Medicine Colloquium Exam - 2015 A

Medicine Colloquium Exam –First Session 2015
Ministry of Education and Higher Learning

Medicine Colloquium Exam – First Session 2015
IMPORTANT INSTRUCTIONS
Each candidate should read this page before answering the questions. The candidate
should follow the directions below:
1. Write clearly your FIRST and FAMILY NAME and APPLICANT NUMBER with ink
(pen) in the designated space (colored square).
2. Please use the pencil ONLY.
3. Do not use any pen (like bic) or ink.
4. Completely Fill the answers squares using pencil only.
5. Only ONE answer is allowed to each question.
6. Avoid erasing as much as you can.
7. When needed, do erase the cancelled answer COMPLETELY.
8. You may use the question bookle as scratch, and make sure to return it with the
answer sheet at the end of the exam.
9. On the answer sheet, you should fill up the square corresponding to the right
answer, in pencil only. No writing allowed at all.
10. Keep your answer sheet clean and tidy, do not fold or tear it.
11. The duration of the exam id THREE HOURS.
12. The composition consists of 180 QUESTIONS.
Important Note:
Any square filled up with a pen or ink cannot be read by the machine. It reads answers
filled up in PENCIL only.
Thank You
&
Good Luck
1
1. An 85-year-old woman presents with a 6-hour history of severe sudden onset c

central abdominal pain. Her heart rate is 110 beats per minute and
irregularly irregular. Her blood pressure is 132/94 mmHg and temperature is
38.1C. Abdominal examination reveals a generally soft but distended and
tender abdomen with no audible bowel sounds. Per rectal examination
reveals guaiac-positive stool. What is the most likely diagnosis?
a. Abdominal aortic aneurysm
b. Acute pancreatitis
c. Mesenteric ischemia
d. Myocardial infarction
e. Peptic ulcer disease
2. A 21-year-old previously healthy arts student male presents with a 2-day e

history of lower abdominal pain and loss of appetite. He is pyrexial and has a
tender palpable mass in his right iliac fossa. Hematology reveals a pyogenic
leukocytosis and a CT demonstrates a 13x15 cm walled-off abscess adjacent to
a large complex inflammatory mass involving and inflamed appendix. What is
the most appropriate management plan?
a. Conservative management (analgesics, intravenous fluid and antibiotics)
b. Conservative management, followed by interval appendectomy at 6-8 weeks
c. Laparoscopy and washout
d. Laparoscopic appendectomy
e. Percutaneous drainage of the abscess and intravenous antibiotics
3. A 43-year-old previously healthy woman presents with pain, swelling and b

erythema in the anorectal area. What is the most appropriate management?
a. CT of abdomen and pelvis
b. Examination under anesthesia and drainage of pus
c. Flexible sigmoidoscopy
d. Intravenous antibiotics
e. MRI of perineum
4. An 84-year-old man presents repeatedly with abdominal distension due to a d

sigmoid volvulus. Which one of the following statements does not apply to the
management of sigmoid volvulus?
a. Following detorsion, volvulus recurs in 50-90% of cases
b. Following sigmoid resection, volvulus recurs in 0% of cases
c. Sigmoidoscopic decompression successfully reduces volvulus in 70-80% of
cases
d. Spontaneous detorsion of volvulus is common
e. Therapeutic barium enema can successfully reduce a volvulus
2
5. A 27-year-old woman sustains multiple rib fractures in a road traffic accident. c

When is an urgent thoracotomy not indicated?
a. Cardiac tamponade
b. Chest drainage of 300 ml blood in the first hour and 250 ml in the next few
hours
c. Flail chest with evidence of hemothorax
d. Immediate chest drainage of >1500 ml of blood
e. Widening of the mediastinum to >8 cm
6. ABO compatibility is advisable for the transfusion of blood products. Which of c

the following products does not require ABO compatibility?
a. Cryoprecipitate
b. Fresh frozen plasma
c. Hemoglobin solution
d. Packed red cells
e. Platelets
7. A 72-year-old man presents with fresh rectal bleeding. He undergoes CT e

angiography, which fails to localize the bleeding source and continues to
bleed. What is the most appropriate investigation?
a. Barium enema
b. CT of chest, abdomen, and pelvis
c. Colonoscopy
d. Flexible sigmoidoscopy
e. Upper gastrointestinal endoscopy and proctoscopy
8. A 39-year-old woman presents to the breast outpatient clinic complaining of c

persistent nipple discharge. Examination reveals no mass lesion in either
breast but blood stained discharge from a single duct. What is the most
appropriate initial investigation?
a. CT of chest, abdomen, and pelvis
b. Ductography
c. Mammogram
d. Nothing else required
e. Ultrasound of the breast
9. A 67-year-old woman presents with a creamy discharge from left nipple which a
has a slit-like appearance. There is no associated underlying mass. What is the
most likely diagnosis?
a. Duct ectasia
b. Ductal papilloma
c. Periductal mastitis
d. Phyllodes tumor
e. Physiological
3
10. A 75-year-old man, 2 years postradiation therapy for prostate cancer, d

presents to the outpatient clinic with anemia and tenesmus. Flexible
sigmoidoscopy reveals mucosal pallor and vascular telangiectasia. What is the
a. Campylobacter enteritis
b. Chlamydia trachomatis infection
c. Ischemic colitis
d. Radiation proctitis
e. Ulcerative colitis
11. Appropriate therapy for metastatic prostate cancer is: a

a. Hormone therapy
b. Chemotherapy
c. Radical radiation therapy with boost doses to the prostate gland
d. Radical prostatectomy or radiation therapy
e. Observation
12. Which of the following procedures is the first test the physician should order b
to establish the diagnosis of deep venous thrombosis?
a. Computed tomography (CT) scan
b. Doppler
c. Lung ventilation and perfusion scans
d. Contrast venography
e. Cardiac catheterization
13. An 80-year-old woman with a history of congestive heart failure develops d

angina pectoris. Her medications are adjusted to include furosemide, digoxin,
nitroglycerine, and potassium supplements. Shortly thereafter, she develops
intermittent frontal throbbing headaches. Which of the following should the
physician do first?
a. Perform a temporal artery biopsy
b. Begin propranolol
c. Obtain a brain computed tomography scan
d. Discontinue nitroglycerin
e. Begin sublingual ergotamine
14. If present, which of the following features distinguishes upper tract (kidney) b
from lower (bladder) infection in women?
a. Pubic tenderness
b. Fever >38.5C
c. Burning on urination
d. Colony count >105/ml
e. White blood cells in urinalysis
4
15. A 65-year-old man reads in the newspaper that prostatic specific antigen e
(PSA) is a good screening for cancer and asks his internist to have this drawn.
The test reveals mildly elevated PSA 10.4 ng/ml. Digital rectal examination
indicates a normal sized prostate, but ultrasound reveals a small hypoechoic
area measuring 5x7 mm in right lobe. Which of the following measures is the
next appropriate step?
a. Perform a bone scan
b. Repeat assays for PSA in three months to check for further elevation
c. Begin leuprolide depot therapy
d. Perform a computed tomography scan of the retroperitoneum, pelvis, and
prostate
e. Perform a transrectal biopsy of the abnormal area revealed by ultrasound
16. A 46-year-old woman has been diagnosed with metastatic renal cell a
carcinoma to the lungs and several ribs. She is experiencing flank pain and
occasional hematuria. The initial treatment at this point is:
a. Resection of primary tumor
b. Supportive care
c. Chemotherapy
d. Resection of all metastatic lesions
e. Radiation
17. Eosinophilia is most likely to be found in which of the following settings? b

a. Pneumococcal pneumonia
b. Schistosomiasis
c. Influenza
d. Corticosteroid therapy
e. Diarrhea caused by Giardia Lamblia
18. A 35-year-old woman with a history of Crohn’s disease develops a painful e

nodule on her lower leg that soon ulcerates. Examination shows an extremely
tender, deep, 8x10 cm ulceration with a purulent base and erythematous
undermined borders. The most likely diagnosis is?
a. Calciphylaxis
b. Vasculitis
c. Stasis dermatitis
d. Erythema nodosum
e. Pyoderma gangrenosum
5
19. A 45-year-old woman complains of nervousness, palpitations, and a 7 kg a

weight loss. Her thyroid gland is enlarged two-fold, and her heart rate is 108
beats/min. Free T4 is 3.6 ng/dl (high), and TSH is undetectable. You
recommend radioiodine therapy, and the patient asks you about possible
complications. What is the most common complication of radioiodine
therapy?
a. Subacute thyroiditis
b. Leukemia
c. Thyroid cancer
d. Thyroid storm
e. Hypothyroidism
20. In the treatment of acute cholecystitis, most patients are best served with: a
a. Early cholecystectomy
b. IV antibiotics and late cholecystectomy
c. Percutaneous drainage of the gallbladder
d. Endoscopic sphincterotomy
e. Cholecystectomy
21. A 61-year-old man comes in because of colicky abdominal pain and vomiting e
of 3 days duration. On physical examination, he is moderately distended and
has high pitched hyperactive bowel sounds and a 5-cm tender groin mass. On
direct questioning, he explains that he has had bulge for many years, but has
always been able to “push it back in” when he lies down. For the past 3 days,
however, he has been unable to do so. He has a temperature of 38.9C (102F),
and a white blood cell count of 12,500/mm3. Which of the following is the
most appropriate management at this time?
a. Sonogram of the mass
b. Trial of nasogastric suction and IV fluids for a few days
c. Insertion of a long rectal tube via sigmoidoscopy
d. Manual reduction of the hernia, followed by a period of observation
e. Urgent surgical intervention
22. A 22-year-old woman is brought to the emergency department after an c

automobile accident and is unconscious, nor breathing, and bleeding
profusely with unstable vital signs. What is the first appropriate step in the
management of this patient?
a. Obtain a full medical history from family members
b. Perform a thorough physical examination
c. Establish an airway and institute mechanical ventilation
d. Blood type and crossmatch, then transfuse 2 units of packed red blood cells
e. Establish intravenous access, and administer a fluid challenge with Ringer’s
lactate
6
23. A newborn with a heart rate of 80/min, no respiratory effort, no response to a

nasal catheter, and a central cyanosis, has an APGAR score of:
a. 1
b. 2
c. 3
d. 4
e. 5
24. A 2-year-old patient presented to the outpatient department for one day c
history of acute ear pain and discharge from right ear. You examined him and
diagnosed an acute otitis media (OM) with a perforated ear drum on right.
The most probable cause would be:
a. Virus
b. Mycoplasma pneumonia
c. Streptococcus pneumonia
d. Staphylococcus aureus
25. Which of the following is a symptom of newborn hypoglycemia? d

a. Episodes of cyanosis
b. Convulsions
c. Apathy
d. All of the above
e. None of the above
26. Symptoms of esophagitis in infants may include: e

a. Feeding problems
b. Anemia
c. Hematemesis
d. Irritability
e. All of the above
27. Subacute sclerosing panencephalitis (SSPE) is associated with: d

a. Mumps
b. Chickenpox
c. Herpes
d. Measles
e. All of the above
28. In acute post-infectious glomerulonephritis, all of the following are present d

EXCEPT:
a. Previous infection (1 to 3 weeks)
b. Hematuria
c. Oliguria
d. Low C4 complement
e. Good prognosis
7
29. In hemolytic uremic syndrome, cardiac failure is due to all these factors c
EXCEPT:
a. Myocardial lesions
b. Hypervolemia
c. Low platelet count
d. Acute renal failure
e. Anemia
30. In the evaluation of a child with short stature, the most important diagnostic c
information is determined from:
a. Bone age
b. Extended family growth history
c. Growth curve
d. Growth hormone levels
e. Serum T4 and thyroid stimulating hormone
31. In which disease there is risk of obstruction and death by triggering a a

laryngeal spasm?
a. Acute epiglottitis
b. Acute pharyngitis
c. Tonsil abscess
d. Retropharyngeal abscess
32. A 6-year-old boy complains of headache arising in the morning before school c
for 2 months. In addition, for the past 2 days the patient has demonstrated
head tilt. Physical examination reveals difficulty in performing rapid
alternating hand movements. The fundi are difficult to visualize. The next part
of the evaluation should be:
a. EEG
b. A visit to school psychologist
c. Brain CT scan
d. Lumbar puncture
e. Vision test
33. Overpassing term pregnancy is defined as: b

a. Term + one month
b. Term + 10 days
c. Term + 15 days
d. Term + 21 days
8
34. A 40-year-old woman gives history of fever for last three weeks accompanied a
by dry cough, night sweats, and weight loss. Chest examination is normal.
Abdominal examination reveals hepatosplenomegaly. Chest x-ray shows
symmetrically distributed fine nodules. The most likely diagnosis is:
a. Miliary tuberculosis
b. Chronic liver disease
c. Malaria
d. Pneumonia
e. Typhoid
35. A 15-year-old girl presents with history of fever, bleeding from gums and a
pallor for last fifteen days. Her peripheral blood film shows pancytopenia. The
most important investigation is:
a. Bone marrow examination
b. Coomb’s test
c. Reticulocyte count
d. Serum folic acid level
e. Serum iron level
36. In a patient with thalassemia, peripheral blood film for red cell morphology a
shows:
a. Hypochromic microcytic cells
b. Normochromic normocytic cells
c. Macrocytosis
d. Sickle cells
e. Spherocytes
37. In a patient with history of shortness of breath, which of the following sign b
indicates left heart failure?
a. Ascites
b. Basal crepitations
c. Dependant edema
d. Engorged neck veins
e. Fourth heart sound
38. A patient presents with history of intermittent fever, abdominal pain and a
headache. Abdominal examination shows tenderness and
hepatosplenomegaly. His blood culture is positive for salmonella typhi. The
antibiotic of choice for this patient is:
a. Ciprofloxacin
b. Gentamycin
c. Metronidazole
d. Tetracycline
e. Vancomycin
9
39. The most common side effect of quinine is: b

a. Coma
b. Deafness
c. Headache
d. Respiratory depression
e. Tremor
40. Renal calcification is an unlikely complication in: d

a. Medullary cystic kidney disease
b. Renal tuberculosis
c. Sarcoidosis
d. Secondary hyperparathyroidism
41. Which of the following statements about post-traumatic epilepsy is correct? e

a. It usually follows head trauma within a month
b. The CT reveals the causative abnormalities
c. It requires surgical therapy in most cases
d. It responds poorly to standard anticonvulsive therapy
e. The EEG reveals its characteristic changes
42. In the nephrotic syndrome: b

a. The prognosis is better in males than in female patients
b. Generalized edema is present
c. Intermittent microscopic hematuria suggests advanced parenchymal damage
d. Administration of steroids is always ineffective
43. Anticardiolipin antibodies are associated with increased incidence of: b

a. Peripheral neuropathy
b. Migraine
c. Epilepsy
d. Myopathy
e. Chronic meningitis
44. Which of the following is the most sensitive test for diagnosing diabetic e
nephropathy?
a. Creatinine clearance measurement
b. Glucose tolerance measurement
c. Serum creatinine measurement
d. Ultrasonography of the kidneys
e. Urine albumin measurement
10
45. A 30-year-old woman presents with small wounds on the sides of her mouth b
for the past 2 weeks. She recently adopted a strict vegetarian diet. On
examination, she has pale conjunctivae, a magenta tongue, and macerated lips
in addition to the angular stomatitis. What is the most likely diagnosis?
a. Thiamine deficiency
b. Riboflavin deficiency
c. Vitamin K deficiency
d. Vitamin D deficiency
e. Iron deficiency
46. The herpes zoster vaccine is made from which of the following components? b
a. Inactivated virus
b. Live attenuated virus
c. Polysaccharides
d. Toxoid
47. In addition to motor and verbal responsiveness, which of the following needs b
to be assessed in order to determine the patient’s Glascow Coma Score?
a. Appearance (skin color)
b. Eye response
c. Reflex response
d. Pulse
48. Which of the following can precipitate a gout attack? a

a. Administration of fluids during surgery
b. Immobilization of a joint
c. Initiation of hormone replacement therapy
d. Prolonged exposure to warm temperatures
49. A 53-year-old man has had malaise for the past 3 months. He is afebrile. His d
heart sounds are distant and he has a friction rub. An echocardiogram shows a
pericardial fluid collection. A pericardiocentesis yields 10 ml of bloody fluid.
Which of the following conditions is most likely to give rise to these findings?
a. Autoimmune disease
b. Chronic renal failure
c. Rheumatic fever
d. Metastatic carcinoma
e. Acute myocardial infarction
50. Which of the following diagnostic studies should be obtained initially for a d
patient who presents to the ED with an acute asthma exacerbation?
a. Arterial blood gas
b. Chest radiography
c. Complete blood count
d. No initial laboratory studies are required
11
51. An infant has the following findings at 5 minutes of life: pulse 130 bpm, d
cyanotic hands and feet, good muscle tone, and a strong cry and grimace. This
infant APGAR score is:
a. 6
b. 7
c. 8
d. 9
e. 10
52. A 10-year-old girl has had diplopia and ptosis and weakness of her neck e
flexors for 2 months. Symptoms are worse in the evening and are usually less
severe on awakening in the morning. She has no fasciculations or myalgias.
The most likely diagnosis is:
a. Hysterical weakness
b. Muscular dystrophy
c. Poliomyelitis
d. Botulism
e. Myasthenia gravis
53. An 18-year-old man shot once in the left chest, has a blood pressure of 80/50 b
mmHg, a heart rate of 130 bpm, and distended neck veins. Immediate
treatment might include:
a. Administration of antibiotics
b. Subxiphoid pericardiotomy
c. Needle decompression of the left chest in the second intercostal space
d. Emergency thoracotomy to cross-clamp the aorta
54. What is the first diagnosis to discuss for a bowel obstruction in a baby of e
6 months?
a. Intestinal atresia
b. Colonic aganglionosis
c. Intestinal malrotation
d. Meconium ileus
e. Acute intestinal invagination
55. A 16-year-old boy patient presents for a painless midline neck mass that he d
noticed few months ago. On physical examination, the mass is painless, 2 cm
in diameter inferior to the hyoid bone and ascend with tongue protrusion.
What is the next step?
a. Surgical excision
b. Order an FNA
c. Observation
d. Order a neck ultrasound
e. 10 days course of oral antibiotics
12
56. A 35-year-old woman with a history of Crohn’s disease develops a painful e

nodule on her lower leg that soon ulcerates. Examination shows extremely
tender, deep, 8x10 cm ulceration with a purulent base and erythematous
undermined borders. The most likely diagnosis is:
a. Calciphylaxis
b. Vasculitis
c. Stasis dermatitis
d. Erythema nodosum
e. Pyoderma gangrenosum
57. In the treatment of acute cholecystitis, most patients are BEST served with: a
a. Early cholecystectomy
b. IV antibiotics and late cholecystectomy
c. Percutaneous drainage of the gallbladder
d. Endoscopic sphincterotomy
e. Cholecystectomy
58. Which of the following infertility factors is the most frequent? c

a. Ovulatory factor
b. Pelvic factor
c. Male factor
d. Cervical factor
e. Unexplained factor
59. Which fetal malformation can be prevented by folic acid intake? b

a. Cardiac abnormalities
b. Abnormalities of the neural tube
c. Trisomy 21
d. Turner’s syndrome
e. Intrauterine growth retardation
60. All of the following are true concerning the amniotic fluid EXCEPT: d
a. It is mainly derived from the fetal urine
b. It protects against the compression of the umbilical cord
c. It contains pulmonary surfactant
d. It is mainly derived from the gastrointestinal secretions
e. It provides a space for fetal movements
61. What is the most frequent complication of an abnormal involution of the b

placenta?
a. Development of fibromes
b. Delayed hemorrhage
c. Infection
d. Infertility
e. Adenomyosis
13
62. What is the most frequent cause of post-partum hemorrhage? a

a. Uterine atony
b. Retention of placental debris
c. Perineal lacerations
d. Uterine rupture
e. DIC
63. What is the most frequently sexually transmitted infection in women? e

a. AIDS (HIV)
b. Herpes
c. Hepatitis B
d. Gonococcus
e. Chlamydia
64. Over passing term pregnancy is defined as: b

a. Term + one month
b. Term + 10 days
c. Term + 15 days
d. Term + 21 days
65. The most important cause of retroplacental hematoma is: d

a. Age of women
b. Parity
c. Twins pregnancy
d. Arterial hypertension
66. A 40-year-old man presents with severe substernal chest pain radiating to the c
neck; made worse by breathing, coughing, and lying on his back, 10 days
following a flu-like illness. Arterial blood gases are normal. His uncle had a
heart attack at age 58. What is the most likely diagnosis?
a. Acute myocardial infarction
b. Dissection of the aorta
c. Acute pericarditis
d. Pulmonary thromboembolism
e. Esophageal spasm
67. A 25-year-old medical student is stuck with a hollow needle during a a

procedure performed on a patient known to have hepatitis B and C viral
infection, but who is HIV negative. The patient’s baseline laboratory studies
include serology: HBsAg negative, anti-HBsAb positive, anti-HBc IgG negative.
Which of the following regarding this medical student’s hepatitis status is
true?
a. Prior vaccination with hepatitis B vaccine
b. Acute infection with hepatitis B
c. Prior infection with hepatitis B
d. The student was vaccinated for hepatitis B but is not immunized
14
68. A 30-year-old man complained of severe back pain after moving a heavy c
object in his home. On physical examination he has urinary incontinence,
grade III power in both lower limbs and loss of ankle and knee jerks. What is
the most likely diagnosis?
a. Spinal cord contusion
b. Spinal cord tumor
c. Central lumbar disc prolapse
d. Muscle strain of erector spinae muscles
e. Subarachnoid hemorrhage
69. A 68-year-old man with a history of end-stage renal disease is admitted for d
chest pain. On examination a pericardial friction rub is noted. His ECG shows
diffuse ST segment elevation. Which of the following is the best treatment?
a. NSAIDs
b. Percutaneous coronary intervention
c. Pericardiocentesis
d. Dialysis
70. A 26-year-old woman goes to her GP with an offensive vaginal discharge and d
vaginal irritation. A vaginal swab is sent to the lab for culture and a heavy
growth of Trichomonas vaginalis is reported. A pregnancy test is negative.
What is the most appropriate treatment?
a. Acyclovir
b. Ampicillin
c. Fluconazole
d. Metronidazole
e. Nystatin
71. A 40-year-old gentleman presents to the emergency after he wakes up this c

morning feeling dizzy with nausea and vomiting. The symptoms are
aggravated with change of head position especially to the right. He denies any
hearing loss or tinnitus. On examination, no neurological deficit was noted.
Which of the following is the most likely diagnosis?
a. Ménière’s disease
b. Transient ischemic attack
c. Benign positional vertigo
d. Labyrinthitis
e. Acoustic neuroma
72. A diabetic patient presented with a black necrotic spot in the nose and d
complaining of headache. What is the most likely diagnosis?
a. Ecthyma gangrenosum
b. Anthrax
c. Tuberculosis
d. Rhinocerebral mucormycosis
15
73. What is the most common cause of secondary hypertension? c

a. Primary hyperaldosteronism
b. Renal artery stenosis
c. Renal parenchymal disease
d. Pheochromocytoma
e. Renal calculi
74. A 34-year-old woman presents with 6 weeks history of progressive weakness b

in the proximal muscles of upper and lower extremities. During the workup
for this problem, a centrally located pulmonary nodule was found and turned
out to be malignant. Which of the following problems is NOT commonly
associated with this cancer?
a. SIADH
b. Hypercalcemia
c. Very aggressive
d. Ectopic ACTH production
e. Most treatment is palliative only
75. A 25-year-old woman is found to have a midsystolic murmur on routine e

evaluation. The murmur does not radiate but it does increase with standing.
She otherwise feels well and the rest of the examination is normal. What is the
a. Aortic stenosis
b. Hypertrophic obstructive cardiomyopathy
c. Mitral regurgitation
d. Tricuspid regurgitation
e. Mitral valve prolapse
76. A 50-year-old patient presents with acute onset of a painful, red eye, with a
impairment of vision and photophobia. What is the most likely diagnosis?
a. Keratitis
b. Episcleritis
c. Viral conjunctivitis
d. Subconjunctival hemorrhage
e. Blepharitis
77. A 14-year-old male collapses and dies while playing basketball at school a
tournament. He has no known past medical history. Which of the following is
the most likely underlying disease in this patient?
a. Hypertrophic cardiomyopathy
b. Coronary atherosclerosis
c. Aortic aneurysm rupture
d. Ventricular septal defect
e. Bicuspid aorta
16
78. For the following explanations for hirsutism, select the most likely cause that d
is often associated with elevated 17-hydroxyprogesterone levels:
a. Drugs
b. Adrenal tumor
c. Polycystic ovarian disease
d. Adrenal hyperplasia
e. Ovarian tumor
79. A 10-year-old child has recurrent signs and symptoms of palpable purpura on d
the buttocks, arthralgias, colicky abdominal pain, and microscopic hematuria.
Which of the following is the most likely diagnosis?
a. SLE
b. Juvenile rheumatoid arthritis Wegener granulomatosis
c. Immune complex vasculitis
d. Influenza
80. During routine physical examination of a 42-year-old woman, a physician b

notes the presence of a 12 mm breast mass. Mammography is negative. Which
of the following statements is true?
a. Mammography should be repeated in 4 to 6 months
b. The patient should be referred for biopsy of the mass
c. The patient should be followed-up after 6 months
d. Ultrasound of the breast should be ordered
e. The woman should be tested for the presence of BRCA-1 gene
81. An otherwise healthy 34-year-old patent develops acute onset of cough with d
episodes of hemoptysis. What is the most likely etiology?
a. Bronchogenic neoplasm
b. Wegener’s granulomatosis
c. Congestive heart failure
d. Acute bronchitis
e. Tuberculosis
82. A 57-year-old woman who underwent emergent cholecystectomy for a b

perforated gallbladder 3 days prior now has a fever of 39.5C, and is
complaining of chills. The patient has not been ambulating and says she is in
great deal of pain at her incision. What is the most likely cause of her fever?
a. Atelectasis
b. Urinary tract infection
c. Wound infection
d. Deep vein thrombosis
e. Abscess
17
83. A patient is admitted to the emergency room because of acute abdominal pain. e
All of the following indicate acute intestinal ischemia EXCEPT:
a. History of atrial fibrillation
b. Acute abdominal pain
c. Diarrhea and/or vomiting
d. History of an arterial emboli of the lower extremities
e. Abdominal rigidity two hours after the onset of pain
84. Fat embolism is best diagnosed by: c

a. Myoglobinuria
b. Presence of fat in urine ans sputum
c. Elevation in serum lipase
d. Results of arterial blood gas
e. Clinical factors
85. Which is not true about subarachnoid hemorrhage? b

a. Usually occurs at a relatively young age
b. Rebleeding is uncommon
c. Most commonly due to an aneurysm
d. Mortality is about 50%
e. The onset of coma is a poor prognostic sign
86. Which of the following pathogens is the most common cause of subacute b
bacterial endocarditis (SBE)?
a. Staphylococcus epidermidis
b. Viridans streptococci
c. Candida albicans
d. Enterococcus faecalis
e. Proteus mirabilis
87. A 54-year-old man with ulcerative colitis is scheduled for total colectomy and c
ileoproctostotomy. His past medical history is significant for chronic smoking,
diabetes, and a prior myocardial infarction. He leads a sedentary lifestyle and
denies any history of angina. What would be the next step in this patient’s
management?
a. Cardiac catheterization
b. Exercise stress testing
c. Left ventricular ejection fraction determination
d. No further evaluation
e. Surgery under epidural anesthesia
18
88. A 57-year-old woman presents to the emergency department with right leg c
numbness, tingling, and weakness one week after coronary angiography. On
examination, there is a pulsatile nontender mass in the right groin (the side of
the arterial puncture). The mass is getting bigger each day. What is the most
likely diagnosis?
a. Acute arterial occlusion
b. Arteriovenous fistula
c. Expanding pseudoaneurysm
d. Femoral nerve injury after angiography
e. Infected pseudoaneurysm
89. A 57-year-old woman with morbid obesity is incidentally noted to have mildly e
elevated AST (SGOT) levels. She does not take any medications nor any
alcohol and a workup for viral hepatitis and hemochromatosis is negative.
Which one of the following is most likely to improve her hepatic condition?
a. Clopidogrel
b. Simvastatin
c. L-carnitine
d. Vitamin E
e. Weight loss
90. You suspect asthma in a 15-year-old healthy male with nighttime cough and b
wheezing for the past several months. Which one of the following would be
most appropriate at this point?
a. Treat empirically with a short-acting beta-agonist
b. Perform spirometry
c. Order a chest x-ray
d. Start an inhaled corticosteroid
e. Start a leukotriene inhibitor
91. Which one of the following is the best treatment for a 36-year-old female e
presented with a several-week history of polyuria and intense thirst. A
urinalysis with low specific gravity and low osmolality and a 24-hour urine
output more than 5 L. All other lab and exam finding are normal.
a. Angiotensin II
b. Aldosterone
c. Renin
d. Insulin
e. Vasopressin
92. Routine vaccination against which one of the following organisms has c
significantly reduced the risk of bacterial meningitis among young children?
a. Borrelia burgdorferi
b. Escherichia coli
c. Hemophilus influenzae
d. Listeria monocytogenes
e. Mycoplasma pneumonia
19
93. To prevent joint damage from gout, uric acid levels should be lowered by a
medication to:
a. <6 mg/dl
b. <8 mg/dl
c. <10 mg/dl
d. A level that keeps the patient symptom-free for 6 months
94. A 50-year-old male presents with gynecomastia. Which one of the following e
antihypertensives medications is most likely to cause this problem?
a. Doxazosin
b. Hydrochlorothiazide
c. Lisinopril
d. Losartan
e. Spironolactone
95. Which one of the following intravenous agents is the best INITIAL d
management for hypercalcemic crisis?
a. Furosemide
b. Pamidronate
c. Hydrocortisone
d. Saline
96. A postmenopausal female presents with a recent onset of painless vaginal b

bleeding. Her pelvic examination is normal and all previous PAP smears were
normal. Which one of the following management options is the preferred next
diagnostic step?
a. Colposcopy with endocervical curettage
b. Transvaginal ultrasonography
c. Saline infusion sonohysterography
d. Hysteroscopy
97. Which one of the following is true about acute COPD exacerbation? a
a. Systemic corticosteroid therapy reduces the hospital length of stay in patients
b. Oral therapy has been shown to be much less effective as the intravenous route
c. A randomized, controlled trial has demonstrated that 5-day courses of systemic
corticosteroid therapy are less effective than 14-day courses
d. Nebulizers generally offer significant advantages over metered-dose inhalers in
most patients
20
98. A 75-year-old woman is admitted because of mild heart failure. She is acutely a
symptomatic with dyspnea. Her heart rate is 96 beats/min, blood pressure of
140/90 mmHg, and an oxygen saturation of 94% on room air. A chest
radiograph shows mild pulmonary congestion. What is your recommendation
regarding placement of an indwelling urinary catheter for accurate
measurement of urine output and for patient comfort?
a. Avoiding indwelling urinary catheter placement
b. Placement of an indwelling urinary catheter only until initial diuresis is
completed
c. Placement of an indwelling urinary catheter overnight
d. Placement of an indwelling urinary catheter and removal within 24 hours
99. A 75-year-old male with a history of hypertension has a TIA episode resolved e
spontaneously within 20 minutes. Carotid Doppler ultrasonography and
cerebral angiography both reveal significant carotid stenosis. In addition to
starting aspirin, which one of the following would be the most appropriate
next step for this patient?
a. Aggressive lowering of blood pressure
b. Clopidogrel
c. Carotid artery stenting
d. Evaluation for occult patent ductus arteriosus
e. High-dose statin therapy
100. Which one of the following is the most accurate imaging study for assessing d
early osteomyelitis?
a. Plain radiography
b. Ultrasonography
c. CT scan
d. MRI
e. Bone scan
101. Which one of the following should be ordered to evaluate the patient for a
hereditary hemochromatosis?
a. Serum iron panel, including serum ferritin level and transferring saturation
b. Alpha-fetoprotein (AFP) level
c. HEF genetic testing
d. Hepatic ultrasonography
e. Liver biopsy
102. Which one of the following is recommended for the initial management of a a
4-year-old male child with ADHD?
a. Behavioral treatment alone
b. Methylphenidate (Ritalin) alone
c. Atomoxetine (Strattera) alone
d. Methylphenidate combined with behavioral treatment
e. Methylphenidate combined with atomoxetine
21
103. Azithromycin should be used with caution in a 65-year-old male with d

coronary artery disease due to an increased risk for:
a. Adverse effect on left ventricular function
b. Peripheral edema
c. Elevation of systolic blood pressure
d. Fatal arrhythmias
104. Which one of the following intranasal medications is considered optimal a

treatment for a young man with known seasonal allergic rhinitis every
autumn who presents to you in September with runny nose?
a. Glucocorticosteroids
b. Cromolyn sodium
c. Decongestants
d. Antihistamines
105. A 30-year-old construction worker fell down on his anterolateral leg from a e
3 m high scaffold 5 hours prior to presentation to emergency. On exam the
anterolateral lower leg is quite tender but only slightly swollen, and there is
exquisite pain in that area with passive plantar flexion of the great toe.
X-rays and rest of the exam are negative. Which one of the following would
be most appropriate?
a. Scheduled oral muscle relaxants
b. 6-day oral corticosteroid taper
c. Physical therapy referral for early mobilization and ultrasound therapy
d. Short leg splint and non-weight bearing for 5-7 days
e. Urgent orthopedic referral for possible fasciotomy
106. Which one of the following diseases is associated with erythema nodosum? b
a. Celiac disease
b. Crohn’s disease
c. Diverticular disease
d. Irritable bowel syndrome
e. Clostridium difficile colitis
107. Postmenopausal hormonal therapy with estrogen and progesterone results e

in a decrease in which one of the following?
a. Ischemic heart disease
b. Dementia
c. All-cause mortality
d. Breast cancer
e. Hip fracture
22
108. TSH receptor side antibodies would indicate which one of the following as e
the cause of thyroid gland enlargement?
a. Toxic multinodular goiter
b. Toxic adenoma
c. Hashimoto’s (lymphadenoid) thyroiditis
d. Subacute (giant cell) thyroiditis
e. Grave’s disease
109. You suspect a patient to be low risk for deep vein thrombosis. Which test is b
preferred to rule it out?
a. Compression ultrasonography
b. D-dimer assessment
c. Contrast venography
d. Impedance plethysmogrpahy
110. A 4-month-old female is brought to your office by her parents for a 3-day b
history of fever up to 38.7C. She is fussy and her oral intake is down. She has
no rash, no emesis, and no diarrhea. Her urine output is normal. On
examination, she is alert but fussy. Her rectal temperature is 38.4C. The
examination is otherwise normal and there are no focal findings of infection.
The parents are reliable and you choose to manage the baby as an
outpatient. Which one of the following tests is likely to be most helpful in
this situation?
a. CBC with manual differential
b. Urinalysis and urine culture
c. Chest radiograph
d. C-reactive protein
e. Lumbar puncture
111. Which one of the following treatments has been shown to improve outcomes d
for a 2-year-old with mild to moderate croup?
a. Humidified air
b. Nebulized albuterol
c. Oral azithromycin
d. Oral dexamethasone
e. Oxygen therapy
112. Which one of the following therapeutic interventions improves outcomes in e

adults with acute respiratory distress syndrome (ARDS)?
a. Early initiation of antibiotics
b. Surfactant therapy
c. Pulmonary artery catheterization
d. Aggressive intravenous fluid resuscitation
e. Starting mechanical ventilation with lower tidal volumes
23
113. The most common cause of serious medical errors is a deficiency of: c
a. Nursing support
b. Staffing
c. Communication
d. Leadership
e. Knowledge
114. A 32-year-old primigravida at 36 weeks gestation diagnosed with severe b

preeclampsia, complains of headache. Her blood pressure is 155/100
mmHg, and a urinalysis shows 4+ protein. Her blood tests are normal. Which
one of the following is the most appropriate management for this patient?
a. Start labetalol and discharge home on bed rest with close follow-up
b. Start magnesium sulfate, and induce labor now
c. Start magnesium sulfate, administer corticosteroids, and induce labor in 48
hours
d. Start magnesium sulfate, lower blood pressure to 140/90 mmHg, and induce
labor at 37 weeks gestation
e. Arrange for urgent cesarean section
115. A 75-year-old otherwise healthy woman states that she has passed out three e
times in the last month during her daily brisk walk. Which one of the
following is the most likely cause of her syncope?
a. Vasovagal syncope
b. Transient ischemic attack
c. Orthostatic hypotension
d. Atrial myxoma
e. Aortic stenosis
116. Which one of the following would support a diagnosis of subacute d

granulomatous thyroiditis?
a. Pretibial myxedema
b. Exophtalmos
c. Multiple nodules on ultrasonography
d. Low radioactive iodine uptake (<5%)
117. Which one of the following strategies for preventing the spread of b
Clostridium difficile infection has been shown to be most effective?
a. Use of alcohol-based hand sanitizer
b. Hand washing with soap and water
c. Screening health care providers for the carrier state
d. Use of masks and negative-pressure rooms
24
118. Which one of the following medications would be most appropriate for a
treating symptoms of delirium in a hospitalized 85-year-old patient?
a. Haloperidol
b. Nortriptyline
c. Pentobarbital
d. Lorazepam
e. Mirtazapine
119. When assessing the nutritional status and growth of a full-term infant, it is c
useful to know that birth weight is expected to double between:
a. 2 and 3 months
b. 3 and 4 months
c. 4 and 5 months
d. 5 and 6 months
120. In a patient presenting with unstable angina, which one of the following b
findings would denote the highest risk for death or myocardial infarction?
a. New-onset angina beginning 2 weeks to 2 months before presentation
b. Angina with hypotension
c. Angina provoked at a lower threshold than in the past
d. Increased anginal frequency
121. A 4-year-old infant is diagnosed with a symptomatic choledochal cyst. What c

is the most appropriate treatment?
a. Cyst gastrostomy
b. Cyst jejunostomy
c. Excision with Roux-en-Y hepaticojejunostomy
d. Primary excision of the lesion
e. Surveillance (endoscopic)
122. A 65-year-old man presents with left iliac fossa pain, pyrexia, and raised d
white cell count 20x100 per mm3, and CRP of 200 mg/l. What is the most
appropriate investigation?
a. Abdominal X-ray
b. Barium enema
c. Colonoscopy
d. CT abdomen and pelvis
e. Flexible sigmoidoscopy
25
123. A 23-year-old woman is referred by the gastroenterology team with e

tachycardia, hypotension, and generalized colonic tenderness. She has had
5 days of intravenous steroids and her bowel movements have decreased
from 12 to 6 bloody stools per day. What is the most appropriate
management?
a. Colonoscopy and biopsies
b. Continue IV steroids
c. Cyclosporine
d. Infliximab
e. Subtotal colectomy and ileostomy
124. A 22-year-old woman has marked lymphedema in her right leg. What is the b
most appropriate management?
a. Diuretic therapy
b. Elevation and elastic support stocking
c. Excision of scarred skin and fibrotic subcutaneous tissue
d. Lymphatic bypass
e. Massage therapy or mechanical compression
125. Match the following syndrome “Gynecomastia” with the appropriate tumor: b
a. Non-small cell lung cancer
b. Testicular cancer
c. Small cell lung cancer
d. Breast cancer
e. Pancreatic cancer
126. A 54-year-old obese woman has chronic gastroesophageal reflux. Which of b

the following drugs are known to exacerbate her reflux esophagitis?
a. Chlorpropamide
b. Theophylline
c. Omeprazole
d. Acetaminophen
e. Metoclopramide
127. A 30-year-old man has had difficulty swallowing for both solids and liquids e
over the past 6 months. What is the most likely diagnosis?
a. Barrett’s esophagus
b. Benign esophageal stricture
c. Schatzki’s rings
d. Esophageal carcinoma
e. Achalasia
26
128. A 17-year-old girl presents to the emergency department with a 2-day e

history of a painful and swollen right big toe. She also has had a fever, with
temperatures up to 38.9C at home for 2 days. On physical examination, her
temperature is 38.8C. Her first metatarsal joint of the right foot is markedly
swollen and very painful to touch. An aspirated fluid from the joint reveals a
white blood count of 55,000/mm3. Which of the following is the most likely
diagnosis?
a. Juvenile rheumatoid arthritis
b. Gout
c. Lyme disease
d. Pseudogout
e. Septic arthritis
129. In the setting of acute trauma, fracture of which bone has the highest d
associated mortality?
a. Lumbar vertebra
b. Femur
c. Rib
d. Pelvis
e. Humerus
130. In acute glomerulonephritis, all of the following are present EXCEPT: d

a. Arterial hypertension
b. Water retention
c. Hematuria
d. Polyuria and polydipsia
e. Uremia
131. A 37-year-old woman is brought to the emergency department because of a

intermittent chest pain for 3 days. The pain is worse with inspiration, and
she feels she cannot take deep breaths. She has not had shortness of breath,
palpitations, or nausea. She had an upper respiratory tract infection 10 days
ago and took an over-the-counter cough suppressant and decongestant and
acetaminophen. Her temperature is 37.2C (98.9F), pulse is 90/min, and
blood pressure is 122/70 mmHg. The lungs are clear to auscultation. S1 and
S2 are normal. A rub is heard during systole. There is no peripheral edema.
An ECG shows normal sinus rhythm and diffuse upwardly concave ST-
segment elevation and PR-segment depression in leads II, III, and aVF. Which
of the following is the most likely diagnosis?
a. Acute pericarditis
b. Aortic dissection
c. Gastroesophageal reflux disease
d. Peptic ulcer disease
e. Unstable angina pectoris
27
132. A previously healthy 42-year-old man is brought to the emergency e

department 1 day after the sudden onset of shortness of breath and chest
pain at rest; the pain is exacerbated by deep inspiration. His pulse is
100/min, respirations are 22/min, and blood pressure is 140/90 mmHg.
Breath sounds are normal. The remainder of the examination shows no
abnormalities. Arterial blood gas analysis on room air shows: pH 7.49, PCO2
30 mmHg, PO2 64 mmHg, O2 saturation 91%. An x-ray of the chest shows o
abnormalities. Which of the following is the most likely mechanism of these
findings?
a. Carbon monoxide poisoning
b. Congenital heart disease
c. Interstitial edema
d. Interstitial fibrosis
e. Ventilation-perfusion mismatch
133. A 36-year-old nulligravid woman with primary infertility comes for a follow- b
up examination. She has been unable to conceive for 10 years; analysis of
her husband’s semen during this period has shown normal sperm counts.
Menses occur at regular 28-day intervals and last 5 to 6 days. She is
asymptomatic except for severe dysmenorrhea. An endometrial biopsy
specimen 5 days before menses shows secretory endometrium.
Hysterosalpingography 1 year ago showed normal findings. Pelvic
examination shows a normal vagina and cervix. Bimanual examination
shows a normal-sized uterus and no palpable adnexal masses. Rectal
examination is unremarkable. Which of the following is the most likely
diagnosis?
a. Anovulation
b. Endometriosis
c. Intrauterine synechiae
d. Male factor
e. Tubal obstruction
134. A 22-year-old man with a seizure disorder has had increasing cough and b
shortness of breath for 3 days and fever for 1 day. He has foul-smelling
sputum. He had a generalized tonic-clonic seizure 1 week ago. His
temperature is 39.4C (103F). Crackles are heard on auscultation of the
chest. An x-ray of the chest shows a right upper-lobe infiltrate of the lung.
Which of the following is the most likely cause?
a. Chemical pneumonitis
b. Pneumonia secondary to anaerobes
c. Pneumonia secondary to gram-negative aerobes
d. Pneumonia secondary to gram-positive aerobes
e. Pneumonia secondary to Mycoplasma pneumonia
28
135. A 37-year-old woman is brought to the emergency department 45 minutes b

after she was found unconscious on her apartment floor. Her coworkers
became concerned when she did not arrive for work. On arrival, she is
unable to provide a history. Her pulse is 96/min, respirations are 12/min,
and blood pressure is 124/58 mmHg. Examination shows erythema,
warmth, and induration of the upper back, buttocks, and posterior thighs.
Her serum creatine kinase activity is 10,300 U/l. Urine toxicology screening
is positive for opiates and cocaine. Urine dipstick is strongly positive for
pigmented granular casts and rare erythrocytes. This patient is at increased
risk for which of the following conditions over the next 24 hours?
a. Acute respiratory distress syndrome
b. Acute tubular necrosis
c. Cerebral edema
d. Cerebral hemorrhage
e. Cocaine-induced cardiomyopathy
136. A 27-year-old woman comes to the physician for a follow-up examination. a

She has a 10-week history of persistent nonproductive cough that is worse at
night and a 1-month history of a hoarse voice. She otherwise feels well. She
has not had loss of appetite or change in exercise tolerance. She has never
smoked. Empiric treatment with an oral decongestant and albuterol inhaler
has not improved her symptoms. She has no history of serious illness. Her
temperature is 37C (98.6F), pulse is 68/min, respirations are 12/min, and
blood pressure is 110/76 mmHg. Cardiopulmonary examination and an x-
ray of the chest show no abnormalities. Her FEV1 is normal. Which of the
following is the most appropriate next step in management?
a. 24-hour monitoring of esophageal pH
b. Echocardiography
c. CT scan of the chest
d. Inhaled corticosteroid therapy
e. Nitroglycerin therapy
137. A 22-year-old man is brought to the emergency department 30 minutes after e

he sustained a gunshot wound to the abdomen. His pulse is 120/min,
respirations are 28/min, and blood pressure is 70/40 mmHg. Breath sounds
are normal on the right and decreased on the left. Abdominal examination
shows an entrance wound in the left upper quadrant at the midclavicular
line below the left costal margin. There is an exit wound laterally in the left
axillary line at the 4th rib. Intravenous fluid resuscitation is begun. Which of
the following is the most appropriate next step in management?
a. Upright x-ray of the chest
b. CT scan of the chest
c. Intubation and mechanical ventilation
d. Peritoneal lavage
e. Left tube thoracostomy
29
138. A 20-year-old man has had frequent upper respiratory tract infections over c
the past 4 years. He has daily purulent sputum and has noted decreased
exercise tolerance over the past 2 years. He and his wife have been unable to
conceive because of his low sperm count. Scattered expiratory wheezing and
rhonchi are heard throughout both lung fields. An x-ray of the chest shows
hyperinflation. Spirometry shows a decreased FEV1/FVC ratio. Which of the
following is most likely to confirm the diagnosis?
a. Arterial blood gas analysis
b. Examination of sputum for eosinophils
c. Sweat chloride test
d. Sputum cytology
e. Bronchoscopy
139. A previously healthy 17-year-old girl comes to the physician because of a d

one-week history of itching and progressive rash. She has no history of skin
problems or associated symptoms. She takes no medications. Her sister with
whom she shares a room had similar symptoms during the previous week.
The patient’s temperature is 36.8C (98.2F). There are multiple 2 to 5 mm
erythematous papules over the trunk, especially at the waistline, and over
the forearms, hands, and fingers. There is no lymphadenopathy or
hepatosplenomegaly. Which of the following is the most likely causal
organism?
a. Epstein-Barr virus
b. Group A streptococcus
c. Measles virus
d. Sarcoptes scabiei
e. Varicella-zoster virus
140. A 3-year-old girl is brought to the physician because of fever and left ear d
pain for 2 days. She has been treated with amoxicillin for the past 5 days for
left otitis media. Her temperature is 38.5C (101.3C), pulse is 100/min,
respirations are 20/min, and blood pressure is 80/60 mmHg. Examination
shows the left ear displaced forward and laterally from the head. There is
edema and tenderness behind the left ear. Otoscopic examination shows a
red, dull, left tympanic membrane that does not move. Which of the
following is the most likely diagnosis?
a. Acoustic neuroma
b. Labyrinthitis
c. Lateral sinus thrombosis
d. Mastoiditis
e. Rhabdomyosarcoma
30
141. A 42-year-old woman comes to the physician because of an 8-week history of a

intermittent nausea and abdominal pain that occurs 20 to 30 minutes after
eating. The pain extends from the epigastrium to the right upper quadrant
and is sometimes felt in the right scapula; it lasts about 30 minutes and is
not relieved by antacids. The last episode occurred after she ate a
hamburger and French fries. She has not had vomiting. She is currently
asymptomatic. She is 165 cm tall and weighs 104 kg; BMI is 38 kg/m 2.
Examination shows no other abnormalities. Which of the following is the
most appropriate next step in management?
a. Abdominal ultrasonography of the right upper quadrant
b. Upper gastrointestinal series with small bowel follow-through
c. CT scan of the abdomen
d. Endoscopic retrograde cholangiopancreatography
e. Immediate cholecystectomy
142. A 67-year-old woman comes to the physician because of easy bruising for 4 e
months. She has a history of lung cancer treated with radiation therapy 6
months ago. She has a 2-year history of hypertension treated with a thiazide
diuretic and an angiotensin-converting enzyme (ACE) inhibitor.
Examination, including neurologic examination, shows no abnormalities
except for multiple ecchymoses. Her hemoglobin concentration is 13 g/dl,
leukocyte count is 5000/mm3, and platelet count is 35,000/mm3. A serum
antiplatelet antibody assay is negative. Which of the following is the most
appropriate next step in diagnosis?
a. Bone scan
b. CT scan of the abdomen
c. CT scan of the chest
d. Bronchoscopy
e. Bone marrow aspiration
143. A 37-year-old man comes to the physician because of non-radiating low back b
pain for 3 days. The pain began after he worked in his yard. He has not had
any change in bowel movements or urination. He had one similar episode 3
years ago that resolved spontaneously. Vital signs are within normal limits.
Examination of the back shows bilateral Paravertebral muscle spasm. Range
of motion is limited by pain. Straight-leg rising is negative. In addition to
analgesia, which of the following is the most appropriate next step in
management?
a. Bed rest
b. Regular activity
c. X-rays of the spine
d. MRI of the spine
e. Lumbar spine traction
31
144. A 62-year-old man comes to the physician because of a 2-month history of b

progressive fatigue ans ankle swelling. He had an anterior myocardial
infarction 3 years ago and has had shortness of breath with mild exertion
since then. Current medications include labetalol and daily aspirin. He has
smoked one-half pack of cigarettes daily for 30 years. His pulse is 100/min
and regular, respirations are 20/min, and blood pressure is 130/75 mmHg.
There are jugular venous pulsations 5 cm above the sternal angle. Crackles
are heard at both lung bases. Cardiac examination shows an S3 gallop. There
is edema from the mid tibia to the ankle bilaterally. Further evaluation of
this patient is most likely to show which of the following findings?
a. Decreased pulmonary capillary wedge pressure
b. Impaired contractility of the left ventricle
c. Prolapse of the mitral valve
d. Thrombosis of the superior vena cava
e. Ventricular septal defect
145. A 77-year-old man is brought to the physician because of a 12-hour history b

of word-finding difficulty and weakness and sensory loss of the right arm
and leg. He has no history of similar symptoms. He has type 2 diabetes
mellitus, hypertension, and atrial fibrillation. Current medications include
metformin, lisinopril, and aspirin. He is alert. His pulse is 80/min and
irregular, respirations are 16/min, and blood pressure is 170/90 mmHg. He
follows commands but has nonfluent aphasia. There is moderate weakness
and decreased sensation of the right upper and lower extremities. Deep
tendon reflexes are 2+ bilaterally. Babinski sign is present on the right. His
serum glucose concentration is 162 mg/dl. Which of the following is the
most appropriate next step in diagnosis?
a. Carotid duplex ultrasonography
b. CT scan of the head
c. EEG
d. Lumbar puncture
e. Cerebral angiography
32
146. A 70-year-old man comes to the physician because of fever, productive b

cough, and pleuritic chest pain for 1 day. Over the past 2 years, he has had
two similar episodes. He also has had persistent pain in the thoracic spine
for 1 month. His temperature is 39.2C, pulse is 110/60 mmHg. There is
dullness to percussion and decreased breath sounds over the right base.
Examination shows tenderness of the midthoracic spine. Laboratory studies
show: hematocrit 34%, leukocyte count 15,000/mm3, segmented
neutrophils 81%, bands 4%, lymphocytes 15%, serum calcium 10.9 mg/dl.
X-ray of the chest shows consolidation of the right lower lobe, lytic lesions at
T8 and T10, and diffuse osteopenia. Which of the following is the most likely
diagnosis of this patient’s back condition?
a. HIV infection
b. Multiple myeloma
c. Prostate cancer
d. Staphylococcal osteomyelitis
e. Tuberculosis osteomyelitis
147. A 52-year-old man comes to the physician with his wife because of a 1-year c
history of excessive daytime sleepiness. He does not think the symptoms are
problematic, but his wife is concerned because he sometimes falls asleep on
the sofa early in the evening when guests are present. He also once fell
asleep while driving at night and drive off the road, narrowly avoiding
injury. His wife says that he has always snored loudly, and over the past
year, he has had episodes of choking or gasping for breath while sleeping. He
is 178 cm tall and weighs 105 kg; BMI is 33 kg/m2. His pulse is 76/min,
respirations are 14/min, and blood pressure is 150/76 mmHg. Physical and
neurologic examinations show no other abnormalities. Which of the
following is most likely to confirm the diagnosis?
a. 24-hour ambulatory ECG monitoring
b. Multiple sleep latency test
c. Polysomnography
d. CT scan of the head
e. Laryngoscopy
148. A 67-year-old woman has had fatigue, dry skin, brittle hair, swelling of the a
ankles and cold intolerance for 1 year; she has gained 9 kg during this
period. Her pulse is 55/min, and blood pressure is 150/90 mmHg. She
appears lethargic. Examination shows dry skin and a nontender thyroid
gland that is enlarged to two times its normal size. There is mild edema of
the ankles bilaterally. The relaxation phase of the Achilles reflex is greatly
prolonged. Which of the following is the most likely diagnosis?
a. Chronic lymphocytic thyroiditis (Hashimoto disease)
b. Graves disease
c. Multinodular goiter
d. Thyroid cyst
e. Thyroiditis
33
149. A 19-year-old man has had fever, headache, sore throat, and swelling of the c
cervical lymph nodes for 5 days. His temperature is 40C, pulse is 120/min,
respirations are 20/min, and blood pressure is 125/85 mmHg. The pharynx
is red and swollen with enlarged tonsils and exudate. There is tender
cervical adenopathy and palpable lymph nodes in the axillary and inguinal
areas. The spleen tip is palpable. Leukocyte count is 14,000/mm3 (25%
segmented neutrophils, 60% atypical lymphocytes, and 15% monocytes). A
throat culture is obtained. Which of the following is the most likely
pathogen?
a. Adenovirus
b. Cytomegalovirus
c. Epstein-Barr virus
d. Group A streptococcus
e. Toxoplasma gondii
150. A healthy 16-year-old boy comes to the physician for an examination prior a
to participation in school sports. He is at the 90th percentile for height and
75th percentile for weight. His temperature is 37C (98.6F), pulse is 66/min,
respirations are 16/min, and blood pressure is 145/95 mmHg. Examination
shows no other abnormalities. Which of the following is the most
appropriate next step in management?
a. Repeat blood pressure measurement in 2 weeks
b. Recommend a low-sodium diet
c. Recommend a weight loss program
d. Begin diuretic therapy
e. No further intervention indicated
151. A 15-month-old girl is brought to the emergency department after a a

generalized tonic-clonic seizure at home. The seizure stopped
spontaneously after 2 minutes, and she seemed sleepy afterward. Her
temperature prior to arrival was 39.6C, and paramedics administered
rectal acetaminophen. Her parents state that yesterday she had a mild runny
nose but otherwise has been well. There is no personal or family history of
serious medical illness or seizures. Development has been appropriate for
age. On arrival, she is afebrile, alert, and interactive. Physical examination
shows a supple neck. Neurologic examination shows no focal findings. Which
of the following is the most appropriate next step in management?
a. Reassurance
b. CT scan of the head
c. Oral administration of phenobarbital
d. EEG
e. Lumbar puncture
34
152. A 3-month-old boy is brought to the emergency department because of a e

3-day history of vomiting and diarrhea. He has a low-pitched cry and
responds only to painful stimuli. His temperature is 35.2C, pulse is
203/min, respirations are 48/min, and blood pressure is 52/35 mmHg.
Peripheral pulses are barely palpable. Capillary refill time is delayed.
Administration of 100% oxygen by nasal cannula is begun. Multiple
attempts at establishing peripheral intravenous access are unsuccessful.
Which of the following is the most appropriate next step in management?
a. Oral rehydration
b. Intramuscular injections of antibodies
c. Intubation and mechanical ventilation
d. Placement of a nasogastric tube
e. Placement of an intraosseaous catheter
153. A 72-year-old female presents with a 6-week history of “carrot colored skin”. d
She denies fever, malaise, or abdominal pain. Her only medications are
hydrochlorothiazide and a baby aspirin daily. On examination she has icteric
sclera and a single enlarged left supraclavicular lymph node which is
nontender. Which one of the following is the most likely diagnosis?
a. Biliary cirrhosis
b. Ascending cholangitis
c. Obstructing pancreatic pseudocyst
d. Carcinoma of the head of the pancreas
e. Hepatocellular carcinoma
154. Hyperbaric oxygen treatment has been shown to be beneficial for which one c
of the following conditions?
a. Tinnitus
b. Malignant otitis externa
c. Crush injury wounds
d. Nonunion of bone fractures
e. Vascular dementia
155. Which one of the following medications should be discontinued in a

pregnancy?
a. Atenolol
b. Bupropion
c. Fluoxétine
d. Glargine
e. Metformin
35
156. A 25-year-old female reports the absence of menses for the past 6 months. c
She has an elevated prolactin level and all her other labs and exams are
normal. Which one of the following would be most appropriate at this point
to further evaluate her pituitary gland?
a. Follow-up serum prolactin level in 4 weeks
b. Prolactin-stimulating hormone level
c. MRI of the pituitary
d. Head CT with intravenous contrast
157. Which one of the following EKG abnormalities would dictate the use of a b
pharmacologic stress test as opposed to an exercise stress test?
a. First degree atrioventricular block
b. Left bundle branch block
c. Poor R-wave progression in leads V1 through V3
d. Q-waves in the inferior leads
e. Ventricular trigeminy
158. An elderly immunosuppressed woman has not been feeling well for the last c
week. She is hospitalized and noted to have an increased respiratory rate.
She has no fever or cough. A chest radiograph reveals diffuse bilateral
interstitial infiltrates. Which one of the following is the most likely
diagnosis?
a. Pneumococcal pneumonia
b. Staphylococcal pneumonia
c. Pneumocystis pneumonia
d. Pulmonary tuberculosis
e. Pneumothorax
159. Which one of the following medications is the most likely cause of vitamin e
B12 deficiency?
a. Hydrochlorothiazide
b. Lisinopril
c. Amlodipine
d. Simvastatin
e. Omeprazole
160. Tramadol should be avoided in patients with a history of which one of the a
following?
a. Seizure
b. Heart failure
c. Ventricular dysrhythmias
d. Hypertension
36
161. For patients on lithium monotherapy for bipolar disease, monitoring should e
include periodic blood levels of lithium, creatinine, and:
a. Calcium
b. HbA1C
c. Lipids
d. Testosterone
e. TSH
162. A 35-year-old otherwise healthy male who is not on any medications, e

complains of 3-4 episodes of watery diarrhea that started 2 days earlier. The
diarrhea is accompanied by some nausea and abdominal cramping. He
denies fever, dehydration, and bloody stool. Which one of the following is
indicated at this time?
a. Testing for fecal leukocytes
b. Stool culture
c. Stool examination for ova and parasites
d. Stool test for Clostridium difficile toxin
e. No testing
163. A 6-year-old boy has right anterior cervical chain lymph node that was noted e
a week ago after he had recovered from an upper respiratory infection. It
measures 2 cm in diameter and is somewhat firm, mobile, and nontender.
The remainder of the examination is normal. Which one of the following
would be most appropriate at this point?
a. Ultrasound evaluation of the lymph node
b. Fine-needle biopsy of the node
c. Excisional biopsy of the node
d. 10-day course of antibiotics
e. Follow-up examination in 1 month
164. Which one of the following is the treatment of choice for Campylobacter b
resistant to quinolones?
a. Amoxicillin
b. Azithromycin
c. Metronidazole
d. Rifaximin
165. Diabetic retinopathy can be distinguished from hypertensive retinopathy by d

which one of the following?
a. Retinal “exudates”
b. Macular “stars”
c. Flame-shaped hemorrhages
d. Microaneurysms
37
166. Post-thyroidectomy high dose radio-iodine therapy improves long-term a

survival in:
a. Papillary thyroid carcinoma
b. Colloid thyroid carcinoma
c. Medullary thyroid carcinoma
d. Anaplastic thyroid carcinoma
167. Absolute indications for dialysis include: c

a. Metabolic acid with pH 7.2
b. Hyperkalemia with K+ 6.5 mEq/l
c. Uremic pericarditis
d. Volume overload with good urinary output
168. A 30-year-old woman with subacute Streptococcus viridans endocarditis has d

penicillin allergy. Which of the following would be the most appropriate
alternative?
a. Intravenous piperacillin
b. Intravenous cefazolin
c. Intravenous gentamicin
d. Intravenous vancomycin
e. Intravenous azithromycin
169. A low-risk patient is discharged from hospital after an acute coronary d

syndrome. His condition is stable. When can he resume driving for short
distances?
a. 6 months
b. Immediately after discharge
c. In 4 to 6 weeks
d. In about 1 week
e. Not until undergoing a postdischarge exercise stress test to confirm adequate
exercise capacity
170. For most patients, which one of the following modalities is the safest to e
confirm cirrhosis diagnosis?
a. Computed tomography scan
b. Liver biopsy
c. Magnetic resonance imaging study
d. Radionuclide imaging
e. Ultrasound
171. High intake if which one of the following foods has been most strongly b
linked to the development of colorectal cancer?
a. Egg
b. Red meat
c. Roasted sesame seed
d. Spicy feta cheese
e. Tuna from Japan
38
172. Which one of the following is most sensitive for detecting alcohol use d
disorders?
a. Carbohydrate-deficient transferrin
b. Elevated gamma-glutamyl transferase
c. Macrocytosis on hemogram
d. Screening questionnaire
173. Which one of the following psychiatric conditions is associated with b

acquired long QT interval?
a. Agoraphobia
b. Anorexia nervosa
c. Bipolar disorder
d. Munchausen syndrome
e. Schizophrenia
174. In chronic subdural hematoma, one is wrong: c

a. More frequent at extreme ages
b. Can mimic any neurological disease
c. Increase by osmosis
d. Increase by bleeding between the membranes
175. In case of acute headache presenting to the emergency room, the first thing c
to do is:
a. CT brain
b. MRI brain
c. Assessment for nucchal rigidity
d. Fundoscopy
176. All the following are features of salicylate intoxication EXCEPT: a

a. Convulsion
b. Hyperventilation
c. Respiratory alkalosis
d. Aciduria
e. Dehydration
177. All the following are critical features in accidental drug poisoning EXCEPT: e
a. Decreased consciousness and respiration
b. Convulsion
c. Cardiac arrhythmia
d. Hyperthermia
e. Vomiting
39
178. Which of the following tests has a high positive predictive value for Juvenile e
Rheumatoid Arthritis?
a. Erythrocyte sedimentation rate
b. C-reactive protein
c. HLA-B27
d. Antinuclear antibody
179. When is adenoidectomy recommended? d

a. Upper airway obstruction
b. Recurrent otitis media
c. Sleep apnea
d. All of the above
180. Which of the following are the most important and clinically useful risk c
factors for breast cancer?
a. Fibrocystic disease, age, and gender
b. Cysts, family history in immediate relatives, and gender
c. Age, gender, and family history in immediate relatives
d. Obesity, nulliparity, and alcohol use
GOOD LUCK
40
ANSWERS
1. c 2. e 3. b 4. d 5. c 6. c 7. e 8. c 9. a 10. d
11. a 12. b 13. d 14. b 15. e 16. a 17. b 18. e 19. a 20. a
21. e 22. c 23. a 24. c 25. d 26. e 27. d 28. d 29. c 30. c
31. a 32. c 33. b 34. a 35. a 36. a 37. b 38. a 39. b 40. d
41. e 42. b 43. b 44. e 45. b 46. b 47. b 48. a 49. d 50. d
51. d 52. e 53. b 54. e 55. d 56. e 57. a 58. c 59. b 60. d
61. b 62. a 63. e 64. b 65. d 66. c 67. a 68. c 69. d 70. d
71. c 72. d 73. c 74. b 75. e 76. a 77. a 78. d 79. d 80. b
81. d 82. b 83. e 84. c 85. b 86. b 87. b 88. c 89. e 90. b
91. e 92. c 93. a 94. e 95. d 96. b 97. a 98. a 99. e 100. d
101. a 102. a 103. d 104. a 105. e 106. b 107. e 108. e 109. b 110. b
111. d 112. e 113. c 114. b 115. e 116. d 117. b 118. a 119. c 120. b
121. c 122. d 123. e 124. b 125. b 126. b 127. e 128. e 129. d 130. d
131. a 132. e 133. b 134. b 135. b 136. a 137. e 138. c 139. d 140. d
141. a 142. e 143. b 144. b 145. b 146. b 147. c 148. a 149. c 150. a
151. a 152. e 153. d 154. c 155. a 156. c 157. b 158. c 159. e 160. a
161. e 162. e 163. e 164. b 165. d 166. a 167. c 168. d 169. d 170. e
171. b 172. d 173. b 174. c 175. c 176. a 177. e 178. e 179. d 180. c
41

Medicine Colloquium Exam - 2015 A

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Medicine Colloquium Exam - 2015 A

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Medicine Colloquium Exam –First Session 2015

Ministry of Education and Higher Learning

1. An 85-year-old woman presents with a 6-hour history of severe sudden onset c

2. A 21-year-old previously healthy arts student male presents with a 2-day e

3. A 43-year-old previously healthy woman presents with pain, swelling and b

4. An 84-year-old man presents repeatedly with abdominal distension due to a d

5. A 27-year-old woman sustains multiple rib fractures in a road traffic accident. c

6. ABO compatibility is advisable for the transfusion of blood products. Which of c

7. A 72-year-old man presents with fresh rectal bleeding. He undergoes CT e

8. A 39-year-old woman presents to the breast outpatient clinic complaining of c

10. A 75-year-old man, 2 years postradiation therapy for prostate cancer, d

11. Appropriate therapy for metastatic prostate cancer is: a

13. An 80-year-old woman with a history of congestive heart failure develops d

17. Eosinophilia is most likely to be found in which of the following settings? b

18. A 35-year-old woman with a history of Crohn’s disease develops a painful e

19. A 45-year-old woman complains of nervousness, palpitations, and a 7 kg a

22. A 22-year-old woman is brought to the emergency department after an c

23. A newborn with a heart rate of 80/min, no respiratory effort, no response to a

25. Which of the following is a symptom of newborn hypoglycemia? d

26. Symptoms of esophagitis in infants may include: e

27. Subacute sclerosing panencephalitis (SSPE) is associated with: d

28. In acute post-infectious glomerulonephritis, all of the following are present d

31. In which disease there is risk of obstruction and death by triggering a a

33. Overpassing term pregnancy is defined as: b

39. The most common side effect of quinine is: b

40. Renal calcification is an unlikely complication in: d

41. Which of the following statements about post-traumatic epilepsy is correct? e

42. In the nephrotic syndrome: b

43. Anticardiolipin antibodies are associated with increased incidence of: b

48. Which of the following can precipitate a gout attack? a

56. A 35-year-old woman with a history of Crohn’s disease develops a painful e

58. Which of the following infertility factors is the most frequent? c

59. Which fetal malformation can be prevented by folic acid intake? b

61. What is the most frequent complication of an abnormal involution of the b

62. What is the most frequent cause of post-partum hemorrhage? a

63. What is the most frequently sexually transmitted infection in women? e

64. Over passing term pregnancy is defined as: b

65. The most important cause of retroplacental hematoma is: d

67. A 25-year-old medical student is stuck with a hollow needle during a a

71. A 40-year-old gentleman presents to the emergency after he wakes up this c

73. What is the most common cause of secondary hypertension? c

74. A 34-year-old woman presents with 6 weeks history of progressive weakness b

75. A 25-year-old woman is found to have a midsystolic murmur on routine e

80. During routine physical examination of a 42-year-old woman, a physician b

82. A 57-year-old woman who underwent emergent cholecystectomy for a b

84. Fat embolism is best diagnosed by: c

85. Which is not true about subarachnoid hemorrhage? b

96. A postmenopausal female presents with a recent onset of painless vaginal b

103. Azithromycin should be used with caution in a 65-year-old male with d

104. Which one of the following intranasal medications is considered optimal a

107. Postmenopausal hormonal therapy with estrogen and progesterone results e

112. Which one of the following therapeutic interventions improves outcomes in e

114. A 32-year-old primigravida at 36 weeks gestation diagnosed with severe b

116. Which one of the following would support a diagnosis of subacute d

121. A 4-year-old infant is diagnosed with a symptomatic choledochal cyst. What c

123. A 23-year-old woman is referred by the gastroenterology team with e

126. A 54-year-old obese woman has chronic gastroesophageal reflux. Which of b

128. A 17-year-old girl presents to the emergency department with a 2-day e

130. In acute glomerulonephritis, all of the following are present EXCEPT: d

131. A 37-year-old woman is brought to the emergency department because of a

132. A previously healthy 42-year-old man is brought to the emergency e

135. A 37-year-old woman is brought to the emergency department 45 minutes b

136. A 27-year-old woman comes to the physician for a follow-up examination. a