Physical Examination Assessment Test

152 Questions | Total Attempts: 78

SettingsSettingsSettings
Physical Examination Assessment Test

Questions and Answers
  • 1. 
    A 45 year old, previously healthy woman is presented with jaundice, confusion, and fever. Initial physical examination is unremarkable except for scattered petechiae on the lower extremities, sclera icterus, and disorientation on mental status examination. Laboratory examination discloses:
    • Hct 27%, WBC 12,000/uL, Platelets 10,000/uL,    PT/PTT=normal
    • Total Bilirubin 5 mg/dL, Direct Bilirubin 0.6 mg/dL, BUN 60 mg/dL, Creatinine 4.5 mg/dL
    • RBC smear looks like this:
    What is your diagnosis?
    • A. 

      Thrombocytopenia

    • B. 

      Hemolytic anemia

    • C. 

      Has recent mechanical valve placement

    • D. 

      Thrombotic thrombocytopenic purpura(TTP)

    • E. 

      Bleeding disorder

  • 2. 
    A patient comes to see you in your general medicine clinic complaining of long-standing generalized weakness. Initially, the weakness started several months ago with difficulty climbing up stairs and rising out of a chair. She had been seen for this several times in the E.D. and most recently had to have stiches placed for a forehead laceration incurred during a "weakness" fall. Having had enough, she comes to you specifically complaining of a 2 week history of difficulty combing her hair. On examination the patient has this.(See image below) What is your diagnosis?
    • A. 

      Infective endocarditis

    • B. 

      Fungal infections

    • C. 

      Hyperkeratosis

    • D. 

      Solar burns

    • E. 

      Dermatomyositis

  • 3. 
    This particular lady has wheezing with her flushing episodes, as well as diarrhea. On examination she also has pulsatile hepatomegaly and a 2/6 systolic ejection murmur along the left sternal border that increases with respiration. She also has associated paroxysmal hypotension during a typical flushing episode. The appropriate diagnosis can be made by which of the following:
    • A. 

      Serum Gastrin level

    • B. 

      Serum VIP level

    • C. 

      Urinary catecholamines, VMA, metanephrines

    • D. 

      Urinary 5-HIAA, 5-HT

    • E. 

      Serum TSH

    • F. 

      Urine collection for histamine, histamine metabolites, PGD2 metabolities with/without serum histamine level

  • 4. 
    A 72 year old white woman presents to the ED complaining of left-leg discoloration, pain, and swelling which developed over several hours, associated with a burning-itching sensation. She noticed that a large area of her left upper leg was reddish-blue with small blisters. The patient denies any fever, trauma, or bites. Doppler ultrasonography of her left leg two weeks prior had yielded normal results. PHYSICAL EXAMINATION: The patient is alert, appears pale and anxious, and is in moderate discomfort from pain in her left leg. Her vital signs are temperature 97.8 degrees F, pulse 73 beats/min, blood pressure 113/59 mm of Hg, and respirations 18 breaths/minute. The results of her HEENT, cardiovascular, respiratory, abdominal, and neurological exams are normal. Her left leg is tender to palpation without crepitus. Pitting edema extends the entire length of the leg with a reddish- blue discoloration. Numerous small vesicles are also noted with three, 3- 5 cm hemorrhagic bullae on the medial thigh. What is your diagnosis?
    • A. 

      Necrotizing fasciitis

    • B. 

      Waterhouse-Friderichsen syndrome

    • C. 

      Pemphigus vulgaris

    • D. 

      Pemphigoid

    • E. 

      Hemophilia

  • 5. 
    A 30 year old woman presents with sudden, progressive "blurring" of vision in the left eye only. You dilate her eyes and do an ophthalmologic examination. Her right eye is normal. The left eye shows the following: What is your diagnosis?
    • A. 

      Brain tumor

    • B. 

      Pseudotumor cerebri

    • C. 

      Intracerebral hemorrhage

    • D. 

      Optic nerve glioma

    • E. 

      Malignant hypertension

    • F. 

      Diabetes Mellitus

  • 6. 
    Which of the following case histories would most likely be associated with the urinary sediment depicted below?
    • A. 

      A 23-year-old man with newly diagnosed lymphoblastic lymphoma who is found to have a rising creatinine level 2 days after the administration of combination chemotherapy

    • B. 

      A 23-year-old woman 1 year after surgery performed because of morbid obesity

    • C. 

      A 45-year-old woman with a history of multiple urinary tract infections with urea-splitting organisms

    • D. 

      A 40-year-old man with edema, hypoalbuminemia and proteinuria.

    • E. 

      An 18-year-old man with flank pain, hematuria and a positive family history for renal stones in youth

  • 7. 
    A 60-year-old mildly obese woman complains of a very bothersome burning pain on the anterolateral aspect of her right thigh from the groin almost as far distally as the knee. Examination shows reduction of sensation to touch and pinprick in the affected area. There is no loss of muscle strength, and reflexes are normal. The most likely diagnosis is?
    • A. 

      Ruptured intervertebral disk

    • B. 

      Femoral hernia

    • C. 

      Nutritional neuropathy

    • D. 

      Compression of the lateral femoral cutaneous nerve

    • E. 

      Disruption of the lumbosacral plexus

  • 8. 
    A 65 year-old man with a history of hypertension and chronic obstructive pulmonary disease secondary to cigarette smoking presents to a physician in the clinic because his wife thought "he looked different". He also has had the development of right back and shoulder pain. This is a picture of his face. What is your diagnosis?
    • A. 

      Grave’s disease

    • B. 

      Glaucoma

    • C. 

      Intracranial hypertension

    • D. 

      Hyperthyroidism

    • E. 

      Pancoast's tumor

  • 9. 
    A 45-year-old man presents to you with the following leg ulcer of the lateral calf. He has had this lesion going on 3-4 months. It is minimally painful and has failed to heal soaking in water, wrapping it with bandages, cleaning with hydrogen peroxide or applying bacitracin. Being the astute clinician you do a complete history and on review of systems you also get a history of arthralgias and occasional bloody diarrhea over the past few years. On exam, he does have some evidence of synovitis in diffuse joints but otherwise the physical exam is unremarkable. The most likely diagnosis is?
    • A. 

      Venous insufficiency ulcer

    • B. 

      Pyoderma Gangrenosum

    • C. 

      Ulceration of squamous cell carcinoma

    • D. 

      Ulceration of squamous cell carcinoma

    • E. 

      Necrotizing vasculitis

    • F. 

      Ulceration associated with arterial insufficiency

  • 10. 
    A 79 year old man is diagnosed with terminal prostate cancer. He is admitted in the Hospice with severe respiratory distress, dehydration and anemia. On examination, B.P 90/60mmHg, R/R 30/min, Pulse is 65/min. He is unconscious. After the examination, the attending Physician writes out the treatment.  The Nurse on duty reminds the ER doctor that the patient has a signed “DNR”.   What is your understanding of the term “Do Not Resuscitate” (DNR)?
    • A. 

      No intubation and ventilation

    • B. 

      No artificial nutrition by tube

    • C. 

      No medication

    • D. 

      No CPR

    • E. 

      No IVF or blood transfusion

    • F. 

      No admission to intensive care

    • G. 

      No life support

    • H. 

      No surgical intervention

  • 11. 
    Paramedics bring a 41- year old man to the emergency room. He is complaining of headache, dizziness, nausea and abdominal pain. The paramedics state that the patient's apartment has a coal furnace. His blood pleasure is 110/70 mmHg, respirations are 20 breath per minute, and pulse is 100 beats per minute. The patient has a cherry red appearance most noticeable around the lips and nail beds. Neurologic examination reveals a disoriented and confused man without facials deficits. Oxygen saturation by pulse oximetry is normal. Which of the following is the most likely disgnosis ?
    • A. 

      Drug overdose

    • B. 

      Carbon monoxide poisoning

    • C. 

      Alcohol intoxication

    • D. 

      Methemoglobinemia

    • E. 

      Anti-freeze poison

  • 12. 
    A 75 year old woman complains of neck pains. She has a prior history of hypertension, diabetes and CHF. On examination, she has kyphosis, BP is 129/87 mmHg, Pulse 78/min., tender lower neck posteriorly, with mild pedal edema.  Her cervical X-ray is shown below. What is your diagnosis?
    • A. 

      Osteomyelitis

    • B. 

      Osteoporosis

    • C. 

      Rheumatoid arthritis

    • D. 

      Osteoarthritis

    • E. 

      Multiple myeloma

  • 13. 
    A 12 year old African migrant girl is diagnosed with iron deficiency anemia. She has koilonychias. Blood work-up showed microcytosis, Increased TIBC, decreased ferritin, and decreased serum Iron. There were no sickled cells.  What else might you find on physical examination?
    • A. 

      Frontal bossing of the skull

    • B. 

      Joint swellings

    • C. 

      Jaundice

    • D. 

      Autosplenectomy

    • E. 

      Glossitis

    • F. 

      Macrocytosis

    • G. 

      Increased TIBC

    • H. 

      Decreased ferritin

  • 14. 
    A 68 year old man with history of prostate cancer, diabetes, hypertension, and fungal infection, comes to the clinic for follow up and complained of problems with his finger nails. The image is shown below.  The doctor notes transverse depression in nail plate and concludes that the patient’s nail finding has something to do with?
    • A. 

      Side effects of antihypertensive medication

    • B. 

      He has onychomycosis

    • C. 

      Cancer metastasis

    • D. 

      Side effect of steroids

    • E. 

      Side effect of antineoplastic drugs

  • 15. 
    During physical examination, a doctor notes that his recently referred 56 year old man has nail plate that is white with narrow pink distal band. He describes it as “ground glass appearance”.  There is no tenderness, and clubbing. Which of the following will not be the likely diagnosis?
    • A. 

      Cirrhosis.

    • B. 

      Chronic CHF.

    • C. 

      Hemodialysis patients.

    • D. 

      Renal transplant recipients.

    • E. 

      HIV/AIDS patients.

    • F. 

      Paronychia

  • 16. 
    A 62 year old bell ringer for 25 years complains of pain resulting from thumb and wrist motion on his right hand. There is no history of trauma. He has no prior medical record, although he drinks alcohol socially. His blood pressure is 135/89 mmHg, chest is clear to auscultation; resp is 16/min., pulse 89/min. He has tenderness, thickening, and a prominence at the radial styloid. Crepitation is felt at the first dorsal compartment over the radial styloid. Flexion of the thumb across the palm and then ulnar deviation of the wrist causes sharp pain at the first dorsal compartment.   What is your most likely diagnosis?
    • A. 

      Carpal tunnel syndrome.

    • B. 

      Rheumatoid arthritis.

    • C. 

      Gout.

    • D. 

      Osteomyelitis.

    • E. 

      De Quervains tenosynovitis.

    • F. 

      Fracture of the radius in the lower one third.

  • 17. 
    A 48 year old white female secretary presents with progressive difficulty typing over the past month. She also notes that her hands begin to feel numb and weak after typing for long periods of time.  On testing which of the following deficits would be predicted?
    • A. 

      Difficulty abducting the fifth finger

    • B. 

      Difficulty in adducting the thumb

    • C. 

      Loss of sensation over the lateral three and half fingers of the palm

    • D. 

      Difficulty in opposition of the thumb

    • E. 

      Loss of sensation over the medial aspect of the palm

  • 18. 
    A 32-year-old secretary comes to the office for a periodic health evaluation and Pap smear. She says, "I've been doing fine except that for the past 2 months my right hand sometimes has been tingling and feels numb, especially at night. I'm always dropping things, too." She takes oral contraceptive pills and thyroid replacement medication for hypothyroidism. She is right-hand dominant. She has no history of acute trauma. On physical examination, she has numbness and tingling in the thumb and first two digits of her right hand after 15 seconds of a wrist flexion test. The remainder of the examination is normal.  Which of the following studies is most likely to establish a diagnosis?
    • A. 

      Cervical spine x-ray films

    • B. 

      MRI of the brain

    • C. 

      Nerve conduction studies

    • D. 

      Serum thyroid-stimulating hormone (TSH) concentration

    • E. 

      X-ray film of the right hand and wrist

    • F. 

      CT scan of the brain and wrist.

  • 19. 
    A 50 year old Japanese man complains of malaise, night sweets, and weight loss. Physical examination is remarkable for faint radial pulses and absent pulses over the lower extremities. What is the likely diagnosis?
    • A. 

      Buerger disease

    • B. 

      Kawasaki disease

    • C. 

      Takayasu disease

    • D. 

      Thrombophlebitis

    • E. 

      Wegener granulomatosis

  • 20. 
    A 70 year old man is admitted for chest pain and dyspnea.  Physical examination reveals a systolic murmur suggestive of mitral regurgitation due to rupture of chordate tendineae. Which of the following will increase in this man?
    • A. 

      Aortic diastolic pressure

    • B. 

      Aortic systolic pressure

    • C. 

      Left atrial pressure at end of diastole

    • D. 

      Left atrial pressure at end of systole

    • E. 

      Right atrial pressure at the end of systole

    • F. 

      Right atrial pressure at the end of diastole

  • 21. 
    A sky jumper injures his arm during training. Physical examination reveals a right wrist drop with absent triceps reflex on the right side.  Which of the following nerves was most probably injured?
    • A. 

      Axillary

    • B. 

      Median

    • C. 

      Musculocutaneous

    • D. 

      Radial

    • E. 

      Ulnar

  • 22. 
    A 22 year old ice-skater dies suddenly on the ice during a performance at the Olympic games with his partner. What would be the most likely finding in his heart at autopsy?
    • A. 

      Thrombosis of the left anterior descending coronary artery

    • B. 

      Aortic outflow obstruction

    • C. 

      Pulmonic outflow obstruction

    • D. 

      Aortic regurgitation

    • E. 

      Congestive heart disease

    • F. 

      Mitral valve prolapse

  • 23. 
    A 65 year old man presents with unilateral throbbing headache, malaise and fatigue. On examination, he is tender at both temples, with low grade fever. A biopsy of the temporal artery is normal. He is anemic with a very high ESR, and positive CRP. This patient should be treated aggressively to avoid?
    • A. 

      Blindness

    • B. 

      Deafness

    • C. 

      Loss of tactile sensation

    • D. 

      Loss of ability to speak

    • E. 

      Stroke

    • F. 

      Myocardial infarction

  • 24. 
    A 3 year old boy is being evaluated for mental retardation. Physical examination is remarkable for long face, large ears, and bilateral enlarged testes. What is your diagnosis?
    • A. 

      Down syndrome

    • B. 

      Edward syndrome

    • C. 

      Fragile X syndrome

    • D. 

      Klinefelter syndrome

    • E. 

      Turner syndrome

    • F. 

      Potter’s sequence

    • G. 

      Fetal alcohol syndrome

  • 25. 
    A neurologist examines a 50 year old banker. When the patient’s right eye is touched with a wisp of cotton wool, both eyes blinks. But when the patient’s left eye is touched with same cotton wisp, neither eye blinks. What might you expect on further examination of this patient?
    • A. 

      Loss of pain and temperature sensations from the left face.

    • B. 

      Loss of taste sensation from anterior two-thirds of the left tongue.

    • C. 

      Ptosis of the left eye.

    • D. 

      Hyperacusis of the left ear.

    • E. 

      Inability to abduct the left eye

    • F. 

      Absence of papillary reflex of the left eye.

  • 26. 
    A 70 year old man presents with weight loss of 15Lb. in 2 months, and cough with hemoptysis. He has been smoking 2 packs a day for the past thirty years.  He was diagnosed with COPD for the past five years. He undergoes a bronchoscopy and biopsy. A diagnosis of bronchogenic carcinoma is reported. The lab reports: Hb 14.8gm/dl, serum Na+ 129mEq/L, K+ 3.9 mEq/L, and Ca. ++ 9.90 mEq/L.  The physician concludes that the tumor must be secreting ?
    • A. 

      ACTH

    • B. 

      ADH

    • C. 

      PTHrP

    • D. 

      Aldosterone.

    • E. 

      Erythropoietin

  • 27. 
    A 4 year old boy is brought to see the family physician with bloody diarrhea. He has a history of recurrent otitis media and pneumonia. On examination, he has extensive eczematous skin rash. He has thrombocytopenia on CBC. This patient has an increased risk of developing which of the following?
    • A. 

      Astrocytoma

    • B. 

      Colon carcinoma

    • C. 

      Malignant lymphoma

    • D. 

      Malignant melanoma

    • E. 

      Osteosarcoma

  • 28. 
    A 20-year-old man is examined by a new family physician who discovers numerous pigmented patches and pedunculated skin tumors on his back. Biopsy of a tumor discloses a benign neoplasm derived from Schwann cells. This patient most likely carries a mutation in a gene that encodes which of the following proteins?
    • A. 

      RNA polymerase

    • B. 

      DNA topoisomerase

    • C. 

      Helicase Single-stranded binding proteins

    • D. 

      GTPase-activating proteins

    • E. 

      DNA ligase

  • 29. 
    • A. 

      Neurofilament

    • B. 

      Desmin

    • C. 

      Cytokeratin

    • D. 

      Vimentin

    • E. 

      Fibrillin

  • 30. 
    A 25-year-old man presents for a routine physical examination. The patient is tall (6 feet, 5 inches) and has long slender fingers. One year later, he suffers a dissecting aortic aneurysm. This patient most likely carries a mutation in a gene that encodes which of the following proteins?
    • A. 

      Neurofilament

    • B. 

      Desmin

    • C. 

      Cytokeratin

    • D. 

      Vimentin

    • E. 

      Fibrillin

  • 31. 
    A 25-year-old boy presents with xanthomas on the extensor surfaces of his fore-arms and fingers. Laboratory studies demonstrate total serum cholesterol of 820 mg/dL. The boy’s mother and maternal grandfather also have elevated serum cholesterol. This patient most likely has mutations in the gene that encodes which of the following proteins involved in lipid metabolism?
    • A. 

      Cholesterol

    • B. 

      Chylomicrons

    • C. 

      LDL

    • D. 

      VLDL

    • E. 

      HDL

  • 32. 
    A 42-year-old woman gives birth to a neonate with multiple congenital abnormalities. Physical findings included a flat facial profile, slanted eyes, epicanthal folds, Brushfield spots, short nose, short neck, dysplastic ears, a large protruding tongue, and a pronounced heart murmur. What is the most common cause of this developmental birth disease?
    • A. 

      Mosaic

    • B. 

      Non-disjunction

    • C. 

      Robertsonian translocation

    • D. 

      Advanced maternal age

    • E. 

      Non-reciprocal chromosomal translocation

  • 33. 
    A 19-year-old college sophomore is referred by his ophthalmologist because of the finding of ectopia lentis, which has resulted in visual difficulties that have interfered with his performance on the varsity basketball team. The patient is very tall, with spider-like fingers. His chest has a "caved-in" appearance, and he also has a modest degree of scoliosis. A mid-systolic "click" is heard. What is the most likely diagnosis ?
    • A. 

      Fragile-X syndrome

    • B. 

      Marfan’s syndrome

    • C. 

      Mitral valve prolapse

    • D. 

      Mitochondrial inheritance

    • E. 

      Genetic imprinting

  • 34. 
    An 18-month-old boy is brought to emergency room for examination of his right arm following a tumble at home. Radiologic examination of the limb reveals a recent fracture of the right ulna and evidence of additional healing fractures. The child is noted to have a blue sclera. The patient most likely carries a mutation in the gene that encodes which of the following proteins?
    • A. 

      Collagen

    • B. 

      Fibrillin

    • C. 

      Neurofilament

    • D. 

      Desmin

    • E. 

      Cytokeratin

    • F. 

      Vimentin

    • G. 

      Fibrillin

  • 35. 
    A 38 year old man is involved in a motorcycle accident in which he was hurled across the road into a chicken fence. There was no loss of consciousness, except for minor bruises on his shoulders, knees and elbows. He complains of loss of ability to extend his thumb. The injured nerve is probably derived from the following cord(s) of the brachial plexus?
    • A. 

      Lateral only

    • B. 

      Medial only

    • C. 

      Posterior only

    • D. 

      Lateral and medial

    • E. 

      Lateral and posterior

    • F. 

      Medial and posterior

  • 36. 
    A 14 month old baby, born to a 45 year old nurse is brought to a family physician because he has delayed developmental milestones. On examination he has mental retardation, a simian crease, and hypotonia and epicanthal eye folds. This patient will have reduced risk for?
    • A. 

      Acute lymphoblastic leukemia

    • B. 

      Hirschsprung’s disease

    • C. 

      Diabetic neuropathy

    • D. 

      Obstructive sleep apnea

    • E. 

      Alzheimer’s dementia

  • 37. 
    A 39 year old woman with carcinoid syndrome undergoes a CT scan that reveals a single tumor with no evidence of metastasis. She has a history of left-sided valvular heart disease. Where is the tumor most likely located?
    • A. 

      Appendix

    • B. 

      Bronchus

    • C. 

      Pancreas

    • D. 

      Rectum

    • E. 

      Small bowel

  • 38. 
    A 48 year old white female secretary presents with progressive difficulty typing over the past month. She also notes that her hands begin to feel numb and weak after typing for long periods of time. On testing which of the following deficits would be predicted?
    • A. 

      Difficulty abducting the fifth finger

    • B. 

      Difficulty in adducting the thumb

    • C. 

      Loss of sensation over the lateral three and half fingers of the palm

    • D. 

      Difficulty in opposition of the thumb

    • E. 

      Loss of sensation over the medial aspect of the palm

  • 39. 
    A 32-year-old secretary diagnosed with carpal tunnel syndrome comes to the office for evaluation of pain, tingling sensation on her right hand for the past 1 year. Medications, splint and steroid injections has not been effective. On physical examination, she has numbness and tingling in the thumb and first two digits of her right hand after 15 seconds of a wrist flexion test. There is also wasting of the thenar muscles. Surgery is planned. Which of the following will not improve following surgery?
    • A. 

      Pain

    • B. 

      Speed of conduction of median nerve

    • C. 

      Tingling sensation

    • D. 

      Positive Phalen’s test

    • E. 

      Positive Tinel’s test

  • 40. 
    A 38 year old male complains of progressive inability to open his door knob for the past six months. He smoked and drank alcohol heavily for five years, but quit three years ago. On examination, he looks well nourished. His Vital signs are normal. He was unable to perform rapid alternating movements when prompted to do so. In addition, his movements appear slow and a little awkward. What is your most likely diagnosis?
    • A. 

      Parkinsonism

    • B. 

      Friedreich’s ataxia

    • C. 

      Dysdiadochokinesia

    • D. 

      Multiple Sclerosis

    • E. 

      Ataxia telangiectasia

  • 41. 
    A 65-year-old white male presents with sudden onset of pain, redness and swelling of the first metacarpophalangeal joint. He also complains of low-grade fever not associated with rigors and chills. He is a non-smoker and non-alcoholic. He has history of hypothyroidism and is on thyroxine. Examination shows redness, swelling and erythema of first metacarpophalangeal joint. Joint aspiration reveals positively birefringent crystals. Which of the following has been highly associated with this patient’s condition?
    • A. 

      Wilson’s disease

    • B. 

      Hemochromatosis

    • C. 

      Alkaptonuria

    • D. 

      Homocystinuria

    • E. 

      Lesch-Nyhan syndrome

    • F. 

      Osteogenesis imperfecta

  • 42. 
    A 70-year-old alcoholic male presents with sudden onset of pain, redness and swelling of the first metatarsophalangeal joint. Aspiration of the joint was done. Monosodium urate (MSU) crystals were seen.  Which of the following should generally be avoided during an acute attack?
    • A. 

      Indomethacine

    • B. 

      Corticosteroid injection

    • C. 

      Allopurinol

    • D. 

      High levels of fluid intake

    • E. 

      Colchicine

  • 43. 
    A 25 year old female presents with blisters on the skin that gradually appeared one week ago. She denies any similar blisters on the membranes of inside of her mouth. She has a mild fever, otherwise she is functional.  On examination, the blisters do not ruptured easily on contact. A punch biopsy was taken. Which of the following would most likely to be seen to confirm the diagnosis?
    • A. 

      IgM auto-antibodies targeting type IV collagen

    • B. 

      IgG auto-antibodies and C3 complement on hemidesmosomes.

    • C. 

      IgM auto-antibodies at the dermoepidermal junction

    • D. 

      IgG and IgM auto-antibodies on hemidesmosomes.

    • E. 

      IgG auto-antibodies targeting the type XVII collagen

  • 44. 
    A 10-year-old girl, who was on medications, developed fever and sore throat followed 3 days later by an erosive conjunctivitis, oral mucositis, urethritis, and a progressive generalized erythema, blistering, and ulcerations. He was admitted to the intensive care unit where he received pulsed high dose intravenous steroids and intravenous immunoglobulin 2 grams/kg over 3 days, but continued to progress to 100% skin and mucous membrane involvement. What is your diagnosis?
    • A. 

      Erythema multiforme

    • B. 

      Steven Johnson syndrome

    • C. 

      Toxic epidermal necrolysis

    • D. 

      Syphilis

    • E. 

      Drug induced maculopapular exanthema

  • 45. 
    A 21 year old woman in her 12th week of gestation comes with fever and a rash.  On physical examination, the attending physician notices what he described as “Slapped cheeks rash" and rashes over the whole body. She is anemia with symmetric arthritis involving the knees, fingers, and wrists. Which of the following complications would this woman and her baby be exposed to?
    • A. 

      Congenital anomalies

    • B. 

      Genetic anomalies

    • C. 

      Abortion

    • D. 

      Bleeding

    • E. 

      Eclampsia

  • 46. 
    A 22 year old college student is on prescription vitamin and antibiotics for severe cystic acne lesions. She presents with severe headache, nausea, vomiting, pulsatile tinnitus, double vision  and irritability. She has papilledema on fundoscopy. What is your most likely diagnosis?
    • A. 

      Hydrocephalus

    • B. 

      Meningitis

    • C. 

      Cerebral abscess

    • D. 

      Pseudo tumor cerebri

    • E. 

      Rupture of berry aneurism

  • 47. 
    A 62-year-old, Caucasian construction worker for 36 years living in Florida, presents to his primary care physician after his wife notices an increasing number of small, pink-scaly patches on his hands, forearms, and scalp. He seems unconcerned and assumes it is a normal part of aging but agreed to go for a check-up. On history, he states that he spends much of the day outside on construction sites. He and his coworkers aren't always careful about wearing hard hats when their supervisor is not onsite, and they often take off their shirts during the hot summer months. He burns at the start of every summer, but it mostly fades to a tan after a while. He does not apply sunscreen to any part of his body. What is your diagnosis?
    • A. 

      Malignant melanoma

    • B. 

      Squamous cell carcinoma

    • C. 

      Actinic keratosis

    • D. 

      Basal cell carcinoma

    • E. 

      Sun burns

    • F. 

      Photo-allergy

  • 48. 
    During physical exam, the physician counts 4 lesions on hands and forearms ranging in size from 4 mm to 12 mm, and an additional 9 lesions are seen on the top of his head where his hairline has receded. On closer inspection, some of the lesions appear to have a light, white/silver crust. Small areas of rough patches can be felt at the edges of his scalp. The crust on one of the lesions on his scalp is particularly hard and has an erythematosus base that appears to be extending outwards. The presence of which of the following would indicate a diagnosis of Squamous Cell Carcinoma?
    • A. 

      Rapid growth of a lesion followed by regression

    • B. 

      Full-thickness invasion of the epidermis on microscopy

    • C. 

      Invasion of the dermis on microscopy

    • D. 

      Slate-gray dots on dermascope

    • E. 

      Appearance of a superficial ulcer

  • 49. 
    A 5 year old boy is brought by his mother with symptoms of pale, loose, greasy and floating stool (Steatorrhea). He has lost significant amount of weight. He also has large patches of hypo- pigmented skin of his face, and dorsum of his arm and forearms. He was started on treatment including a gluten free diet. The hypo-pigmented patches disappeared. What is your diagnosis?
    • A. 

      Coeliac disease with Vitiligo

    • B. 

      Ulcerative colitis with extra-intestinal manifestations

    • C. 

      IgA deficiency syndrome.

    • D. 

      Crohn’s disease with eczema

    • E. 

      Mal-absorption syndrome

  • 50. 
    A 4 year old boy presents with persistent fever not responsive to antipyretics. On examination, he has conjunctivitis, enlarged cervical nodes, “Strawberry tongue”, Urticariform rashes, peeling of skin in genital area, Cyanosis, and erythema of palms. What complications do you anticipate with this boy’s condition?
    • A. 

      Meningitis

    • B. 

      Myocardial infarction

    • C. 

      Scalded skin syndrome

    • D. 

      Failure to thrive

    • E. 

      Blindness

  • 51. 
    A 55 year old man presents with severe pains at the base of his right big toe. Examination showed inflamed and tender first metatarsophalangeal joint. Laboratory test revealed a serum uric acid level of 11.6mg/dl (N: 4.5 - 8.0mg/dl), and monosodium urate crystals in the aspirate. The patient has hypersensitivity type - I reaction to aspirin.  What is the most appropriate management of this patient’s arthritic pain?
    • A. 

      Acetaminophen

    • B. 

      Allopurinol

    • C. 

      Colchicine

    • D. 

      Indomethacine

    • E. 

      Probenecid

  • 52. 
    This patient presented with pigmented rash over sun exposed areas, difficulty with short-term memory and chronic diarrhea. What is your diagnosis?
    • A. 

      Vitamin B1 deficiency.

    • B. 

      Folate deficiency.

    • C. 

      Vitamin B2 deficiency

    • D. 

      Vitamin E deficiency.

    • E. 

      Vitamin C deficiency.

    • F. 

      Vitamin B3 deficiency.

    • G. 

      Vitamin B7 deficiency.

    • H. 

      Vitamin B12 deficiency

  • 53. 
    A 30 year old woman is being treated with antibiotics for a community-acquired urinary tract infection. After a day of horseback riding, she developed a severe rash on sun-exposed surfaces. Which of the following antibiotics is she most likely taking?
    • A. 

      Amoxicillin-Clavulanate

    • B. 

      Aztreonam

    • C. 

      Cefotaxime

    • D. 

      Cephalexin

    • E. 

      Ciprofloxacin

  • 54. 
    This 3 weeks old baby manifested at birth with a port-wine stain on the forehead and upper eyelid of one side of the face.  He was rushed to the ER with seizures on the side of the body opposite the birthmark. On examination, there was muscle weakness on the side of the body opposite the birthmark. what is your diagnosis?
    • A. 

      Congenital hemangioma

    • B. 

      Congenital melanocytic nevus

    • C. 

      Port wine stain

    • D. 

      Infantile hemangioma

    • E. 

      Sturge-Weber syndrome

  • 55. 
    A 4 year old boy presents with myalgia, anorexia, malaise, headache, low-grade fever, pain and swelling on the left cheek. On examination, he has a swelling on the left cheek over the jaw in front of the ears. He has no ear discharge. Other systems are essentially normal. What is your most likely complication as a result of this condition?
    • A. 

      Septic meningitis

    • B. 

      Hepatitis

    • C. 

      Conduction hearing loss

    • D. 

      Otitis Media

    • E. 

      Bilateral Orchitis

    • F. 

      Salivary gland cancer

  • 56. 
    A plastic surgeon is volunteering his time in South America. He is asked to evaluate an 18 month baby with incomplete development of her upper lip. There is a defect extending to the left nostril and involving the anterior portion of the palate.This anomaly developed because?                       
    • A. 

      Malformation of the fourth and fifth brachial arch

    • B. 

      Drug toxicity taken during first trimester of pregnancy

    • C. 

      Malunion of the palatine shelves

    • D. 

      Failure in development of the 4th and 5th pharyngeal pouches

    • E. 

      Fusion failure of maxillary processes and medial nasal swellings.

  • 57. 
    A 4 year old boy develops persistent fever not responsive to antipyretics. He was taken to the family doctor who noted conjunctivitis, enlarged cervical nodes, Urticariform rash, peeling of skin in genital area, Cyanosis, erythema of palms and a “Strawberry tongue”. Despite vigorous treatment, the boy dies on third day of admission. What is the most probable cause of death?
    • A. 

      Myocardial Infarction

    • B. 

      Meningitis

    • C. 

      Heart Failure

    • D. 

      Hemorrhage

    • E. 

      Hepatic failure

    • F. 

      Renal failure

  • 58. 
    A 6 year old boy presented with long face, large ears and mental retardation.  What else might you find on physical examination?
    • A. 

      Macroorchidism

    • B. 

      Lymphadenopathy

    • C. 

      Arthritis of fingers

    • D. 

      Scoliosis

    • E. 

      Abdominal mass

  • 59. 
    A newborn male infant with Down syndrome fails to pass meconium within the first 24 hours after birth. A rectal examination shows a narrow anal canal and absence of stool in the rectal vault. An abdominal radiograph shows distended loops of colon. Which of the following is the most likely diagnosis?
    • A. 

      Anorectal malformation

    • B. 

      Enterocolitis

    • C. 

      Functional constipation

    • D. 

      Hirschprung's disease

    • E. 

      Malrotation

  • 60. 
    After a protracted pushing phase of delivery, a full-term male newborn is found to have a large, soft, non-pulsatile mass on his molded head with overlying cutaneous ecchymosis. On exam, a mass that extends over the parietal bones feels to be boggy and crosses suture lines. What is the most likely diagnosis?
    • A. 

      Caphalhematoma

    • B. 

      Lipoma

    • C. 

      Amniotic fluid collection

    • D. 

      Caput succedaneum

    • E. 

      Subcutaneous fat necrosis

  • 61. 
    A 12 year old patient with Down’s syndrome is sent for routine investigations before he can be allowed to participate in sports. A neck X-ray is done. The distance between the 1st and 2nd vertebra is 5.2mm. This patient is at most risk of?
    • A. 

      Heart failure

    • B. 

      Leukemia

    • C. 

      Dementia

    • D. 

      Atlanto/Odontoid dislocation

    • E. 

      Hirschsprung’s disease

    • F. 

      Intestinal obstruction

    • G. 

      Arthritis

  • 62. 
    A 29 year old woman presents with pain in front of the neck, following one week of an upper respiratory tract infection.  She claims to have this lump in her neck since childhood that moves with swallowing or movement of the tongue. What is your diagnosis?
    • A. 

      Thyroiditis

    • B. 

      Myxedema

    • C. 

      Thyroglossal abscess

    • D. 

      Lymphadenitis

    • E. 

      Laryngitis

  • 63. 
    A 34 year-old femail presents to the outpatient clinic swelling in the lower anterior aspect of her neck. She does not complain of insomnia, weight loss, or increased appetite, and she does not express decreased tolerance to heat or increased tolerance to cold. Clinical examination reveals a solitary nodule in the right lobe of the thyroid gland. The nodule is nontender and firm. No additional signs (e.g., lid lag, proptosis, tremulousness of the hands) are present. Which of the following would be the most likely indication that this nodule is malignant?
    • A. 

      Evidence of a cold nodule on an iodine-131 scan

    • B. 

      Cystic on fine-neeedle aspiration

    • C. 

      History of previous irradiation of the neck

    • D. 

      History of hyperthyroidism

    • E. 

      History of Hashimoto's thyroiditis

  • 64. 
    A 50 year old man was hanging some decorations on the wall while on a ladder with both hands stretched up and touching both sides of his head. A couple of minutes later, the wife noticed that the husbands face and neck became cyanosed. The cyanosis disappeared when he brings his hands down. He has two weeks history of pain and weakness in the muscles of the right arm and hand.  He smoked one pack of cigarette a day for 18 years. His B.P is 160/95 mmHg, Pulse 88/min., and Resp. 15/min. He is on treatment for hyperlipidemia and hypertension. What is your most likely diagnosis?
    • A. 

      Carcinoid syndrome

    • B. 

      Cervical rib

    • C. 

      Pancoast tumor

    • D. 

      Retrosternal enlarged goiter

    • E. 

      Eisenmenger’s complex

    • F. 

      Right to left cardiac shunt

  • 65. 
    A 68 year old woman complains of pain when she clenches her teeth or when she simply opens and closes her mouth. The pain is located in front of the right ears. She has no ear discharge or itching. Her visions are not affected. She underwent a successful right hip replacement operation one month ago. Her vital signs are; BP 152/93 mmHg, T. 98F, pulse 78/min. There are no obvious swellings. What is the most likely diagnosis?
    • A. 

      Temporal arteritis

    • B. 

      Tempero-mandibular joint arthritis

    • C. 

      Otitis media

    • D. 

      Tension headache

    • E. 

      Otitis externa

    • F. 

      Dental caries

  • 66. 
    A 72 year old man presents with a two weeks history of pain at the back of his neck which he describes as "electrical sensation" radiating down the back and into the arms and legs any time he extends or flexes his neck. He was involved in a car wreck three years ago during which he fractured his right Humerus. He has since recovered. He retired 10 years ago from construction work. His other medical history is unremarkable. What is your most likely diagnosis?
    • A. 

      Cervical osteoarthritis

    • B. 

      Metastatic prostate cancer

    • C. 

      Myositis

    • D. 

      Multiple myeloma

    • E. 

      Pott’s disease

  • 67. 
    A 79 year old man with uncontrolled hypertension is referred to an ophthalmologist for evaluation of visual problems. He was recently discharged from hospital for congestive heart failure. His BP is 159/98 mmHg, pulse 90/min and respiration is 18/min. Which of the following is a late sign of hypertensive retinopathy?
    • A. 

      Flame hemorrhages

    • B. 

      Cotton wool spots

    • C. 

      Hard exudates

    • D. 

      Proliferative changes

    • E. 

      Silver wiring

  • 68. 
    A baby boy is born with bilateral cataracts to a diabetic mother who did not attend antenatal during her pregnancy.  She drank alcohol moderately in the third trimester of pregnancy and admitted doing cocaine once or twice during the same period. On examination, the baby has Microphthalmia, Microcephaly, Micrognathia, and blue baby Muffin rash. What type of murmur would you most likely hear in this patient?
    • A. 

      Pansystolic murmur

    • B. 

      Early diastolic murmur

    • C. 

      Crescendo-decrescendo murmur

    • D. 

      Mid-Systolic click

    • E. 

      Machinery murmur

  • 69. 
    A 15-month old girl was admitted with bruising around the eyes and a one month history of abdominal pain accompanied by fever. Physical exam shows bilateral ecchymosis and Proptosis. She also had a left sided abdominal mass (5x8cm) that crossed the midline. Lab. Investigations revealed Hb of 12gm/dl, WBC of 10,000/mm3 and platelet count of 34,000/mm3. Urinary vanillymandelic acid level was high. What is your diagnosis?
    • A. 

      Child abuse

    • B. 

      Wilm’s tumor

    • C. 

      Hemophilia

    • D. 

      Orbital cellulitis

    • E. 

      Lymphoma

    • F. 

      Neuroblastoma

  • 70. 
    A 56 year old man presents with mild abdominal swelling and a shrunken liver. He is diagnosed with cirrhosis. He denies alcohol intake and previous history of hepatitis. He is faithful to his wife to whom he has been married for 30 years. He is seeing his psychiatrist for obsessive compulsive disorder.  On examination, he has golden brown ring in his descemet membrane of both eyes. What else might you find on physical examination?
    • A. 

      Involuntary movements

    • B. 

      Cataracts

    • C. 

      Retinal hemorrhages

    • D. 

      Macroglossia

    • E. 

      Arcus senilis

    • F. 

      Xanthelasma

  • 71. 
    A 14-year-old boy with soreness, redness, and tearing in his right eye is brought to the emergency department by his mother. He went to the beach earlier in the day and notes it was a windy day. He normally does not wear glasses or contact lenses. On physical examination, the right eye is tearing, and there is redness of the conjunctiva. Visual acuity is 20/40 in both eyes, and the intraocular pressures are not elevated. Slit-lamp examination with fluorescein stain shows linear corneal abrasions.  What is the most appropriate next step?
    • A. 

      Apply antibiotic ointment and recheck in 24 hours

    • B. 

      Call for ophthalmology consultation

    • C. 

      Evert the upper eyelid to examine the conjunctiva for foreign bodies

    • D. 

      Irrigate the eye copiously

    • E. 

      Order tetanus immunization

  • 72. 
    A 71 year old diabetic patient comes in complaining of pains and problems with vision in his right eye. These symptoms have been worsening for the past five years. He has not had an eye check up for the past 7 years. He claims that his reading glasses are no longer helpful. He was recently discharged from hospital after a successful treatment for a clot in his right calf. His FBS is 168mg, and HBA1c is 7.2. He is referred to see an ophthalmologist. Below is his Perimetry chart study tracing of his right eye. What is your diagnosis?
    • A. 

      Cataracts

    • B. 

      Retinal detachment

    • C. 

      Advanced glaucoma

    • D. 

      Age related macular degeneration

    • E. 

      Strabismus

    • F. 

      Optic neuritis

    • G. 

      Blood clot to the ophthalmic artery

  • 73. 
    A 59 year old woman with uncontrolled diabetes for the past 15 years. She presents with purulent discharge that seem to be coming from above the opening of the ear canal of the left ear for the past 10 months. She complains of severe, unrelenting, deep-seated otalgia, temporal headaches, and facial nerve dysfunction. MRI is done. What is your diagnosis?
    • A. 

      Otitis media

    • B. 

      Otitis externa

    • C. 

      Malignant otitis externa

    • D. 

      Osteomyelitis of facial bone

    • E. 

      Brain abscess

  • 74. 
    A 68 year old male patient presents with hearing problems with one of his ears for the past two months. He denies recent history of otitis media, except during childhood. He was hit 32 years ago on the side of the head during a baseball game, but he did not pass out, and did not seek medical treatment. On Rinne’s test, his air conduction is more than his bone conduction for both the right and left ears. When Weber’s test was done, it lateralized to the right ear. What is your diagnosis?
    • A. 

      Right sensorineural deafness

    • B. 

      Left sensorineural deafness

    • C. 

      Left conduction deafness

    • D. 

      Right conduction deafness

    • E. 

      Left sensorineural and conduction deafness

    • F. 

      Right sensorineural and conduction deafness

    • G. 

      Age related normal hearing

  • 75. 
    10 year old boy presents with a 4 year history of recurrent nasal obstruction, mouth breathing, nasal voice, snoring and restless sleep. In addition, he has a history of chronic middle ear effusions.  On examination, he has a high arched palate, a shortened upper lip, with a staring expression of the eyes.  The face is slightly elongated and the upper teeth are prominent. What is your diagnosis?
    • A. 

      Chronic otitis media

    • B. 

      Sleep apnea

    • C. 

      Tonsillitis

    • D. 

      COPD

    • E. 

      Large adenoids

    • F. 

      Hyperthyroidism

  • 76. 
    A 56 year old farmer presents with soft, painless growths on the linings of the nasal passages of his left nostril that has been growing slowly for the past 2 years. They hang down like grapes.  He has recurrent sinusitis, allergies, loss of the sense of smell, and drug sensitivity especially to aspirin. On examination, he has large polyploid mass blocking the nasal passages of the left nostril. He has no breathing problems. This condition is most strongly associated with?
    • A. 

      Squamous cell carcinoma of nasal mucosa

    • B. 

      Basal cell carcinoma of nasal mucosa

    • C. 

      Nasal and septal perforations

    • D. 

      Non-obstructive sleep apnea

    • E. 

      Asthma

    • F. 

      Lymphoma

    • G. 

      Aseptic meningitis

  • 77. 
    A 39 year old female African-American patient with sickle cell disease is rushed to the Er with a sudden, painless loss of vision in her left eye. She also complained of seeing flashes of light, straight lines appearing curved, floating objects and Impression of veil drawn over her field of vision. What is your most likely diagnosis?
    • A. 

      Central retinal vein occlusion

    • B. 

      Acute narrow-angle glaucoma

    • C. 

      Central retinal artery occlusion

    • D. 

      Hyphema

    • E. 

      Optic neuritis

    • F. 

      Retinal detachment

  • 78. 
    A 45 year old female has worsening vision, pain and discharge in her right eye. She routinely sleeps with her contact lenses on. On examination, she has severe opaque corneal infiltrate with pus exudation.  The most likely cause is?
    • A. 

      Staphylococcus aureus

    • B. 

      Streptococcus Viridans

    • C. 

      Bacillus cereus

    • D. 

      Pseudomonas aeruginosa

    • E. 

      Acanthamoeba

    • F. 

      Gonorrhea

  • 79. 
    A 10 day old infant is brought by the mother for evaluation of purulent discharge from both eyes. Discharge appeared 3 days ago after which the child developed cough. On exam, eyes have purulent discharge, chest has diffuse rales without wheezing. Chest x ray shows hyperinflated chest.  What is the diagnosis?
    • A. 

      Gonococcal conjunctivitis

    • B. 

      Chlamydia infection

    • C. 

      Rubella infection

    • D. 

      Chemical conjunctivitis

    • E. 

      Adenoviral infection

  • 80. 
    A blue-eyed Caucasian 75 year-old man has had gradual loss of vision for the past 5 years. He initially had trouble reading fine print and road signs, and similar distant objects appeared blurred. The vision loss has progressed to the point that if he looks directly at a book or an object he cannot make out what it is. However, he found that he can compensate to a large extent by looking at things using side vision. As a consequence, he can still walk around and even cross a street safely unaided. Which of th following is the most likely cause of his visual loss?
    • A. 

      Macular degeneration

    • B. 

      Trauma

    • C. 

      Cataract surgery

    • D. 

      Optic neuritis

    • E. 

      Diabetic retinopathy

  • 81. 
    A 25 year-old man was thrown to the ground in a motorcycle accident. The paramedics transported him to the nearest emergency department. The physician on duty notes bruising about the orbit and blood in the external auditory meatus. Clear fluid exudes from his ear. The physician suspects that it is cerebrospinal fluid (CSF). Chemical analysis of the fluid compared with that of serum would be expected to show which of the following?
    • A. 

      A higher protein concentration than serum

    • B. 

      A higher chloride concentration than serum

    • C. 

      A higher glucose concentration than serum

    • D. 

      More white blood cells (WBCs) in the CSF than in the serum

    • E. 

      Absence of prealbumin on CSF electrophoresis

  • 82. 
    A 70 year old man presents with problems with his right ear. Neurologic examination revealed damage to the 7th cranial nerve. Which of the following symptoms most probably prompted the man to seek medical attention?
    • A. 

      Difficulty distinguishing low from high frequency sounds.

    • B. 

      Difficulty hearing high-frequency sounds

    • C. 

      Difficulty hearing low-intensity sounds

    • D. 

      Pain with loud sounds

    • E. 

      Tinnitus in right ear

  • 83. 
    A 21 year old college footballer is involved in a road traffic accident and complains of anosmia and head-aches. He is brought to the ER and examined by the intern on duty. His BP is 130/85 mmHg, Pulse 100/min. and R/R is 18/min. He has what the intern described as “raccoon eyes”, right facial paralysis, epistaxis, and ecchymosis behind this right ear.                              What is your most likely diagnosis?
    • A. 

      Temporal skull bone fracture

    • B. 

      Frontal skull bone fracture

    • C. 

      Basilar skull bone fracture

    • D. 

      Occipital skull bone fracture

    • E. 

      Bell’s palsy

    • F. 

      Intracranial hypertension

  • 84. 
    An 18 year old female develops ear pain, one week after an upper respiratory tract infection. She has no ear discharge. On Auroscope, she has bullous lesions on the ear canal, with few hemorrhages on the tympanic membrane. What is your diagnosis?
    • A. 

      Otitis Media

    • B. 

      Otitis Externa

    • C. 

      Bullous myringitis

    • D. 

      Malignant Otitis

    • E. 

      Herpes simplex II

  • 85. 
    A 35 year old woman presents to her primary care physician with runny nose and congestion of both nostrils for the past nine months. On questioning, she could not say specifically what triggers her symptoms. She admits that changes in environmental temperature, humidity, hair sprays, spicy foods, and alcohol worsen her symptoms. Recently she noticed that sexual arousal; and emotional factors are contributory factors. What is your most likely diagnosis?
    • A. 

      Seasonal allergic rhinitis

    • B. 

      Non-seasonal allergic rhinitis

    • C. 

      Vasomotor rhinitis

    • D. 

      Nasal polyps

    • E. 

      Asthma

    • F. 

      Chronic sinusitis

  • 86. 
    A 21year old college drop-out presents with severe headache and dizziness. He has no prior medical record. He has no fever or history of trauma. On examination, he was in severe distress. His BP is 165/100 mmHg. and pulse is 90/min. He has large septal perforation on his nose. What is your most likely diagnosis?
    • A. 

      Leprosy

    • B. 

      Syphilis

    • C. 

      Wegener granulomatosis

    • D. 

      Sarcoidosis

    • E. 

      Snorting cocaine

    • F. 

      Primary hypertension

  • 87. 
    A 52 year old alcoholic with liver cirrhosis is admitted with abdominal pain that started suddenly. He could not pin-point the area of tenderness. He rates the pain as 9 out of 10. He passes stool well and has no history of peptic ulcer. He vomited once. On examination, BP 128/78 mmHg, Pulse 88/min, T 98.0 F. He had generalised abdominal tenderness with mild ascites. Paracentesis was done and analysis showed leukocytosis. What is your most probable diagnosis?
    • A. 

      Ruptured appendicitis

    • B. 

      Cholecystitis

    • C. 

      Fulminant Hepatitis

    • D. 

      Perforated D.U

    • E. 

      Spontaneous bacterial peritonitis

    • F. 

      Hepatic failure

  • 88. 
    A 29 year old sex hawker presents with sudden onset of right lower abdominal pains. She missed her contraceptive pills for one week about two weeks ago, but eventually completed the pack. She also complained of dizziness, weakness, nausea and spotting of blood. The clinician suspects ectopic pregnancy. An ultrasound is done. What is the strongest indication that the diagnosis was correct?
    • A. 

      Positive Pregnancy test with urine sample

    • B. 

      High levels of B-HCG in the blood

    • C. 

      Empty uterus on Ultrasound

    • D. 

      An ultrasound showing a non-viable uterine implanted fetus

    • E. 

      Spotting of blood

    • F. 

      She has strong risk factors

  • 89. 
    A 28 year old female presents with lower abdominal pain, vomiting, dizziness, fatigue, and vaginal blood spotting. Her last period was 6 weeks ago. She became sexually active at 18. In the past two years, she has had multiple sexual partners without protection. Twice in the past 18 months, she was treated for severe lower abdominal pains. Laparoscopy was done and an unruptured ectopic pregnancy in her left fallopian tube was detected, measuring <3.5 cm. What is your best treatment at this time?
    • A. 

      Urgent Salpingectomy

    • B. 

      Repeat Ultrasound in 2 weeks

    • C. 

      Observe with serial β-hCG

    • D. 

      Methotrexate

    • E. 

      Repeat laparoscopy in 2 weeks

    • F. 

      Urgent Dilatation & Curette

    • G. 

      Urgent Salpingostomy

    • H. 

      Treat for PID

    • I. 

      Do HIV test

    • J. 

      Antibiotics and Steroids

  • 90. 
    A 14 year old girl who is sexually active presents with a  3 year history of lower abdominal pains. She describes the pain as piercing and alternating between the right and left lower abdomen. Presently, the pain is on the right side. Her last menses was two weeks ago. She has no discharge or dysuria. Flexing the hip against resistance did not cause any pain. She is afebrile.     What is your most likely diagnosis?
    • A. 

      Acute appendicitis

    • B. 

      Ectopic pregnancy

    • C. 

      Dysmenorrhea

    • D. 

      PID

    • E. 

      Mittleschmerz

    • F. 

      UTI with renal stones

  • 91. 
    A 40 year old man presents to ER with sudden onset of generalised abdominal pains. He has prior history of epigastric pain for the past two years. He rates his pain as 10 out of 10. On examination, he is diaphoretic and anemic. His BP is 90/60 mmHg. He has board-like rigidity on his abdomen. X-ray is done. What is your most likely diagnosis?
    • A. 

      Rupture appendix

    • B. 

      Ruptured gastric ulcer

    • C. 

      Ruptured aortic abdominal aneurism

    • D. 

      Fulminant hepatitis

    • E. 

      Cholecystitis

    • F. 

      Intestinal obstruction

  • 92. 
    A 47 year old man is admitted with generalised abdominal pains, vomiting and constipation. He had surgery five years ago for ruptured appendix. On examination, his abdomen is distended, tender and tympanitic with increased bowel sounds. A plain abdominal X-ray is done. What is your diagnosis?
    • A. 

      Ruptured viscous

    • B. 

      Large bowel obstruction

    • C. 

      Acute pancreatitis

    • D. 

      Small bowel obstruction

    • E. 

      Volvulus

    • F. 

      Peritonitis

  • 93. 
    A 48-year-old male is brought to the emergency department by his wife, who seems extremely concerned. She states that her husband has been having nausea, temperature, intense upper abdominal tenderness, and vomiting for the past 3 days. His past medical history is significant for hypertension treated with lisinopril, hypercholesterolemia treated with lovastatin, and gallstones. He does not smoke or drink and his family history are noncontributory. Quickly examining him, he appears quite ill. He is jaundiced, and his temperature is 39.4°C (102.9°F), blood pressure is 110/60 mm Hg, pulse is 90 beats per minute, and respiration rate is 20 per minute. His heart reveals a regular rate and rhythm and his lungs are clear to auscultation bilaterally. Abdominal examination shows tenderness localized to the right upper quadrant. What is your diagnosis?
    • A. 

      Cholecystitis

    • B. 

      Hepatitis

    • C. 

      Hepatic Cyst

    • D. 

      Side effect of a medication

    • E. 

      Cholangitis

  • 94. 
    A 72 year-old femail is seen in the emergency department with a history of sudden, sever, colicky midabdominal pain and nausea and vomiting over the past 3 hours. During the examination, she vomits a bile-stained vomitus. Physical examination reveals generalized abdominal tenderness with diminished bowel sounds. Radiography of the abdomen shows a radiopaque mass in the distal small bowel on the right side, with dilated loops proximally. No free air is noted under the diaphragm, but air is present in the biliary tree. Which of the following is the most likely diagnosis?
    • A. 

      Lymphoma of the small bowel

    • B. 

      Acute pancreatis

    • C. 

      Acute appendicitis with radiopaque fecalith

    • D. 

      Gallstone ileus

    • E. 

      Intussusception

  • 95. 
    A 29 year-old man sustained a gunshot wound to the right upper quadrant. He is taken to the operating room and, after management of a liver injury is found to have a complete trans-section of the common bile duct with significant tissue loss. Which of the following is the optimal surgical management of this patient's injury?
    • A. 

      Choledochoduodenostomy

    • B. 

      Loop choledochojejunostomy

    • C. 

      Primary end-to-end anastomosis of the transected bile duct

    • D. 

      Roux-en-Y L-choledochojejuonostomy

    • E. 

      Bridging of the injury with a T lube

  • 96. 
    A 44-yr-old male presents with cough and sore throat. He has on and off epigastric abdominal pains, change of voice and painful swallowing .He also complained that his wife found him irritating because he has to clear his throat repeatedly.  On examination he looks healthy. He admits that he is alcoholic. On auscultation wheezing is found. What could be the diagnosis?
    • A. 

      Pancreatitis

    • B. 

      Asthma

    • C. 

      Bronchitis

    • D. 

      CHF

    • E. 

      Cirrhosis

    • F. 

      Pharyngitis

    • G. 

      Foreign body inhalation

    • H. 

      Gastric ulcer

    • I. 

      GERD

  • 97. 
    A 75 year old woman presents with fever and worsening pain in the left lower quadrant of the abdomen for three days. She lives alone and her meals consisted mainly of low residue and low fiber diet.  She is on medication for hypertension and osteoporosis, but not compliant because of Alzheimer’s dementia which was diagnosed 3 years ago. She has prior history of constipation. On examination, she is febrile with abdominal tenderness worst in the left lower quadrant of the abdomen. Her BP is 155/98 mmHg, Pulse 98/min. WBC count is 16,000, N 75%, L 25%. What is your most likely diagnosis?
    • A. 

      Side effects of medication

    • B. 

      Appendicitis

    • C. 

      Diverticulosis

    • D. 

      Pelvis Inflammatory disease

    • E. 

      Volvulus

    • F. 

      Intestinal obstruction

  • 98. 
    A 53 years old female, complains of dysphagia that started approximately 11 months ago and has become worse. She has problems swallowing solids as well as liquids. Occasionally she has some regurgitation of food. She has lost 7 kg of weight. She has no other symptoms and claims that 1 year ago she did not have any swallowing problems. Her past medical and surgical histories reveal hypertension and a tonsillectomy. Her medication includes aspirin and metoprolol. She has no allergies and does not smoke or drink. Barium test is done. What is your diagnosis?
    • A. 

      Esophageal neoplasm

    • B. 

      Achalasia

    • C. 

      Large hiatal hernia

    • D. 

      Esophageal diverticulum

    • E. 

      Diffuse esophageal spasm

    • F. 

      Barrett’s esophagus

  • 99. 
    A 48 year old male complains of dysphagia, and problems swallowing solids and liquids. A manometric study is done. (See below). What is your best interpretation of this study?
    • A. 

      Esophageal peristalsis and impaired relaxation of the lower esophageal sphincter.

    • B. 

      Aperistalsis of the distal esophagus and complete relaxation of the lower esophageal sphincter

    • C. 

      Hypertensive lower esophageal sphincter and low-amplitude esophageal body contractions.

    • D. 

      Hypotensive lower esophageal sphincter and low-amplitude esophageal body contractions.

    • E. 

      High amplitudes in distal esophagus and impaired relaxation of the lower esophageal sphincter.

  • 100. 
    A 47 year old male, complains of chest pain especially after drinking cold beverages. He has no previous history of peptic ulcer. He had mild hypertension for which he is taking HCTZ. A barium meal is done. What is your diagnosis?
    • A. 

      Diffuse esophageal spasm

    • B. 

      Achalasia

    • C. 

      Esophageal stricture

    • D. 

      Esophageal ring (Schatzki ring)

    • E. 

      Esophageal carcinoma

    • F. 

      Zenker's divericulum

    • G. 

      Esophageal varices

  • 101. 
    A 16 year-old boy has had lifelong constipation. He requires suppositories and, often, enemas to initiate bowel movements. His abdomen is distended. Palpation reveals a tubular mass in the left lower quadrant. Rectal exam reveals no stool in the vault. Barium enema reveals colon above a normal-appearing rectum. Which of the following is the most likely diagnosis?
    • A. 

      Colon carcinoma

    • B. 

      Gardners syndrome

    • C. 

      Peutz-Jeghers syndrome

    • D. 

      Hirschpruch's disease

    • E. 

      Volvulus

  • 102. 
    A 60 year-old man, who is an alcoolic and a cigarette smoker for the past 40 years, complains of difficulty swallowing solids but not liquids. In addition, he has progressive weight loss and weakness. A barium swallow reveals an obstructive lesion in the midesophagus. Which of the following is the most likely diagnosis?
    • A. 

      Diffuse esophageal spasm

    • B. 

      Zenker's diverticulum

    • C. 

      Achalasia

    • D. 

      Squamous cell esophageal carcinoma

    • E. 

      Plummer-Vinson syndrome

    • F. 

      An esophageal adenocarcinoma

  • 103. 
    A 77 year-old woman is brought to the emergency department with a history of having lost large quantities of blood hile having a bowel movement. She presents with hypotension; cold, clammy skin; and a rapid pulse when lying down. Results of an abdominal examination are normal. Which of the following is the most likely cause of this patient's condition?
    • A. 

      Meckel's divericulum

    • B. 

      Small bowel infarction

    • C. 

      Angiodysplasia

    • D. 

      Internal hemorrhoids

    • E. 

      Ulcerative colitis

  • 104. 
    A 32-year-old man presents to the physician, because he noticed a large amount of blood in the toilet bowl while defecating this morning. The blood was bright red in color and located primarily in the bowl. The stool was brown-colored and did not have an unusual smell. He smokes 1 pack of cigarettes a day for the last 10 years, and drinks 30 to 40 g of ethanol weekly. His father and brother have also had several episodes of bright red blood per rectum, but he denies any knowledge of a family history of colon cancer. On examination, his vital signs are  BP, 118/75 mm Hg; pulse, 77 beats/minute; temperature, 99.7°F; R/R, 13/min. There are multiple telangiectasias on the face, inside the nose, on the oral mucosa, and upper thorax. What is the most likely diagnosis?
    • A. 

      Osler-Rendu-Weber syndrome

    • B. 

      Familial colonic polyposis syndrome

    • C. 

      Gardner syndrome

    • D. 

      Meckel's diverticulum

    • E. 

      Peutz-Jeghers syndrome

  • 105. 
    A 62 year old man presents with yellowness of his eyes and skin for the past 4 weeks. He has lost significant weight. He does not drink alcohol or smoke cigarette. He complains of mild epigastric discomfort. His bowel habit has significantly changed from daily to once a week. He admits to passing “silver” colored stools. Stool examination is positive for Malena.  Her liver function tests were as follows: ALT, 37 U/l (normal 0–31); AST, 32 U/l (normal range, 0–32); alkaline phosphatase, 598 U/l (normal range, 0–240); total Bilirubin, 203.2 mg/l ( range, 1–11); direct Bilirubin, 151.6 mg/l (normal range, 0–3). Ultrasonography, computed tomography, and magnetic resonance imaging studies showed intrahepatic and extrahepatic bile duct dilatation. What is your most likely diagnosis?
    • A. 

      Cirrhosis of the liver

    • B. 

      Carcinoma of ascending Colon

    • C. 

      Carcinoma of the Pancreas

    • D. 

      Carcinoma of ampulla of Vater

    • E. 

      Carcinoma of gallbladder

  • 106. 
    A 2-week-old boy is brought for a well child examination. His parents note that he has become increasingly yellow over the past week. He is otherwise well, breastfeeding every 2 to 3 hours. He was born 7 lbs. 8 oz at term via a normal spontaneous vaginal delivery. There were no complications during the pregnancy.  Mom is blood type A (Rh-Pos.). On examination, he is afebrile; weighing 8 lb. Laboratory results noted a Bilirubin level of 18 mg/dL. Phototherapy is recommended. What is the etiology of the recommended treatment method?
    • A. 

      Isomerization of Bilirubin into compounds that the newborn can excrete via urine and stools without glucuronidation.

    • B. 

      Isomerization of Bilirubin into compounds that the newborn can excrete via urine and stools with glucuronidation.

    • C. 

      Non- Isomerization of Bilirubin into compounds that the newborn can excrete via urine and stool.

    • D. 

      Exchange blood transfusion to avoid kernicterus

    • E. 

      Recommend that the mother discontinue breast feeding to stop breast–milk jaundice

  • 107. 
    A 46-year-old white male with a 16-year history of alcoholism and a 7-year history of alcoholic cirrhosis. In the past month, he has unintentionally gained 15 pounds, and his abdomen has become significantly swollen. This week, he has become increasingly lethargic and disoriented. He appears restless and is disoriented to person, place, and time. He responds to questions slowly, and his answers are often inappropriate.  His skin and sclera have a jaundiced tone, and he has several ecchymoses to the lower extremities. PERRL. Lungs clear to auscultation. Abdomen distended, firm, and tender with prominent veins at the umbilicus. Bowel sounds positive in all 4 quadrants. He has hepatosplenomegaly. Hemorrhoids are present and slight asterixis is observed. He has Cruveilhier-Baumgarten murmur. This murmur is most likely due to what?
    • A. 

      Increased blood flow to the heart causing systolic dysfunction.

    • B. 

      Venous hum heard in epigastric region because of collateral connections between portal system and the peri-umbilical veins in portal hypertension.

    • C. 

      Rapid flow of blood in the inferior and superior vena cava

    • D. 

      He has congestive heart failure

    • E. 

      Sinusoidal congestion in liver failure

    • F. 

      Venous congestion causing hepatosplenomegaly

  • 108. 
    An 18 months old baby develops bile-stained vomitus and progressive abdominal distension. He has not gained weight significantly after birth. He has frequent attacks of chest infections. After about 5 days, he has still not passed meconium. A diagnosis of meconium ileus is made.  What is the most probable cause?
    • A. 

      Cystic fibrosis

    • B. 

      Galactosemia

    • C. 

      Lesch-Nyhan disease

    • D. 

      Ulcerative colitis

    • E. 

      Hirschsprung's disease

  • 109. 
    A 35-year old woman comes to the office complaining of numbness and tingling in the fingers of both of her hands and around her mouth. When the nurses takes her blood pressure, the patient's hand closes involuntarily and starts to have painful spasm. The nurses removes the blood pressure cuff and attempts to take the blood pressure from the other arm, and the same thing happens. Which of the following is correct concerning this woman's condition ?
    • A. 

      Electrocardiogram probably will show QT interval shortening.

    • B. 

      You should ask about a recent history of thyroid surgery.

    • C. 

      She most likely has Graves' disease.

    • D. 

      Voluntary hyperventilation may improve symptoms.

    • E. 

      The patient requires high-dose corticosteroids.

  • 110. 
    A 75 year old man presents one hour after a sudden onset of crushing chest pain in the Retrosternal area. The pain started as he was working in his garden. He is obese with a BMI of 34. He does not drink alcohol or smoke cigarette. His father died of lung cancer. His cardiac enzymes are diagnostic of a myocardial infarction. What is the most likely complication following this myocardial infarction?
    • A. 

      First degree AV block

    • B. 

      Second degree block -Mobitz Type I (Wenkebach)

    • C. 

      Second Degree Block - Mobitz Type II

    • D. 

      Third Degree AV Heart Block

    • E. 

      Bundle Branch Blocks

  • 111. 
    A 70 year old woman presents with recurrent episodes of epigastric pain radiating to the left inner arms. She has uncontrolled diabetes and hypertension. Her compliance to medications has been poor. Cardiac enzymes are minimally raised. A coronary arteriogram is done and a left main coronary artery stenosis of more than 70% is found. She is scheduled for a Coronary Artery By-pass Graft.  Which artery is most preferred for this procedure?
    • A. 

      Saphenous vein

    • B. 

      Intercostal arteries

    • C. 

      Femoral artery

    • D. 

      Internal iliac artery

    • E. 

      Internal mammary artery

  • 112. 
    A 56yr old man comes to the office after an episode of chest pain. He has no risk factors. He has a normal EKG and CK-MB. He has severe arthritis of knees, lower back problems, dizziness and asthma. What is the most appropriate in his further management?
    • A. 

      Dipyridamole stress test.

    • B. 

      Dobutamine stress test.

    • C. 

      Repeat CK-MB and EKG after 24 hours.

    • D. 

      Do LDL level.

    • E. 

      Thread Mill Stress test.

    • F. 

      Cardiac catheterization.

    • G. 

      Reassess patient when next he has chest pain.

  • 113. 
    A 65 year old man presents with sudden onset of chest pains radiating to the back, diaphoresis, palpitations, and dizziness. He has prior history of uncontrolled hypertension. Heart sounds are normal. EKG shows slight ST elevation. Cardiac enzyme are  results are normal.  CXR is done. What is your most likely diagnosis?
    • A. 

      Unstable angina

    • B. 

      Myocardial infarction

    • C. 

      Pericardial effusion

    • D. 

      Tamponade

    • E. 

      Dissecting thoracic aortic aneurysm

  • 114. 
    An 18 year old boy in high school in USA dies suddenly during a football game. At autopsy, he had asymmetrical inter-ventricular septal hypertrophy. Microscopic examination of his heart muscle showed myocardial disarray. His team-mates are concerned. What is the best screening test for the team-mates?
    • A. 

      CXR

    • B. 

      MRI

    • C. 

      EKG

    • D. 

      History and physical examination

    • E. 

      Echocardiogram

    • F. 

      Stress test

    • G. 

      Cardiac catheterization

  • 115. 
    A 78 year old man presents with right hip pains that started over the night. He rates his pain as 8/10. He woke up suddenly to pick up a call, and felt dizzy before passing out. He found himself on the floor of his bedroom, unable to get up a couple of minutes afterwards. He has prior episodes of dizziness for the past one year. He is otherwise in good health condition. The attending physician determines that he had syncope. How did he arrive at this diagnosis?
    • A. 

      EKG

    • B. 

      Arteriogram

    • C. 

      Echocardiogram

    • D. 

      Blood sugar levels

    • E. 

      Complete blood count

    • F. 

      Supine and erect Blood pressures

  • 116. 
    On examination, a 73 year old woman is found to have left lower limb edema, and abdominal swelling. Other physical examinations are essentially normal. What is your most probable diagnosis?
    • A. 

      Renal failure

    • B. 

      Huge ovarian mass

    • C. 

      CHF

    • D. 

      Liver failure

    • E. 

      Osteomyelitis

    • F. 

      Lymphangitis

    • G. 

      Malnutrition

  • 117. 
    A 5 year old boy is brought to see a primary care Physician because he turn “blue” , with   difficulty breathing,  and sometimes passes out after running around for a couple of minutes with his play-mates. He then squats to relief symptom. What is your diagnosis?
    • A. 

      “Tet” spells

    • B. 

      Central cyanosis

    • C. 

      Peripheral cyanosis

    • D. 

      Central cyanosis

    • E. 

      Anemia

    • F. 

      Asthma

    • G. 

      Congestive Heart Failure

  • 118. 
    A medical student is doing her electives in surgery and she is asked to examine a 21 year old female patient who comes in complaining of headaches for over six months. She has no fever. The medical student determines that the headache is 4/10, frontal, non-radiating, with no aggravating or relieving factors.  During physical examination, her BP was 170/100 mmHg. Pulse is 82/min in left upper arm, but was 54/min in the femoral artery. Further examination or investigation of this patient would most likely show?
    • A. 

      Web in the neck

    • B. 

      Abnormal karyotype

    • C. 

      Systolic crescendo-decrescendo murmur

    • D. 

      Hearing loss

    • E. 

      Rib notching

  • 119. 
    A 12 year old girl is being evaluated for a bilateral web in the neck that has been there since birth. The eyes are sloped with the outer corners lower than the inner and a skin fold at the inner corners of the eyes. She also has a strabismus and Ptosis. The lower jaw is small and the ears are low set. The head seem to have an unusual shape. She has a hearing loss. A systolic murmur is heard. The Karyotype is determined to be normal. The web in the neck is due to?
    • A. 

      Congestive heart failure

    • B. 

      Venous congestion

    • C. 

      Cystic fibrosis

    • D. 

      Cystic hygroma

    • E. 

      Unusual fat distribution

    • F. 

      Lymphadenopathy

  • 120. 
    A student was doing his electives in the Radiology department. The senior resident pulled out an X-ray. (See below). What cardiac feature is associated with this X-ray?
    • A. 

      Cardiomyopathy

    • B. 

      Aortic stenosis

    • C. 

      Ventricular septal defect (VSD)

    • D. 

      Pulmonic stenosis

    • E. 

      Mitral valve prolapse

  • 121. 
    A medical assistant calls your attention because she could not count and record the arterial pulse of a patient. You ask for an EKG. The report is shown below.    What is your diagnosis?
    • A. 

      Myocardial infarction

    • B. 

      Atrial fibrillation

    • C. 

      First degree AV block

    • D. 

      Second degree AV block -Mobitz Type I

    • E. 

      Second Degree AV Block - Mobitz Type II

    • F. 

      Third Degree AV Heart Block

  • 122. 
    A 60-year old man complaints of pain and numbness in the left leg when walking. The pain is relived by resting. He also complains of impotence. Physical examination reveals atrophy of the left leg muscle, normal reflexes, and a bruit over the femoral artery. Which of the following is the most likely diagnosis ?
    • A. 

      Leriche's sydrome

    • B. 

      A hernlated lumbar disc

    • C. 

      Osteoarthritis of the hip

    • D. 

      Phlegmasia alba dolens

    • E. 

      A peripheral neuropathy

  • 123. 
    A 72 year old man is watching a football game on television. He tries to get up and take a drink from the fridge, but slumps. He is conscious and alert, but unable to get back up. He complains that the right side of his body is very weak. His wife calls 911. The medics arrive and take him to emergency. Ninety minutes has now elapsed after this incident, before the doctor comes to see him. He now regains full muscle strength and can walk around to the amazement of his wife. What is your diagnosis?
    • A. 

      Transient ischemic attack

    • B. 

      Amaurosis fugax

    • C. 

      Rupture of bridging vein

    • D. 

      Orthostatic hypotension

    • E. 

      Bleeding middle cerebral artery

    • F. 

      Stroke in evolution

  • 124. 
    A 62-year-old breast cancer survivor visits her physician because of weakness, fatigue, fever, and weight gain 5 years following her radiation therapy. The physician also elicits complaints about abdominal discomfort and exertional dyspnea. Physical examination reveals hepatomegaly and jugular venous distention that fails to subside on inspiration, but shows no evidence of hypotension or Pulsus paradoxus. An echocardiogram shows reduced end-diastolic volumes and elevated diastolic pressures in both ventricles. Which of the following is the most likely diagnosis?
    • A. 

      Cardiac tamponade

    • B. 

      Congestive heart failure

    • C. 

      Constrictive Pericarditis

    • D. 

      Dilated cardiomyopathy

    • E. 

      Recurrence of breast cancer

  • 125. 
    A 39-year-old man is seen by the physician, because he is becoming increasingly short of breath during mild exercise. The shortness of breath typically comes on after walking two to three level city blocks and is associated with moderate diaphoresis. In the last month, he has also noticed mild orthopnea. He denies chest pain, chest tightness, hemoptysis, or changes in weight. His previous medical history is notable for rheumatic fever in childhood.  Auscultation of the heart reveals an increased first heart sound and opening snap following the second heart sound. Additionally, there is a low-pitched, grade III/VI mid-diastolic murmur that is best heard over the apex of the heart in the left lateral decubitus position. What finding would most likely be detected on investigation of this patient?
    • A. 

      Elevated left atrioventricular pressure gradient

    • B. 

      Elevated left ventricular diastolic pressure

    • C. 

      Left ventricle muscle dysfunction

    • D. 

      Myxomatous degeneration of mitral valve

    • E. 

      Right atrial hypertrophy

  • 126. 
    A 34 year old male comes for check-up  6 months after an open heart surgery. He has no complaints at this time. Blood film is shown below. What is your diagnosis?
    • A. 

      Sickle cell disease

    • B. 

      Heart failure

    • C. 

      Hemolytic disease

    • D. 

      Prior mechanical valve replacement

    • E. 

      Bone marrow failure

    • F. 

      Sepsis

    • G. 

      Leukemia

  • 127. 
    A 72-year-old African American female (AAF) was admitted from a nursing home with complaints of abdominal pain, nausea and vomiting, dizziness, confusion and double vision for 5 days.  On examination, she had a diastolic decrescendo murmur. Her pulse was high pounding and the cardiologist noted pulsations in her fingers. Her head was also noted to bopping up and down with each pulse. Her friends had earlier complained about her persistent nodding. An undiagnosed murmur is noted on her femoral artery. What is your diagnosis?
    • A. 

      Mitral stenosis

    • B. 

      Aortic stenosis

    • C. 

      Mitral regurgitation

    • D. 

      Aortic regurgitation

    • E. 

      Congestive heart failure

    • F. 

      Mitral valve prolapse

  • 128. 
    A 53 year old Caucasian is admitted with syncopal attacks and fever. He also complains of dyspnea on exertion especially after climbing 20 steps. On examination, he was noted to have a mid-systolic click, then late systolic murmur. Result of trans- esophageal echo is shown. What is your diagnosis?
    • A. 

      Mitral valve prolapse

    • B. 

      Mitral valve vegetation

    • C. 

      Aortic stenosis

    • D. 

      Atrial myxoma

    • E. 

      Large thrombus

    • F. 

      Rupture of papillary muscle

  • 129. 
    A 16yr old boy comes in for annual physical exam. He is found to have a BP of 110/70, PR 65/min. and a fixed, wide splitting murmur at the left sternal border that does not change with respiration. What is your diagnosis?
    • A. 

      ASD

    • B. 

      VSD

    • C. 

      Aortic stenosis

    • D. 

      Mitral stenosis

    • E. 

      Pulmonic regurgitation

  • 130. 
    A 45-year old male is taken to the emergency room of a local hospital with a history of sudden onset of difficulty breathing. The patient states that he had been suffering from shortness of breath, difficulty climbing stairs, headaches and recently noticed swelling of his feet. He also complained of nonradiating chest pain, mainly in the precordial area. He has not been on any medications. Physical examination reveals a man in acute distress, who is orthopneic, has a blood pressure of 150/110 mm hg, pulse of 89 beats per minute with dropped beats, and a respiratory rate of 20 breaths per minute with some audible wheezes. His temperature is 37C (98.6 F). The nail beds are bluish, and no clubbing is noted. His accessory muscles of respiration are active, and rales and crepitations are heard in both lungs, the latter mainly at a base. Auscultation of his heart will reveal which of the following sounds ?
    • A. 

      A loud S1

    • B. 

      A fixed splitting of S2

    • C. 

      A soft A2

    • D. 

      A loud P2

    • E. 

      An S3

    • F. 

      Widened splitting of S2

    • G. 

      An absent S4

  • 131. 
    A male neonate born at full term is noted to have a systolic and diastolic continuous murmur at the right upper sternal border. His vital signs are normal and he is overall doing well. He is diagnosed with PDA. The ductus arteriosus usually closes spontaneously by which of the following mechanisms?
    • A. 

      Prostaglandin production in the lungs.

    • B. 

      Indomethacine administration.

    • C. 

      Inhibition of bradykinin release.

    • D. 

      Surgical correction.

    • E. 

      Oxygen tension inhibits ductal smooth muscle voltage-dependent potassium channels.

    • F. 

      Inhibition of influx of calcium and ductal constriction.

  • 132. 
    A 33-year-old HIV-positive woman has had increasing inability to think clearly, with forgetfulness, and headaches over the past 3 weeks. She has no history of seizures. On examination she is oriented to time, place and date. She is indifferent to her surroundings. She is unable to perform calculations and has difficulty in word finding. MR of her brain shows an irregular ring-enhancing lesion involving left frontal lobe white matter. Her CD4 count is 90/microliter. Which of the following is the most likely diagnosis?
    • A. 

      Infarction

    • B. 

      Toxoplasmosis

    • C. 

      Contusion

    • D. 

      Astrocytoma

    • E. 

      Cysticercosis

  • 133. 
    A 47-year-old man has had the new onset of headaches for the past 4 months. The headaches are associated with dull pain and seem diffuse, but they are becoming more frequent and prolonged. On physical examination he has no focal neurologic deficits. His memory is intact. MR imaging reveals enlargement of the lateral ventricles. There is a 4 cm homogenous, well-circumscribed mass within the fourth ventricle. Which of the following is the most likely diagnosis?
    • A. 

      Astrocytoma

    • B. 

      Choroid plexus papilloma

    • C. 

      Ependymoma

    • D. 

      Meningioma

    • E. 

      Metastatic bronchogenic carcinoma

    • F. 

      Shwannoma

  • 134. 
    A 26-year old woman complaints of headaches and double vision. She is 5 ft 7 in tall (26.4 cm) and weighs 230 Ib (104.3 kg). Her physician suspects that she has benign intracranial hypertension (pseudotumor cerebri). Which of the following is the most feared complication of this condition ?
    • A. 

      Visual loss

    • B. 

      Sixth nerve palsy

    • C. 

      Herniation syndrome

    • D. 

      Migraine headache

    • E. 

      Hemiplegia

  • 135. 
    A 70-year-old man has a 2 day history of worsening generalized headache and increasing obtundation. He now complains of stiffness in his neck. On physical examination vital signs include T 38.7 C, pulse 85/minute, respirations 23/minute, and blood pressure 130/85 mm Hg. A CBC reveals a WBC count of 16,850/microliter. Serum electrolytes include a glucose of 88 mg/dL. A lumbar puncture yields cloudy cerebrospinal fluid with a glucose of 32 mg/dL, protein 146 mg/dL, and cell count of 3800 WBCs (95% PMNs and 5 % mononuclears) and 122 RBCs. He receives antibiotic therapy and improves. Which of the following long-term complications is most likely to develop from this man's current disease?
    • A. 

      Cerebral infarction

    • B. 

      Cerebellar tonsillar herniation

    • C. 

      Encephalitis

    • D. 

      Hydrocephalus

    • E. 

      Subdural hematoma

  • 136. 
    A 28 year old male has nocturnal attacks of severe periorbital headaches about 11pm each day, lasting for about an hour. It is associated with ipsilateral rhinorrhea and lacrimation. He has no family history. BP is 125/75 mmHg. What is your diagnosis?
    • A. 

      Cluster headaches

    • B. 

      Depressive headaches

    • C. 

      Giant cell arteritis

    • D. 

      Migraine

    • E. 

      Tension headaches

    • F. 

      Trigeminal neuralgia

  • 137. 
    A 68yr. old woman presented with five days of unilateral headache, pain and stiffness of pelvic and shoulder muscles, fever, and jaw claudication. Other vital signs are normal. This patient’s diagnosis has the strongest association with?
    • A. 

      Crohn's disease

    • B. 

      Dermatomyositis

    • C. 

      Discoid lupus erythematosus

    • D. 

      Sjögren’s syndrome

    • E. 

      Polymyalgia rheumatica

    • F. 

      Demyelination disorder

  • 138. 
    A 38-year old man comes to the emergency department with his girlfriend complaining of a severe constant headache that started 4 hours ago. The girlfriend state that the patient was walking up a flight of stairs when he suddenly and became unresponsive for roughly 2 minutes. He then woke up confused and has had the headache since, with two episodes of vomiting. The patient does not get headaches normally. Past medical and social history are unremarkable. Family history is significant for a mother and 36-year-old brother with early adult onset of kidney failure requiring dialysis. Vital signs are with normal limits. Neurologic examination is within normal limits other than mild confusion and an unwillingness of the patient to move the neck because of pain, which also is a new symptom according to the girlfriend. Which of the following is most likely to be true ?
    • A. 

      Lumbar puncture would reveal numerous neutrophils and a high bacterial count.

    • B. 

      The carotid arteries contains critical stenoses bilaterally.

    • C. 

      The patient's kidney contains multiple large cysts.

    • D. 

      Echocardiography would clinch the diagnosis

    • E. 

      Anticoagulation with heparin would improve symptoms.

  • 139. 
    A 50-year-old man was involved in a vehicular accident in which he was not wearing any restraint device and struck his head against the windshield of his van. He did not lose consciousness at that time or at any point thereafter. Physical examination showed a minor contusion to his forehead. However, a month later he began complaining of headaches, becoming irritable and acting strangely. Which of the following intracranial vascular abnormalities most likely developed in this man?
    • A. 

      Epidural hematoma

    • B. 

      Chronic subdural hematoma

    • C. 

      Cerebral contusions

    • D. 

      Subarachnoid hemorrhage

    • E. 

      Intracerebral hematoma

  • 140. 
    A 25-year-old man falls while skateboarding and strikes the left side of his head against a concrete wall. On physical examination only a minor scalp abrasion is present at the site of the impact. He is initially alert following this accident, but then became unconscious 30 minutes later. A head CT scan reveals a convex, lens-shaped area of hemorrhage centered over the left parietal region. These events are most likely to be associated with damage to which of the following parts of the intracranial vasculature?
    • A. 

      Bridging veins

    • B. 

      Cavernous sinus

    • C. 

      Great vein of Galen

    • D. 

      Inferior cerebellar artery

    • E. 

      Middle Meningeal artery

    • F. 

      Ophthalmic branch of external carotid artery

  • 141. 
    A 66-year-old male moved in with his daughter after his wife of 44 years died of breast cancer a year ago. His daughter now insists he visit his family physician and accompanies him when he does. She tell the physician that her father has been behaving in a rather odd manner over the last few months. He seems to be losing his memory, is unable to recall names, dates, and places, and has getting lost at times at home. He used to be very good at mathematics, which he taught at a local junior college, but now he has difficulty doing simple calculation. In facts, he got angry and yelled at her one day when she stated that he had written a check for the wrong amount. Sometimes she noticed that he would kick his legs and he jerks his arms in a weird way while resting. The most likely diagnosis in this patient is which of the following?.
    • A. 

      Multiinfarct dementia

    • B. 

      Chronic subdural hematoma

    • C. 

      Pseudodementia

    • D. 

      Alzheimer's disease

    • E. 

      Creutzfeldt-Jakob disease

  • 142. 
    A 42 year old man reports an abrupt onset of a severe, throbbing headache that is localized initially before spreading to other areas. He also complained of neck pain, vomiting, drowsiness, sweating, sensitivity to light , double vision, weakness on one side of the body Physical exam: The individual is semi- conscious, pupils are  dilated, the neck is  rigid (stiff) . Blood pressure is 145/95 mmHg.  EKG showed ST segment elevation. Cardiac enzymes and heart auscultations are normal. What is your diagnosis?
    • A. 

      Myocardial infarction

    • B. 

      Subdural hematoma

    • C. 

      Intracerebral hemorrhage

    • D. 

      Epidural hematoma

    • E. 

      Subarachnid hemorrhage

  • 143. 
    A 50-year-old African-American man has headaches for the past month. On physical examination his blood pressure is 182/108 mm Hg. He cannot afford to take any medications. He is admitted to the hospital after suddenly losing consciousness 2 months later. When he is aroused, he cannot speak and he cannot move his right arm or his right leg. Which of the following intracranial pathologic abnormalities is most likely to be present?
    • A. 

      Middle cerebral artery embolus

    • B. 

      Subfrontal Meningioma

    • C. 

      Cerebral venous thrombosis

    • D. 

      Central pontine myelinolysis

    • E. 

      Basal ganglia hemorrhage

  • 144. 
    A child was in her usual state of good health when she developed a focal seizure while playing with her sister. The mother, a registered nurse, states that the seizure lasted approximately 5 minutes. The 911 Emergency Services were called and the child arrived postictal to the emergency department approximately 1 hour after the seizure first occurred. On physical examination the vital signs are stable, but the patient is noted to have weakness and hemiparesis. Remarkably, within 24 hours the weakness and neurologic deficits disappear. Which of the following is the most likely diagnosis ?
    • A. 

      Hemiplegia complicating a migraine headache

    • B. 

      Spastic hemiplegia

    • C. 

      Postviral encephalitis

    • D. 

      Todd's paralysis

    • E. 

      Infratentorial tumor

  • 145. 
    A 65 year old man presents with blurred vision in his right eye with intermittent loss of vision. He describes it as a “curtain passing vertically” across the visual field. He suffers from uncontrolled diabetes and hypertension. On examination, the conjunctiva are clear, and the pupils are 3-4mm and reactive. Cranial nerves are intact. What is your most likely diagnosis?
    • A. 

      Diabetic retinopathy

    • B. 

      Hypertensive retinopathy

    • C. 

      Retinal artery occlusion

    • D. 

      Amaurosis fugax

    • E. 

      Retinal detachment

    • F. 

      Retinal vein occlusion

  • 146. 
    A 45 year-old woman with long-standing rheumatoid arthritis is diagnosed as having "anemia of chronic disease." The predominant mechanism causing this type of anemia in persons with chronic inflammatory disorders is?
    • A. 

      Defective porphyrin synthesis

    • B. 

      Impaired incorporation of iron into porphyrin

    • C. 

      Intravascular hemolysis

    • D. 

      Depressed erythroid maturation due to decreased erythropoietin production

    • E. 

      Impaired transfer of reticuloendothelial storage iron to marrow erythroid precursors

  • 147. 
    Few hours after birth, a new born started vomiting after the mother was instructed to breastfeed him. His delivery was spontaneously vaginal.  Apgar score was 9 and 10. The mother’s antenatal period was non-eventful, except that her uterus was consistently large for gestation. She was properly immunized, and did not smoke cigarette, but drank some alcohol five months into her pregnancy during family re-union.  The baby’s vital signs are normal. A pain erect abdominal X-ray is done. What is your diagnosis?
    • A. 

      Polyhydramnious

    • B. 

      Imperforate anus

    • C. 

      Duodenal atresia

    • D. 

      Intestinal obstruction

    • E. 

      Congenital megacolon

  • 148. 
    A 38 year old woman presents with generalised body itch, without any rashes or wheals especially after taking a warm bath.  His stools and urine are normal.  There is no jaundice or pallor. BP132/83 mmHg. She has scratch marks all over her arms, abdomen, shoulders and thighs. She denies changing her body cream, and toilet soap. Her diet has not changed and is homemade most of the time. Her CBC showed a hematocrit of 58%, and platelets of 500,000 mm3. Further laboratory or physical examination is most likely to show?
    • A. 

      High erythropoietin

    • B. 

      High erythrocyte sedimentation rate

    • C. 

      Splenomegaly

    • D. 

      Hepatomegaly

    • E. 

      Low WBC, with high eosinophils count

    • F. 

      Cardiomegaly

  • 149. 
    A 57-year-old obese, hypertensive woman who had been well until the onset of severe chest pain and hypotension. She had to be defibrillated four times on her way to the hospital. The diagnosis of acute inferior-posterior infarction was made by electrocardiogram (ECG) and there was a markedly elevated serum creatine kinase (CK) (including the MB fraction). The patient had a very low cardiac output and ejection fraction. A new systolic murmur was heard and the patient dies on 7th day of admission. Autopsy would most likely reveal?
    • A. 

      Anterolateral papillary muscle rupture

    • B. 

      Posteromedial papillary muscle rupture

    • C. 

      Ventricular septal wall rupture

    • D. 

      Left ventricular aneurysm

    • E. 

      Dressler’s Syndrome

  • 150. 
             A 52 year old woman with high blood pressure presents with peripheral cyanosis worst during winter periods. He has muscle weakness, joint pain, stiffness and suffers from shortness of breath and coughing. He  has lost weight significantly because of dysphagia. He complains that his dental prostheses are difficult to insert and remove. What is the most likely diagnosis?
    • A. 

      Raynaud's phenomenon

    • B. 

      GERD

    • C. 

      Scleroderma

    • D. 

      Cancer of esophagus

    • E. 

      Side effect of medication

    • F. 

      COPD

  • 151. 
                A 1 year old Child presents with sudden onset of severe abdominal pain with vomiting at frequent intervals. During the episodes of pain, he draws his knees up to his abdomen while crying. He passed a currant jelly stool just before he was taken to ER. Which of the following will assist most in the diagnosis?
    • A. 

      H. Pylori will be detected

    • B. 

      Congenital absence of ganglion cell

    • C. 

      Air enema will be both diagnostic and therapeutic

    • D. 

      Intestinal obstruction

    • E. 

      Twisting of a segment of bowel on it’s vascular mesentery

  • 152. 
    Which one do you like?
    • A. 

      Option 1

    • B. 

      Option 2

    • C. 

      Option 3

    • D. 

      Option 4