Multiple Choice Questions for Dr Doobay

1) A 23-year-old type 1 diabetic is brought to the emergency department after being found in a
coma. The scent of acetone is present on the patient's breath. Urinary catheterization with
subsequent dipstick analysis demonstrates marked positivity for glucose and ketones. Stat
blood chemistries would most likely show which of the following values for the anion gap?
(A) 6 mEq/L
(B)11 mEq/L
(C) 15 mEq/L
(D) 20 mEq/L

2) A 35-year-old woman arrives on the floor after an uneventful hysteroscopy to evaluate her
long history of uterine fibroids. About 30 minutes after her arrival, she begins to complain of
nausea and has two episodes of vomiting. The physician administers 0.625 mg of droperidol
and 400 mg of acetaminophen by mouth. On follow-up evaluation, the patient's neck is
involuntarily flexed to one side. She is alert, oriented, and conversant and has an otherwise
normal neurologic examination. Which of the following is the most likely diagnosis?
(A) Cerebral vascular accident
(C) Dystonic reaction to droperidol
(D) Munchausen syndrome
(E) Seizure

3) A 25-year-old man who was recently admitted to a psychiatric hospital with the diagnosis of
severe depression complicated by psychosis is brought to the emergency room because of
worsening mental status and fever. The patient is unable to give a history because he is
profoundly confused and claims to be on Mars. The psychiatrist informs you that the patient
has been started recently on haloperidol and amitriptyline. Physical findings include a rectal
temperature of 40.6_C (105_F), muscle rigidity, and dry skin. A cooling blanket is ordered,
and you administer acetaminophen. Which of the following agents would be most
appropriately ordered at this time?
(A) Dantrolene
(B) Atropine
(C) Chlorpheniramine
(D) Methylprednisolone

4) How many alpha genes are deleted in hemoglobin H disease?

(A) 1
(B) 2
(C) 3
(D) 4
5) Which of the following statements concerning the difference between hemophilia A and
hemophilia is correct?
(A) Patients with hemophilia A have a prolonged partial thromboplastin time; patients
with hemophiliaB have a prolonged partial thromboplastin time and a prolonged
prothrombin time.
(B) Hemophilia A is inherited in a sex-linked fashion, hemophilia B is inherited in an
autosomal dominant fashion.
(C) Hemophilia A patients have a defect in a clotting protein not dependent on
vitamin K; hemophilia B patients have a defect in a clotting protein that is vitamin
K dependent.
(D) Hemophilia A patients present with bleeding into the joints; hemophilia B patients
present with mucosal bleeding.

6) Evaluation of a person who has pure red blood cell aplasia would be expected to reveal
(A) markedly hypocellular bone marrow
(B) normochromic, normocytic red blood cells
(C) a reticulocyte count of 2.0%
(D) decreased urinary erythropoietin content

7) A 70-year-old woman has been in long-standing poor health, with severe diabetes
mellitus and rheumatoid arthritis. Her physician notes that she appears pale and orders a
hematocrit, which shows a result of 35%. Examination of the blood smear reveals a
microcytic anemia. The physician is considering a differential diagnosis of iron deficiency
anemia versus anemia of chronic disease. Which of the following laboratory determinations
would be most helpful in distinguishing these conditions?
(A) Serum iron
(B) Presence or absence of polychromatophilic target cells
(C) Presence or absence of microcytes
(D) Serum ferritin

8) Why are patients with the factor V Leiden mutation at higher risk for venous thrombosis
during pregnancy or after surgery?
(A) Platelets aggregate abnormally
(B) This mutation is associated with an antibody to protein C
(C) Inability of protein C to cleave factor V
(D) This mutation results in the production of fibrin that is resistant to clot dissolution

9) A patient with stable phase chronic myeloid leukemia is being managed with interferon
therapy. After having done well for 2 years, he now presents with an increasingly left shifted
white cell differential on blood smear. Bone marrow examination shows a hypercellular
marrow with increased numbers of basophils. Cytogenetic analysis reveals that there are
 two Philadelphia chromosomes per cell. The most likely explanation for this cytogenetic
change is
(A) interferon effect
(B) accelerated or blastic phase
(C) error in interpretation of cytogenetic result
(D) it is a favorable prognostic sign

10) The most common cause of high serum calcium in a patient with a known cancer is
(A) ectopic production of parathyroid hormone
(B) direct destruction of bone by tumor cells
(C) local production of tumor necrosis factor and IL-6 by bony metastasis
(D) production of parathyroid hormone– like substance

11) Which of the following is likely to be a neoplasm of T-lymphocyte lineage?

(A) Chronic lymphocytic leukemia
(B) Burkitt’s lymphoma
(C) Mycosis fungoides
(D) Small lymphocytic (well-differentiated) lymphomas

12) Listeria monocytogenes most frequently causes which of the following infections?
(A) Endocarditis
(B) Peritonitis
(C) Meningitis
(D) Conjunctivitis

13) A 48-year-old man is admitted to the coronary care unit with an acute inferior myocardial
infarction. Two hours after admission, his blood pressure is 86/52 mmHg; his heart rate is 40
beats per minute with sinus rhythm. Which of the following would be the most appropriate
initial therapy?
(A) Immediate insertion of a temporary transvenous pacemaker
(B) Intravenous administration of atropine sulfate, 0.6 mg
(C) Administration of normal saline, 300 mL over 15 min
(D) Intravenous administration of dobutamine, 0.35 mg/min

14) Digitalis glycosides enhance myocardial contractility primarily by which of the following
mechanisms?
(A) Opening of calcium channels
(B) Release of calcium from the sarcoplasmic reticulum
(C) Stimulation of myosin ATPase
(D) Inhibition of membrane Na_, K_-ATPase
15) Which of the following agents has been shown to reduce mortality in patients with
congestive heart failure?
(A) Digitalis
(B) Furosemide
(C) Enalapril
(D) Aspirin

16) A 53-year-old man presents to the emergency room after the acute onset of chest pain. The
episode occurred 8 h prior to his arrival and lasted for a total of 20 to 30 min. The chest pain
is now resolved. The patient has a long history of diabetes mellitus and hypocholesteremia
and has smoked approximately 1 to 1 1/2 packs per day of cigarettes for the past 30 years.
On physical exam he has a blood pressure of 84/52, and his pulse is 54. He has jugular
venous distention to the angle of the mandible and clear lung fields. His rhythm strip reveals
a Wenkebach pattern. Given his hypotension, a Swan-Ganz catheter is placed. Right atrial
pressure is estimated at 16 mmHg (normal 0– 5), pulmonary artery pressure at 20/10 mmHg
(normal 12– 28/3– 13), and the pulmonary capillary wedge pressure is 8 mmHg (normal
range 3– 10). Which of the following is most consistent with this clinical picture?
(A) An anterior wall myocardial infarction
(B) A right ventricular infarction
(C) A constrictive pericarditis following a myocardial infarction
(D) A lateral wall myocardial infarction

17) What is the best EKG lead to report on for the patient above
(A) V1
(B) V2L
(C) V4R
(D) V8

18) A 52 yr old patient with a history of Hypertension for 12 years has been treated by your
team in the hospital for heart failure. He is being discharged today on Captopril, Atenolol
and furosemide. On seeing this treatment you proceed to ask Dr. Doobay if it would be wise
to add which of the following drugs:
(A) Digoxin
(B) Isosorbide dinitrate
(C) Aldactone
(D) None of the above

19) A 73-year-old patient develops acute renal failure secondary to bladder obstruction. His
serum creatine is 327 _mol/L (3.7 mg/dL) with a potassium of 6.5 meq/L. The patient had an
electrocardiogram, which revealed peaked T waves as the only abnormality. If the
hyperkalemia were not corrected, what would be the expected next electrocardiographic
abnormality?
 (A) PRprolongation and P-wave flattening
(B) Prolongation of the QT interval
(C) Widening of the QRS interval
(D) Torsade de pointes

20) In patients with chronic renal failure, which of the following is the most important
contributor to renal osteodystrophy?
(A) Impaired renal production of 1,25-dihydroxyvitamin D
(B) Hypocalcemia
(C) Hypophosphatemia
(D) Loss of vitamin D and calcium via dialysis

21) Normal serum complement levels would be seen in patients with hematuria, proteinuria,
and hypertension resulting from which of the following?
(A) Mixed essential cryoglobulinemia
(B) Diffuse proliferative lupus nephritis
(C) Henoch-Scho¨nlein purpura
(D) Poststreptococcal glomerulonephritis

22) As a consequence of severe liver damage, hepatic amino acid handling is deranged. In this
situation, plasma levels of which of the following are likely to be lower than normal?
(A) Ammonia (NH ) 3
(B) Ammonium (NH ) _4
(C) Alanine
(D) Urea

23) Which one of these extraintestinal complications of inflammatory bowel disease is LEAST
likely to be associated with ulcerative colitis?
(A) Pyoderma gangrenosum
(B) Arthritis
(C) Uveitis
(D) Oxalate kidney stones

24) Which of the following features is more commonly associated with ulcerative colitis than
with Crohn’s disease?
(A) Fistulas
(B) Rectal bleeding
(C) Segmental involvement
(D) Mesenteric lymph node involvement
25) A 70-year-old woman presents with blurring of vision in the left eye since waking earlier in
the morning. She reports 2 months of fevers, sweats, anorexia, and a 4.5-kg (10-lb) weight
loss. She also reports increasingly severe left temporal headaches over the same time
period. Her physical examination reveals scalp tenderness over the left temporal region. Her
laboratories reveal a normochromic, normocytic anemia, mildly elevated alkaline
phosphatase, and an erythrocyte sedimentation rate of 92. Appropriate action includes
(A) obtaining an emergent MRI/MRA of her head
(B) referring the patient for a biopsy of her temporal artery, but abstaining from
initiating therapy until the biopsy results are available
(C) initiating high-dose glucocorticoid therapy and referring the patient for a temporal
artery biopsy
(D) obtaining a head CT to rule out metastatic disease and scheduling a colonoscopy

26) A patient with diffuse cutaneous scleroderma (systemic sclerosis) who had been stable for
several years is recently noted to have hypertension. This patient is at significant risk of
dying from
(A) thrombotic stroke
(B) central nervous system hemorrhage
(C) renal failure
(D) pulmonary hypertension

27) A 14 yrs old girl on exposure to cold has pallor of extremities followed by pain and cyanosis.
In later ages of life she is prone to develop?
(A) SLE
(B) Scleroderma
(C) Rheumatoid arthritis
(D) Gout

28) A 37-year-old woman presents with complaints of severe heartburn with or without meals.
She has a history of hypertension, which has been treated with captopril. She also has
a history of Raynaud disease, multiple facial telangiectasias, and very taut skin on the
dorsum of both hands. She has failed to obtain relief for her heartburn with large doses of
antacids, ranitidine, or omeprazole. Esophageal manometry is ordered. Which of the
following would be the most likely results of this test?
(A) Decreased esophageal peristalsis and decreased LES pressure
(B)Decreased esophageal peristalsis and increased LES pressure
(C)Increased esophageal peristalsis and decreased LES pressure
(D)Increased esophageal peristalsis and increased LES pressure
29) Which of the following studies is most sensitive for detecting diabetic nephropathy?
(A) Creatinine clearance
(B) Urine albumin
(C) Glucose tolerance test
(D) Ultrasonography

30) A 41-year-old previously healthy woman presents to an emergency room complaining of

nausea and vomiting. Her calcium is found to be 2.9 mmol/L (11.7 mg/ dL) with an albumin
of 40 g/L (4.0 g/dL). Hyperparathyroidism is diagnosed, and an exploration of her four
parathyroid glands reveals one large parathyroid tumor, which is removed. One day after
the operation the patient complains of paresthesia in her hands and around her mouth. Her
calcium is 1.8 mmol/L (7.3 mg/dL). Her phosphorus is 0.6 mmol/L (1.8 mg/dL). Four months
later she still requires aggressive calcium and vitamin D supplementation. The most likely
etiology of her hypocalcemia is
(A) hypoparathyroidism secondary to inadvertent surgical removal of all four
parathyroid glands
(B) hypoparathyroidism secondary to atrophy of the three remaining parathyroid glands
(C) hungry bone syndrome
(D) magnesium deficiency

31) A 73-year-old woman is admitted to the hospital with chest pain. An astute intern sends her
for thyroid function tests after learning that the patient has gained 23 kg (50 lb) over the last
year and suffers from cold intolerance. Cardiac catheterization reveals three-vessel disease,
and coronary artery bypass is recommended. While preparing the patient for surgery the
next day, the intern checks the thyroid function tests. The TSH is 81 mU/mL (HIGH). What
course of action is most appropriate?
(A) Postpone the surgery, start levothyroxine replacement at 0.025 mg/d, and increase
the dose slowly. When the patient is euthyroid, recommend surgery.
(B) Give T3 to make the patient euthyroid quickly so that surgery need be postponed no
more than a week.
(C) Proceed to surgery as scheduled. Start levothyroxine postoperatively.
(D) Start propylthiouracil therapy before surgery.

32) A 64-year-old man is admitted with angina and found to be hyperthyroid. He is scheduled for
a cardiac catheterization. What effect is the procedure likely to have on his thyroid function?
(A) Exacerbate the hyperthyroidism
(B) Improve the hyperthyroidism
(C) If the hyperthyroidism is secondary to Graves’ disease, it may improve; if it is
secondary to toxic multinodular goiter, the hyperthyroidism may worsen
 (D) If the patient has Graves’ disease, the hyperthyroidism may worsen; if he has toxic
multinodular goiter, it may improve
33) A 25-year-old female nurse presents with palpitations and heat intolerance. Her thyroid is
not painful. TSH is _0.01 mU/L (LOW) , free T 4 is 243 nmol/L (19 _g/dL) (HIGH), and total T
3is 3.6 nmol/L radioactive iodine uptake is 0%. Thyroglobulin is low. What is the most likely
diagnosis?
(A) Graves’ disease
(B) Silent thyroiditis
(C) Toxic multinodular goiter
(D) Thyrotoxicosis factitia

34) A 29-year-old woman who uses oral contraceptives comes to the emergency room because
when she looked in the mirror this morning, her face was twisted. It felt numb and swollen.
While eating breakfast, she found that her food tasted different and she drooled out of the
right side of her mouth when swallowing. Neurologic examination discloses only a dense
right facial paresis equally involving the frontalis, orbicularis oculi, and orbicularis oris. Finger
rubbing is appreciated as louder in the right ear than in the left. The physician should
(A) instruct the patient in using a patch over the right eye during sleep
(B) recommend that she discontinue the use of oral contraceptives
(C) order brainstem auditory evoked potentials to assess her hearing asymmetry
(D) order an echocardiogram to rule out mitral valve prolapse as a source of emboli

35) A 45-year-old man presents with a daily headache. He describes two attacks per day over
the past 3 weeks. Each attack lasts about an hour and awakens the patient from sleep. The
patient has noted associated tearing and reddening of his right eye as well as nasal
stuffiness. The pain is deep, excruciating, and limited to the right side of the head. The
neurologic examination is nonfocal. The most likely diagnosis of this patient’s headache is
(A) migraine headache
(B) cluster headache
(C) tension headache
(D) brain tumor

36) During the evaluation of a patient with a gait disorder, it is noted that the patient is unable
to identify accurately the direction of examiner-initiated movement of the great toe. Pain
and temperature sense in the same distribution are intact. This abnormality reflects a lesion
in which of the following structures?
(A) Posterior column on the same side as the affected toe
(B) Spinothalamic tract on the same side as the affected toe
(C) Lower sensory neuron on the same side as the affected toe
(D) Frontal cortex on the opposite side from the affected Toe
37) A patient being evaluated for aphasia is unable to repeat sentences correctly or name
objects properly. However, the patient’s speech is effortless and melodic. There are
frequent errors in word choice and obvious difficulties in comprehension. The remainder of
the patient’s neurologic examination is normal. Damage in which area of the brain would
account for this type of aphasia?
(A) Posterior temporal and parietal lobes, dominant hemisphere
(B) Frontal and parietal lobes, dominant hemisphere
(C) Posterior parietal and temporal lobes, nondominant hemisphere
(D) Parietal and occipital lobes, nondominant hemisphere

38) The most common presenting finding or symptom of multiple sclerosis is

(A) transverse myelitis
(B) cerebellar ataxia
(C) optic neuritis
(D) urinary retention

39) The major pathologic feature of idiopathic inflammatory polyneuropathy (Guillain-Barre´

syndrome) is
(A) loss of anterior horn cells
(B) destruction of axons
(C) wallerian degeneration
(D) segmental demyelination

40) A 30-year-old woman presents with a complaint of visual difficulty. She bumps into objects
that are beside her and has noticed that she must turn her head to either side to see things
on the right and left. She also has noticed a change in her usually regular menstrual cycle.
Which test is most likely to be abnormal?
(A) Visual evoked potentials
(B) Serum prolactin level
(C) CSF protein
(D) Neuropsychological testing

41) Which of the following statements is true of Stokes-Adams attacks?

(A) They are caused by high-degree atrioventricular block.
(B) They are caused by recurrent paroxysmal tachyarrhythmias.
(C) They are usually preceded by an aura.
(D) Focal neurologic signs are common after these episodes.

42) A lesion in the corticospinal tract rather than in an anterior horn neuron projecting to
muscle cells is suggested by
 (A) spasticity
(B) marked atrophy
(C) fasciculations
(D) decreased patellar reflexes

43) Which of the following antiepileptic drugs is the most appropriate choice for a patient with
absence seizures?
(A) Ethosuximide
(B) Phenytoin
(C) Phenobarbital
(D) Lorazepam

44) A 22-year-old woman with a history of intermittent wheezing in response to exercise

presents to the emergency room with shortness of breath. Her attack occurred during an
aerobics class. At this point she is having obvious difficulty breathing and has diffuse
wheezes on pulmonary examination. O 2 saturation is 95% by pulse oximetry. The most
effective treatment at this point would be
(A) intravenous aminophylline
(B) inhaled albuterol
(C) intravenous hydrocortisone
(D) inhaled beclomethasone

45) (45) A 35-year-old man seeks medical attention for breathlessness on exertion. He has never
smoked cigarettes and has not been coughing. One sibling died of respiratory failure at 40
years of age. His three children are healthy. Physical examination reveals him to be
tachypneic as he exhales through pursed lips. His chest is tympanitic to percussion, and
breath sounds are poorly heard on auscultation. Chest x-ray shows flattened diaphragms
with peripheral attenuation of bronchovascular markings that is most noticeable at the lung
bases. Expected results of the pulmonary function testing of the man described above would
include
(A) increased lung elastic recoil
(B) increased total lung capacity
(C) reduced functional residual capacity
(D) increased vital capacity