Paper 1, April 2010 Final With Key

8/8/2019 Paper 1, April 2010 Final With Key

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The Reset Examination in Medicine

27/4/2010

* * *

The Final Written ExamPaper - I

Tuesday 27/4/2010

TIME ALLOWED 2 HOURS

:1. 12.2. :

.)(25 )Case Scenario(.)(20 )Data Interpretation(

:1. .2. .3. .4. 5. 6. .


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Section (A): CaseScenarios

1- A 66 year old man, whois a knowncaseoftype 2 diabetes mellitus for 18 years, presentedwith a suddenonsetofdyspnea that awaked him from sleep. When arrived atemergencyroom he was anxious,dyspnic, with cyanosedlips andextremities, his pulseis regular at arate of 112/min, respiratory rate of 34/min, blood pressure of 160/100mmHg. Chestexamination revealed bi-basalcrepitations.You shouldconsider allofthefollowing treatmentoptions for his case, EXCEPT:

a) i.v. Morphine.b) Oxygen in a concentration of 60%c) i.v. Frusemide.d) i.v. Atenolole) i.v.glyceryl trinitrate

2- A 23 year oldfemale presented with a 3 days history ofchest pain and shortness ofbreathwhich is worse on inspiration, coughing and lying flat and relieved by sitting. Physicalexamination revealed a thinfemale innoobvious distress. Blood pressure was 130/80 andpulse was 80. Lungs were clear and cardiovascular examination revealed a friction rubheard best attheleftlower sternal border.Allofthefollowing statements regarding this patients case aretrue, EXCEPT:

a) History of a recent upper respiratory tract infection is relevant.b) Serum markers of inflammation are expected to be raised.c) Absence of pericardial effusion excludes your diagnosis.d) Usually it is a self-limiting condition, and symptoms are controlled by non-steroidal anti-

inflammatory drugs.e) Chronic constrictive pericarditis is a potential complication.

3- A 39 year old man, known hypertensiveonirregular treatment, presentedtotheemergencyroom with history ofblurring ofvision and headachefor the past 7 hours. Onexamination,helooks unwell, pulseis regular at a rateof88/min, Blood pressureis 270/150mmHg.Allofthefollowing aretrue statements regarding this patients case, EXCEPT:

a)Cocaine drug abuse may contribute to his condition.b)He should be managed in an intensive care unit with immediate treatment of his high

blood pressure.c)Fundoscopy is expected to reveal papilledema, hemorrhage and exudates.d)If his serum potassium is high, this suggests Conns disease is the likely underlying cause.e)Sudden drop of his blood pressure may cause an ischemic stroke.

4- A 30 year oldfemale, knowncaseofbronchial asthma, shefailedto respond adequately tobudesonide 400g /day and salbutamolinhaler.

Thenext step inthe managementofthis patient would be:a) Doubling the dosage of inhaled corticosteroidsb) Addition of a long-acting b-agonistc) Addition of a leukotriene antagonistd) Addition of theophyllinee) Addition of systemic corticosteroids


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5- A 16-year-old male patient, previously healthy, came to the emergency department withcomplaints ofshortness ofbreath andchest pain which startedoneday ago. The shortnessofbreath was mild in severity, made worse by exertion and relieved with rest, associatedwith left sidedchest pain, sharp innature. Hedenied any similar symptoms inthe past. Hedid drink alcohol, denied drug abuse and there was no history of trauma.On examination; Blood pressure was 112/70 mm/Hg, pulse rate of 90/min, afebrile andrespiratory rateof23/min. Chestexamination revealed a trachea in midline with a hyper

resonanceon percussionoftheleft sideofthechest, auscultation showedno breath soundson the left side with nocrepitations or wheeze. His cardiac and abdominalexaminationswereunremarkable. Oxygen saturation was 90% at room air.Allofthefollowing aretrue regarding this case, EXCEPT:

a)About 90% of cases are smokers or were smokers.b)This condition most commonly affects men between 2040 years of agec)Some individuals have a genetic predisposition to it.d)A CT scan of the chest is the best initial radiological assessment tool in this case.e)A Chest tube has to be placed and connected to underwater seal.

6- A 30 year oldfemale patient with history ofCaesarean section 20 days ago, presented witha sudden onset of right sided chest pain and hemoptysis. She gives a history for beingtreatedfor DVT twice with anticoagulants thelast was a year ago. Onexamination she iscyanosed,tachypnic, her oxygen saturation is 82%, pulse 120/min-regular, blood pressure120/80mmHg,chestexaminationis unremarkable, she has leftlower limb edema.Allofthefollowing aretrue regarding her condition, EXCEPT:

a) Chest X-ray is expected to be normal.b) D-dimer


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9- A 44 year old woman presents to the outpatient clinic complaining of tiredness, loss ofappetite and weightloss of6 kg over the past 4 months. She has diarrhea thatis associatedwith abdominal pain, there is no blood in the stool. Onexamination, she is underweight,pale with angular stomatitis, she has mildtenderness inthe rightiliacfossa. Her Hgb is 7.1g/dl, MCV 61 fl, WBC 7.8 x 109/l, platelets 560 x 109/l, ESR 91 mm/1st Hr.Allofthefollowing statements regarding this patients condition aretrue, EXCEPT:

a) The presence of fistula in-ano and perirectal abscesses are of diagnostic significance.b) Colonoscopy is contraindicated in this patient.c) Elevation of CRP concentration is helpful in monitoring disease activity.d) MRI scan is helpful in diagnosing perineal involvement.e) Development of colonic cancer is a known complication.

10-A 52 year old man, previously healthy, presented with fatigability, headaches, pruritusfollowing a warm bath and recurrent attacks ofepistaxis over thelast 8 months. Heneversmoked and has no history of any significant illness in himself or in his family. Onexamination;the patientlooks plethoric, afebrile with a pulseof88/min, blood pressureof120/80 mmHg. Abdominal examination revealed a palpable spleen. Investigations reveal;Hgb 19g/dl. WBC 14.3 x 109/l, Platelets 500 x 109/l

Thefollowing statements aretrue regarding this case, EXCEPT:a) Hyperuricaemia is may be a finding in this patient.b) Venesection gives prompt relief of symptoms.c) Aspirin is used to reduce the risk of thrombosis.d) Splenectomy is the treatment of choice.e) Peptic ulceration may be associated with this disease.

11-A 22 year old female, previously healthy, presented with sore throat, menorrhagia andbruises over the skin which developed over the past week. On examination, she is pale,temperature 38oC, regular pulse of 108/min, blood pressure 120/70 mmHg, she hasgeneralizedlymph nodeenlargement, her spleenis palpable andthere are multiple bruisesover the skin. Throatis congested andchest andcardiacexaminations wereunremarkable.Investigations show; Hgb 8.8 g/dl, WBC 18 x 109/l, Platelets 54 x 109/l, peripheral bloodfilm examination shows 24% lymphoblasts.Basedonthe givendata thediagnosis ofthis patientis compatible with:

a) Acute myelogenous leukemiab) Chronic lymphocytic leukemiac) Acute lymphoblastic leukemiad) Myelofibrosis.e) Infectious mononucleosis.

12-A 32 year old female, previously healthy, presented with a 2 month history of fatigue,exertionaldyspnea and palpitation which worsenedinthelast week sothat she gets dyspnic

even after walking few steps out of bed. On examination, she is pale, regular pulse of96/min, blood pressure 120/60mmHg. Chest, Cardiac and abdominal examination wereunremarkable. Hgb 5.6 g/dl, MCV 60fl (N80-100), MCH 16 pg (N26-34), WBC 7.3x109/l,Platelets 218 x 109/l.Allofthefollowing statements aretrue, EXCEPT:

a) A history of NSAID intake is of significance.b) You expect a low serum ferritin and high iron binding capacity.c) Packed Red Cell transfusion is indicated in this patient.d) Parentral iron leads to faster improvement in hemoglobin level than oral iron.e) Vitamin C helps improve absorption of iron from animal sources.


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13-A 40 year old womanis referredto you becauseoflethargy,coldintolerance,constipation,dry skin and weight gain. Physical examination shows mildly enlarged thyroid, enlargedtongue and slow reflexes.Which test bestconfirms theclinicalimpressionofprimary hypothyroidism?

a) Measurement of serum T4b) Measurement of serum T3c) Measurement of serum TSHd) Measurement of serum thyroglobulin.e) Test for antithyroidal antibodies.

14-A 38 year old male presented with a six month history of weight loss, increased skinpigmentation, dizziness upon standing and episodic severe colicky abdominal pain.Investigations revealed; Hgb 12 g/dl, MCV 84 fl, Urea 32 mg/dl, Sodium 125 mmol/l,Potassium 6.1 mmol/l, random blood sugar 54mg/dl.Which ofthefollowing is the most appropriatenextinvestigation?

a) Glucocorticoid suppression test.b) MRI of the pituitary glandc) Insulin leveld) Short ACTH stimulation test.e) Renin-Aldosterone ratio.

15-A 24 year old female, diagnosed 5 years ago with type 1 diabetes mellitus. She is onmorning dose of NPH insulin of 26U/day. She lost 15 kg of her weight and she is non-compliant to her treatment and follow-up. She attended the diabetic clinic for a pre-employment check up. Her fasting blood sugar was 220mg/dl, and random 6 pm bloodsugar was 118mg/dl.Allofthefollowing statements aretrue, EXCEPT:

a) Presence of swelling at injection site is consistent with lipodystrophy.b) Hemoglobin A1C is expected to be > 7%c) Increasing the morning dose of insulin is advisable.d) Adverse fetal outcome is expected if tight blood sugar control is not adopted during

pregnancy.e) Regular screening for retinopathy by fundal photography is recommended

16-A 58 year old man presents with 7 month history ofinvoluntary shaking movements ofhisleft hand. On examination, there was a coarse slow resting tremor of the hands with nointentionalcomponent, muscletone in limbs was increasedthroughoutthe whole rangeofmovement and his face was masked.Which ofthefollowing statements is TRUE?

a) The blink reflex is expected to be exaggerated.b) Up going planters is typical finding in this case.c) CT Brain is needed to confirm the diagnosis.d) Levodopa should be initiated as soon as the diagnosis is suspected.e) Benzhexol is an excellent option in old people with hypokinesia.


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21-A 44 year old man was admittedfor treatmentoflobar pneumonia. Immediately after commencingantibiotic treatment he developed a severe facial swelling, stridor and shortness of breath. Onexamination helooks seriously ill, with profuse sweating andfacialflushing, his pulse was weak andhis blood pressureis 80/50 mmHg.Whatis your most appropriateimmediate managementofthis patient?

a) i.v. normal saline.b) i.v. plasma.c)

i.m adrenaline.d) i.v. hydrocortisone.

e) i.v. penicillin22-A 32 year old male patient presented with patches ofhair loss over the scalp for 3 weeks duration.

On examination the patches were round with normal appearing skin. There are exclamationmark hairs attheedgeofthe patches.Allofthefollowing statements aboutthis case aretrue, EXCEPT:

a) Involvement of the eye brows and eye lashes is not expected.b) Nail pitting may be seen.c) It is associated with autoimmune disorders.d) The condition may be recurrent.e) Intralesional steroids are used.

23-A 28 year old male presentedtodermatology clinic with a 4 week history ofitchy lesions over thewrists. Onexamination,there were multipleflattopped purplish papules over theinner surfaceofboth wrists and ankles.Allofthefollowing regarding this case aretrue, EXCEPT:

a) Kbner phenomenon is expected to be seen in this case.b) Wickhams striae over the papules are characteristic.c) Annular lesions are common on the penis.d) The nails are usually affected.e) Local corticosteroids may help improve itching.

24-A 19 year old medical student was brought by his father to the psychiatric casualty because ofsuddenonsetofbizarre behavior andtalking to people whilenoone is beside him. His father saidthat his sonis socially withdrawn, has insomnia and reports that he hears somevoices ordering himto injure his brother. The patient also believes that his intelligent ideas have been stolen from hismind by a superpower. Thefather was confidentthat his sonis not abusing any drugs.The mostlikely diagnosis ofthis conditionis:

a) Bipolar disorder.b) Hysteria.c) Obsessive compulsive neurosis.d) Schizophrenia.e) Panic disorder.

25-A 33 year old woman was admitted to psychiatric hospital after a suicidal attempt. She has ahistory of previous trials of suicide 2 times before. She expressed sense of hopelessness, feelingguilty ofdoing wrong and she was tearful andnot interested to talkto her doctor. She was slowspeaker and her movements were retarded.Allofthefollowing statements aretrue regarding this patient, EXCEPT:

a) Hypothyroidism should be excluded.b) Antidepressant therapy should be commenced.c) Sympathetic psychotherapy is needed.d) Lithium carbonate will help improve her depressed mood.e) Her condition indicates admission to psychiatry ward.


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Section (B): Data Interpretation

26-A 66 year old man who was admitted to coronary care unit because of myocardialinfarction 7 hours ago. Suddenly the patient becameunresponsive, pulseless and his ECGmonitor shows thefollowing trace:

The NEXT step inthe managementofthis patient would be:a) i.v. lignocaine.b) i.v. adrenaline.c) Start cardiac massage.d) i.v. atropine.e) Insertion of intra-aortic balloon pump.

27-This is an ECG ofa 69 year old man who suffers from diabetes and hyperlipidaemia.

Which abnormality does this ECG show?a) Left ventricular hypertrophy.b) Right ventricular hypertrophy.c) Left bundle branch block pattern.d) Right bundle branch block pattern.e) Acute anterior myocardial infarction.


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28-This ECG is takenfrom anelderly patient whois complaining ofpalpitation.

Which ofthefollowing diseases you willlookfor inthis patient?a) Renal Failure.b) Lung Cancer.c)

Thyrotoxicosis.d) Hypothyroidism.

e) Subdural Hematoma.29-A 44 year oldlady presenting with exertionaldyspnea. Her Respiratory functiontests

shows:FEV1 LowVC LowFEV1/VC Normal

This respiratory functiontest reportis compatible with allofthefollowing, EXCEPT:a) Pulmonary fibrosis.b) Left ventricular failure.c) Chronic bronchitis.d) Pleural effusion.e) Sarcoidosis.

30-A 43 year old man, his arterial blood gas analysis shows:ypH 7.12yPaO2 112 mmHgyPaCO2 22 mmHgyHCO3 9 mmol/l

Allofthefollowing cancausethis abnormality, EXCEPT:

a)

Morphine overdose.b) Diabetic ketoacidosis.c) Salicylate poisoning.d) Acute renal failure.e) Diarrhea.


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31-A 33 year old woman recovering from acute gastritis. Her ABG analysis shows:ypH 7.43yPaO2 102 mmHgyPaCO2 46mmHgyHCO3 32 mmHg

This arterial blood gas abnormality is compatible with:a) Mixed metabolic alkalosis and respiratory acidosis.b) Compensated Metabolic acidosisc) Compensated Respiratory alkalosisd) Respiratory Acidosise) Compensated Metabolic Alkalosis

32-This is a liver profileofa 44 year oldladyy Total bilirubin 7.2 mg/dl (N 0.1-1.2)y Indirect bilirubin 1.2 mg/dl (N 0.1-0.5)y AST 98 units/l (N0-35)y ALT 100 units/l (N7-50)y Alkaline phosphatase 1107 units/l (N 41-133)

Thesefeatures arecompatible with which ofthefollowing diseases?a) Acute viral hepatitisb) Liver cirrhosisc) Multiple gall bladder stones.d) Chronic lymphocytic leukemiae) Gilbert syndrome

33-A hepatitis profileofa 27 year old man was performed and shown below:y HBSAg Negativey HBeAg Negativey Anti HBC Negativey Anti HBS Positivey Hepatitis C Ab Negative

Thesefindings arecompatible with which ofthefollowing?a) A patient with acute viral B hepatitisb) A patient with post infection of more than one year with hepatitis B.c) Treated hepatitis C infectiond) Immunization for hepatitis B without previous infectione) Previous infection with hepatitis B virus.

34-This is a complete bloodcountofa 85 year oldfemaley Hgb 5.6 g/dly MCV 122 fly WBC 2.2 x 109/ly Platelets 66 x 109/l

This CBC is compatible with thediagnosis of;a) Thalassemia Majorb) Vitamin B12 deficiency.c) Chronic lower gastrointestinal bleedingd) Chronic lead poisoning.e) Hyperthyroidism.


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35-A 44 year old woman presented with epistaxis, her CBC shows:y Hgb 12.4 g/dly WBC 8.1 x 109/ly Platelets 24 x 109/l

Allofthefollowing may beusedinthe managementofthis case, EXCEPT:a) Platelet transfusion.b) Prednisolone.c) Rituximab.d) Chlorambucile) High dose immunoglobulin.

36-A 56 year old man has thefollowing laboratory resultsy Urea 108 mg/dly Creatinine 2.2 mg/dly Na 130 mmol/ly K 3.1 mmol/l

Theselaboratory findings arecompatible with a patient who has:a) Lung cancer on cisplatin treatment.b) Inappropriate secretion of antidiuretic hormone.c) Addisons disease.d) Pure water loss complicated by dehydration.e) Anuric acute renal failure.

37-In assessing a 70 year old male patient with polyuria, polydypsia,constipation andlethargey,thefollowing analysis was performed:

y Serum Calcium 15 mg/dl (N 8.5 10.5)y Serum phosphorus 2.2 mg/dl (N2.5 4.5)y Alkaline phosphatase 400 units/l (N 41-133)y Serum albumin normal

Allofthefollowing statements aretrue, EXCEPT:a) A chest X-Ray could help reach the diagnosis.b) ECG may show short QT interval.c) Bisphosphonates are treatment options.d) Proper hydration is essential in management of these patients.e) Glucocorticoids should be avoided in these cases.

38-A urine routineexamination was performedfor a 40 year oldlady,it shows;y pH Alkaliney WBCs 28/hpf(N


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39-A 16 year old female, presented with an acute attackof bone aches and chest pain. Herbrother has a similar condition. Haemoglobinelectrophoresis shows:

y Hb A 0% (N97-99)y Hb A2 2% (N1-2)y Hb F 10% (N


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43-A 52 year oldlady, knowndiabeticonoral hypoglycemicdrugs, presentedfor regularfollow up, her investigations show:

y FBS 118 mg/dl (N70-110)y HbA1C 5.7% ( N

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