Professional Documents
Culture Documents
MCQ Practice
MCQ Practice
INSTRUCTIONS
1. For multiple-choice items which have only one correct or best answer the options
have been lettered A, B, C, etc.
2. For multiple-choice items which have one or more correct answers the options
have been lettered a, b, c, etc.
3. For multiple choice/single response type questions, mark your choice(s) on the
optical score sheet provided. Use the pencil provided and erase any errors
thoroughly.
4. If you have any comments or criticisms about an item or the overall examination,
please make them on the blank sheet at the end of this booklet.
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EXAMINATION QUESTIONS
Please answer questions 1-3 based on information from the following vignette.
Mr. John Wong, a 34-year-old restaurant owner, visits his family physician’s office for a
routine check-up. On repeated testing his blood pressure is elevated at 180/105 mmHg.
He admits to stress at work and states that his father was diagnosed as hypertensive at the
age of 60 but, thus far, has not required treatment. He has no symptoms with the
exception of mild constipation for which he takes bran supplements. He is on no
prescribed medication although he does admit to occasionally taking Chinese herbal
remedies. He denies taking any other medications. He smokes 25 cigarettes per day but
takes no alcohol. On physical examination he is not obese, has no signs of cardiovascular
disease, and no hypertensive retinopathy. The results of investigations are given below:
Na 146 mmol/L
K 2.8 mmol/L
Cl 102 mmol/L
HCO3 33 mmol/L
Urea 4.2 mmol/L
Creatinine 92 mmol/L
Glucose 6.2 mmol/L
2
3. Which of the following is/are appropriate step(s) in management?
*****
Primary hypertension is almost always the most likely diagnosis for patients with
hypertension. For each patient in questions 1-3 select the SECONDARY CAUSE of
hypertension worthy of investigation from choices A-N. If No secondary cause is worthy
of investigation, SELECT CHOICE “O”. Choices A-O may be used once, more than once
or not at all.
4. Mr. Harry Conroy, a 52-year-old newspaper assistant editor, is seen in the office of his
family physician complaining of blood in the urine over the past four days. He states that
he has had this on two previous occasions, both in relation to an upper respiratory tract
infection. On both previous occasions the urine cleared spontaneously over a period of
five to seven days.
At the time of the present visit he states that he has been feeling lethargic with a sore
throat for the past five days. He is a vegetarian and smokes a pack of cigarettes each day.
Blood pressure is 170/95 mmHg in both arms, sitting and supine, on repeat testing. Urine
analysis shows specific gravity 1020, nitrites negative, +++ blood and +++ protein. Urine
microscopy reveals oxalate crystals, dysmorphic red blood cells and red cell casts.
3
5. Mr. James McKeen, a 49-year-old tax assesor, visits his family physician’s office for
his monthly blood pressure check. He has been hypertensive for the past four years and
his blood pressure control has been erratic during this time. His only other medical
problem is gout, which he experiences on average once every eighteen months. He
continues to smoke two packages of cigarettes per day. He has a maternal family history
of hypertension and cerebrovascular disease and a paternal family history of lung
carcinoma. His present antihypertensive medications are hydrochlorothiazide and adalat
XL. On physical examination he is obese with blood pressure is 174/96 mmHg. Urine
analysis at his last three visits has shown a trace of protein. Urine microscopy is
unremarkable. A 24 hour urine collection shows a normal creatinine clearance with
excretion of 340mg of albumin during this time period. Serum liver enzymes are normal.
6. Ms. Jane Wallace, a 29-year-old interior decorator, visits his family physician’s office
for a routine check-up. On repeated testing her blood pressure is elevated at 180/105
mmHg. She admits to stress at work and states that her father was diagnosed as
hypertensive at the age of 60 but, thus far, has not required treatment. She has no
symptoms with the exception of mild constipation for which she takes bran supplements.
She is on no prescribed medication although she does admit to occasionally taking
Vitamins C and E. She denies taking any other medications. She does not smoke but
takes alcohol socially. On physical examination she is not obese, has no signs of
cardiovascular disease, and no hypertensive retinopathy. The results of investigations are
given below:
4
Please answer questions 7 – 9 using information from the following vignette.
Mrs. Hogan brings her daughter Natascha to the emergency room. Natascha is a
previously well, one-year-old girl who developed a fever two days ago. Her temperature,
measured orally by her mother, was 39.8o C. For the past two days Natascha has been
listless and has eaten very little other than juice and milk. She has had neither diarrhea
nor vomiting. Her mother thinks she may have had a bit of a runny nose earlier in the
week. Her mother has been treating her with Tylenol, and although Natascha appears
flushed and ill when the fever is high, she is her usual self when the fever is down. Her
mother is concerned because Natascha has had a fever once before and it was an ear
infection that required antibiotics. Her mother is wondering if she needs some today.
Natascha has otherwise been a healthy child and has received all her immunizations
including MMR vaccine one week ago.
On examination, she is sleeping in her mother’s arms during the interview. She cries
during the entire exam, but is comforted after by her mother and stops crying. Her
temperature is 40 degrees Celsius rectally. Her tympanic membranes are normal. Her
throat is mildly erythematous, with no exudate. Her lungs are clear, respiratory rate is
30/min, and there are no extra heart sounds. Abdomen is soft. She has a diaper rash.
9. A CBC is drawn and her WBC is 20 x 109/L, with a high neutrophil count. All other
investigations are normal. How would you manage this case?
a. administer aspirin q4h
b. administer ibuprofen q6h
c. administer acetaminophen q4h
d. admit to hospital, refer to a pediatrician
e. administer Ceftriaxone im
*****
5
Please answer questions 10 - 13 using information from the following vignette.
Her physical examination revealed a thin, pale, tired looking female appearing younger
than her stated age. Vital signs revealed a BP of 110/70 mmHg, HR 90/min, temperature
36.5 C. Pale conjunctiva, no oral lesions or lymphadenopathy. Her chest and
cardiovascular exam was normal except for a 2/6 systolic ejection murmur at the LSB.
MSK and CNS exam were normal except for leukonychia, a vesicular rash and
excoriations on her buttocks. Mild hepatomegally was noted by percussion and palpation
but no masses, tenderness or splenomegally were noted. Rectal exam was normal.
CBC: Hgb 82 g/l, microcytic red cells and Howell Jolly bodies were noted on the
peripheral smear. Her electrolytes and glucose were normal.
10. In assessing the cause of her diarrhea which of the following is/are correct;
11. Which of the following is/are consistent with the diagnosis of irritable bowel
syndrome;
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12. Which of the following is/are a likely causes of Ms AK’s problems;
A. Ulcerative colitis
B. Antibiotic associated colitis
C. Celiac disease
D. Cystic fibrosis
E. Hemochromatosis
13. In regards to investigating the cause of Ms A.K.’s problems which of the following
are true.
a. There is a reproducible and accurate blood test for the diagnosis of Crohn’s disease.
b. There is a reproducible and accurate blood test for the diagnosis of Celiac disease.
c. An upper endoscopy may aid in the diagnosis of both Celiac disease and Giardia.(0.5)
d. HIV serology should be ordered
e. A macrocytic anemia favors the diagnosis of ulcerative colitis over Crohn’s disease.
*****
Cody, a six-year-old boy presently undergoing treatment for Wilm's tumor, visits the
oncology clinic regarding a sudden loss of vision in his right eye of one day's duration.
He has completed his treatment protocol six months ago and has been stable until this
new symptom developed. His general physical examination shows no obvious problems.
His vision in the right eye is restricted to light perception only. His vision in the left eye
is 20/20. Pupils are 4 mm in size each eye, pupillary reactions are sluggish right eye, but
brisk with a normal consensual reaction when the light is shown to the left eye. Swinging
the flashlight from left to right eye, the right pupil dilates. Swinging the flashlight from
right to left eye, the left pupil constricts. Fundal examination shows a normal optic
nerve, peripheral retina, within normal vessel pattern.
7
15. The most likely diagnosis is:
*****
16. A 64-year-old man is brought to see you by his wife because of increasing memory
problems and confusion over three months. He has become gradually more listless and
apathetic, with a significant change in personality. She has noted that he has had
increasing difficulty with recalling recent events. One week ago, while he was driving
home with her from visiting a friend, he became lost and was unable to find his way
home. The patient does not complain of memory problems, but has complained of
bilateral headache over the past two months, for which he has been taking
acetaminophen, 1mg daily.
Review of systems shows that he smokes one pack per day, and has drunk four bottles of
beer every day for twenty years, although his drinking has decreased over the last two
months.
On examination, the patient is disoriented for time, does not recall the name of the
current Prime Minister, and has difficulty subtracting 7 from 100. He shows hyperactive
reflexes in his legs, and plantar responses are upgoing bilaterally. His gait is slightly
unsteady and wide-based.
8
Please answer questions 17 – 18 based on information from the following vignette.
A fourteen-year-old boy attends his family physician’s office for examination of his eyes.
His mother believes something is wrong with them because he is constantly blinking.
The boy is otherwise well. He was suspected to have Attention Deficit / Hyperactivity
Disorder (AD/HD) in elementary school, but was never placed on stimulant medication.
He currently takes no medications. He was adopted at birth, thus his family history is not
known. During conversation with the boy, you note that he frequently clears his throat,
yet he denies sore throat or other upper respiratory tract symptoms. He blinks frequently,
yet is able to hold his eyes open during examination with an ophthalmoscope. His fundi,
visual acuity, extraocular movements, visual fields, eyelids and eyelashes are normal. He
also exhibits intermittent facial grimacing without apparent pain. The remainder of his
examination is normal.
17. This boy’s eye movements are most consistent with which of the following?
A. Fidgeting
B. Motor tics
C. Simple partial seizures
D. Blepharospasm
E. Blepharitis
18. Which of the following conditions are frequently associated with this boy’s
diagnosis?
*****
9
Please answer questions 19 – 20 based on information from the following vignette.
A 14-year-old male presents to your office complaining of recent growth of his breasts.
He has a history of cardiac disease and is currently taking digoxin and
hydrochlorothiazide. On examination your patient is slim, his blood pressure is 160/96
mmHg, and he has bilateral non-tender gynecomastia. The remainder of his physical
examination is within age normal limits.
19. The patient asks you why his breasts are growing and you site which of the following
reasons as a possible cause?
A. His slender body habitus
B. Digitalis
C. His elevated blood pressure
D. Hydrochlorothiazide
E. His underlying cardiac disease
20. Your patient desires more information about breast enlargement in males. Which of
the following information should be given?
a. Gynecomastia is very uncommon and he needs to have his breast tissue biopsied as
soon as possible to exclude breast carcinoma.
b. Asymptomatic palpable breast tissue can be seen in normal males, particularly in
neonates, at puberty and with increasing age above 45 years.
c. Avoid heavy alcohol abuse since it may be lead to gynecomastia
d. Gynecomastia will almost never spontaneously regress leading to the single
therapeutic option of surgical removal of the breast tissue.
e. Gynecomastia results from an increased estrogen to testosterone ratio.
*****
Mr. William Connell, a 41-year-old freelance photographer, is seen in the office of his
family physician complaining of red discolouration of his urine over the past four days.
He states that he has had this on two previous occasions, both in relation to an upper
respiratory tract infection. On both previous occasions the urine cleared spontaneously
over a period of five to seven days.
At the time of the present visit he states that he has been feeling lethargic with a sore
throat for the past five days. He is a vegetarian and smokes a pack of cigarettes each day.
Blood pressure is 170/95 mmHg in both arms, sitting and supine, on repeat testing. Urine
analysis shows specific gravity 1020, nitrites negative, +++ blood and +++ protein. Urine
microscopy reveals oxalate crystals, dysmorphic red blood cells and red cell casts.
10
21.Which ONE of the following is the most likely diagnosis?
A. IgA nephropathy
B. Ingestion of beets
C. Renal calculi
D. Bladder carcinoma
E. Post-streptococcal glomerulonephritis
a. Cystoscopy
b. Urine culture
c. Serum creatinine
d. Plain X-ray of the kidney, ureter and bladder
e. 24 hour urine collection for creatinine clearance and protein excretion
A. Urine infection
B. Delay in analysis of the urine sample
C. Glomerular bleeding
D. Urothelial malignancy
E. Urinary tract calculus
*****
Miss Tracy Patterson, a 17-year-old university student, visits her family physician’s
office complaining of fatigue and “strong smelling” urine. Her only past medical problem
is infectious mononucleosis two years previously form which she made a complete but
protracted recovery. Her only medication is the birth control pill. She is a member of the
university basketball team and has noted a dip in her performance since the onset of these
symptoms. She denies any other symptoms. There are no abnormal findings on
examination. Blood pressure is 110/68 mmHg. Urine analysis shows specific gravity
1030, nitrites negative, + protein. Urine microscopy reveals a few vaginal epithelial
cells/hpf, 0-1 wbc’s/hpf, and 0-1 hyaline casts/hpf. A 24 hour urine collection shows a
normal creatinine clearance with 0.41g of protein for this time period.
11
24. Which ONE of the following is the most likely diagnosis?
A. IgA nephropathy
B. Membranous glomerulonephritis
C. Exercise-induced proteinuria
D. Urinary tract infection
E. Reflux nephropathy
a. Cystoscopy
b. Split urine collections (0800 – 2000, and 2000 – 0800)
c. Repeat 24 hour collection after avoiding exercise
d. Renal biopsy
e. Serum and urine electrophoresis
*****
Theresa Gallagher, arrives at her family physician’s office complaining of easy bruising
over the past month. She is not as concerned about her “rash-like” skin bruising as she
is about her gums bleeding with brushing her teeth over the past three days. Theresa is
25 years old and otherwise healthy. She is not taking any medications, and drinks only
socially. She has never been hospitalized except for the birth of her daughter three years
ago after an uneventful pregnancy. Family history is completely negative. She denies
any large bruises, denies deep muscle or joint pain, and has not noticed any blood in her
urine.
27. The only abnormality detected is a platelet count of 70,000/mm3. What is/are the
possible cause(s)?
a. Renal failure
b. Folate/B12 deficiency
c. Lymphoma/leukemia
d. Factor VIII deficiency
e. SLE
*****
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28. A concerned father calls your office because his three-week-old son Damien has a
fever of 39.5 degrees Celsius measured axially. He was born at term and had no
complications after a spontaneous vaginal delivery. He was breast-feeding well until
yesterday. Since then he has been sleeping more. He has a two-year-old brother who has
a cold.
A. Treat the fever with Tylenol, bring the baby to the office if fever lasts over 48 hours
B. Bring baby to the office for further evaluation sometime later today.
C. Take baby to the emergency room for hospital admission
D. Make a house call
E. Make appointment for the baby with a pediatrician
Mr. David Wallace is a 57 year old male that presents with a longstanding history of
heartburn and reflux of acid-like material in to his mouth. He usually treats himself with
oral antacids but lately they have not been as effective. Yesterday he had some pain and a
sticking sensation after swallowing a piece of bread. He has noticed this on at least on 3
separate occasions before, these episodes having occurred over the last 2 months or so.
When asked to point to where he feels the food is sticking he points to he points to an
area just below his thyroid gland. Each time he could not swallow, he was able to down
the food with water and did not need to seek medical attention. He has not had trouble
swallowing hot or cold liquids. His past medical history is significant for polio as a child
and feels he has some arm and leg weakness due to that. He has a 50-pack year smoking
history. His family history is negative except he has one sister that died of breast cancer.
His physical exam is completely normal.
a. Since he points to an area near his thyroid he probably has oropharyngeal dysphagia
secondary to post polio syndrome.
b. Assess for signs of stroke or post-polio syndrome since his dysphagia is likely due to
a neuromuscular disease.
c. He likely has uncomplicated reflux esophagitis and should be managed with a proton
pump inhibitor and requires no further investigation.
d. Esophageal carcinoma usually presents with both liquid and solid dysphagia
e. Since coughing, choking, and aspiration are absent, difficulty in initiating swallowing
(in contrast to difficulty swallowing) may be safely excluded
13
30. Which of the following management/investigation strategies is/are most appropriate
for Mr. Wallace?
a. Start him on H2 antagonist (ranitidine) and arrange for him to have an upper
endoscopy.
b. If a barium swallow is normal and his symptoms progress start him on a proton pump
inhibitor and advice him that since the barium swallow is normal no further
investigation are required.
c. Since an upper endoscopy is not available in your community you order a chest xray
and a barium swallow.
d. His barium swallow is normal but the dysphagia persists, order a CT scan of his head
to rule out a neurological cause of his dysphagia.
e. Since dysphagia can occur in uncomplicated reflux esophagitis you reassure the
patient that he has uncomplicated gastroesophageal reflux and counsel him on
conservative management of reflux disease suggest he eat small meals, quits smoking
and limits his caffeine consumption.
*****
32. The emergency room nurse pages you to come examine a two-year old girl who is the
daughter of one of your patients. Upon arriving in the emergency room, you see an
obtunded girl with no known prior medical problems. Her father states that his daughter
fell down the stairs earlier in the evening, but he does not think that she hit her head
during the fall.
Physical examination shows no visible signs of external injury. After a brief but
complete physical examination, the only abnormality detected was on examination of her
eyes. Although examination of her anterior chambers is normal, posteriorly in each eye
there are large, dome-shaped hemorrhages in the macula. In addition, there are multiple
scattered retinal hemorrhages visible in the retinal periphery of each eye.
14
The most likely diagnosis in this case is:
34. Sara has terminal bone cancer unresponsive to chemotherapy. She is 7 years old and
has been in hospital for palliative care for just over 3 weeks. Today she is feeling tired,
she is repeatedly complaining of pain in her leg, and wants to be held in her mother’s
arms. She refuses to eat because according to her there is no point in eating if she will
die anyway.
Which of the following procedures is/are appropriate for Sara (choose all correct ones):
a. force feed
b. provide adequate analgesia
c. initiate parental nutrition
d. prescribe antidepressants
e. provide emotional support
15
Please answer questions 35 – 36 based on information from the following vignette.
A full term infant with a birth weight of 3.5 kg, length of 50 cm and head circumference
of 35 cm (all at 50th percentile) comes for an office appointment at 2 weeks of age. The
mothers states that the infant was discharged home at 24 hours of age and has done well
since. The infant is being fed Carnation milk diluted to 25%. The child’s sleep pattern is
characterised by 1.5 hours of sleep after each feed. His weight today is identical to birth.
On exam the infant appears to be well hydrated, the mucosa colour is normal and in no
distress. The exam is unremarkable except for irritability.
36. Considering the appropriate nutritional management of infants, select the appropriate
advice to be given to new mothers:
A. Avoid feeding newborn infants in the first 12 hours of life in order to prevent
aspiration
B. Breast milk is deficient in iron and iron supplementation is recommended for
breast fed infants
C. Breast milk does not contain enough vitamin D and vitamin D supplementation is
recommended for exclusively breast fed infants
D. Institute solid food at three months of age
E. Breast milk may causes diarrhea if used exclusively, so formula should be added
*****
16
Please answer questions 37 – 39 based on information from the following vignette.
Mr. Lyle Murrin, a 75-year-old retired train engineer, saw his family physician on March
18, 2000 complaining of breathlessness. He had signs of cardiac failure with atrial
fibrillation. Serum creatinine at that time was 145 µmol/L, similar to the value from eight
months ago. Because he was in moderate distress, he was admitted to hospital. No
invasive procedures were considered necessary. His diagnosis of congestive heart failure
led to treatment with enalapril, furosemide, and digoxin. He was discharged from hospital
on March 28, 2000.
Today, April 3rd, 2000 he returns to the office of his family physician complaining of
increasing nausea, vomiting, decreasing amounts of urine, pain in his right great toe and
difficulty sleeping.
37. What is the most likely explanation for the rise in serum creatinine?
A. Hypertensive nephrosclerosis
B. Bilateral renal artery stenosis
C. Dehydration secondary to diuretics
D. Urate-containing renal calculi
E. Chronic glomerulonephritis
17
39. Which of the following treatments is/are indicated?
*****
Mr. Tom McDonald, a 51-year-old accountant, visits his family physician’s office for his
three monthly blood pressure check. He has been hypertensive for the past five years and
his blood pressure control has been erratic during this time. His only other medical
problem is gout, which he experiences on average once every eighteen months. He
continues to smoke a pack of cigarettes per day. He has a paternal family history of
hypertension and cerebrovascular disease and a maternal family history of colonic
carcinoma. His present antihypertensive medications are hydrochlorothiazide and
nifedipine XL. On physical examination he is obese with a BMI of 32. Blood pressure is
170/94 mmHg. Urine analysis at his last three visits has shown a trace of protein. Urine
microscopy is unremarkable. A 24 hour urine collection shows a normal creatinine
clearance with excretion of 270mg of albumin during this time period. Stool occult blood
test is negative on three occasions.
a. Cystoscopy
b. Split urine collections (0800 – 2000, and 2000 – 0800)
c. Fasting blood glucose
d. Renal biopsy
e. Fasting lipids
A. membranous glomerulonephritis
B. orthostatic albuminuria
C. diabetic nephropathy
D. glomerular hypertension
E. tubulo-interstitial nephritis
*****
18
42. The laboratory calls a physician’s office to report an INR of 10 on Mr. Becker. Upon
review of the office chart, it is noted that the patient is a 68-year-old man on Coumadin 5-
mg daily for atrial fibrillation. He also has osteoarthritis of the knee and chronic
obstructive pulmonary disease. Other medications being taken include Ventolin,
Atrovent, Becloforte, and Indocid. When Mr. Becker is reached at home by telephone,
he is feeling well and has not noticed any bleeding.
a. admit to hospital
b. decrease the dose of Coumadin to 3 mg per day and recheck the INR in 3 days
c. hold the Coumadin and recheck INR daily for the next three days
d. discontinue the Indocid
e. administer vitamin K 10 mg sc/po daily for 3 days.
Fernando Fournasier is a new patient who recently moved into town and has arranged to
have a routine physical exam for life insurance. He is a healthy 60-year-old restaurant
owner. His only medical problem has been hypertension that was diagnosed 6 years ago
and has been well controlled on Enalapril, 10 mg daily. He has no complaints. He
doesn’t smoke and attempts to eat a low fat diet.
On physical exam, you note that his blood pressure is 140/88, and his heart rate 80. JVP
is 2 cm above the sternal angle. Upon listening to his chest, you hear a systolic murmur
at the left sternal border that is as loud as his heart sounds. He has no extra sounds. He
has no heaves or thrills. He states he has never been told he had a murmur. The rest of
his exam is normal.
44. Signs and symptoms that indicate the need for further investigation are:
a. Dyspnea
b. petechia
c. fatigue
d. syncope
e. the presence of a thrill
19
45. If a pathologic murmur is likely, initial investigation(s) would include:
a. BP 24-hr monitor
b. ECG
c. Holter monitor
d. Echocardiogram
e. thallium scan
*****
Ms Webb, a 19-year-old female presents to her family physician’s office with a 3-day
history of vomiting (7 to 10 times per day) and retching. Yesterday, for the first time, she
noticed some streaks of blood in her greenish vomit on one occasion. She has not had a
bowel movement in two days and denies diarrhea, blood in her stool, early satiety, pain
associated with eating, or weight loss. She admits to feeling cold, weak and light headed
for 3 days. Over the last several years she occasionally brings up sour tasting liquid into
her mouth and often this is associated with epigastric pain and burning in her chest. Her
past medical history and family medical history is negative. She is has been taking
Tylenol (acetaminophen) for back pain the last few days.
Her physical exam reveals; BP 90/70, HR 110, temperature 38.4C. Head and neck, chest
and cardiovascular exams are normal except for a 2/6 systolic murmur and some
tenderness to percussion over her left lower lung field posteriorly. Her abdominal exam
was normal.
b. An ultrasound of the pancreas, liver and biliary track should be ordered immediately
to rule out gallstones or pancreatitis.
c. Blood cultures would be unlikely to be helpful since her temperature is less that 38.5.
d. Due to the blood in the vomit, this is classic for peptic ulcer disease.
20
47. For Ms Webb’s vomiting, select the most useful initial investigation / treatment
B. Send a stool sample for cultures and sensitivity and ova and parasites to rule out food
poisoning
C. A full neurological exam followed by a CT scan of the head if abnormalities are noted
D. Routine lab work including a CBC, electrolytes and send urine for routine and
microscopic exam.
E. Give her a pink lady (liquid antacid mixed with viscous xylocaine) and see if that
improves her symptoms.
A. Gastroenteritis
B. Acid Peptic disease
C. Obstruction of bowel
D. CNS infection
E. Systemic infection
*****
James Smith, a nine-year-old boy, is sent to the emergency room for further evaluation.
He has had three days of treatment with intravenous cefuroxime and cloxacillin with no
improvement in his left eye signs and symptoms. He has had a three-week history of
purulent rhinorrhea, a temperature of 37.2 C, and a white count of 10. 5 x 109. The
referral notes indicates that a recent X-ray showed evidence of pansinusitis.
On examination, his vision was 20/20 in each eye, the eyelids of the left eye were swollen
shut. There was marked conjunctival induration, chemosis, proptosis, and limited
elevation of the left eye. Pupillary reactions were sluggish in the left eye. Fundal
examination was normal in both eyes, without evidence of papilledema or optic atrophy.
21
50. The most likely diagnosis in this case is:
*****
52. Mr. R.M. is 76 years of age. He has a past history of age-related macular
degeneration, hypertension, prior alcohol abuse, osteoarthritis of his right hip, and manic-
depressive disorder. Current medications are - lithium carbonate 300 mg. t.i.d,
hydrochlorothiazide 25 mg. daily, and indomethacin 25 mg. tid. Over the last year he has
complained of mild word finding problems with delayed retrieval ("its at the tip of my
tongue") and mild problems with recall. With cueing he can usually recall the item.
About two weeks ago he was started on indomethacin for worsening hip pain. A week
ago he was seen by his ophthalmologist and told he should give up driving because of his
deteriorating vision. You were called by his wife to see him at home because of the
development of confusion over the last 2-3 days. According to the wife the confusion
varies over the course of the day. On examination he is intermittently agitated and has
trouble focusing his attention. He is disoriented to time and his short-term memory is
impaired.
A. Acute Mania.
B. Delirium.
C. Dementia.
D. Grief Reaction.
E. Major Depression.
22
Please answer questions 53 – 54 based on information from the following vignette.
A 32 weeks gestation infant is born with a birth weight of 1000 grams (< 3rd percentile).
At birth the infant required no resuscitation but has quickly developed tachypnea and
cyanosis on room air. The physical examination is remarkable for respiratory distress
with bilateral rales on lung auscultation. The vital signs at 1 hour age revealed a heart
rate of 150 beats per minute, respiratory rate of 80 / min, temperature of 35.7 o C and heel
stick glucose check of < 2 mmol/L.
53. How would you classify this infant according to gestational age and measurement
parameters?
A. Adequate for Gestational Age
B. Small for Gestational Age
C. Large for Gestational Age
D. Dysmature
E. Full term
*****
23
Please answer questions 55 – 56 based on information from the following vignette.
Miss Patricia Thomson, a 36-year-old schoolteacher, attended the office of her family
physician one week ago complaining of dysuria. Urine culture had grown E coli for
which trimethoprim and pyridium (bladder analgesic) were started. She has chronic renal
insufficiency due to reflux nephropathy with a baseline serum creatinine of about
150µmol/L. Her only regular medication is the birth control pill.
Today she complains of nausea and vomiting since starting trimethoprim along with a
bad taste in her mouth. On physical examination, she appears well with a heart rate of 84
bpm and sitting BP of 110/68 mmHg. She has no renal angle tenderness. The results of
her investigations are given below:
55. What is the most likely explanation for the rise in potassium?
*****
24
Please answer questions 57 – 58 based on information from the following vignette.
Mr. Balwindar Singh, a 54 year old accountant, who is seen in the office of a walk-in
clinic complaining of increasing breathlessness on exertion. He has been an IDDM for 12
years, hypertensive for seven years and had a myocardial infarction complicated by
“mild” cardiac failure one year ago. He also complains of thirst, polyuria and daytime
somnolence. He smokes half a pack of cigarettes per day and takes four units of alcohol
per day. On examination his pulse is regular at 92 beats per minute and blood pressure is
174/96 mmHg with no postural change. Jugular venous pulse is 5cm above sternal angle.
Prescribed medications are lisinopril 5mg, hydrochlorothiazide 25mg, atorvastatin 10mg,
ASA 325mg, and insulin. The results of investigations are given below:
Urine analysis negative Urine electolytes
Na 125 mmol/L Na 105 mmol/L
K 4.8 mmol/L K 54 mmol/L
Cl 92 mmol/L Cl 101 mmol/L
HCO3 22 mmol/L Serum osmolarity 273 mmol/L
Urea 4.1 mmol/L Urine osmolarity 586 mmol/L
Creat 86 mmol/L
Glucose 8.2 mmol/L
Cholesterol 4.2 mmol/L
Triglycerides 1.4 mmol/L
A. Mineralocorticoid deficiency
B. Thiazide diuretics
C. Inappropriate ADH secretion
D. Hyperglycemia
E. Psychogenic polydipsia
58. Which of the following is the most appropriate management of hyponatremia in this
case?
A. Oral demeclocycline
B. Water restriction
C. Stop lisinopril
D. Oral Sodium Chloride supplements
E. Add a loop diuretic
*****
25
59. Mrs. Danbury, a 60-year-old woman attends her family physician’s office to discuss
some chest discomfort that she has had recently. She has difficulty describing her
discomfort. It is not really pain, but there is definite discomfort in the area of her
breastbone. She has had the ‘discomfort’ on waking up in the morning, and it has
recurred for four or five times over the past month. She is not very active, but she has
noticed a “twinge” in her chest when she was walking with her dog yesterday. She has
also noticed the same chest discomfort after dinner the past two nights. The discomfort
usually lasts a few minutes. The main reason for her visit today is because last night the
pain lasted for half an hour. Associated symptoms include shortness of breath while
walking upstairs over the past two weeks. She denies any chest discomfort at the present
moment. She does not smoke. Her father died of a stroke and had also had a heart attack
at 53 years of age; her mother died of stomach cancer when the patient was 8 years old.
Physical examination is normal and the BP is 150/95 mmHg, similar to her reading the
previous year.
A. Pulmonary embolus
B. Peptic ulcer disease
C. myocardial infarction
D. stable angina
E. unstable angina
F. pericarditis
G. aortic dissection
A 69-year-old man comes into your office for a complete physical. He has had
hypertension for 20 years well controlled with a beta blocker. He also has high
cholesterol for which he has had prescribed Pravachol for the past 13 years. He does not
smoke. He has no complaints.
On physical examination his blood pressure is 146/87 mmHg and no other abnormalities
are discovered.
Routine blood work reveals: Na 142 mmol/L, K 4.5 mmol/L, Chloride 109 mmol/L,
bicarbonate 21 mmol/L, creatinine 212 :mol/L.
60. What further questions would you ask this patient, given the lab results?
a. Any change in vision
b. Any change in pattern of voiding
c. Any NSAID use
d. Any headaches
e. Any bone pain
26
61. Additional investigations should include:
a. intravenous pyelogram
b. microscopic urinalysis
c. 24-hr urine for protein and creatinine clearance
d. 24-hr urine for protein electrophoresis
e. renal ultrasound
*****
Her vital signs are normal, and her physical exam is normal except that she is obese and
she has mild periumbilical tenderness. Rectum is empty.
A walk-in clinic she attended 3 days ago obtained stool cultures. These were negative she
was told she has irritable bowel syndrome. The patient desires a second opinion.
a. She does not meet the criteria for the diagnosis for diarrhea since some days she is
only having 4 bowel movements per day.
b. Her symptoms are consistent with a flare of her irritable bowel syndrome and since
stool cultures were negative no further investigations are required. Advise increasing
the fiber in her diet to 12-20 g per day and to avoid stress.
c. She is unlikely to be Giardia since the stool culture was negative and she has not seen
blood in her stool.
d. Bloody diarrhea is more common in ulcerative colitis than Crohn’s disease.
e. The diagnosis of Giardia often requires multiple stool collections.
27
63. Which of the following statements is/are true?
a. Large volume diarrhea is more commonly associated with a small bowel pathogen
than a large bowel pathogen.
b. Sigmoidoscopy is the only way to confirm the diagnosis of Giardia
c. Stool culture and sensitivity is the diagnostic test of choice in assessing a patient you
suspect may have antibiotic induced colitis.
d. Bacterial pathogens generally cause a shorter duration of illness than parasitic and
protozoan infections.
e. Of viral pathogens, cytomegalovirus (CMV) is the most likely cause of her
symptoms.
64. In the management of acute diarrhea which of the following is/are correct?
a. Most patients with stool cultures positive for Salmonella require treatment.
b. First line therapy for Giardia is metronidazole
c. First line therapy for Salmonella is metronidazole
d. First line therapy for Clostridium difficile is metronidazole
e. In treatment of traveler’s diarrhea antibiotics are not of proven value.
A. Rotavirus
B. E.Coli, enterotoxigenic
C. Protozoa
D. Inflammatory bowel disease
E. Irritable bowel
*****
28
Please answer questions 66 – 67 based on information from the following vignette.
A 6-hour-old infant is admitted to the special care nursery for hypotonia. She was
delivered following an uncomplicated term pregnancy by spontaneous vaginal delivery.
Her mother is a 40 year old gravid 3, para 3 healthy woman and her father is 38 years old
and healthy. There is no family history of pregnancy loss, neonatal problems or
congenital abnormalities.
The infant’s birth weight was 3.66 kg. On examination, her heart rate is 130 beats/min,
respiratory rate is 30 breaths/min, and temperature is 37.1oC. She has a round face,
upslanting palpebral fissures, small ears and excess nuchal skin. She has bilateral single
palmar creases. The infant is hypotonic. There is no respiratory distress but a II/VI
cardiac murmur is audible. Abdominal examination reveals no masses and there is a 2-
vessel umbilical cord. She has normal female genitalia and stable hips.
66. Which of the following laboratory result would confirm your diagnosis of this infant?
67. Based upon this child’s most likely diagnosis, what are important investigations to
complete in the neonatal period? (Choose all that apply.)
a. Cranial ultrasound
b. Cardiac echocardiogram
c. Hip X-ray
d. TSH and free T4
e. Chromosome analysis
*****
29
Please answer questions 68 – 69 based on information from the following vignette.
For each elderly patient with dizziness, select the most likely diagnosis (A-J).
Diagnosis:
A. Benign Paroxysmal Positional Vertigo.
B. Parkinson's Disease.
C. Postural Hypotension.
D. Multi-sensory deficits.
E. Central Vascular Disease.
F. Peripheral polyneuropathy
G. Anxiety.
H. Poor vision.
I. Cervical Spondylosis.
J. Drug Toxicity.
68. A 65 year old female with complaints of dizziness. She has a history of hypertension
and mild high frequency hearing loss. On examination her blood pressure is 163/87
lying and 156/81 standing. Visual acuity is 6/9 in both eyes. Vigorous head or neck
movements worsen her complaints of dizziness. She has a restricted range of neck
motion. Touch and vibration sense is normal. You cannot elicit her ankle jerks. She
had a negative response to the Dix-Hallpike test.
69. A 72 year-old male with complaints of transient spinning dizziness when he turns
over in bed at night. He suffers from degenerative arthritis of his weight-bearing
joints and takes 282's (ASA 375 mg.-cafeine citrate 30 mg.-codeine phosphate 15
mg.) every four hours as needed (he takes 4-6 tablets per day) for this. On
examination his blood pressure is 134/82 lying and 139/80 standing. Visual acuity
was 6/6 (with his glasses on). He had a positive response to the Dix-Hallpike test.
*****
30
Please answer questions 70 – 71 based on information from the following vignette.
A 18 year old female presents to you with unwanted hair growth on her chest, abdomen
and face. This is of recent (2-3 years) onset and she is shaving these areas daily. Upon
further questioning you also elicit a 5-6 year history of oligomenorrhea (previously her
menses occurred every month since menarche at age 13 years), increasing weight,
decrease in strength and easy bruising.
70. Which of the following would you be specifically looking for on physical
examination?
A. Acne
B. Peripheral neuropathy
C. Purple striae
D. Hepatomegaly
E. Decreased axillary and pubic hair growth
*****
31
Please answer questions 72 – 75 based on information from the following vignette.
Mrs. Agnes Carlin, a 50-year-old homemaker, visits the office of her family physician
complaining of increasing breathlessness, anorexia, weight loss and fatigue. She has been
a NIDDM for 11 years and has developed complications of proliferative retinopathy,
ischemic heart disease and peripheral vascular disease. She was diagnosed to be
hypertensive eight years previously and was first noted to have microalbuminuria at that
same time.
Past history revealed that about 18 months previously she had noted a lump in her right
breast, but mammography was normal. At that same visit routine laboratory investigation
was normal except for mild elevation of her serum creatinine which was 152µmol/L. Six
months ago she developed ankle swelling, and at which time her serum creatinine was
204 µmol/L.
Her medication at present includes ASA 325mg daily, furosemide 120mg daily, hormone
replacement therapy , metformin 500mg twice daily, and nifedipine XL 90 mg daily. On
physical examination she has diffuse nodularity in both breasts, pulse is regular at 78
bpm, sitting BP is 184/92 mmHg in her right arm sitting, and JVP is 6cm above sternal
angle. She has a left femoral bruit, bilateral basal inspiratory crackles, bilateral leg edema
and absent pedal pulses on the left. The results of the initial investigations are:
72. What is the most likely explanation for the elevated serum creatinine?
A. Chronic glomerulonephritis
B. Dehydration secondary to diuretics
C. Reflux nephropathy
D. Bilateral renal artery stenosis
E. Diabetic nephropathy
32
74. Which of the following treatments is/are indicated?
a. Beta-blocker
b. Increase dose of metformin
c. Fluid challenge of 500mls normal saline
d. ACE inhibitor
e. Increased dose of diuretics
*****
Mrs. Margaret Devlin is an 84-year-old nursing home resident whom you have been
called to see. She has become increasingly confused over the past ten days and has not
had a bowel movement during this time. She does not give a coherent history and there
are no other complaints reported by her son or the staff at the nursing home. She has been
at the nursing home for ten months and suffers from multi-infarct dementia. She is a diet-
controlled diabetic. Her regular medications are thyroxine 0.1 mg, daily ASA 325 mg
daily, and lorazepam 1mg at night. She has not been taking her medication for the past
week. On examination she has reduced skin turgor and dry mucous membranes. Pulse is
regular at 98 beats per minute and blood pressure is 104/66 mmHg supine. Jugular
venous pulse is not visible. The results of investigations are given below:
33
77. Which of the following is the most appropriate management of hypernatremia in this
case?
A. Intravenous 0.9% saline
B. Intranasal DDAVP
C. Intravenous D5W solution
D. Salt-restricted diet
E. Intravenous tri-iodothyroxine (T3)
*****
On examination, he is in mild distress. His heart rate is 100 per minute, BP is 150/85
mmHg, respiratory rate is 30 per minute and he is afebrile. He has diffuse inspiratory
crackles at both lung bases, and expiratory wheezes. He has no murmurs and it is difficult
to hear his heart sounds because of his somewhat labored breathing. His JVP is 6 cm
above the sternal angle.
The results of the initial investigations are: Hgb 140 g/L, WBC 5.8 x 109/L, platelets 200
x 109/L, Na 130 mmol/L, Potassium 4 mmol/L, Creatinine 135 :mol/L. A chest x-ray
reveals a diffuse interstitial infiltrate in both lung fields, with vascular redistribution.
Oxygen saturation monitor reads 84%.
34
80. Ms Johnson, a 47-year-old female, presents with a 2-month history of epigastric pain
following meals. She denies vomiting, weight loss, gastrointestinal blood loss, dysphagia,
early satiety or pain that wakes her form sleep.
Her past medical his is significant for being sexually abused as a child by her step father,
and panic attacks about which she states that she has an appointment to see a psychiatrist.
Occasionally, she notes a burning sensation in her chest which concerns her since her
brother had a heart attack at the age of 54. She has a longstanding history of alternating
constipation and diarrhea and diffuse abdominal pain but assures you that this pain is
different.
a. Ms Johnson most likely has irritable bowel syndrome and no further investigations
are required
b. Heartburn and dyspepsia occur in up to 20 to 40% of the adult population, but the
possibility of cardiac ischemia should be investigated
d. Request that you see her again in 3 months, but warn her that she may develop pain
with swallowing and possibly a sticking sensation. Should this occur, she will be
started on a course of omeprazole.
e. Panic attacks, non-cardiac chest pain, non-ulcer dyspepsia, and a history of sexual
abuse are all more common in patients with irritable bowel syndrome.
Mrs. Smith brings her six-year-old son James to your office for evaluation. She has
identified James as having a cross left eye that was first noticed six months ago. Her
concern increased when James started to complain of frontal headaches when reading.
Occasionally, his mother noticed that James was less attentive to books, and less
interested in coloring and drawing. There is no family history of strabismus.
James has a large angle left Esotropia, fixing only with his right eye. Structurally, his eye
examination is normal. His pupillary reactions are normal and he has full movement of
both eyes with no nystagmus. On comparing red reflexes with your ophthalmoscope
from right to left eye, the left reflex appears less distinct than the right.
35
81. The most likely diagnosis is:
A. Convergence insufficiency
B. Congenital Esotropia
C. Acquired Exotropia
D. Sixth cranial nerve palsy
E. Thyroid ophthalmopathy
82. The patient most likely has what type of refractive error:
A. Myopia (nearsighted)
B. Hyperopia (farsighted)
C. Astigmatism
D. Emmetropia (no refractive error)
E. Myopia and astigmatism combined
*****
83. A 70-year-old retired farmer complains of difficulty walking because of poor balance
for three months. His symptoms have become gradually worse, so that he now uses a
cane, and no longer leaves the house after dark. Review of systems is negative except for
some fatigue, a chronic cough, and some numbness in his feet. He has a 40 pack-year
smoking history. His neurologic examination shows normal optic fundi, normal strength
in all limbs, and downgoing plantar responses. His gait is wide-based. He is able to
stand with his feet together and his eyes open, but begins to fall almost immediately when
he closes his eyes.
Which of the following tests is most likely to give the correct diagnosis:
A. Chest x-ray.
B. MRI scan of the spinal cord.
C. Contrast enhanced brain CT scan.
D. Serum Vitamin B12 level.
E. Blood glucose level.
36
84. Mr. N.C. is 77 years old. You have seen him on five separate occasions over the last
six months. His blood pressures were 172/85, 168/80, 164/77, 165/83 and 171/83
respectively. He has no symptom signs of ischemic heart disease, cerebrovascular
disease, peripheral vascular disease, or renal insufficiency. Urinalysis, Complete Blood
Count, Potassium, Sodium, Fasting Glucose, Fasting Lipids, and Standard ECG are all
normal. He is a non-smoker and drinks one to two beers per week. His height is 176 cm.
and he weighs 68 kg. Serum urate is 512 :mol/L (normal range 210-490 :mol/L). There
is no history of gout. He has been restricting his dietary sodium intake to 110-130
mmol/day for the last six months. He habitually walks briskly three to four times a week
for sixty minutes.
A 15-year old boy man with a 2-year history of type 1 diabetes mellitus presents to your
office for the first time. He is currently injecting both R (regular) and N (intermediate)
insulin before breakfast and before supper. In the past week his Hemoglobin A1c was
0.068 (N: 0.043-0.061), but his home glucose monitoring profile shows fasting blood
glucose levels ranging from 2.5 to 18.8 mmol/L. He generally feels unwell, has poor
concentrating ability, sleeps poorly and frequently has nightmares.
85. Which of the following would now be the most appropriate plan of action?
A. Instruct the patient that his overall glycemic control is within the optimal target range
and hence no changes are required in his glycemic control.
B. Send the patient to the diabetes dietician for instructions in how to treat his morning
blood sugars by altering his breakfast.
C. Send him to the sleep apnea clinic for evaluation of his sleep disturbance.
D. Decrease his R and N insulin before breakfast
E. Check for nighttime hypoglycemia by home blood glucose monitoring at 3 am.
*****
37
COMMENTS
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ANSWER KEY
The correct answer is underlined.
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Diagnostic Laboratory Investigations
Electrolytes: Hematology:
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