PAPER 1B MEDICAL

1. 35 years old woman presents with fever associated with chills, rigor, dysuria and
frequency. On examination, her blood pressure is 120/90 mmHg, pulse rate is 90
bpm and temperature is 38.7℃. Her renal punch is positive.

What is the most signi cant nding in the urinalysis?

A. Bacteria
B. Nitrate
C. Pus cells
D. Red blood cells
E. White cell cast

Reference:
https://www.uptodate.com/contents/acute-complicated-urinary-tract-infection-
including-pyelonephritis-in-adults

2. 20 years old man presents to neurology clinic for abnormal behaviour. He had an
episode of blank stare with lips smacking during the incident at the o ce which
lasted for 2 minutes. He could not remember the incident but he remembered that
he had intense deja vu prior to that. It occurred twice this week. On examination,
there is no neurological de cit found. His magnetic resonance imaging shows
hippocampal atrophy and electroencephalogram is normal.

What is the next step of management?

A. Perform lumbar puncture
B. Repeat EEG
C. Refer for surgery
D. Urine for methamphetamine
E. Start lamotrigine

Reference:
Consensus Guidelines On The Management Of Epilepsy (2017)
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 3. 62 years old man presents with light-headedness for 2 weeks. There is no vertigo or
syncopal attack. He has occasional cough for 2 years. He is active smoke with 40
packs per year. On examination, his vital signs are normal. There is reduced chest
expansion bilaterally with prolonged expiratory phase on lungs. His investigation
result is as below:

Full blood count

Hemoglobin 19.2
Hematocrit 59
Platelet 234

What is the most appropriate investigation for initiation of treatment?

A. Arterial blood gas
B. Bone marrow aspiration
C. Chest x-ray
D. Peripheral blood smear
E. Lung spirometry

Reference:
https://www.uptodate.com/contents/chronic-obstructive-pulmonary-disease-
de nition-clinical-manifestations-diagnosis-and-staging

4. 68 years old woman alleged fall after she tripped at home today. She had no loss of
consciousness. She has underlying diabetes mellitus for the past 25 years on
maximum dose oral hypoglycaemic agents. Her latest HbA1c is 6.5%.
On examination, her blood pressure is 130/70 mmHg and pulse rate is 66 bpm.
Lower limbs examination shows loss of hair and hyperpigmented skin changes over
the shins. Limb power is normal. Bilateral re exes, vibration and pin prick sensation
are reduced up to ankle. Dorsalis pedis and posterior tibialis pulses are normal.
Plantar re exes are downgoing. Eye examination reveals bilateral immature cataract.

What is the most important assessment at this stage?

A. Advice for home glucose monitoring
B. Nerve conduction study
C. Start gabapentin
D. Refer occupational therapist for functional assessment
E. Refer ophthalmologist for eye assessment

Reference:
Not available
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5. 65 years old woman complains of epigastric pain and shortness of breath on
exertion which is relieved with rest. She denies palpitation. She has hypertension for
10 years. On examination, her blood pressure is 130/80 mmHg, pulse rate is 64
beats/min and respiratory rate is 18 breaths/min. Other systemic examination is
normal. Blood investigation and electrocardiogram are normal.

What is the most likely diagnosis?

A. Aortic dissection
B. Gastritis
C. Gastroesophageal re ux disease
D. Non ST elevation myocardial infarction
E. Stable angina

Reference:
CPG Management Of Stable Coronary Artery Disease (2018)

6. 40 years old woman presents with shortness of breath and wheezing for 1 day.
She has history of cough with yellowish sputum since 2 days ago. She has
underlying bronchial asthma on MDI Salbutamol 200 mcg PRN. On examination,
she is alert and speak in phrases. Her blood pressure is 120/80 mmHg, pulse rate is
110 beats/min, respiratory rate is 24 breaths/min and oxygen saturation is 92%
under room air. Lungs auscultation reveals generalized rhonchi.

What is the most appropriate assessment at this stage?

A. Arterial blood gas
B. Chest x-ray
C. Peak expiratory ow rate
D. Lungs spirometry
E. Sputum culture and sensitivity

Reference:
CPG Management of Asthma In Adults (2017)
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7. 18 years old woman presents with signi cant weight loss, polyuria and polydipsia for
1 month. Her mother was diagnosed with type 1 diabetes mellitus at age of 15.
Her paternal grandfather has diabetic on oral hypoglycaemic agents.
On examination, her body mass index is 20.5 kg/m2. Her blood pressure and pulse
rate are normal. Her investigation results are as below:

Fasting blood sugar 12

C-peptide 0.5 (Normal)

What is the most appropriate investigation at this stage?

A. B cell antibodies
B. GAD antibodies
C. HbA1c
D. MODY genetic study
E. Oral glucose tolerance test

Reference:
CPG Management Of Type 1 Diabetes Mellitus In Children & Adolescents (2015),
Diagnosis, Page 1

8. 55 years old man comes for follow up for his gouty arthritis. He was admitted 1
month ago for high grade fever, rash and blisters following treatment for his gouty
arthritis. Currently, he is asymptomatic and not on medications. On examination, his
blood pressure is 130/90 mmHg and pulse rate is 90 beats/min. There are multiple
tophi over his pinna and elbow.

What is the most appropriate management?

A. Allopurinol
B. Azathioprine
C. Febuxostat
D. Prednisolone
E. Probenecid

Reference:
https://www.uptodate.com/contents/pharmacologic-urate-lowering-therapy-and-
treatment-of-tophi-in-patients-with-gout
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 9. 28 years old man presents with intermittent fever, dry cough and shortness of breath
for 2 weeks. He has history of drug abuse. On examination, he looks cachexic. His
vital signs are normal. Lungs examination is clear. HIV rapid test is reactive. His
chest x-ray is as below:

What is the most appropriate treatment for this patient?

A. Start antiretroviral therapy
B. Start antituberculosis
C. Start oral steroid
D. Start azithromycin
E. Start trimethoprim-sulfamethoxazole

Reference;
https://www.uptodate.com/contents/treatment-and-prevention-of-pneumocystis-
infection-in-patients-with-hiv

10. 22 years old woman presents with abdominal cramps and bloody diarrhea for
2 days. Currently, there is Escherichia coli outbreaks among her hostel mates.
On examination, her capillary re ll time is is 2 seconds. Her blood pressure is
110/70 mmHg, pulse rate is 90 beats/min and temperature is 37℃. There is
generalized tenderness over the abdomen. Stool for culture and sensitivity is still
pending.

What is the most appropriate treatment?

A. Cipro oxacin
B. Hyoscine
C. Loperamide
D. Oral rehydration salt
E. Probiotics

Reference:
https://www.uptodate.com/contents/pathogenic-escherichia-coli-associated-with-
diarrhea
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11. 25 years old man presents with acute confusional state. He is known case of
recreational drug user. 3 hours prior to presentation, he snorted white powder drug
and then started to scream and became violent. On examination, his blood pressure
is 150/90 mmHg, pulse rate is 100 beats/min, temperature is 38.5 ℃ and pupils are
dilated. His electrocardiogram and random blood sugar are normal.

What is the management at this stage?

A. Diazepam
B. Haloperidol
C. Nitroglycerin
D. Verapamil
E. Thiamine

Reference:
https://www.uptodate.com/contents/cocaine-acute-intoxication

12. 58 years old male with underlying hypertension, diabetes mellitus and chronic
kidney disease presents with mild exertional dyspnea. On examination, his blood
pressure is 150/90 mmHg and pulse rate is 80 beats/min. His current investigation
compared to 3 months ago are as below:

Current Previous
Hemoglobin 8.0 8.3
HbA1c 6.4 6.3
Potassium 5.9 5.6
Glomerular ltration rate 19 22

What is the best features that suggest the renal replacement therapy at this stage?
A. eGFR
B. Potassium
C. Anemia
D. Blood pressure
E. Albumin

Reference:
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13. 20 years old man complains of severe headache associated with nausea and
vomiting. His cerebrospinal uid result is as below:

Appearance Cloudy
Opening pressure High
Glucose Low
Protein High
AFB staining Negative
Indian ink Negative

What is the diagnosis?

A. Cerebral toxoplasmosis
B. Cryptococcus
C. Herpes simplex encephalitis
D. Meningococcal meningitis
E. TB meningitis

Reference:
https://www.uptodate.com/contents/diagnosis-of-meningococcal-infection

14. 22 years old male with no known medical illness complains of crushing chest pain
and shortness of breath for 2 hours. He has similar recurrent history for the past 1
year. He has family history of sudden death. On examination, he is alert and
conscious. His blood pressure is 130/80 mmHg and pulse rate is 80 beats/min.
Noted ejection systolic murmur at left sternal edge grade 3/6. There is no pedal
edema. His electrocardiogram is as below:

What is the diagnosis?

A. Atrial stenosis
B. Atrial septal defect
C. Hypertensive cardiomyopathy
D. Hypertrophic obstructive cardiomyopathy
E. Non-ST elevation myocardial infarction

Reference:
https://www.uptodate.com/contents/hypertrophic-cardiomyopathy-clinical-
manifestations-diagnosis-and-evaluation
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 15.

16. 40 years old man collapses after participating a charity run and brings to
Emergency Department. He is known case of hyperthyroidism but defaulted
treatment for 6 months. On examination, he is agitated and confused. His blood
pressure is 170/110 mmHg, pulse rate is 140 beats/min with irregularly irregular
rhythm and temperature is 38.5℃.

What is the most appropriate investigation at this stage?

A. Electrocardiogram
B. Echocardiogram
C. Thyroid function test
D. Full blood count
E.

Reference:
https://www.uptodate.com/contents/thyroid-storm

17. 49 years old man with underlying hypertension plans for jungle trekking to Taman
Negara Sarawak this weekend.

What is your management?

A. Reassure
B. Insect repellent
C. Malarone
D. Doxycycline
E. Me oquine

Reference:
CPG Management Of Malaria In Malaysia (2014), Malaria Chemoprophylaxis,
Page 39

18.
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19. 41 years old woman with underlying Sjogren’s syndrome presents with 1 month
history of generalized weakness and lethargy. She now feels it is a ecting her
lifestyle. On examination, she is afebrile and vital signs are stable. Her skin and lips
are dry and parotid glands are mild swollen. Other systemic examination is normal.
Her investigation results are as below:

Full blood count Normal

Potassium 2.3
Glomerular ltration rate 60.5

What is the most appropriate next assessment?

A. ANA test
B. Serum cortisol test
C. Short Synacthen test
D. Urine ammonium extraction test
E. Urine pH test

Reference:
https://www.uptodate.com/contents/evaluation-of-the-adult-patient-with-
hypokalemia

20. 32 years old female presents with severe right temporal headache with right nasal
congestion for 2 days. It lasts about 1 hour and occurs about 6 times per day. She
had similar attacked 2 months ago. On examination, her BP 138/79 mmHg, PR 80
bpm and SPO2 98%. Physical examination is unremarkable.

What is the most appropriate management?

A. Administer 100% oxygen
B. Naproxen
C. Sumaptriptan
D.
E. Ergotamine

Reference:
https://www.uptodate.com/contents/cluster-headache-treatment-and-prognosis
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 21. 62 years old man with known case of hypertension on T. Hydrochlorothiazide 50 mg
OD presents with lethargy and weakness for 1 week. He also has loose stool.
On examination, he is lethargy and mucous membrane is dry. His physical
examination is unremarkable. His investigation results are as below:

Renal function test

Urea 15
Creatinine 150
Sodium 132
Potassium 2.3

Electrocardiogram Poor R wave progression

Flat T wave

What is the most appropriate management?

A. IV normal saline
B. IV normal saline with potassium
C. Start antibiotic
D. Sent stool for culture and sensitivity
E. O hydrochlorothiazide

Reference:
https://www.uptodate.com/contents/clinical-manifestations-and-treatment-of-
hypokalemia-in-adults

22. 75 years old man presents with fever, cough and shortness of breath for 2 days.
He just discharged from ward for cellulitis 3 days ago. On examination, his
temperature is 39℃, respiratory rate is 24 breaths/min and oxygen saturation is
95%. There is bilateral lung crepitation and reduced air entry at lower zone.

What is the most appropriate management?

A. IV AnfoB
B. IV Cefuroxime
C. T. Clarythromycin
D. T. Tamil u
E. IV Tazosin

Reference:
National Antimicrobial Guideline (2019), Hospital Acquired Pneumonia, Page 122
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23. 35 years old woman with known case of systemic lupus erythematous on
T. Prednisolone 30 mg OD for 6 weeks. She presents with weight increment and
abdominal striae. Her serum cortisol level is 1200.

What is the most appropriate management at this stage?

A. For bone densitometry
B. For plasma glucose
C. For ACTH test
D.
E. Taper down Prednisolone

Reference:
https://www.uptodate.com/contents/glucocorticoid-withdrawal

24. 26 years old woman presents with high grade fever for 3 days associated with
headache, productive cough, abdominal pain and diarrhea. She had history of
swimming in freshwater 2 weeks ago. On examination, she is lethargy and jaundice.
Noted bilateral conjunctiva su usion. Her blood pressure is 100/75 mmHg, pulse
rate is 100 beats/min and temperature is 39℃. There is tenderness over right
hypochondriac area. Serology and blood for culture and sensitivity are taken. Urea,
creatinine and liver enzymes are elevated.

What is the most appropriate management?

A. Ampilicillin
B. Azithromycin
C. Ceftriaxone
D. Doxycycline
E. Penicillin

Reference:
National Antimicrobial Guideline (2019), Leptospirosis, Page 165

25. 40 years old man with underlying chronic hepatitis B comes to clinic with ancée.
Their wedding will be in 2 months time. His investigations result are as below:

HBsAg Positive
HBeAg Non reactive
Hepatitis C Non reactive
Anti-HBs < 10
Liver function test Normal
Ultrasound HBS Normal

What is your advice to ancee at that moment?

A. Advise for barrier contraception
B. Advise for hepatitis B vaccination
C. Take serum HBsAg
D. Take hepatitis B antibody
E. Reassurance and no intervention needed

Reference:
https://www.uptodate.com/contents/hepatitis-b-virus-immunization-in-adults
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 26.

27. 40 years old man presents with progressive muscle weakness for 2 months.
On examination, his vital signs are normal. His neurological examination is as below:

Upper limb Lower limb

Right 4/5, left 3/5 Right 4/5, left 3/5
Fasciculation Hypertonia
Hypore exia Hyperre exia

What is the most likely diagnosis?

A. Gullain-Barre syndrome
B. Multiple sclerosis
C. Motor neuron disease
D. Spinal muscular atrophy
E. Syringomyelia

Reference:
https://www.uptodate.com/contents/clinical-features-of-amyotrophic-lateral-
sclerosis-and-other-forms-of-motor-neuron-disease

28.

29. 82 years old man presents with worsening cough for 10 days. He was treated with
T. Augmentin and T. Erythromycin for 5 days but the symptom not improved. He has
underlying chronic kidney disease stage 3B. On examination, his blood pressure is
122/70 mmHg, pulse rate is 102 beats/min and oxygen saturation is 95% under
room air. Lung examination reveals coarse crepitations on the right lower zone.
Chest x-ray shows opacity over right lower zone.

What is the most appropriate management?

A. Give in uenza vaccine
B. Give supplemental oxygen
C. Admit for IV Ceftriaxone
D. Give T. Fluoroquinolone
E. Send sputum AFB

Reference:
National Antimicrobial Guideline (2019), Community Acquired Pneumonia, Page 119
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30. 20 years old man was diagnosed with pulmonary tuberculosis and started on EHRZ
regime 1 week ago. He complains of knee and ankle pain for 2 days with pain score
4/10. On examination, he is pink and not jaundice. Knee and ankle examination
reveal normal underlying skin. There is tenderness over active and passive
movement. Range of movement is normal.

What is the most appropriate management?

A. Change ethambutol to streptomycin
B. Do x-ray of ankle and knee
C. Prescribe topical analgesic
D. Prescribe ibuprofen
E. Withold pyrazinamide

Reference:
Not available

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32.

33. 40 years old man presents with fever and lethargy for 1 month associated with night
sweat and loss of weight. On examination, he is pale and not jaundice. His blood
pressure is 130/80 mmHg, pulse rate is 110 bpm, temperature is 38.5 ℃ and
respiratory rate is 20 breaths/min. There is hepatosplenomegaly and multiple
painless cervical and inguinal lymphadenopathy with the largest 2x2 cm. His blood
investigation shows pancytopenia with high LDH.

What is the most likely diagnosis?

A. Acute myeloid leukemia
B. Hepatocellular carcinoma
C. Infectious mononucleosis
D. Non-Hodgkin lymphoma
E. TB lymphadenitis

Reference:
https://www.uptodate.com/contents/clinical-presentation-and-initial-evaluation-of-
non-hodgkin-lymphoma
 34. 54 years old woman has underlying diabetes mellitus and hypertension. Currently
she is on T. Metformin 1 g BD, T. Gliclazide 80 mg BD, T. Amlodipine 10 mg OD,
T. Simvastatin 40 mg OD. She complains of muscle pain for 2 weeks.
On examination, her blood pressure is 140/90 mmHg. Her physical examination is
unremarkable. Her investigation results are as below:

Creatine kinase Raised

Triglycerides 2.4
HDL-cholesterol 1.0
LDL-cholesterol 3.3

What is the most appropriate management?

A. Reduce T. Amlodipine dose
B. Stop T. Amlodipine
C. Change T. Simvastatin to T. Rosuvastatin
D. Reduce T. Simvastatin
E. O T. Simvastatin

Reference:
https://www.uptodate.com/contents/statin-muscle-related-adverse-events

35. 30 years old woman presents with oral ulcer and pain during sexual intercourse.
She also complains of blurring of vision. On examination, her visual acuity is 6/36
and funduscopy reveals retinal haemorrhage. On speculum, noted ulcers over the
genital area.

What is the most likely diagnosis?

A. Herpes simplex virus infection
B. Human immunode ciency virus infection
C. Behcet's syndrome
D. Reiter's syndrome
E. Systemic lupus erythematosus

Reference:
https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-
behcet-syndrome
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 36. 22 years old vegetarian female complains of increasing fatigue for 3 months.
Otherwise, she had no fever, palpitation and no constitutional symptom.
She has regular menses with normal ow. She has no family history of blood
disorder. On examination, she is pale and not jaundice. Her vital signs are stable.
Her physical examination is normal. Her blood results are as below:

Full blood count

White blood cell 7.0
Red blood cell 4.8
Hemoglobin 9.3
Hematocrit 41
Mean corpuscular volume 72
Mean corpuscular hemoglobin 22
Platelet 238
Retic count 1.17

Mentzer index 15.1

Full blood picture Marked anisopoikilocytosis
No target or blast cell

What is the most appropriate investigation at this stage?

A. Hb electrophoresis
B. Esophagogastroduodenoscopy
C. Serum ferritin
D. Stool for occult blood
E. Stool for ova and cyst

Reference:
https://www.uptodate.com/contents/causes-and-diagnosis-of-iron-de ciency-and-
iron-de ciency-anemia-in-adults

37. 40 years old man with known case of bronchial asthma presents with shortness of
breath and wheezing. It is preceded with cough with yellowish sputum.
On examination, he talks in phrases. His blood pressure is 120/80 mmHg, pulse rate
is 116 beats/min, temperature is 36.6 ℃ and respiratory rate is 24 breaths/min.
There is generalized rhonchi on both lungs.

What is next investigation at this stage?

A. Arterial blood gas
B. Chest x-ray
C. Peak ow assessment
D. Spirometry
E. Sputum C&S

Reference:
CPG Management of Asthma In Adults (2017), Page XII
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 38. 28 years old man complains of frequent passing loose motion for the past 3 months
as he is having stress. On examination, his vital signs are stable. His abdomen is
soft and non-tender and per rectal is normal. He already tried lifestyle and dietary
modi cation but the symptoms not improved.

What is the next step management?

A. Amitryptilline
B. Loperamide
C. Ranitidine
D. Sulfasalazine
E. Paroxetine

Reference:
https://www.uptodate.com/contents/approach-to-the-adult-with-chronic-diarrhea-
in-resource-rich-settings

39. 42 years old male presents with productive cough for 2 weeks. On physical
examination, there is stony dullness over the chest. His investigation results are as
below:

Pleural uid analysis

pH 7.35
Glucose 5.0
Protein 49.4
Lactate dehydrogenase 332
Total cells 3.7
Lymphocytes 90

Blood investigation
Glucose 8.0
Protein 64
Lactate dehydrogenase 150

What is the next step management?

A. CT thorax
B. Pleural biopsy
C. Pleural uid for AFB
D.
E. Pleural uid for C&S

Reference:
https://www.uptodate.com/contents/tuberculous-pleural-e usion
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40. 42 years old Malay woman para 4 presents with amenorrhea and decrease libido for
10 months. On examination, her blood pressure is 140/88 mmHg and pulse rate is
70 beats/min. There is facial hair and clear discharge over the left breast.

What is the most appropriate investigation to aid diagnosis?

A. Serum follicle-stimulating hormone
B. Serum gonadotropin-releasing hormone
C. Serum prolactin
D. Serum testosterone
E. Ultrasound pelvis

Reference:
https://www.uptodate.com/contents/clinical-manifestations-and-evaluation-of-
hyperprolactinemia

41. 40 years old man presents with skin lesion as below:

What is the most appropriate management?

A. Ampicillin
B. Doxycycline
C. Chloramphenicol
D. Azithromycin
E.

Reference:
https://www.uptodate.com/contents/scrub-typhus-treatment-and-prevention
 42. 55 years old man with known case of non-alcoholic fatty liver disease, diabetes
mellitus and dyslipidemia comes for follow up for persistent transaminitis. On
examination, he is not jaundice. His blood pressure is 140/90 mmHg, pulse rate is
70 beats/min and body mass index is 30 kg/m2. His abdomen is soft, non-tender
and no hepatosplenomegaly. The broscan result is 0.97 which is evidence of
advanced brosis.

What is the most appropriate management?

A. Liver biopsy
B. Monitor liver enzyme
C. Start pioglitazone
D. Prescribe vitamin E
E. Refer for bariatric surgery

Reference:
https://www.uptodate.com/contents/management-of-nonalcoholic-fatty-liver-
disease-in-adults

43. 50 years old man complains of fever, cough and shortness of breath for 1 day. He
just came back from Saudi Arabia 10 days ago. On examination, he is alert,
conscious and pink. His blood pressure is 120/70 mmHg, pulse rate is 100 bpm,
respiratory rate is 24 breaths/min and oxygen saturation is 96%. There is
crepitations over the right lower zone of his lungs.

What is the most appropriate management at this stage?

A. Notify
B. Isolate
C. Supplementary oxygen
D. Start antiviral
E. Start antibiotic

Reference:
https://www.uptodate.com/contents/middle-east-respiratory-syndrome-coronavirus-
treatment-and-prevention
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44. 65 years old man presents with nausea, vomiting and abdominal discomfort for
3 days. He also has lethargy for few weeks and loss of weight for few months.
On examination, he is dehydrated, pale but not jaundice. His blood pressure is
140/90 mmHg, pulse rate is 86 beats/min and temperature is 37.2 ℃.
Systemic examination is unremarkable. His investigation results are as below:

Renal function test

Urea 16
Creatinine 125
Potassium 3.6
Sodium 140
Calcium 3.0 (High)
Phosphate 3.0

What is the most appropriate investigation?

A. 24 hour urine calcium
B. Chest x-ray
C. Serum alkaline phosphatase
D. Serum parathyroid hormone
E. Serum protein electrophoresis

Reference:
https://www.uptodate.com/contents/diagnostic-approach-to-hypercalcemia

45. 60 years old woman was diagnosed with advanced colon cancer and planned for
palliative management. She complains of sudden shortness of breath for 1 day.
On examination, she is pink. Her blood pressure is 130/85 mmHg, pulse rate is
120 bpm, respiratory rate is 26 breaths/min and oxygen saturation is 92% under
room air. Her lungs air entry is equal and there is no crepitation.

What is the most likely diagnosis?

A. Acute coronary syndrome
B. Pneumothorax
C. Lung metastasis
D. Pulmonary embolism
E. Pneumonia

Reference:
https://www.uptodate.com/contents/clinical-presentation-evaluation-and-diagnosis-
of-the-nonpregnant-adult-with-suspected-acute-pulmonary-embolism
 46. 19 years old boy complains of sudden chest pain after playing badminton.
Otherwise, he has no cough or shortness of breath. His blood pressure is
120/80 mmHg, pulse rate is 100 beats/min and oxygen saturation is 92%.
There is reduced air entry over the right side of his lung. His chest x-ray nding
is as below:

What is the next management?

A.
B. Give high- ow mask oxygen
C. Aspirate pleural with small needle catheter
D. Give analgesics and follow up
E. Repeat chest x-ray after 24 hours

Reference:
https://www.uptodate.com/contents/treatment-of-primary-spontaneous-
pneumothorax-in-adults

47. 45 years old man presents with fever and increased scrotal swelling for 1 week. In
examination, there is non tender bilateral scrotal edema. The transillumination test is
positive. His inguinal lymph nodes are palpable.

What is the most appropriate management?

A. Ultrasound scrotum
B. Take FNAC from lymph node
C. Perform blood C&S
D. Send urine albumin
E. Send peripheral blood lm

Reference:
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 48. 65 years old man comes for warfarin clinic follow up. He is on T. Warfarin 3 mg OD
for atrial brillation. His international normalized ratio has been stable for last 1 year
between 2.0-2.5. He is planned for cataract surgery next month. He is referred for
assessment prior to the surgery. His latest investigation results are as below:

Coagulation pro les

International normalized ratio 2.2
Prothrombin time 16
Activated partial thromboplastin time 35

What is the most appropriate advice?

A. Continue warfarin
B. Reduce to 2.5 mg
C. Change to low-molecular-weight heparin
D. Withhold for 5 days prior to surgery and continue after 1 day post-operation
E. Change to rivaroxaban

Reference:
https://www.uptodate.com/contents/perioperative-management-of-patients-
receiving-anticoagulants

49. 57 years old man with underlying hypertension and hyperlipidemia on T. Amlodipine
and T. Simvastation presents with chest pain for 3 hours. On examination, his blood
pressure is 210/110 mmHg and pulse rate is 100 bpm. Noted his apex beat is
displaced to sixth intercostal space.

What is the most appropriate management?

A. IV labetolol
B. IV nitroglycerin
C. Oral nifedipine
D. Repeat electrocardiogram
E. Send urine for protein

Reference:
CPG Management Of Hypertension (2018)
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50. 70 years old man presents with confusion and agitation for 5 days. He had history of
myocardial infarction on T. Bisoprolol, T. Aspirin and T. Omeprazole. He lives
independently with his wife. His vital signs are stable. Di cult to perform central
nervous system examination. His investigation results are as below:

Full blood count

White blood cell 14
Hemoglobin 11
Platelet 250

Random blood sugar 5.0

Urine FEME Normal

What is the best investigation to help in management?

A. Blood C&S
B. CT brain
C. Electrocardiogram
D. Thyroid function test
E. Urine C&S

Reference:
https://www.uptodate.com/contents/evaluation-of-abnormal-behavior-in-the-
emergency-department
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