PALESTINE MEDICAL SCHOOL

AL AZHAR UNIVERSITY

Introduction to Clinical Medicine Final Examination

4th YEAR 2009 / 2010
MEDICINE

Name:
No.
Answer Sheet
Quest Answ Questi Answ Questi Answ Quest
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1
21
41
61
2
22
42
62
3
23
43
63
4
24
44
64
5
25
45
65
6
26
46
66
7
27
47
67
8
28
48
68
9
29
49
69
10
30
50
70
11
31
51
71
12
32
52
72
13
33
53
73
14
34
54
74
15
35
55
75
16
36
56
76
17
37
57
77
18
38
58
78

Ans
wer

Quest Answ
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81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98

19
20

39
59
40
60
Select only one answer

79
80

99
100

All of the following conditions can lead to

malabsorption of nutrients EXCEPT:
A.Crohn's disease
B.Celiac disease
C.Ulcerative colitis
D.Chronic pancreatitis
E.Resection of terminal ileum
63- In a patient with ascites, which of the following
physical examination findings suggests a superior
vena cava obstruction instead of intrinsic hepatic
cirrhosis?
A. Bulging flanks
B. Collateral venous flow downward toward the umbilicus
C. Everted umbilicus
D. Pulsatile liver
E. Venous hum at the umbilicus
73- A54-year-old woman with rheumatoid arthritis
(RA) presents with fatigue and low white
count (white blood cells [WBC] 2500/mL) on routine
blood work. She has no active joint symptoms and her
RA is controlled on lowdose methotrexate and
NSAIDs. On examination, she has chronic joint
deformities of her hands and a palpable spleen, which
is a new finding. Which of the following is the most
likely diagnosis for her low white count?
(A) methotrexate therapy
(B) rheumatoid nodules disrupting bone marrow architecture
(C) Feltys syndrome
(D) normal variation
(E) myelofibrosis
5. All of the following valvular heart disease lead to
systolic murmur EXCEPT:
A. Aortic regurgitation
B. Aortic stenosis
C. Pulmonary stenosis

D. Ventricular septal defect

E. Mitral regurgitation
7. All of the following valvular heart disease lead to
diastolic murmur EXCEPT :
A. Mitral valve stenosis
B. Pulmonary valve regurgitation
C. Tricuspid valve stenosis
D. Aortic valve regurgitation
E. Mitral valve prolapse
9. The commonest cause of hypertension is :
A. Primary hypertension
B. Kidney disease
C. Adrenal disease
D. Coarctation of aorta
E. Thyrotoxicosis
10. Normal blood pressure as classified by JNC 7 is :
A. < 120 / < 80
B. 125/80
C. 130/85
D. 140/90
E.160/100
11. All of the following can cause isolated systolic
hypertension EXCEPT
A. Ageing
B. Thyrotoxicosis
C. Anaemia
D. Aortic regurgitation
E. Aortic stenosis
14. All of the following are characteristic of innocent
murmur ,Except.
A. Grade I to II murmur in left sterna border.
B. Diastolic murmur
C. No other abnormal sounds or murmurs
D. Normal precordium , apex & first heart sound
E. No evidence of left ventricular hypertrophy

15. In hypertensive emergency . all of the following

are true EXCEPT :
A. Associated with end organ damage
B. Usually associated with blood pressure > 210 / 130
C. Require immediate reduction of blood pressure within 1
hour
D. Commonly associated with headache & epistaxis
E. The common reason is secondary hypertension
74- A 32-year-old woman develops symptoms
secondary to a dry mouth and dry eyes. She
has enlarged salivary glands. Studies for
autoantibodies to Ro (SS-A) are positive. Asalivary
gland biopsy reveals lymphocytic infiltration. Which of
the following is the most likely diagnosis?
(A) sarcoidosis
(B) primary Sjgrens syndrome
(C) human immunodeficiency virus (HIV) infection
(D) lymphoma
(E) amyloidosis
75- A young woman presents with a facial rash,
arthralgias, and fatigue. The rash on her face is
erythematous and raised, her heart and lungs are
normal, and wrists are swollen and tender
on palpation. She has mild thrombocytopenia
(90,000/mL). Which of the following is the most
appropriate initial autoantibody test?
(A) anti-double-stranded (ds) deoxyribonucleic acid (DNA)
(B) anti-Sm
(C) anti-Ro or La
(D) ANA
(E) antiphospholipid antibodies (lupus anticoagulant)
77- A 63-year-old man presents with weakness and
hemoptysis, but no fever, cough, or sputum.
He has a 60-pack-per-year history of smoking. The
chest x-ray (CXR) reveals a lung mass with
mediastinal widening. On examination, there is a blue
purple discoloration of the upper eyelids and

erythema on his knuckles. He has proximal muscle

weakness rated 4+/5, normal reflexes, and sensation.
Which of the following is the most likely diagnosis for
his muscle weakness?
(A) SLE
(B) scleroderma
(C) dermatomyositis (DM)
(D) polyarteritis
(E) Weber-Christian disease
more severe stiffness at night and hip pain. The
symptoms improve in the morning after doing
some stretching exercises. On physical
examination, there is paravertebral muscle and
sacroiliac joint tenderness with limited flexion of the
lumbar spine. A2/6 diastolic murmur is also heard at
the left sternal border radiating to the apex. Which of
the following is the most likely diagnosis for the
diastolic murmur?
(A) mitral stenosis
(B) tricuspid stenosis
(C) aortic insufficiency
(D) pulmonic insufficiency
(E) tetralogy of Fallot
82- A bad batch of potato salad at a company picnic
causes 100 people to develop severe gastroenteritis.
A 36-year-old man recovers from the diarrhea, but
two weeks later develops arthritis in his right knee
and severe Achilles tendinitis. What is the most likely
diagnosis?
A. Septic arthritis likely from staphylococcal food poisoning
B. Acute gout caused by dehydration and stress
C. Lyme disease contracted at the picnic
D. Reactive arthritis
E. Osteoarthritis
20-A 33 year old intravenous drug abuser is
positive for HIV .She has experienced pain on
swallowing .Upper endoscopy reveals a few raised ,
creamy white plaques and several sharply

demarcated small areas of shallow ulceration in the

mid to lower oesophagus .Which one of the
following is the most likely cause of this proble ?
A- Herpes simplex oesophagitis
B- Cytomegalovirus infection of the oesophagus
C- Barretts oesophagus
D- Oesophageal candidiasis
E- Oesophageal web
27- Which one of the following disorders is MOST likely to
be associated with H .pylori infection?
A Non ulcer dyspepsia.
B Reflux oesophagitis.
C Coeliac disease.
D- Gastric lymphoma.
E Achalasia of the cardia.
42- A 55 year old man presents with a six month
history of arthralgia and vasculitic skin rash affectin
the lower limbs .Further investiation reveals
monoclonal and polyclonal cryoglobulins. This
condition is often associated with which one of the
following infections ?
A- Hepatitis C virus (HCV )
B- Hepatitis B virus (HBV )
C- Epstein Barr virus (EBV )
D- Parvovirus
E- Cytomegalovirus (CMV )
36 Hepatic encephalopathy can be precipitated by each
of the following conditions EXCEPT ?
A Upper gastrointestinal bleeding.
B Hypokalaemia.
C- Constipation.
D- Diuretics.
E High carbohydrate diet.
22- Which one of the following types of arthritis.is the
MOST common type of psoriatic arthropathy ?
A Distal interphalangeal (DIP ) joint disease.
B Arthritis mutilans.
C Peripheral symmetric arthropathy.
D Peripheral asymmetric oligoarthropathy.

E Psoriatic spondylitis.
The following are causes of nephrotic syndrome
except:
A.Amyloidosis.
B.Henoch- Schonlein purpura.
C.Renal vein thrombosis.
D.Gold therapy
E.Minimal Change Glomerulonephritis

All the following are causes of clubbing of fingers

EXCEPT:
A. Idiopathic pulmonary fibrosis.
B. Biliary cirrhosis.
C. Bronchiectasis.
D.Bronchial asthma.
E. Chronic lung abscess
.
A 65 years old woman presents with a chronic cough.
Which of the following problems might be
contributing to this symptom
A. Gastroesophageal reflux.
B. Congestive heart failure.
C. Bronchial asthma.
D. Postnasal drip.
E. All of the above.
The commonest cause of hemoptysis is:
A. Lung cancer.
B. Acute bronchitis.
C. Pulmonary tuberculosis.
D. Pulmonary infarction.
E. Mitral stenosis.

Vitiligo is associated with each of the following

disorders EXCEPT :
A Nelsons syndrome.
B Alopecia areata.
C Graves disease.
D Addisons disease.
E Diabetes mellitus type I
A 67 year old male presents to the Emergency Room
with epigastric pain associated with nausea and
vomiting, found to be hypotensive .What is the FIRST
investigation to be done ?
A Random blood sugar.
B Abdominal X ray.
C Electrocardiogram(ECG )
D Serum amylase.
E Abdominal Ultrasound.
Treatment of peptic ulcer disease in H. pylori positive
patient is
A-Proton pump inhibitor + Clarithromycine + Amoxicillin
B-Misoprotol 200ug /x4.
C-Dual therapy is effective as triple therapy.
D-Proton pump inhibitor alone can eradicate H.pylori.
E-Metronidazole is better than Amoxicillin.
The worst prognosis of aortic stenosis is associated
with which of the following signs or symptoms.
A.Angina pectoris
B.Congestive heart failure
C.Palpitation
D.Exertional dyspnea
E.Syncope
2009
Part one
Q.1. A 28-year-old law student comes to your clinic
complaining of back pain. He is concerned that he has
ankylosing spondylitis. Which of the following

symptoms would support that diagnosis?

A. Back pain worsening on forward flexion with radiation to
the buttocks
B. Severe back pain in the evening
C. Morning stiffness for two hours in the back that improves
with exercise
D. Diarrhea alternating with constipation
E. Acute onset of pain after lifting
3--A26-year-old woman develops a red rash over her
cheeks and pain, and swelling in both wrists as well as
several small joints in her hands. The rash gets worse
on sun exposure and involves her cheeks, nose, ears,
and chin. Medical evaluation reveals oral ulceration
and 3+ proteinuria. Which of the following is the most
specific test for diagnosis of this condition?
(A) lupus erythematosus (LE) cells
(B) antinuclear antibody (ANA)
(C) anti-Sm antibody
(D) anti-Ro antibody
(E) antiphospholipid antibody
4-A39-year-old woman complains of developing painful
pale fingers on cold exposure for the past 5 years.
Recently, she has noticed swollen fingers and tight
skin, which limit flexion and extension. She also has
new abdominal symptoms that are bothersome. On
examination, the skin on the fingers is smooth and
shiny with associated edema. The rest of the
examination is normal. Which part of the
gastrointestinal (GI) tract is most frequently involved
in thiscondition?
(A) esophagus
(B) stomach
(C) duodenum

(D) ileum
(E) colon
9- Which of the following is not a feature of systemic
lupus erythematosus ?
A-Thrombocytopenia.
B- Seizures.
C-Pericardial friction rub.
D-Erosive arthritis.
E-Isolated pleural effusion
15- In rheumatoid arthritis, which one of the following
is true?
A. Association of seropositivity with HLA-DR1.
B. Concordance rate of > 60% for identical twins.
C. Peak incidence in the third decade.
D. Progression from predominantly small peripheral joint
disease to involve more proximal, larger joints.
E. Sacroiliac joint disease is common.
1. Causes of raised JVP include all of the followings
except:
A.
mediastinal lymphoma
B.
mediastinal irradiation 2 years previously .
C.
ST elevation in lead rV4 and chest pain
D.
Liver Cirrhosis .
E.
Ebstien anomaly
8. The following are major critera of rheumatic fever
EXCEPT :
A- Erythema marginatum.
B- Prolonged P-R interval in ECG
C Fleetin arthritis .
D Carditis .
E Chorea
13- A 23 year-old male is referred to you after
developing reddish brown urine 1 day after playing
football. He also notes that for the past two days he

has had a sore throat and cough. He has no Past

Medical Hx, takes no medications and has a family
history of nephrolithiasis. Chemistries reveal a BUN of
16 mg/dL and creatinine of 1.0 mg/dL. ANA is
negative and C3 is normal. A 24 hour urine protein
excretion is 200 mg and creatinine clearance is 120
cc/m. Microscopic analysis reveals many RBC with
some dysmorphic cells. Renal U/S is normal. The most
likely diagnosis is:
A. Post-streptococcal glomerulonephritis
B. Minimal change disease
C. IgA nephropathy
D. Nephrolithiasis
E. Rhabdomyolysis
15- In the evaluation of a patient with raised urea and
creatinine, pre-renal failure is unlikely if there is:
K. Decreased pulmonary wedge pressure.
L. Postural hypotension.
M. Urine osmolality > 500 mosm/1.
N. Urine sodium > 20 mmol/l
O. Urine to plasma urea ration of > 8.
16- A 19-year-old man presents with malaise,nausea,
and decreased urine output. He was previously well,
and his physical examinationis normal except for an
elevated jugular venous pressure (JVP) and a
pericardial rub. His electrolytesreveal acute renal
failure (ARF). Whichof the following findings on the
urinalysis ismost likely in keeping with acute
glomerulonephritis (GN)?
(A) proteinuria
(B) white blood cell casts
(C) granular casts
(D) erythrocyte casts
(E) hyaline casts

11- A63-year-old woman presents for routine

evaluation. She has had diabetes for the past 12
years
with complications of neuropathy and retinopathy.
You decide to screen her for renal complications
of diabetes. Which of the following findings is not
compatible with diabetic nephropathy?
(A) nephrotic range proteinuria
(B) microalbuminuria
(C) hypertension
(D) red blood cell (RBC) casts in urine
(E) renal tubular acidosis (RTA) type IV
16- A 75 year old female is referred to you because of
recent onset of lower extremity edema, and 4+
proteinuria on urinalysis. Further work-up revealed 8
grams/day of proteinuria, creatinine clearance of 72
cc/min, HgbA1C of 6%, normal complement levels,
negative HIV and hepatitis. She has had a long
history of rheumatoid arthritis and has been treated
with NSAIDS and brief courses of prednisone.
However, on physical examination there is only mild
joint destruction. The most likely cause of her
proteinuria is:
A. Minimal change disease
B. Membranous nephropathy
C. Amyloidosis
D. Membranoproliferative glomerulonephritis
E. Focal segmental glomerulosclerosis
17- Cyclosporin, all are seen except:
a) Hirsutism
b) Hypertension
c) Renal failure
d) Bone marrow suppression
e) Tremor
22- Hypocomplementaemia is seen in the following
,EXCEPT
A-Ventriculo-atrial shunt nephritis.
B- Membrano-proliferative glomerulonephritis.

C-Acute post streptococcal nephritis.

D-Henoch Schonlein nephritis.
E-Systemic lupus nephritis
25- Which of the following is the drug of choice for
hypertensive encephalopathy?
(A) Sodium nitroprusside.
(B) Nifedipine.
(C) Hydralazine.
(D) Methyldopa.
(E) Propranolol
36- In mitral stenosis all are true except:
a) Formal anticoagulation is indicated in severe stenosis
without AF
b) low cardiac output state
c) rarely congenital
d) S3 sound is commonly seen
e) 20 % stays in sinus rhythm despite severe stenosis
37- characteristic Complications of long standing
hypertension include all of the followings except:
a) Diastolic heart failure
b) Coronary artery disease.
c) Stroke
d) peripheral vascular disease
e) Systolic heart failure
50 - All these statements about Barretts esophagus
are true, except:
a) It is associated with 30- to 40-fold greater risk to
develop adenocarcinoma
b) It appears as salmon-pink mucosa on endoscopy
c) It is associated with high risk for esophageal bleeding
d) It represents replacement of the stratified squamous
epithelium by columnar epithelium with goblet cells
e) It could be a complication of long-standing reflux
esophagitis
51- Hepatitis C infection is characterized by which one
of the following:
a) Absence of carrier status

b) Highest incidence of chronic hepatitis among other viral

hepatitis
c) No increase risk for hepatocellular carcinoma
d) It can be transmitted by eating contaminated food
54-A 51 year old patient with cirrhosis presents with
melaena. Urgent upper GI endoscopy does not reveal
varices or peptic ulceration. There is chronic gastric
congestion, punctate erythema and gastric erosions.
Which one of the following is most likely source of
bleeding?
a) Variceal haemorrhage
b) Rectal polyps
c) Portal hypertensive gastropathy
d) Mallory-weiss syndrome
e) Duodenal ulcer
56- A 47-year-old man has a history of drinking 1 to 2
liters of Alcohol per day for the past 20 years. He has
had numerous episodes of nausea and vomiting in the
past 5 years. He experiences a bout of prolonged
vomiting, followed by massive hematemesis. On
physical examination in the emergency room, he has
vital signs with T 36.8 C, P 110, RR 22, and BP 80/40
mm Hg. His heart has a regular rate and rhythm with
no murmurs and his lungs are clear to auscultation.
There is no abdominal tenderness or distension and
bowel sounds are present. His stool is negative for
occult blood. Which of the following is the most likely
diagnosis?
A.Barretts esophagus
B.Esophageal stricture
C.Esophageal lacerations (Mallory Weiss syndrome)
D.Esophageal squamous cell carcinoma
E.Achalasia
57- Which of the following statements about alcoholic
liver disease is not true?
A. Alcoholic cirrhosis is often characterized by diffuse fine
scarring with small regenerative nodules.

B. The ratio of ALT to AST is often higher than 2

C. Elevated MCV can be seen
D. Concomitant hepatitis C significantly accelerates the
development of alcoholic cirrhosis.
E. Serum prothrombin times(PT) may be prolonged, but
activated partial thromboplastin times(APTT) are usually not
affected.
1-Which of the following would be the first indication
of infection in a patient with acute hepatitis B?
A. Anti-HBc (antibody to hepatitis B core antigen)
B. Clinical symptoms such as fever, jaundice, and abdominal
pain
C. HBeAg (hepatitis B e antigen)
D. HBsAg (hepatitis B surface antigen)
E. Increased transaminases
2-A 32-year-old Asian man presents with diarrhoea
after returning from a visit to see his family in
Pakistan. He is afebrile and also complains of lower
abdominal pain. His stools do not contain blood. What
is the most likely diagnosis?
1 ) Amoebic dysentery
2 ) Campylobacter
3 ) Giardiasis
4 ) Salmonella
5 ) Shigella
5- H.pylori is best diagnosed by a non invasive test ,
which one you will do :
A- Rapid urease test.
B-Urea breath test.
C-Ig G antibodies.
D-Ig M antibodies.
E-Biopsy and pathology.
6- Bloody diarrhea can be induced by the following,
EXCEPT

A-E.histolytica
B-Shingella shigae
C-Giardia lamblia
D-Ulcerative colitis
E.Cancer rectum
7- The most common presentation of primary biliary
cirrhoses is:
A. Jaundice.
B. Ascites.
C. Prurtis.
D. Splenomegaly.
E. Abdomenal pain.
8- 35 yo presents w/ nocturnal wheezing. She does not
have h/o asthma & has no known allergies. She
awakens at 3AM with coughing, SOB, & bronchspasm.
Inhalers & prednisone are not helping. Which is the
most appropriate diagnostic study ?
A. EGD
B. Barium Swallow
C. 24-hour ambulatory esophageal pH
D. Esophageal manometry
E. Gastroduodenoscopy
11- A 58 year old patient complains of dysphagia which
is progressive and unrelenting. Initially the patient had
difficulty in swallowing solids only but recently also
liquids. He has lost weight and complains of anorexia.
Select the correct diagnosis for each of the above
B. carcinoma of the oesophagus
C. Achalasia
D. Diffuse oesophageal spasm
E. Cricopharyngeal dysfunction
F. Schatzki ring
4- Select the type of anemia in A 32 year-old man,
status post terminal ileum
resection of crohn's disease:

A. Iron deficiency.
B. B12 deficiency.
C. Aplastic anemia.
D. Hemolytic anemia.
E. Thalassemia trait.
62- Which of the following extraintestinal
manifestations of inflammatory bowel disease
typically worsens with exacerbations of disease
activity?
A. Ankylosing spondylitis
B. peripheral joint arthritis
C. Nephrolithiasis
D. Primary sclerosing cholangitis
E. Uveitis
178. A 22-year-old female licensed practical nurse is
about to start a new position. Hepatitis B
vaccination is required prior to beginning work.
The patient refuses to have this done because she
believes that she has already received the
vaccine.
Which of the following laboratory studies would
support prior vaccination for hepatitis B virus:
A. Antibody to hepatitis B surface antigen
(anti-HBs).
B. Antibody to hepatitis B e antigen (antiHBe).
C. IgM antibody to hepatitis B core
antigen (IgM anti-HBc).
D.IgG antibody to hepatitis B core
antigen (IgG anti-HBc).
E. Hepatitis B surface antigen (HbsAg).
175. A 56-year-old white man has a 15-year history
of epigastric discomfort and heartburn. He denies
dysphagia and weight loss and currently takes no
medications. Physical examination is normal. A

once-daily proton pump inhibitor is begun and the

patients symptoms resolve rapidly.
Which of the following should be done next:
A. Barium swallow.
B. Upper endoscopy.
C. Ambulatory 24-hour oesophageal pH
monitoring.
D.Oesophageal manometry.
E. No diagnostic studies are needed.
1.

A 20-year-old lady complains of tiredness,

intermittent right upper quadrant abdominal
pain. She has one child. On examination,
unremarkable, she has two small tattoos, CBC
and LFT are normal, anti-hepatitis C virus
antibodies are positive.
The following statements are false, EXCEPT:
A. Tattooing is the most likely route of
infection.
B. She has chronic hepatitis C infection.
C. Urgent liver biopsy is needed.
D. Anti-viral therapy should be offered
immediately.
E.
There is a risk that she has transmitted
HCV infection to her child.
F. A 63 year old man underwent
gastroscopy for investigation of long
standing history of heartburn and
dyspepsia . Barretts oesophagus was
diagnosed .Which one of the follwing
statewments about this condition is true ?
A- It is asymptomatic in most cases
B- Aapproximatly 20 % per year progress to
adenocarcinoma
C- It has autosomal recessive inheritance
D- Helicobacter pylori eradication therapy is
very effective initial treatment
E- The lesion is usually located at the mid
point of the oesophagus

2.

A 43 year- old woman c/o itching that keeps her

up at night. PE is normal except for a liver span 7
cm below R costal margin. Labs show: CBC is
WNL. Creat 0.8
T.bili 0.6 ALT 78
Alb 4.2
Alk Phos 450 .Which test would you order next
for diagnosis?
A. Serum protein electrophoresis
B. Anti-smooth-muscle Ab
C. Antimitochondrial Ab
D. Technetium-99m liver-spleen scan
E. ERCP
3. The gastroscopy report confirmed the diagnosis of
duodenal ulcer in a 40 year old man ,The
possibility of Helicobacter pylori infection was
raised .Which one of the following tests is considered
the gold standard for detection of H. pylori infection ?
A. Rapid urease test
B. Gastric biopsy histopathology
C. Gastric biopsy specimen culture
D. H.pylori IgG antibodies in serum
E. H.pylori IgM antibodies in serum
16- A63-year-old man with a long history of
alcoholabuse presents with ascites. He is
experiencingmild abdominal discomfort and
nausea.Examination reveals tense ascites and
generalized tenderness but no rigidity. A diagnostic
paracentesis of the fluid is performed. Which of the
following ascitic fluid results is most likely to suggest
an uncomplicated ascites due to portal hypertension
from cirrhosis?
(A) hemorrhage
(B) protein >25 g/L
(C) bilirubin level twice that of serum
(D) serum to ascites albumin gradient>1.1 g/dL
(E) more than 1000 white cells/mm3

12- The following can be an indicator of acute

respiratory failure except
A- cyanosis .
B- tachypnea .
C- Paco2
55 mmHg .
D- grimacing and nasal flaring .
E- Pao2
80 mmHg .
17- On clinical examination of the cardiovascular
system during inspiration which one of the following
findings is consistent with normal physiology?
A. An increased jugular venous pressure.
B. A diastolic pulmonary venous flow murmur.
C. Increased systemic arterial blood pressure.
D. Decreased pulse rate.
E. Increased splitting of the second heart sound.
6-A 63-year-old woman develops exertional angina
and has had two episodes of syncope. Examination
shows a systolic ejection murmur with radiation to
the carotids and a soft S2. Which of the following is
the most likely diagnosis?
(A) mitral stenosis
(B) mitral insufficiency
(C) aortic stenosis
(D) aortic insufficiency
(E) tricuspid stenosis
9- In a patient with severe uraemia ,the following
would indicate chronic renal disease EXCEPT :
A-Osteodystrophy.
B- Skin pigmentation.
C-Neuropathy.
D-Small kidneys
E- Pericarditis

Multiple Choice Questions (Chest) - Dr. Walid

Daoud
Select ONE best answer for the following:
1- A 58-years old man has a routine chest x-ray. He
is asymptomatic. The chest x-ray shows a
solitary round lung nodule which on biopsy is
metastatic carcinoma. The most common primary
tumor is;
(a)
carcinoma of the thyroid.
(b)
renal cell carcinoma.
(c)
carcinoma of the liver,
(d)
carcinoma of the bladder,
(e)
carcinoma of the adrenal gland,
2- The commonest cause of hemoptysis is:
(a) lung cancer.
(b) pulmonary tuberculosis.
(c) bronchiectasis.
(d) acute bronchitis.
(e) bronchial carcinoid tumor.
3- In lung function tests, small airflow limitation can
be diagnosed by:
(a) FEV1.
(b) FEV1/FVC %.
(c) FEF 25-75%.
(d) FVC
(e) RV/TLC
4- The drug of choice in treatment of legionella
pneumonia is:
(a) ciprofloxacin.
(b) doxycycline.
(c) erythromycin.
(d) penicillin.
(e) ceftriaxone.

5- Pneumatocele in chest x-ray is typically seen in:

(a) pneumococcal pneumonia.
(b) klebsiella pneumonia.
(c) pulmonary tuberculosis.
(d) pulmonary embolism.
(e) staphylococcal pneumonia.
6- Drug-induced lung fibrosis is caused by:
(a) ceforuxime.
(b) colchicine.
(c) bleomycin.
(d) trimethoprim-sulfamethoxazole.
(e) ofloxacin.
7- A spirometer can be used to measure directly:
(a) functional residual capacity.
(b) inspiratory capacity.
(c) residual volume.
(d) total lung capacity.
(e) none of the above.
8- A man breathing at 20 breaths per minute has a
minute ventilation of 8000 ml/min
and a dead space of 150 ml. His alveolar ventilation
is:
(a) 250 ml/min.
(b) 400 ml/min.
(c) 2500 ml/min.
(d)
3000 ml/min.
(e)
5000 ml/min.
9- Which of the following are associated with
Mycoplasma pneumoniae infection:
(a erythema multiforme
(b)
Reynaud's phenomenon
(c)
hemolytic anemia
(d)
bullous myringitis
(e)
all of the above.

10- All the following are characteristics of chylous

pleural effusion EXCEPT:
(a) milky white fluid.
(b)
triglyceride level more than 110 mg/dl.
(c)
the commonest cause is lymphoma.
(d)
rich in lymphocytes.
(e)
the fluid clears with addition of ethyl
alcohol.
11- All of the following are signs of acute severe
asthma EXCEPT:
(a)
silent chest.
(b)
high Pco2.
(c)
altered mental status.
(d) diffuse wheezing.
(e) respiratory rate more than 25 breath / min.
12- Which one of the following medications should be
initial therapy for a symptomatic
patient with COPD resulting from tobacco abuse:
(a) theophylline.
(b) ipratropium by inhalation.
(c) prednisone.
(d) salmeterol by inhalation.
(e) spironolactone.
13- The antihypertensive drug of choice in asthmatic
patients is:
(a)
atenolol.
(b)
captopril.
(c)
nefidepine.
(d)
alpha-methyl dopa.
(e)
furisemide.
Answer Key:
1- b
2- d
3- c

8- e
9- d
10- e

4- c
5- e
6- c

11- d
12- b
13- c

All the following are vitamin Kdependent .1

coagulation factors except
A. factor X
B. factor VII
C. protein C
D. protein S
E. factor VIII
Which of the following statements regarding .2
?polycythemia vera is correct
A. An elevated plasma erythropoietin level is not consistent
.with diagnosis
.B. Transformation to acute leukemia is common
.C. Thrombocytosis correlates strongly with thrombotic risk
D. Splenomegaly is rare at presentation
E. Hypocellular bone marrow
A 68-year-old man seeks evaluation for fatigue, .3
weight loss, and early satiety that have been present
for about 4 months. On physical examination, his
spleen is markedly enlarged. His hemoglobin is 11.1
g/dL, and hematocrit is 33.7%. The leukocyte and
platelet count within normal limits. The white cell
count differential is 75% PMNs, 8% myelocytes, 4%

metamyelocytes, 8% lymphocytes, 3% monocytes,

and 2% eosinophils. The peripheral blood smear
shows teardrop cells, nucleated red blood cells, and
.immature granulocytes
?What is the most likely diagnosis
A. Chronic idiopathic myelofibrosis
B. Chronic myelogenous leukemia
C. Polycythemia vera
D. Acute lymphoblastic leukemia
E. Microangiopathic hemolytic anemia
A 50-year-old female presents to your clinic for .4
evaluation of an elevated platelet count. The latest
complete blood count is white blood cells (WBC)
7,000/mm3, hematocrit 34%, and platelets
.600,000/mm3
All the following are common causes of
thrombocytosis except
A.Iron-deficiency anemia
B. Essential thrombocytosis
C. Chronic myeloid leukemia
D. Myelodysplasia
E. Pernicious anemia

All of the following statements regarding the .5

epidemiology of and risk factors for acute myeloid
leukemias are true except
A. Anticancer drugs such as alkylating agents and
topoisomerase II inhibitors are the leading cause of drug.associated myeloid leukemias

B. Individuals exposed to radiation are at risk for acute

myeloid leukemia
C. Paraxismal nocturnal hemoglobinuria is a preleukemic
disorder
D. The incidence of acute myeloid leukemia is greatest in
.individuals <20 years
E. Trisomy 21 (Down syndrome) is associated with an
increased risk of acute myeloid leukemia

All the following are characteristic of tumor lysis .8

syndrome except
A. hyperkalemia
B. hypercalcemia
C. lactic acidosis
D. hyperphosphatemia
E. hyperuricemia

All of the followings are included in the .9

international prognostic index as poor prognostic
factors in non-Hodgkins lymphoma except
A. Age above 60 years
B. Serum LDH more than normal
C. Stage III-IV
D. Extranodal involvement of more than one site
.E. Performance status of 1-2
Which one of the following statements .10
?regarding non-Hodgkins lymphoma is incorrect
A. Diffuse large B cell lymphoma is the most common type
B. Burkitts lymphoma is the most aggressive type

C. indolent lymphomas are usually localized at

presentation
D. Aggressive lymphomas are curable with chemotherapy
E. Indolent lymphomas are incurable disorders
A 28-year-old female develops progressive .11
confusion. In the emergency department she has a
brief generalized seizure. CBC documents
normocytic anemia and thrombocytopenia. The
peripheral blood smear reveals schistocytes and a
paucity of platelets. Prothrombin time and
activated partial thromboplastin time are normal.
The urinalysis reveals proteinuria (2+). The serum
.creatinine is 3.0 mg/dL
All of the following are possible underlying
:conditions except
A. Pregnancy
B. Cancer
C. Systemic lupus erythematosus
D. Clopidogrel
E. Blood transfusion
Which of the following red blood cells product is .12
indicated for the prevention of febrile non?hemolytic transfusion reactions
A. leucocytes depleted red blood cells
B. washed red blood cells
C. irradiated red blood cells
D. frozen red blood cells
E. CMV negative red blood cells
The evaluation in a newly diagnosed case of acute .13
lymphoid leukemia (ALL) should routinely include all
of the following except
A. bone marrow biopsy
B. cell-surface phenotyping

C. plasma viscosity
D. cytogenetic testing
E. lumbar puncture
All of the following have been associated with .14
development of a lymphoid malignancy except
A. celiac sprue
B. Helicobacter pylori infection
C. Hepatitis B infection
D. HIV infection
E. Human herpes virus 8 (HHV8) infection
F. Inherited immunodeficiency syndromes

Which of the following carries the best disease .15

?prognosis with appropriate treatment
A. Burkitts lymphoma
B. Diffuse large B cell lymphoma
C. Follicular lymphoma
D. Mantle cell lymphoma
E. Nodular sclerosing Hodgkins disease
A 49-year-old woman presented with menorrhagia .16
of 5 months duration. The spleen was palpable 5 cm
below the left costal margin. The leukocyte count was
56x109/L with 62% neutrophils,11% lymphocytes,
12% basophils, 3% monocytes, 8% metamyelocytes,
and 12% myelocytes. The platelet count was 100
x109/L. Which test would most likely establish the
?correct diagnosis
a. Fat aspirate
b. Imaging of the uterus
c. Flow cytometry
d. JAK2 mutation analysis
e. BCR-ABL molecular genetic studies

All of the following disorders are associated . 17

with the development of microangiopathic
hemolytic anemia except
A. malignant hypertension
B. thrombotic thrombocytopenic purpora
C. disseminated malignancy
D. Dissemenated intravascular coagulation
E.Myeloprolepherative disorders
Which one of the following statements .18
?regarding platelets disorders is false
A. Glanzmanns thrombasthenia is caused by lack of
glycoprotein IIbIIIa
B. BernardSoulier syndrome causes failure of platelets
adhesion
C. Thrombocytopenia is the primary mechanism of
bleeding in renal failure
Von willibrand disease causes prolongation of both PTT
and bleeding time. .D
E. Storage pool disease is associated with platelets
dysfunction

NOTES: THE ANSWERS ARE BELOW, THANKS

1..
Major Jones criteria in rheumatic fever ,
include all of the following except:
A.Polyarthritis.
B.Erythema marginatum.
C.Pancarditis.
D.Chorea.
E. High ESR .

2. Ausculltatory findings in mitral stenosis include all

of the following except:
A. mid diastolic murmur.
B. presystolic accentuation.
C. opining snap.
D. the murmur has rumbling character.
E. muffled first heart sound.
3. indications for aortic valve replacement in aortic
stenosis , include all of the following except:
A. severe symptoms, despite treatment.
B. other cardiac surgery.
C. pressure gradient > 70 mmhg.
D. aortic valve area < 0.8 cm.
E. left ventricular hypertrophy.
4.
A.
B.
C.
D.
E.

the most common cause of mitral regurge is :

Rheumatic heart disease.
Ischemic.
Congenital ( mitral valve prolapse).
Inflammatory.
Degenerative.

5. Irregular wide complex tachycardia , include all of

the following , except:
A.. AF, with LBBB.
B. AF , with RBBB.
C. ventricular tachycardia.
D. AF, with aberrant conduction.
E, AF, with WPWN syndrome.
6. 70 years old male patient , presented to the
emergency department, with palpitations, dyspnea,

dizziness, BP 60/30 MMHG, his ECG , showed fast atrial

fibrillation, the treatment of choice is:
A.. amiodarone IV.
B. verapamil.
C. DC SHOCK A SYNCHRONIZED.
D. DC SHOCK, SYNCHRONIZED.
E. digoxin IV.
7. Acute coronary syndrome, include all of the
following , except:
A. sudden cardiac death.
B. ST elevation MI.
C. Non ST elevation MI.
D. Stable angina .
E.
Unstable angina.

8.
signs of successful streptokinase therapy,
include:
A. Relief of chest pain.
B. ST segment regression.
C. Reperfusion arrhythmia.
D. Early peak of cardiac enzymes.
E.
All of the above.
9. The most specific cardiac enzyme , is:
A. CK( MB).
B. LDH.
C. TPOPONIN.
D. MYOGLOBIN.
E. AST.

10. IN the management of acute coronary syndrome,

all of the following drugs, considered evidence based
class A,except:
A. aspirin.
B. b. blockers.
C. clopidogrel.
D. ca channel blockers.
E. streptokinase , in ST elevation MI.
11.Unstable angina , include all of the following ,
except:
A. angina de novo.
B. crescendo angina.
C. angina at rest.
D. effort angina.
E. post MI angina.

12.Wich of the following drugs, associated with

prolongation of the
interval :

Q-T

A. Gentamycin.
B. Digoxin.
C. Erythromycin.
D. Cefalexin.
E. Isoniazed.

13. apex beat , in aortic stenosis , is:

A. diffuse, in 5th intercostals space, heave , no sustained.

B. localized, shifted out ward , weak, no sustained.

C. localized, shifted downward, forceful, heave sustained.
D. diffuse. Shifted, downward, no sustained.
E. localized, in 5th intercostal space, sustained.

14.All the following are features of Aortic regurge

except:
A.
B.
C.
D.
E.

Head nodding.
Pistol shot.
paradoxical pulse
Corrigan pulse.
Hills sign.

15 . Cardiomyopathies, include the following diseases ,

except;
A. dilated cardiomyopathy.
B. hypert rophic cardiomyopathy.
C. constrictive cardiomyopathy.
D. Right ventricular dysplasia.
E.. Restrictive cardiomyopathy.

ANSWERS:
1. E

2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

E
E
C
C
D
D
E
C
D
D
C
C
C
C