
E. Cardiac evaluation
F. Blood c/s

20. post op oliguria. pathology can be

a. increase water clearence
b. increase Na conc.in distal tubule
c. increase water transport in distal tubule
d. increase Na reabsorption in distal tubule
e. deceased osmolality and decrease creatinine clearance
f. increase osmolality and high creatinine

21. which of the follwoing is a possible indication of surgery in a pt with ca lung

a. recurrent laryngeal nerve involvement
b. svc obstruction
c. osteodystrophy
d. paraneoplastic syndrome

22. 25yrs old healthy man gets fever nd neck stiffness. his CXR shows diffuse opaque rounded
shadow most likely dx
a. coccidiomycosis
b. cryptocococcus
c. sarcoidosis
d. primary ca of lung
e. multiple. secondaries from distant tumor

23. A woman has been diagnosed with carrying the BRCA1 gene. What is her lifetime risk of breast
cancer?
1030%
3040%
4060%

5080%
6090%

24. A 25yo male who recently noticed change in his shoe size, he is also constipated, has a
preference to hot weather, his skin is dry, has severe pain in wrist joint. Joint is red and swollen.
What is the most probable dx?
a. Chondro-sarcoma
b. Lipo-sarcoma
c. Gout
d. Pseudogout
e. Ankylosing spondylitis

D because pseudogout can have association with the following diseases..hypothyroidism, hyperparathyroidism,
hepercalcemia, hemochromatosis.
Here it shows there are features of hypothyroidism..hence D

25. drugs causing cholestatic jaundice is

a. paracetamol
b. erythromycin
c. tetracycline
d. chlorpromazine

26. type 1 D.M. patient is on diet and insulin therapy suddenly reduces requirements of insulin.
probable dx is
a. islet cell tumor
b. pt is permanently cure
c. pt ws wrongly dx as type1 DM
d. pt is in latent phase of his DM
e. period

27. 8 weeks Primigravida came to you with nausea & vomiting, choose the statement that guide you
to hyperemmesis gravidarm:
a) ketones
b) ECG evidence of hypokalemia
c) Metabolic acidosis
d) Elevated liver enzyme
e) Jaundice

28. pt with upper limb weakness and lower limb stiffness nd increased knee jerk refkex. cause is
a. amyotrophic lateral sclerosis
b. Guillain Barre syndrome
c. multiple sclerosis

29. A 4-year-old previously healthy girl presents to the emergency department with a 24-hour history
of rectal bleeding and dizziness. She has no other gastrointestinal symptoms. On examination, she
appears pale. Her heart rate is 140 beats/min, and she has a 20 mmHg postural drop in systolic
blood pressure. The childs abdomen is nondistended and nontender, and fresh blood and clots are
in the rectal vault on rectal examination.
Which of the following is the most likely diagnosis?
(A) a bleeding Meckels diverticulum
(B) juvenile rectal polyp
(C) hemorrhoids
(D) an anal fissure
(E) intussusceptions

30. What is the initial management for a middle age patient newly diagnosed knee osteoarthritis.
a) Intra-articular corticosteroid.
b) Reduce weight
c) Exercise.
d) Strengthening of quadriceps muscle.

31. A patient had an uncomplicated cesarean delivery 6 days previously. She has been on a regimen
of ampicillin, gentamicin, and clindamycin for 5 days for postpartum fevers, but still has
temperature spikes of 39.4C (103F). Physical examination is normal. Which of the following
is the most likely cause of her fever?
(A) pelvic abscess
(B) septic pelvic thrombophlebitis
(C) endometritis
(D) pyelonephritis
(E) breast engorgement

32. A 40-year-old previously healthy man presents with sudden onset of severe abdominal pain that
radiates from the right loin (flank) to groin. This pain is associated with nausea, sweating, and urinary
urgency. He is distressed and restless, but an abdominal examination is normal.
Which of the following is the most likely diagnosis?
(A) torsion of the right testicle

(B) pyelonephritis
(C) appendicitis
(D) right ureteral calculus
(E) acute urinary retention

33. Upper limb amputation handicaps. Complication of prosthesis

a. motor
b. sensory
c. cosmetic
d. weight
e. all

34. A 64 yr old male with Deep vein thrombosis is being treated with unfractionated heparin. On the
4th day of tx, his platelet counts drops to 80 thousand/cm. His previous platelet count on day 2 was
within normal range. He denies any bleeding-related complications and is completely asymptomatic.
His complete examination does not reveal any signs of bleeding. His b.p is 128/80 mm hg, pulse is
78/mint, and respirations r 20/mint. He is afebrile. What is the most appropriate step in the
management of this pt?
A) switch to LMWH
B) stop heparin & start warfarin
C) stop heparin
D) start plasmapheresis
E) stop heparin & start platelet transfusion

35. A 17-year-old G1P1001 is now 5 weeks postpartum after a routine vaginal delivery. She
calls your office to report a 3-week history of difficulty sleeping and feeling blue. On further
questioning, she reports difficulty concentrating, very poor appetite, occasional
wishes that she had never become pregnant, and feelings of guilt about those wishes. She
has not left her home in more than a week because she just cant find the energy to go
anywhere. This patients symptoms are most consistent with:
A) postpartum blues
(B) normal adolescent adjustment to motherhood
(C) postpartum depression
(D) hypothyroidism
(E) postpartum psychosis

36. The patients serum 17-hydroxyprogesterone level is normal. In addition, her serum prolactin
concentration is 13 ng/mL (normal, <20). Which of the following is the most likely diagnosis?
(A) polycystic ovary syndrome
(B) attenuated 21-hydroxylase deficiency
(C) pituitary adenoma
(D) Sertoli-Leydig cell tumor
(E) adrenal adenoma

37. A 1-year-old child in a large nursery school develops fever, irritability, confusion, a possible
stiff neck, and a petechial rash, over the course of several hours. Which of the following agents
is recommended for others in the nursery schools that have had contact with the child, to
control a possible outbreak?
(A) rifampin, ciprofloxacin or ceftriaxone
(B) gamma globulin
(C) group A meningococcal vaccine
(D) group C meningococcal vaccine
(E) quadrivalent meningococcal vaccine

38. Causes of retinopathy

1) hypertension n obesity
2) pregnancy n medications
3) pregnancy n hypertension
4) smoking n hypertension

39. A lady with non viral chronic hepatitis wants to get married and have children. Your suggestion
to the patient will be
1) your future husband should do hepatitis vaccination
2) no chance of transmission of hepatitis so don't worry
3) minimal chance of transmission
4) all

40. 20 years old male presented with stabbed wound in the abdomen. The most appropriate
statement:

a) Should be explored
b) Observation as long as vital signs are stable
c) Exploration depends on peritoneal lavage findings.
d) Exploration depends on ultrasound findings.
e) Exploration depends on whether there is peritoneal penetration or not.

41. A 20-year-old asymptomatic college student presents to your clinic for contraception. She
states that she has been sexually active for 2 years with one partner, and that they usually
use condoms. Along with a Papanicolaou (Pap) smear and pelvic examination, which of the
following should you also recommend?
(A) self-breast examination
(B) screening for chlamydia
(C) screening for syphilis
(D) thyroid-stimulating hormone (TSH) test
(E) screening for gonorrhea

42. pt with neck pain with movement he has osteoarthritis and symptom not relive by non-steroid
anti-inflammatory drug what your advice
a- medical treatment
b- surgical rx
c- cervical soft collar
d- bed rest

43. A70-year-old man presents to urgent care complaining of a painful, swollen left knee. He
previously has had no problems with this knee. Three days prior to onset, he went out dancing
for 23 hours but recalls no specific injury. Examination of the knee reveals a moderatesized
effusion and mild pain with any range of motion. Plain x-ray shows no fracture. Which
of the following is the best next management?
(A) MRI of knee

(B) aspiration of effusion fluid

(C) rest, ice, and leg elevation
(D) physical therapy referral
(E) arthroscopy

44. For to control hypertension ur advise to pt (also dha exam mcq)

1) walk can't control b.p
2) only walk can control b.p
3) stick sodium control might help
4) non

45. One of the following is a characteristic of syncope (vasovagal attack):

a) Rapid recover
b) Abrupt onset
c) When turn neck to side
d) Bradycardia
e) Neurological deficit

46. A 56-year-old woman presents to the physicians office with complaints of a new left
breast mass. She denies any pain, nipple discharge, or skin dimpling. She has a prior history
of breast cysts 5 years ago, treated by aspiration at that time. Her last mammogram
was at age 53. Past history is pertinent for a 30 pack-year smoking history, prior total abdominal
hysterectomy-bilateral salpingo-oophorectomy (TAH-BSO) at age 54 for leiomyomas, and current use
of hormone replacement therapy (HRT). Family history is negative for breast disease. Examination
reveals a firm, welldefined, mobile, 1.5-cm nodule in the upper outer quadrant of the left breast
without any regional lymphadenopathy. Which of the following is the most appropriate next step in
management?
(A) fine-needle aspiration (FNA) biopsy
(B) discontinuation of HRT and reexamination in 46 weeks

(C) breast imaging

(D) open surgical biopsy
(E) core needle biopsy

47. A 23-year-old man presents complaining of severe crampy abdominal pain and blood in
his stool over the past 2 days. Asimilar episode occurred a few months ago and spontaneously
resolved. No history of travel. Abdominal x-ray shows mild colonic dilatation. Which of the
following is the most likely diagnosis?
(A) ulcerative colitis
(B) viral gastroenteritis
(C) irritable bowel syndrome
(D) celiac sprue
(E) Whipple disease

48. A 5-week-old infant presents with a 1-week history of progressive nonbilious emesis, associated
with a 24-hour history of decreased urine output. The infant continues to be active and eager to feed.
On examination, the infant has a sunken fontanelle and decreased skin turgor. The abdomen is
scaphoid, and with a test feed, there is a visible peristaltic wave in the epigastrium.
Which of the following is the most likely diagnosis?
(A) viral gastroenteritis
(B) gastroesophageal reflux
(C) urinary tract sepsis
(D) pyloric stenosis
(E) milk protein allergy

49. A health insurance company decides to market its services to a population that will not incur
high charges. The use of health services in the United States is most strongly associated with
which of the following characteristics?
(A) age

(B) sex
(C) race
(D) education
(E) income

50. A 55-year-old man presents to the emergency department with left lower quadrant abdominal
pain. The pain has been present for 1 week, but has increased in intensity over the last 2 days
associated with nausea, constipation, and dysuria. Past history is unremarkable. Examination
reveals a temperature of 101F, pulse rate of 95/min, BP of 130/70 mmHg, and normal heart and
lung examinations. Abdominal examination reveals fullness and marked tenderness in the left lower
quadrant, with voluntary guarding and decreased bowel sounds. Laboratory tests reveal a WBC
count of 18,000 with a left shift and 2050 WBCs in the urinalysis. A CT scan of the abdomen
reveals a thickened sigmoid colon with pericolonic inflammation. He is admitted to the hospital
for treatment. Which of the following is the most likely diagnosis?
(A) colon cancer with contained perforation
(B) ischemic colitis
(C) pseudomembranous colitis
(D) diverticulitis
(E) pyelonephritis

51. A 25-year-old previously healthy man is scheduled for elective inguinal hernia repair under
general anesthesia. After induction of anesthesia and initial inguinal incision, the patient develops
tachycardia, muscle rigidity, fever of 38.5C, and elevated end-tidal carbon dioxide. Which of the
following is the most likely diagnosis?
(A) pneumonia
(B) atelectasis
(C) urinary tract infection
(D) myocardial infarction
(E) malignant hyperthermia

52. young male 26 yr old pt having Hernia , when he lift weight feel pain,other wise vitally stable. no
vomiting, no abdominal involvement.while coughing hernia prominent but reducible. What will be the
management.
a) assurance that it will not harm at this moment.
b) wait till other sign symptoms develop
c) refer to surgeon for emergency surgery.
d) refer to surgeon for check up.
D we should refer him to surgeon for planned hernioplasty later on cuz it can become obstructed later if intestines
become involved

53. 5y child with UTI what is best to exclude uti complecation

1 USS
2 C.T
3 MGUG
4 IVU

54. A 20-year-old asymptomatic college student presents to your clinic for contraception. She states
that she has been sexually active for 2 years with one partner, and that they usually use condoms.
Along with a Papanicolaou (Pap) smear and pelvic examination, which of the following should you
also recommend?
(A) self-breast examination
(B) screening for chlamydia
(C) screening for syphilis
(D) thyroid-stimulating hormone (TSH) test
(E) screening for gonorrhea

55. Female pt 8 wks postpartum,not smoker diagnosed to have asthma, her asthma was not
controlled she attended ER 3 times last month,on B2 agonist and oral steroid,she came c/o

wheezing and s.o.b mildly cyanosed using her intercostal muscles, wheezy chest,BP:160/100 P:120
PO2:72 PEF:36,there is oedema in her foot up to the knee, the most likely diagnosis:
1. COPD
2. pulmonary embolism
3. Acute asthma attack
4. Angioedema

56. Woman came in with the complaint of slight symptoms of dizziness and syncope not to the point
of fainting her Bp was elevated though 140/91 on auscultation there was diminished sounds over the
carotids and her mother died before she the age of 40 due Cardiac disease, next best appropriate
step in managing this patient is:1) Dopler of the carotids.
2) Monior Blood pressure.
3) Reassure patient and give antihypertensive.

57. Sudden painless loss of vision with flashes and resembling curtains being pulled
-central vein occlusion
-retinal detachment
arterial occlusion

58. 50 year man with chronic psychosis and not complains for treatment .your advice
a- depot haloperidol or floxtin
b-oral lorasepam
c-oral buspiron??

59. A worker complains of paresthesias, numbness, and tingling that started distally in the lower
extremities but that is starting to affect his hands. He is developing muscle weakness. He feels tired,
and has a headache and complains of memory deficit. Electromyographic abnormalities suggest
axonal degeneration and demyelination. Exposure to which of the following is the most suspect

cause of this clinical picture?

(A) lead
(B) benzene
(C) zinc
(D) carbon disulfide
(E) vibration

60. A patient with long-standing RA is to have coronary bypass surgery. Which of the following is
most important prior to surgery?
a. Cervical spine x-ray
b. Rheumatoid factor
c. Extra dose of methotrexate
d. ESR
e. Pneumococcal vaccination

61. A 33-year-old woman complains of generalized, throbbing headache that is worse in the morning
and with coughing. She occasionally feels dizzy and nauseated. Examination is significant only for
obesity and bilateral papilledema. ACT scan of the head is normal.
At lumbar puncture, the opening pressure is 220 mmH2O;
CSF is clear, with protein of 12 mg/100 mL (normal, 1545), glucose of 68 mg/100 mL (normal, 45
80), and no cells are seen. Which of the following is the most likely diagnosis?
(A) migraine headache
(B) multiple sclerosis
(C) malignant carcinomatosis
(D) pseudotumor cerebri
(E) glaucoma
Correct Answer (D) Pseudotumor cerebri is a disorder of increased intracranial pressure that has no obvious cause.
The typical patient is an obese young woman who complains of headache and is found to have papilledema. Slight
decrease in visual fields and enlargement of blind spots may also be observed. Neurologic examination is otherwise

normal, and the patient appears to be healthy. CSF is under increased pressure and may have slightly low protein
concentration, but is otherwise normal. CT scan, arteriogram, and other x-ray studies are usually normal. The most
serious complication is severe visual loss, which occurs in about 10% of affected persons. Treatment with a carbonic
anhydrase inhibitor decreases intracranial pressure by decreasing production of CSF. Weight loss is important but
often unsuccessful. If the carbonic anhydrase inhibitor and weight loss fail, or if visual loss develops, lumboperitoneal
shunting or optic nerve sheath fenestration are important maneuvers to prevent blindness.
(Kasper et al., 2005, pp. 169170)

62. A22-year-old man complains of low back pain and stiffness that is worse on arising and improves
with exercise. On examination, he is found to have limited mobility of the sacroiliac joints and lumbar
spine. A serum test for histocompatibility antigen HLA-B27 is positive.
What is the most common extraskeletal manifestation of this disease?
(A) premature cataracts
(B) splenomegaly
(C) acute iritis
(D) aortic insufficiency
(E) pulmonary fibrosis
Correct Answer (C) The clinical features of the patient described in the question are most compatible with ankylosing
spondylitis, an inflammatory arthritis that occurs most often in young men. Early findings of low back pain and
stiffness may progress to involve the entire spine with straightening (poker spine). The most common extraskeletal
manifestation is acute anterior iridocyclitis, occurring in 2530% of patients. Additional manifestations, which occur
rarely, include heart block, aortitis with aortic insufficiency, and upper-lobe pulmonary fibrosis. Splenomegaly is
associated with rheumatoid arthritis (Felty syndrome) but is not a feature of ankylosing spondylitis, nor are
cataracts. (Kasper et al., 2005, pp. 19931995)

63. A 70-year-old man presents to urgent care complaining of a painful, swollen left knee. He
previously has had no problems with this knee. Three days prior to onset, he went out dancing
for 23 hours but recalls no specific injury. Examination of the knee reveals a moderatesized
effusion and mild pain with any range of motion. Plain x-ray shows no fracture. Which
of the following is the best next management?
(A) MRI of knee

(B) aspiration of effusion fluid

(C) rest, ice, and leg elevation
(D) physical therapy referral
(E) arthroscopy
Correct Answer (B) The presence of effusion generally signifies
significant disease. Aspiration of the effusion
will help in evaluation for hemarthrosis, septic
arthritis, and inflammatory crystal disease. Each
of these is important to identify and treat early.
An MRI and/or arthroscopy would be later considerations.
Orthopedic referral likely would be
necessary. (Ferrari and Bach, 1998, pp. 5263)

64. A60-year-old previously healthy man presents

with massive rectal bleeding. Which of the following

is the most likely diagnosis?
(A) diverticulosis of the colon
(B) ulcerative colitis
(C) external hemorrhoid
(D) ischemic colitis
(E) carcinoma of the colon

Correct Answer (A) The causes of lower gastrointestinal (GI)

bleeding include hemorrhoids and anal fissure
diverticulosis, carcinoma, vascular ectasia, colitis,
and polyps. Carcinoma of the colon usually
causes chronic GI bleeding, resulting in anemia.
Diverticulosis and vascular ectasia are common
causes of massive GI bleeding in the elderly
patient. Inflammatory bowel disease can also
cause massive GI bleeding but is more frequent

in younger age group patients. Most patients

with ischemic colitis will be quite sick and will
have had symptoms before the onset of bleeding.
(Kasper et al., 2005, pp. 235238)

65. A 35-year-old man presents with acute low

back pain after lifting a couch in his home. Pain

is in the lumbosacral area and increases with
walking and bending. Examination reveals
paraspinal muscle spasm and tenderness and
negative straight leg raise bilaterally. Lower
extremity strength is intact. Which of the following
is the best next step in managing this
patient?
(A) bed rest for 1 week
(B) referral to an orthopedic specialist
(C) x-ray of lumbosacral spine
(D) treatment with anti-inflammatory medication
and gradual return to normal
activity
(E) referral to a pain clinic
Correct Answer (D) In younger patients, low back pain tends to
be mild and self-limited, typically resolving in
46 weeks. Patients should be encouraged to
remain active and symptom control can be
achieved with pain medications. Low back
pain is the leading cause of work-related disability
in the United States. The absence of
alarm symptoms such as unilateral or bilateral
leg weakness and bladder, bowel or sexual dysfunction
makes a cauda equine syndrome or

other spinal cord injury unlikely. Age >50, constant

pain at night, history of cancer, unexplained
weight loss, and lack of response to
conservative therapy make further investigation
including radiologic evaluation appropriate.
(Kasper et al., 2005, pp. 94104)

66. During a routine checkup, a 45-year-old executive

is found to have hypercalcemia. Subsequent

workup reveals elevated parathormone,
decreased phosphorus, elevated chloride, and
normal blood urea nitrogen (BUN), and creatinine
in serum. Urinary calcium is above normal
levels. What is the most likely etiology?
(A) multiple myeloma
(B) primary hyperparathyroidism
(C) hypervitaminosis D
(D) sarcoidosis
(E) milk alkali syndrome

Correct Answer (B) Primary hyperparathyroidism is characterized

by hypercalcemia, hypophosphatemia,
hyperchloremia, increased urinary calcium
excretion, and an increase in serum parathormone
level. Multiple myeloma is associated with
hypercalcemia when there are many lytic lesions.
Chronic ingestion of 50100 times the normal
requirement of vitamin D is required to produce
hypercalcemia in normal people, so hypervitaminosis
D is rare and parathormone levels
would be suppressed. With milk alkali syndrome,

which is caused by excess ingestion of

calcium and absorbable antacids, parathormone
levels would also be suppressed. In sarcoidosis,
about 10% of patients have hypercalcemia attributable
to increased intestinal absorption of calcium
and increased production of 1,25(OH)2D.
(Kasper et al., 2005, pp. 22522263)

67. A 59-year-old woman had a left modified radical

mastectomy for intraductal carcinoma 2 years previously.

She presents with confusion, lethargy, and
thigh pain. X-rays reveal a lytic lesion in the shaft of
the femur.
19. Which of the following blood abnormalities is
most likely?
(A) high glucose
(B) low calcium
(C) high potassium
(D) high calcium
(E) low magnesium

(Correct Answer (D) Hypercalcemia is a common complication of

malignancy. Mechanisms include bone metastases,
humoral secretion (e.g., osteoclast-activating
factor), prostaglandin, or ectopic
parathormone production and immobilization.
Hypercalcemia is often manifested by confusion
and lethargy. The other metabolic abnormalities
usually are not associated with
confusion. Therapy is directed at increasing
renal calcium clearance and inhibiting further

bone resorption. Saline infusion raises the

glomerular filtration rate and decreases calcium
reabsorption in the proximal tubule.
Under life-threatening circumstances, the infusion
may need to be aggressive, as much as 6 L
of saline daily plus furosemide. Radiotherapy
will do nothing for the calcium. Tamoxifen is an
antiestrogen used in the treatment of breast
carcinoma and other malignancies. When used
in the presence of bone metastases, it may contribute
to hypercalcemia. Chemotherapy will
not decrease the calcium levels. Glucocorticoids
have an antitumor effect and reduce tumor production
of humoral mediators, but

68. A man with a history of prostate cancer comes to the emergency department with

severe back pain and leg weakness. He has tenderness of the spine, hyperreflexia,
and decreased sensation below his umbilicus.
What is the most appropriate next step in the management of this patient?
a. Dexamethasone
b. MRI
c. X-ray
d. Radiation
e. Flutamide
f. Ketoconazole
g. Finasteride
h. leuprolide (GnRH agonist)
i. Biopsy
j. Orchiectomy

Answer: A. When there is obvious cord compression, the most important step is to
begin steroids urgently in order to decrease the pressure on t he cord. Radiation is necessary
in those with metastatic cancer to the cord, but it does not work as fast as giving
steroids. X-ray may show vertebral damage, and MRI is the most accurate imaging study,
but preventing permanent paralysis with steroids is more important to do first. Leuprolide is
actually dangerous without first blocking the peripheral receptors to testosterone with
flutamide. GnRH agonists will give a tra nsient burst up in testosterone levels. Finasteride
is a 5-alpha reductase inhibitor that is not helpful for prostate cancer. Finasteride is
used for benign prostatic hypertrophy and male pattern hair loss. Ketoconazole is a
second-line agent in inhibiting a ndrogens. The fastest way to lower androgen levels is
with orchiectomy, but this step is rarely necessary. Biopsy is done if the etiology is not
clear. The key issue in this question is timing: What decompresses t he spine fastest? The
answer is glucocorticoids like dexamethasone .

69. which of following is most likely to benefit asymptomatic patient with multiple first degree realtives

with brest cancer'

1. ..tamoxifen or raloxifen
2.brca testing
3=aromatase inhibiters 4.dietary modification .5 her-2/neu testing

70. Patients with end-stage renal disease who

receive dialysis are typically covered by what
form of insurance?
(A) Medicare
(B) Medicaid
(C) Private Insurance
(D) Due to the high costs associated with
dialysis, most insurance companies are
not able to cover dialysis

71. A 25-year-old man sustains head trauma in a motor vehicle accident. A large epidural
hematoma is found. Immediately after Intubation and mannitol, surgical
evacuation is successfully performed.
Which of the following will most likely benefit the patient?
a. Repeated doses of mannitol
b. Continued hyperventilation
c. Proton pump inhibitor (PPI)
d. Nimodipine
e. Dexamethasone

72. A 78-year-old female presents to your office

with a 2-year history of a cognitive decline
which includes an impairment in short-term
memory. Her husband brought her in because
he is very worried about her. This past week
she became lost coming home from the neighborhood
grocery store. Which of the following
is the most likely diagnosis?
(A) vascular dementia
(B) alcohol-related dementia
(C) Alzheimers dementia
(D) delirium NOS (not otherwise specified)
(E) Picks disease

73. A30-year-old male patient presents to your office

as a new patient. His past medical history is significant
only for having a splenectomy 5 years
ago after a motor vehicle accident. What vaccinations
should you make sure that the patient

has received based on his past medical history?

(A) hepatitis A vaccine series
(B) hepatitis B vaccine series
(C) tetanus vaccine
(D) meningococcal and pneumococcal vaccinations
(E) measles, mumps, and rubella vaccination

74. A 55-year-old diabetic female comes to the emergency room with painful swelling on left side of
her face, for 1 day. She is also having high-grade fever. Her diabetes mellitus (DM) was diagnosed 3
years ago and her blood sugar is well controlled with diet, exercise and oral hypoglycemics. She has
no complications of DM. Her PR is 90/min, BP is 125/75mm Hg, and Temperature is 39.2C(102.5F).
Examination of the left side of her face shows an area of erythema that is warm and tender and has
a raised and well-demarcated border. Which of the following is the most likely causative organism in
this patient?
A. Staphylococcus aureus
B. Haemophilus influenza
C. Group A streptococcus
D. Pseudomonas
E. Clostridium perfringens

75. A 36-year-old alcoholic patient has cirrhosis

and pancreatic insufficiency due to recurrent
pancreatitis. He complains of night blindness,
decreased ability to taste food, and dry skin
with hyperpigmentation. These complaints
suggest deficiency of which of the following?
(A) copper
(B) zinc
(C) selenium

(D) chromium
(E) manganese

76. A new screening test for prostate cancer

becomes available. You assess whether this will
be useful to your practice by reviewing the
operating characteristics of the test. The tests
ability to correctly classify diseased persons as
having disease is called what?
(A) specificity
(B) sensitivity
(C) positive predictive value
(D) negative predictive value
(E) reproducibility

77. A 23-year-old male presents to the emergency

department after sustaining a single gunshot to the
right chest. He is awake and alert and complaining
of significant abdominal pain and chest pain. He
has a pulse of 110, blood pressure (BP) of 90/60,
respirations of 24. On examination, his breath
sounds are decreased on the right. His chest is dull
to percussion on the right. His abdomen is slightly
distended and diffusely tender. His pulse oximeter
shows 88% on 6 L oxygen by face mask.
What is the next appropriate step in this
patients management?
(A) immediate intubation
(B) pericardiocentesis

(C) resuscitative thoracotomy

(D) placement of two large-bore IVs
(E) placement of right chest tube

78. A 65-year-old diabetic male underwent abdominal

exploration for a bleeding duodenal ulcer.
On postoperative day 3, he feels well and is
hungry. He is afebrile and has a pulse of 90. His
blood glucoses have been poorly controlled
and have been greater than 200 for his entire
hospital stay. You are called to the bedside to
evaluate a large amount of salmon colored
fluid that has spontaneously drained from his
midline wound. What is the next appropriate
step in this patients management?
(A) open wound at the bedside
(B) ultrasound-guided drainage of fluid
collection
(C) CT scan of the abdomen
(D) immediate esophagogastroduodenoscopy
(EGD)
(E) immediate exploration of wound in the
operating room (OR)

79. A 72-year-old man has the sudden onset of suprapubic

pain and oliguria. His temperature is 38.0C
(100.4F), pulse is 100/min, respiration rate is
12/min, and BP is 110/72 mmHg. Abdominal

examination is remarkable only for a tender, distended

urinary bladder.
Which of the following is the most appropriate
immediate management of this patient?
(A) plain x-ray of the abdomen
(B) abdominal ultrasonography
(C) urethral catheter
(D) IV furosemide
(E) intravenous pyelogram (IVP)
Acute oliguria is a medical emergency requiring
the immediate identification of any correctable
cause. Distention of the urinary
bladder indicates bladder outlet obstruction.
Immediate management should be the passage
of a urethral catheter to relieve the obstruction
and provide urine for examination. An abdominal
flat plate, ultrasonography, or IVP may
yield a diagnosis but delay the relief of obstruction.
Furosemide may be harmful if given
while the bladder is obstructed. Bladder outlet
obstruction may be caused by prostatic hypertrophy
or prostatitis, stones, clots, malignancy,
or urethral stricture; it may also be neurogenic.
Posterior urethral valves are a congenital defect
that could cause obstruction in children but
rarely in adults. Renal carcinoma would not
cause outlet obstruction. Renal arterial occlusion
can cause acute renal failure but not
obstructive uropathy. If urethral catheterization
fails to relieve the obstruction, further evaluation,
including radiographic or ultrasound
studies, is in order. Suprapubic cystostomy

may be necessary to empty the bladder. (Kasper

et al., 2005, pp. 16441652)

80. A62-year-old man presents with weakness and

aching in his hips and shoulders which has
progressed over the last few months. He
reports generalized fatigue and malaise.
Workup includes a normal complete blood
count, kidney and liver tests, and a sedimentation
rate of 102. Which of the following is the
most likely diagnosis?
(A) SLE
(B) diabetes
(C) Wegeners granulomatosis
(D) polymyalgia rheumatica
(E) Graves disease

81. A 34-year-old woman with a history of SLE is admitted with pneumonia and confusion.
As you are wrestling with the decision over a bolus of high-dose steroids
in a person with an infection, you need to determine if this is a flare of lupus, or
simply an infection with sepsis causing confusion.
Which of the following will help you the most?
a. Rise in anti-Sm
b. Rise in ANA
c. Decrease in complement
d. Decrease in complement and rise in anti-DS DNA
e. MRI of the brain
f. Response to steroids

82. A patient is admitted with vomiting and diarrhea from gastroenteritis. His volume
status is corrected with intravenous fluids and the diarrhea resolves. His pH is 7.40
and his serum bicarbonate has normalized. Despite vigorous oral and intravenous
replacement, his potassium level fails to rise.
What should you do?
a. Consult nephrology
b. Magnesium level
c. Parathyroid hormone level
d. Intracellular pH level
e. 24-hour urine potassium level

83. A patient develops ATN from gentamicin. She is vigorously hydrated and treated
with high doses of diuretic, low-dose dopamine, and calcium acetate as a phosphate
binder. Urine output increases but she still progresses to end-stage renal
failure. She also becomes deaf.
What caused her hearing loss?
a. Hydrochlorothiazide
b. Dopamine
c. Furosemide
d. Chlorthalidone
e. Calcium acetate

84. Which of the following is the most dangerous to a pregnant woman?

a. Mitral stenosis
b. Peripartum cardiomyopathy
c. Eisenmenger phenomenon
d. Mitral valve prolapse
e. Atrial septal defect

85. What is the most common cause of death from PCKD?

a. Intracerebral hemorrhage
b. Stones
c. Infection
d. Malignancy
e. Renal failure

86. A man comes to the emergency department after a triathlon, followed by status
epilepticus. He takes simvastatin at triple the recommended dose. His muscles are
tender and the urine is dark. Intravenous fluids are started.
What is the next best step in the management of this patient?
a. CPK level
b. EKG
c. Potassium replacement
d. Urine dipstick
e. Urine myoglobin
Answer: B. EKG is done to detect life-threatening hyperkalemia. Your question may
have "potassium level" as the answer. CPK level, urine dipstick for blood and myoglobin
should all be done, but the EKG will see if he is about to die of a fatal arrhythmia from
hyperkalemia. Potassium replacement in a person with rhabdomyolysis would be fatal.

87. man with a calcium oxalate stone is managed with lithotripsy and the stone is
destroyed and passes. His urinary calcium level is increased.
Besides increasing hydration, which of the following is most likely to benefit this
patient?
a. Calcium restriction
b. Hydrochlorothiazide
c. Furosemide

d. Stent placement
e. Increased dietary oxalate

88. A 64-year-old patient with diabetes for 20 years comes to the office with several
months of abdominal fullness, intermittent nausea, constipation, and a sense of
"bloating." On physical examination, a "splash" is heard over the stomach on auscultation
of the stomach when moving the patient.
What is the most appropriate next step in the management of this patient?
a. Abdominal CT scan
b. Colonoscopy
c. Erythromycin
d. Upper endoscopy
e. Nuclear gastric emptying study

89. A 16-year-old girl comes to the clinic for a

checkup. Her parents are concerned about her
weight. Over the past year, she has lost 20 lbs.
She has not been ill. She is an excellent student
and active in many after-school activities. On
physical examination, she is emaciated,
hypothermic, and bradycardic. Which of the
following is the most likely diagnosis?
(A) anorexia nervosa
(B) bulimia
(C) hyperthyroidism
(D) diabetes mellitus
(E) depression

90. A 46-year-old woman presents with a 4-hour

history of left flank pain with fever and chills.
On examination, her temperature is 103F,
pulse rate is 120/min, respiratory rate is
40/min, and supine BP is 80/40 mmHg. She
has marked tenderness over the left flank and
left upper quadrant of the abdomen without
rebound. Urinalysis shows multiple red blood
cells (RBCs), multiple WBCs, and WBC casts.
Which of the following is the most likely diagnosis?
(A) appendicitis
(B) pyelonephritis
(C) cholelithiasis
(D) diverticulitis
(E) pelvic inflammatory disease

91. A 57-year-old man is admitted to the intensive care unit with altered mental
status, hyperventilation, and a markedly elevated glucose level.
Which of the following is the most accurate measure of the severity of his
condition?
a. Glucose level
b. Serum bicarbonate
c. Urine ketones
d. Blood ketones
e. pH level on blood gas
Answer: B. Hyperglycemia is not the best measure of the severity of DKA. The glucose
level can be markedly elevated without the presence of ketoacidosis. Urine ketones
mean very little. Although blood ketones are important, they are not all detected. If the
serum bicarbonate is very low, the patient is at risk of death. If the serum bicarbonate

is high, it does not matter how high the glucose level is, in terms of severity. Serum
bicarbonate level is a way of saying "anion gap." If the bicarbonate level is low, the
anion gap is increased.

92. What is the single most accurate test for myeloma?

a. Skull x-rays
b. Bone marrow biopsy
c. 24-hour urine
d. SPEP
e. Urine immunoelectrophoresis (Bence-Jones protein)

93. A 67-year-old man comes to the emergency department with the sudden onset of
chest pain. He also has pain between his scapulae. He has a history of hypertension
and tobacco smoking. His blood pressure is 169/ 108.
What is the best initial test?
a. Chest x-ray
b. Chest CT
c. MRA
d. Transesophageal echocardiogram
e. Transthoracic echocardiogram
f. CT angiogram
g. Angiography
Answer: E. Although not as sensitive as the other tests, the chest x-ray might show
widening of the mediastinum, which is an excellent clue as to the presence of aortic
dissection.

94. A 38-year-old man is evaluated for seizures. He achieves partial control with the
addition of a second antiepileptic medication. He drives to work each day.
What do you do about his ability to drive?

a. Confiscate his license

b. Allow him to drive if he is seizure-free for 1 year
c. Allow him to drive as long as his seizure history is noted on his license
d. Recommend that he find an alternate means of transportation
e. Do not let him leave the office unless he is picked up by someone; no further driving
f. Allow him to drive as long as he is accompanied

95. A 56-year-old woman comes to the clinic because her symptoms of epigastric pain
from an endoscopically confirmed duodenal ulcer have not responded to several
weeks of a PPI, clarithromycin, and amoxicillin.
What is the most appropriate next step in the management of this patient?
a. Refer for surgery
b. Switch the PPI to ranitidine
c. Abdominal CT scan
d. Capsule endoscopy
e. Urea breath testing
f. Vagotomy
g. Add sucralfate

96. A 69-year-old woman is admitted with severe back pain that has suddenly worsened.
She also feels a "pop" when she coughs followed by tenderness over the
ribs. X-ray shows lytic lesions. Her calcium level is 2 points above normal, the
hematocrit is 27%, and her creatinine is elevated. Urinalysis shows trace protein,
but the 24-hour urine show 5 grams of protein.
What do you expect to find on technetium bone scan?
a. Normal
b. lytic lesions at the site of the fractures
c. Increased uptake diffusely
d. Decreased uptake

97. A70-year-old man presents to urgent care complaining

of a painful, swollen left knee. He previously
has had no problems with this knee.
Three days prior to onset, he went out dancing
for 23 hours but recalls no specific injury.
Examination of the knee reveals a moderatesized
effusion and mild pain with any range of
motion. Plain x-ray shows no fracture. Which
of the following is the best next management?
(A) MRI of knee
(B) aspiration of effusion fluid
(C) rest, ice, and leg elevation
(D) physical therapy referral
(E) arthroscopy

CORRECT ANSWER (B) The presence of effusion generally signifies

significant disease. Aspiration of the effusion
will help in evaluation for hemarthrosis, septic
arthritis, and inflammatory crystal disease. Each
of these is important to identify and treat early.
An MRI and/or arthroscopy would be later considerations.
Orthopedic referral likely would be
necessary. (Ferrari and Bach, 1998, pp. 5263)

98. A 42-year-old man comes to the office with several weeks of epigastric pain radiating
up under his chest which becomes worse after lying flat for an hour. He also
has a "brackish" taste in his mouth and a sore throat.
What is the most appropriate next step in the management of this patient?
a. Ranitidine

b. liquid antacid
c. Lansoprazole
d. Endoscopy
e. Barium swallow
f. 24-hour pH monitoring

99. A 15-year-old girl is brought to the clinic by her mother, who found her vomiting
in the bathroom. Her mother reports that the girl vomits daily after each meal.
She is sometimes observed exercising excessively. She has numerous calluses on
her hands as well as cavities. She is 5'5" and weighs 90 pounds.
What is her most likely diagnosis?
a. Bulimia nervosa
b. Anorexia nervosa
c. Eating disorder not otherwise specified
d. Obesity
e. Atypical depression

100. A 70-year-old woman comes to the emergency department with crushing

substernal chest pain for the last hour.
Which of the following EKG findings would be associated with the worst prognosis?
a. ST elevation in leads II, Ill, aVF
b. PR interval >200 milliseconds
c. ST elevation in leads V2-V4
d. Frequent premature ventricular complexes (PVCs)
e. ST depression in leads V1 and V2
f. Right bundle branch block (RBBB)

101. Male patient who is a known case of hypercholesterolemia, BMI: 31, his investigations show
high total cholesterol, high LDL & high TG, of these investigations what is the most important risk

factor for developing coronary artery disease?

a) Elevated LDL
b) Elevated HDL
c) Low HDL
d) Elevated cholesterol
e) Elevated triglyceride level

102. A patient with long-standing RA is to have coronary bypass surgery. Which of the
following is most important prior to surgery?
a. Cervical spine x-ray
b. Rheumatoid factor
c. Extra dose of methotrexate
d. ESR
e. Pneumococcal vaccination
to r/o atlanto axial subluxation

103. A 56-year-old woman comes to the clinic because her symptoms of epigastric pain
from an endoscopically confirmed duodenal ulcer have not responded to several
weeks of a PPI, clarithromycin, and amoxicillin.
What is the most appropriate next step in the management of this patient?
a. Refer for surgery
b. Switch the PPI to ranitidine
c. Abdominal CT scan
d. Capsule endoscopy
e. Urea breath testing
f. Vagotomy
g. Add sucralfate

104. A 72-year-old man has the sudden onset of suprapubic

pain and oliguria. His temperature is 38.0C
(100.4F), pulse is 100/min, respiration rate is
12/min, and BP is 110/72 mmHg. Abdominal
examination is remarkable only for a tender, distended
urinary bladder.
Which of the following is the most likely cause
of this condition?
(A) urinary tract infection
(B) prostatic hypertrophy
(C) posterior urethral valves
(D) renal carcinoma
(E) renal arterial occlusion
ANSWER (B) Acute oliguria is a medical emergency requiring
the immediate identification of any correctable
cause. Distention of the urinary
bladder indicates bladder outlet obstruction.
Immediate management should be the passage
of a urethral catheter to relieve the obstruction
and provide urine for examination. An abdominal
flat plate, ultrasonography, or IVP may
yield a diagnosis but delay the relief of obstruction.
Furosemide may be harmful if given
while the bladder is obstructed. Bladder outlet
obstruction may be caused by prostatic hypertrophy
or prostatitis, stones, clots, malignancy,
or urethral stricture; it may also be neurogenic.
Posterior urethral valves are a congenital defect
that could cause obstruction in children but
rarely in adults. Renal carcinoma would not
cause outlet obstruction. Renal arterial occlusion

can cause acute renal failure but not

obstructive uropathy. If urethral catheterization
fails to relieve the obstruction, further evaluation,
including radiographic or ultrasound
studies, is in order. Suprapubic cystostomy
may be necessary to empty the bladder. (Kasper
et al., 2005, pp. 16441652)

105. A22-year-old man complains of low back pain

and stiffness that is worse on arising and
improves with exercise. On examination, he is
found to have limited mobility of the sacroiliac
joints and lumbar spine. A serum test for histocompatibility
antigen HLA-B27 is positive.
What is the most common extraskeletal manifestation
of this disease?
(A) premature cataracts
(B) splenomegaly
(C) acute iritis
(D) aortic insufficiency
(E) pulmonary fibrosis

106. A47-year-old man is postoperative day number

2 after an open cholecystectomy. He becomes
short of breath and a medicine consultation is
called to evaluate. Vital signs include a temperature
of 100F, pulse rate of 110/min, blood
pressure (BP) of 110/60 mmHg, and respiratory
rate of 24/min. Blood gas shows a pH of
7.52, carbon dioxide of 28, PO2 of 58, and calculated

bicarbonate of 20. What is the primary

acid-base disorder in this patient?
(A) metabolic acidosis
(B) respiratory acidosis
(C) metabolic alkalosis
(D) respiratory alkalosis
(E) metabolic and respiratory acidosis

107. During a routine checkup, a 45-year-old executive

is found to have hypercalcemia. Subsequent
workup reveals elevated parathormone,
decreased phosphorus, elevated chloride, and
normal blood urea nitrogen (BUN), and creatinine
in serum. Urinary calcium is above normal
levels. What is the most likely etiology?
(A) multiple myeloma
(B) primary hyperparathyroidism
(C) hypervitaminosis D
(D) sarcoidosis
(E) milk alkali syndrome

108. A 25-year-old man was admitted to the intensive

care unit with a severe head injury, with
fracture of the base of the skull. Approximately
18 hours after the injury, he developed
polyuria. Urine osmolality was 150 mOsm/L
and serum osmolality was 350 mOsm/L. IV
fluids were stopped, and 3 hours later, urine
output and urine osmolality remained

unchanged. Five units of vasopressin were

intravenously administered. Urine osmolality
increased to 300 mOsm/L. Which of the following
is the most likely diagnosis?
(A) central diabetes insipidus
(B) nephrogenic diabetes insipidus
(C) water intoxication
(D) solute overload
(E) syndrome of inappropriate antidiuretic
hormone secretion (SIADH)

109. A 19-year-old high school senior complains of

feeling fat and ugly despite being extremely
thin. She takes small amounts of food at meals
and occasionally gags herself to induce vomiting
after meals. Which of the following is
commonly associated with this disorder?
(A) menorrhagia
(B) metrorrhagia
(C) loss of body hair
(D) bradycardia
(E) thrombocytopenia

110. All of following are causes of secondary ammenorrhoea EXCEPT:

a) Diabetes
b) Drug Abuse
c) Eating Disorder
d) Asherman's Syndrome
e) Autoimmune Disorder

111. Apreviously healthy male postal worker complains

of fever, headache, myalgia, and cough
for the past 3 days. He reports that several of his
coworkers have also been ill with similar complaints.
His leukocyte count is normal with a
relative lymphopenia. Achest x-ray shows only
enlarged hilar shadows. Which of the following
is the most likely cause of this infection?
(A) Influenza A virus
(B) Bacillus anthracis
(C) Francisella tularensis
(D) Yersinia pestis
(E) Clostridium botulinum

112. The major cause of morbidity and mortality in

Marfan patients is cardiac. Which of the following
is a common complication?
(A) pulmonary stenosis
(B) ventricular septal defect (VSD)
(C) pulmonary hypertension
(D) aortic root dilatation
(E) coronary artery disease (CAD)

113. Contraindication to use in Migraine :

a) Buprobion
b) Lithium
c) valium

114. Male patient, who is otherwise healthy, has depression for 4 months. He retired 6 months ago.
O/E:
unremarkable except for jaundice. Whats your diagnosis:
a) Major depressive disorder
b) Mood disorder due to medical illness
c) Adjustment disorder, depressed type

115. A 4-year-old child presents to his pediatrician

with a complaint of a mild rash and fevers. His
travel history is positive for a camping trip 2
weeks prior. The parents do not recall a tick
bite on the child and do not remember if there
were ticks in the area. No other members of
the family complain of similar symptoms and
the child does not attend day care. Physical
examination is positive for a temperature of
100.9F with an erythematous rash noted over
the childs trunk. Which of the following factors
would significantly increase the possibility that
the child has Lyme disease?
(A) The camping trip occurred in an area
endemic for the tick Ixodes dentatus.
(B) The camping trip occurred in Texas.
(C) The camping trip occurred in an area
with a high indigenous population of
lizards.
(D) The camping trip occurred in an area
endemic for the white-footed mouse.
(E) The camping trip occurred in an area

which had recently been sprayed with

pesticides

116. A 72-year-old man has the sudden onset of suprapubic

pain and oliguria. His temperature is 38.0C
(100.4F), pulse is 100/min, respiration rate is
12/min, and BP is 110/72 mmHg. Abdominal
examination is remarkable only for a tender, distended
urinary bladder.
58. Which of the following is the most appropriate
immediate management of this patient?
(A) plain x-ray of the abdomen
(B) abdominal ultrasonography
(C) urethral catheter
(D) IV furosemide
(E) intravenous pyelogram (IVP)

117. A 30-year-old asymptomatic male presents to your

office because his father just had a heart attack. He
is concerned that he may have inherited his fathers
condition because a cholesterol level test done at his
work site last year was 220 mg/dL. You review his
history and find that he smokes 25 cigarettes a day,
eats mostly at fast food restaurants, sits at a desk
job, and has no regular moderate intensity physical
activities. His blood pressure is 130/85 mmHg and
his body mass index (BMI) is 26.
26. Which of the following is the best first recommendation?

(A) electrocardiography (ECG)

(B) ECG and an exercise treadmill test
(ETT)
(C) a diet for weight loss
(D) commencement of a daily exercise
routine
(E) antihypertensive medication

118. On the second day after an appendectomy, a

33-year-old man complains of chest pain. Vital
signs are: temperature 102F, BP 130/70
mmHg, pulse rate 100/min, and respiration
rate 22/min. Room air ABG reveals a pH of
7.50, PCO2 of 29, and PO2 of 49. His WBC count
is elevated and CXR shows a right lower lobe
infiltrate. Which of the following is the most
likely diagnosis?
(A) pulmonary embolism
(B) myocardial infarction
(C) pneumonia
(D) asthma
(E) congestive heart failure

119. An HIV-positive African American man is admitted with dyspnea, dry cough, high
LDH, and a p02 of 63 mm Hg. He is started on TMP/SMX and prednisone. On the
third hospital day he develops severe neutropenia and a rash. He has anemia and
there are bite cells visible on his smear.
What is the most appropriate next step in the management of this patient?
a. Stop TMP/SMX

b. Begin antiretroviral medications

c. Switch TMP/SMX to intravenous pentamidine
d . Switch TMP/ SMX to aerosol pentamidine
e. Switch TMP/ SMX to clindamycin and primaquine

120. A62-year-old woman with a long-standing history

of diabetes and hypertension presents for
evaluation of hyperkalemia. Her room air arterial
blood gas (ABG) and electrolytes are the
following:
pH 7.38/PCO2 34/PO2 89
Na 140 Cl 106 BUN 51
K 5.9 CO2 20 Cr 2.8
Which of the following is the underlying renal
abnormality?
(A) renal tubular acidosis (RTA), type 2
(B) focal segmental glomerulonephritis
(C) interstitial nephritis
(D) RTA, type 4
(E) Barter syndrome

121. By the 6th postoperative day, the patient has

normal bowel function and is tolerating a full
oral diet. However, she develops a spiking fever
pattern and complains of increasing incisional
discomfort. On examination, there is a small
amount of drainage on the wound dressing, and
the incision is erythematous and tender.
Appropriate evaluation and management at this

point should include which of the following?

(A) blood, urine, and sputum cultures; chest
x-ray and abdominal CT scan
(B) discharging the patient on oral antibiotics
(C) culture of the wound drainage, and initiation
of IV antibiotics
(D) opening the incision, culture of the
wound drainage, and initiating local
wound care
(E) opening the incision, culture of the
wound drainage, and initiating IV
antibiotics

122. Patricia, aged 25 yrs has been diagnosed with polycystic ovarian syndrome. in counselling this
patient regarding long term consequences the MOST APPROPRIATE advise would be:
a) There are no serious long term consequences
b) There is an increased risk of endometrial hyperplasia
c) There is an increased risk of cervical cancer
d) There is an increased risk of osteoporosis
e) There is an increased rsik of premature menopause