INTERNAL MEDICINE
Instructions: Each item below contains a question or incomplete statement followed by suggested responses. Select the one best response to each question
1. A 42-year-old man develops shortness of breath (SOB) and chest pain 7 days after an open cholecystectomy. His blood pressure is 145/86 mm Hg, pulse is 120/min, respirations 24/min, and oxygen saturation of 97%.Pulmonary embolism is clinically suspected. Which of the following is the most common ECG finding of pulmonary embolism?
2. Which of the following antiarrhythmic drugs mediates its effect by interfering with movement of calcium through the slow channel?
3. A 16-year-old boy is found to have hypertension on routine evaluation. On examination, the blood pressure in his arms is higher than in his legs by more than 10 mm Hg. Which of the following is the most likely diagnosis?
4. A 57-year-old man with a 40-pack-per-year history of smoking experiences symptoms of shortness of breath on exertion. He has bilateral wheezes on expiration and increased resonance to percussion of the chest. Pulmonary function tests confirm the diagnosis of chronic obstructive lung disease (COPD). Which of the following is the best definition of this condition?
5. A 63-year-old woman presents with dyspnea and coughing up foul smelling purulent sputum. She has had many similar episodes in the past. There are no other constitutional symptoms and she denies excessive alcohol intake. On physical examination, she appears chronically ill with clubbing of the fingers. Heart sounds are normal, JVP is measured at 4 cm, and there are inspiratory crackles heard at the lung bases posteriorly. There is no hepatosplenomegaly or any palpable lymph nodes. CXR shows scaring in the left lower lobe, which on chest CT scan is identified as cystic changes with airway dilatation and bronchial wall thickening. Which of the following is the most appropriate initial next step in management?
6. An 83-year-old man with Parkinson’s disease presents with low-grade fever and cough for several weeks. Lately, he has been experiencing more rigidity and difficulty with his walking. He is on a levodopa/carbidopa combination for treatment for the past 5 years. On examination, his gait is shuffling and slow. He has a tremor in his left hand at rest, and there is cogwheel rigidity of the forearm. There are crackles in the left lower lung fiele. CXR reveals a lung abscess in the left lower lobe. Which of the following is the most likely bacteriologic diagnosis for the lung abscess?
7. A 19-year-old man presents with malaise, nausea, and decreased urine output. He was previously well, and his physical examination is normal except for an elevated jugular venous pressure (JVP) and a pericardial rub. His electrolytes reveal acute renal failure (ARF). Which of the following findings on the urinalysis is most likely in keeping with acute glomerulonephritis (GN)?
8. A 64-year-old woman has metabolic alkalosis and the bicarbonate level is 34 mEq/L. Which of the following is the most likely cause?
9. A 63-year-old woman has Type II diabetes mellitus, which is well-controlled. Her physical examination is positive for peripheral neuropathy in the feet and non proliferative retinopathy. A urinalysis is positive for proteinuria. Which of the following treatments is most likely to attenuate the course of renal disease? A. Calcium channel blockers
10. A 71-year-old man develops progressive weight loss and dysphagia over a 3-month period. Upper endoscopy and biopsy of the lesion confirm esophageal cancer. Which of the following statements regarding this cancer is most likely correct?
11. A 29-year-old man with acquired immune deficiency syndrome (AIDS) comes to the emergency department because of progressively increasing abdominal discomfort. Examination shows voluntary guarding in the upper abdomen. His biochemistry is normal except for an elevated amylase at 370 U/L (25–125 U/L). Which of the following infections can trigger this disorder in AIDS patients?
12. A 40-year-old male with long-standing alcohol abuse complains of abdominal swelling, which has been progressive over several months. He has a history of gastrointestinal bleeding. On physical exam, there are spider angiomas and palmar erythema. Abdominal collateral vessels are seen around the umbilicus. There is shifting dullness, and bulging flanks are noted. An important first step in the patient’s evaluation is
13.A paracentesis is performed on the patient previously described. The serum albumin minus ascitic fluid albumin equals 1.4 g/dL. The most likely diagnosis is
14.An 18-year-old woman has periodic episodes that begin with severely decreased vision, followed by ataxia, dysarthria, and tinnitus. The symptoms last for 30 minutes and are then followed by a throbbing occipital headache. Which of the following is the most likely diagnosis?
15. A 40-year-old man is injured in a car accident and fractures his left elbow. He now complains of numbness of his fourth and fifth fingers, and weakness in his hand grip. Neurologic findings confirm weakness of handgrip with weakness of finger abduction and adduction, and decreased sensation over the fifth finger and lateral aspect of fourth finger. Which of the following is the most likely diagnosis?
16. A 94-year-old man presents with progressive headaches, light-headedness, drowsiness, and unsteady gait over 6 weeks. On examination, his blood pressure is 160/90 mm Hg, pulse 70/min, lungs clear, and he has no focal weakness. His gait is unsteady but sensation in the feet is normal. A CT scan reveals a hyperintense clot over the left cerebral cortex. Which of the following is the most likely cause for this clot?
17. A 32-year-old man, previously well, develops a fever and dry cough. On examination, his chest is clear and heart sounds are normal. A chest x-ray (CXR) reveals a diffuse interstitial infiltrate. Which of the following is the most likely causative organism?
18. A 60-year-old man presents with fever and malaise 6 weeks after mitral valve replacement. On examination, his temperature is 38oC, blood pressure 130/80 mm Hg, pulse 80/min, and a loud pansystolic murmur at the apex, which radiates to the axilla. He has no skin or neurologic findings. Which of the following is the most likely causative organism?
19. A patient with human immunodeficiency virus (HIV) infection has progressed to developing AIDS (clinical category C). Which of the following conditions is considered an AIDS defining illness?
20. Which of the following is the most common presentation of anterior pituitary hyposecretion in a 26-year-old woman?
21. A 19-year-old woman develops weight loss, tremor, and heat intolerance. On examination, she has goiter, warm skin, and a fine tremor of her hands. Her TSH is low and her free T4 and T3 are elevated. Which of the following cardiac findings is most likely to occur in her?
22. Which of the following is the most common manifestation of multiple endocrine neoplasia, type I (MEN I)?
23. A 26-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?
24.A 63-year-old man develops pain and swelling in his knee. It appears warm, red, and swollen with decreased range of movement. A diagnostic aspiration is performed. Which of the following will most likely distinguish pseudogout from gout?
25.Which of the following statements concerning the articular manifestations of rheumatoid arthritis (RA) is correct?
26.A 19-year-old man has had recurrent bleeding occur in his knee when playing contact sports. He has no history of spontaneous bleeding, but his brother had similar problems. Consultation with a specialist reveals that he has “mild” hemophilia A. Which of the following factor abnormalities is consistent with this diagnosis?
27.A 25-year-old woman is pregnant for the first time. At prenatal assessment, she is found to have blood group A and Rhd. negative. Her husband is tested and he is Rhd. positive. Which of the following is the most appropriate initial test to determine her risk for hemolytic disease of the newborn (erythroblastosis fetalis) due to Rh incompatibility?
28. A 30-year-old black female has had a history of cough, and a chest x-ray shows bilateral hilar lymphadenopathy. A biopsy shows noncaseating granuloma. The skin lesion most consistent with the patient’s diagnosis is
29. A 50 year old man presents with tiredness, dyspnoea and paraesthesia. On examination he showed extensor plantars, brisk knee jerks and absent ankle jerks. His blood film shows macrocytic anaemia.
30. A 45 year old man with chronic glomerulo-nephritis presents with severe headache. On examination he has papilloedema and bilateral retinal haemorrhages. His BP is 240/132 mmHg.
PAEDIATRICS
Instructions: Each item below contains a question or incomplete statement followed by suggested responses. Select the one best response to each question
31. The pediatric surgeon is requesting an echocardiogram on a hospitalized newborn with a congenital defect of the gastrointestinal tract. Which of the following defects has the highest incidence of associated cardiac defects?
32. A medical student in your office is assessing a 1-week-old term infant. The mother has been exclusively breastfeeding and the student is not sure how to interpret the change in the infant’s weight compared to the birth weight. Which of the following is the expected weight flux for an infant in the first week of life?
33. You are formulating a differential diagnosis for a newborn infant with respiratory distress. Which of the following is most closely associated with the development of neonatal respiratory distress syndrome (hyaline membrane disease)?
34. You are seeing a healthy, full-term infant just after delivery. The mother plans on breast-feeding the baby and asks you how long immunity transferred to the baby from the pregnancy would be present. When does passively transferred maternal IgG antibody reach a nadir?
35. The mother of a 6-month-old child seeing you for a well visit, requests immunization against measles as she has heard it is present in the community. At what age should the first dose of live attenuated measles vaccine (as MMR) be routinely administered in the absence of a community measles outbreak?
36. A 15-year-old female comes to your office with 4-day history of fever and cough. Chest x-ray findings include bilateral patchy infiltrates. Oxygen saturation is normal. What is the most likely etiology of her pneumonia?
37. A 5-year-old unimmunized child fell while playing in an old barn and sustained a laceration to his leg. After local wound care, what would be the most appropriate management regarding tetanus prophylaxis?
38. You are in a health clinic in Cameroon. An 18-month old child is brought in for your help. On inspection you note that the child is edematous, has a dark desquamating skin rash over most of the pressure points on the Page 347 of 463 body, has very thin hair, and what hair is left is reddish in color. Of the following, what laboratory test is most likely to be present?
39. A worried mother brings her 2-year-old to the pediatrician for a well-child check. She is concerned because the child still has only 50 words in his vocabulary. Which of the following best describes the characteristic age of a toddler who speaks 50 words?
40. An 11-month-old girl presents to your emergency department with irritability, fever, and stiff neck. When performing the lumbar puncture in this child, you should
41. You suspect the diagnosis of a brain tumor in a 2-year-old girl with a recent history of ataxia, slurred speech, and early morning vomiting. Which statement about childhood brain tumors is true?
42. A 2-year-old toddler has a large abdominal mass and pancytopenia. Which of the following diagnoses would most likely be established by bone marrow aspiration?
43. The family of a child just diagnosed with acute lymphoblastic leukemia asks for information about the child’s prognosis. Included as a poor prognostic sign is which of the following?
44. A 1-year-old child presents with failure to thrive, frequent large voids of dilute urine, excessive thirst, and three episodes of dehydration not associated with vomiting or diarrhea. Over the years, other family members reportedly have had similar histories. The likely diagnosis is
45. A 2 year old boy presents with painless jelly-like blood in his stool. Full blood count shows an iron-deficiency anaemia. What is the single most likely diagnosis?
46. A 10 year old boy is given amoxicillin for otitis media. He presents an anaphylactic shock. His mother was not aware that amoxicillin was in the same class as penicillin and had not informed the doctor that the child was allergic to penicillin. What is the single most appropriate initial treatment?
47. A mother brings in her 15 month old for a measles, mumps, rubella vaccine. She informs you that she and her baby have HIV. What is the single most appropriate course of action?
48. A 14 year old boy complains of sudden pain in his groin after cycling 10 kilometres. What is the single most likely diagnosis?
49. A 4 year old girl presents with bloody diarrhoea and crampy abdominal pain. Blood tests show anaemia and thrombocytopenia. What is the most likely diagnosis?
50. A child presents with malabsorption and bronchiectasis with progressive productive cough and green sputum. What is the most likely diagnosis?
SURGERY AND ANAESTHESIA
Instructions: Each item below contains a question or incomplete statement followed by suggested responses. Select the one best response to each question
51. Five days after an uneventful cholecystectomy, an asymptomatic middle-aged woman is found to have a serum sodium level of 120 meq/L. Proper management would be:
52. A 65-year-old man undergoes a technically difficult abdominoperineal resection for a rectal cancer during which he receives three units of packed red blood cells. Four hours later in the intensive care unit he is bleeding heavily from his perineal wound. Emergency coagulation studies reveal normal prothrombin, partial thromboplastin, and bleeding times. The fibrin degradation products are not elevated but the serum fibrinogen content is depressed and the platelet count is 70,000/µL. The most likely cause of the bleeding is
53. A victim of blunt abdominal trauma requires a partial hepatectomy. He is rapidly transfused with 8 units of appropriately crossmatched packed red blood cells from the blood bank. He is noted in the recovery room to be bleeding from intravenous puncture sites and the surgical incision. His coagulopathy is likely due to thrombocytopenia and deficiencies of which clotting factors?
54. Compensatory mechanisms during acute hemorrhage include
55. An 18-year-old woman develops urticaria and wheezing after an injection of penicillin. Her blood pressure is 120/60 mm Hg, heart rate is 155 beats/min, and respiratory rate is 30 breaths/min. Immediate therapy should include
56. Which of the following statements regarding carpal tunnel syndrome is correct?
57. Which of the following conditions is most likely to follow a compression-type abdominal injury?
58. Among the physiologic responses to acute injury is
59. True statements regarding Paget’s disease of the breast include that it:
Questions 60-61 A 45-year-old woman is explored for a perforated duodenal ulcer 6 h after onset of symptoms. She has a history of chronic peptic ulcer disease treated medically with minimal symptoms.
60. The procedure of choice is
61. Six weeks after surgery, the patient returns complaining of postprandial weakness, sweating, lightheadedness, crampy abdominal pain, and diarrhea. The best management would be
62. Correct statements regarding rectal carcinoid tumors include
63. A noncyanotic 2-day-old child has a systolic murmur along the left sternal border; the examination is otherwise normal. Chest X-ray and electrocardiogram are normal. These findings are most closely associated with which of the following congenital cardiac anomalies?
64. A 2-year-old asymptomatic child is noted to have a systolic murmur, hypertension, and diminished femoral pulses. Which of the following is true about this child’s disorder?
65. The condition shown in the X-rays below is compatible with which of the following manifestations?
66. Which of the following statements regarding benign prostatic hyperplasia (BPH) is true?
67. Volkmann’s ischemic contracture is associated with
68. Which of the following statements regarding compartment syndromes following orthopedic injuries is true?
69. Controlled hyperventilation (induced hypocapnia) is frequently recommended following head trauma. The therapeutic consequences of this therapy include
70. Which of the following statements regarding skull fractures is true?
OBSTETRICS AND GYNAECOLOGY
Instructions: Each item below contains a question or incomplete statement followed by suggested responses. Select the one best response to each question
71. A 24-year-old woman has had three first-trimester spontaneous abortions. Which of the following statements concerning chromosomal aberrations in abortions is true?
72. The placenta of twins may be
73. A pelvis characterized by an anteroposterior diameter of the inlet greater than the transverse diameter is classified as
74. A patient comes to your office with last menstrual period (LMP) 4 weeks ago. She denies any symptoms such as nausea, fatigue, urinary frequency, or breast tenderness. She thinks that she may be pregnant because she Page 358 of 463 has not gotten her period yet and is very anxious to find out because she has a history of a previous ectopic pregnancy and wants to be sure to get early prenatal care. Which of the following evaluation methods is most sensitive in diagnosing pregnancy?
75. A 28-year-old G1P0 presents to your office at 18 weeks gestational age for an unscheduled visit secondary to right-sided groin pain. She describes the pain as sharp and occuring with movement and exercise. She denies any change in urinary or bowel habits. She also denies any fever or chills. The application of a heating pad helps alleviate the discomfort. As her obstetrician, what do you tell this patient is the most likely etiology of this pain?
76. Which of the following statements concerning placenta previa is true?
77. True statements about pregnancy-induced hypertension include which of the following?
78. A pregnant woman is discovered to be an asymptomatic carrier of Neisseria gonorrhoeae. A year ago, she was treated with penicillin for a gonococcal infection and developed a severe allergic reaction. Treatment of choice at this time is
79. When treating urinary tract infection (UTI) in the third trimester, the antibiotic of choice should be
80. A 21-year-old G2P1 with a history of asthma presents to the emergency room at 25 weeks gestational age complaining of an acute exacerbation of her asthma. On presentation, she is tachypneic and struggling to breathe. All of the following are appropriate next steps in the management of this patient except
81. In the mother, suckling leads to which of the following responses?
82. A 21-year-old has difficulty voiding 6 h postpartum. The least likely cause is which of the following?
83. An 18-year-old consults you for evaluation of disabling pain with her menstrual periods. The pain has been present since menarche and is accompanied by nausea and headache. History is otherwise unremarkable, and pelvic examination is normal. You diagnose primary dysmenorrhea and recommend initial treatment with which of the following?
84. Which of the following findings characterizes a normal semen sample?
85. A 59 year old-postmenopausal woman presents with a month’s history of per vaginal bleeding. On speculum examination, the cervix appears normal and there is no vaginal discharge. What is the single most appropriate diagnostic test?
86. A 15 year old school girl complains of period pains. She has a regular cycle. What is the single most appropriate management?
87. A 40 year old woman has an antenatal serum triple marker test. The alpha foeto-protein and oestriol levels are low but the hCG is twice normal. What is the single most likely potential diagnosis?
88. A 46 year old woman informs you that her mother was diagnosed with ovarian cancer at age 55. She is concerned as she now smokes, drinks and is on HRT(hormone replacement therapy). What is the single most appropriate management?
89. A 45 year old woman reports nipple changes. On examination, there are scaly, erythematous plaques on and around the inverted nipple. On squeezing the nipple, a serosanguinous discharge appears. What is the single most likely diagnosis?
90. A 40 year old woman with a pregnancy of 34/40 weeks is noted to have an incidental BP of 160/100mmHg on an antenatal review. She denies blurring vision. There is no proteinuria and no signs of peripheral oedema. Blood tests are normal. What is the single most appropriate management?
PUBLIC HEALTH
Instructions: Each item below contains a question or incomplete statement followed by suggested responses. Select the one best response to each question
91. In nine families surveyed, the numbers of children per family were 4, 6, 2, 2, 4, 3, 2, 1, and 7. The mean, median, and mode numbers of children per family are, respectively,
Questions 92-94 The results of a study of the incidence of pulmonary tuberculosis in a village in Cameroon are given in the table below. All persons in the village are examined during two surveys made two years apart, and the number of new cases was used to determine the incidence rate.
92. What is the incidence of new cases per 1000 person-years in house-holds that had a culture-positive case during the first survey?
93. What is the incidence of new cases per 1000 person-years in households that did not have a culture-positive case during the first survey?
94. What is the relative risk of acquiring tuberculosis in households with a culture-positive case compared with households without tuberculosis?
95. In a study of the cause of lung cancer, patients who had the disease were matched with controls by age, sex, place of residence, and social class. The frequency of cigarette smoking was then compared in the two groups. What type of study was this?
96. The use of matching as a technique to control for confounding is most appropriate for which type of study?
Questions 97-98 On a Friday afternoon, a 30-year-old nurse is brought to employee health for evaluation following a needle-stick injury that occurred at the AIDS clinic. The source patient is known to be infected with HIV and has advanced AIDS.
97. Which of the following factors carries the greatest risk for transmission of HIV to the health care worker?
98. Which is the most appropriate course of action for this health care worker?
99. Which of the following substances is causally associated with pneumoconiosis?
100. A 15-year-old girl presents to your office because she has been having vaginal discharge. In the course of the history, she informs you that she is sexually active with her boyfriend who is also 15 years of age. The examination reveals mucopurulent cervicitis, but no lower abdominal, cervical motion or adnexal tenderness. The most appropriate intervention is to
