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 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?
2. A 32-year-old asymptomatic woman has a rapidly rising, forceful pulse that collapses quickly. Which of the following is the most likely diagnosis?
3. A 62-year-old man has progressive symptoms of dyspnea, and more recently noticed difficulty lying supine. Examination shows an elevated JVP at 8 cm, with a third heart sound, pedal edema, and bibasilar crackles on auscultation. Which one of the following may be implicated in fluid retention for this condition?
4. A 40-year-old man has a routine CXR, which reveals a posterior mediastinal mass. Which of the following is the most likely diagnosis?
5. A 66-year-old man with chronic alcoholism has had a low grade fever and cough for several weeks. His heart sounds are normal and there are crackles in the left lower base. A CXR reveals a left lower lobe lung abscess. Which of the following is the most appropriate therapy?
6. A 40-year-old alcoholic develops cough and fever. Chest x-ray shows an air-fluid level in the superior segment of the right lower lobe. The most likely etiologic agent is
7. A 68-year-old woman has used large amounts of analgesic for years to relieve severe headaches and arthritis. She now has an elevated urea and creatinine consistent with chronic renal failure. Which of the following changes in the kidney is most likely seen with her diagnosis?
8. A 32-year-old man has trace proteinuria on dipstick urinalysis. A 24-hour urine collection reveals 380 mg/day of protein excretion in the urine. Which of the following statements concerning this degree of proteinuria is correct?
9. A 63-year-old man has stools positive for occult blood. Which of the following is the most likely location of bowel cancer?
10. A 55-year-old man is known to have chronic liver disease, secondary to hepatitis B infection. He has recently felt unwell, and his hemoglobin level has increased from 130 g/L, 1 year ago, to 195 g/L. Which of the following is the most appropriate initial diagnostic test?
11. A 50-year-old black male with a history of alcohol and tobacco abuse has complained of difficulty swallowing solid food for the past 2 months. More recently, swallowing fluids has also become a problem. He has noted black, tarry stools on occasion. The patient has lost 10 kg. Which of the following statements is correct?
12. A 74-year-old woman develops acute neurologic symptoms and presents to the emergency room. An urgent magnetic resonance imaging (MRI) scan demonstrates acute occlusion in the right posterior cerebral artery. Which of the following clinical symptoms is she most likely to have?
A 63-year-old man developed a transient episode of vertigo, slurred speech, diplopia, and paresthesias. He is symptom-free now, and clinical examination is entirely normal. His past medical history is significant for hypertension and dyslipidemia. Which of the following is the most likely cause for his symptoms?
14. A 27-year-old man presents with symptoms of fever, chills, malaise, and joint discomfort in his hands and knees. He looks unwell, his temperature is 39.4oC, blood pressure 115/70 mm Hg, pulse 110/min, head and neck is normal, and his jugular venous pressure (JVP) has a prominent c-v wave. There is also a 3/6 pansystolic murmur heard at the right sternal border that increases with respiration. His lungs are clear, abdomen is soft, and hand joints are normal. He has multiple puncture sites on his forearms from injection drug use. Which of the following is the most likely causative organism?
15. An elderly bedridden patient in the hospital develops cough, fever, and shortness of breath. On examination, the JVP is 4 cm, heart sounds are normal, and there are crackles on inspiration in the right lower lobe. A CXR reveals a new right lower lobe infiltrate and his WBC is 15,000/mL. He was admitted to the hospital 7 days ago for the treatment of congestive heart failure. Which of the following is the most likely diagnosis?
16. A 24-year-old man with known HIV infection presents with a right hemiparesis that developed over several days. Cognitive examination reveals global impairment, and a computed tomography(CT) scan reveals multiple cortical lesions that are spherical and ring enhancing. Which of the following is the most likely diagnosis?
17. A 19-year-old woman presents with primary amenorrhea. Her physical examination is normal, and she has female sex characteristics and breast development. The only abnormality is the absence of body hair. Genetic testing reveals an XY chromosome pattern. Which of the following mechanisms is most likely to explain her phenotypic pattern and amenorrhea?
18. A patient with polyuria and polydipsia is newly diagnosed with central diabetes insipidus (DI). Which of the following is the most likely finding on magnetic resonance imaging (MRI) of the brain?
19. A 61-year-old woman with poorly controlled Type II diabetes is seen in follow-up. Her blood sugars are persistently elevated to levels greater than 200 mg/dL. On examination, she is obese, blood pressure 165/90 mm Hg, pulse 80/min, and there is sensory loss in the feet. Which of the following fasting lipid profiles is most likely to be consistent with her values?
20. A 32-year-old woman develops symptoms secondary to a dry mouth and dry eyes. She has enlarged salivary glands. Studies for auto-antibodies to Ro (SS-A) are positive. A salivary gland biopsy reveals lymphocytic infiltration. Which of the following is the most likely diagnosis?
21. A 79-year-old woman on chronic hemodialysis presents with severe pain in her left knee. On examination, the knee is warm, swollen, and painful to move. Diagnostic joint aspiration is performed. Which of the following is the most likely finding in her joint fluid?
22. Which of the following is the most likely effect of increased levels of red blood cell 2,3 diphosphoglycerate (2,3-DPG)?
23. A 57-year-old man, with a history of chronic alcohol ingestion, is admitted to the hospital with acute alcoholic intoxication and lobar pneumonia. Physical examination reveals pallor; a large, tender liver; and consolidation of the right lower lobe. Laboratory data include hemoglobin of 7 g/dL, WBC of 4000/mL, and platelet count of 85,000/mL. Which of the following is the most likely factor for the anemia?
24. A 62-year-old man presents with dark tarry stools and light-headedness. Upper endoscopy finds an ulcerating lesion in his stomach and biopsies confirm gastric cancer. Which of the following is a risk factor for carcinoma of the stomach?
25. A 23-year-old man is newly diagnosed with Hodgkin’s lymphoma. Which of the following is the most likely presenting symptom of this type of lymphoma?
26. A 22-year-old woman develops an acute contact dermatitis to a household-cleaning agent. Which of the following treatments is most appropriate during the bullous, oozing stage?
27. Which of the following differentiates a patch from a macule?
28. A 78 year old man has been short of breath for a few weeks. His chest radiography shows a right basal shadow rising towards the axilla.
29. A 55 year old man presents with breathlessness. You suspect heart failure. Which single investigation for heart failure has been shown to be the most cost effective?
30. Standard therapy for community acquired pneumococcal pneumonia not requiring hospital admission.
PAEDIATRICS
Instructions: Each item below contains a question or incomplete statement followed by suggested responses. Select the one best response to each question
31. A 3-day-old infant is requiring phototherapy for hyperbilirubinemia. Which of the following risk factors best predicts the occurrence of ABO isoimmune hemolytic disease in a newborn?
32. A healthy term infant is circumcised and experiences excessive blood loss eventually requiring transfusion. The most likely diagnosis is which of the following?
33. The mother of a baby tells you that she has read that breast-feeding immunity is different than that acquired in utero. What is the major source of immunity conferred in breast milk?
34. A 3-month-old infant has had upper respiratory symptoms for a few days and presents to the emergency department with respiratory distress, wheezing, and hypoxia. You diagnose bronchiolitis. What is the most common cause of acute bronchiolitis in infants?
35. The parents of a 1-month-old female infant bring their daughter to the emergency department for febrile illness. The parents deny any localizing symptoms, but report fussiness. You proceed with laboratory evaluation including complete blood count, urinalysis with culture, blood culture, and CSF examination. The most common serious bacterial infection encountered in a febrile 1-month-old infant is
36. You are attending in the newborn nursery and are informed that a baby was born to a mother with human immunodeficiency virus (HIV). What is the best test to diagnose HIV infection in this infant?
37. A 23-month-old female is hospitalized for severe malnutrition. Which of the following problems is most likely to be the result of inappropriately rapid treatment of the severely malnourished child?
38. A 6-month-old girl, comes in for her checkup with her mother and grandmother. A look in the girl’s mouth reveals no teeth. What is the usual age for the eruption of the primary teeth?
39. An 18-month-old child is brought to the emergency center after the family reports she had a seizure. They note that the child was in her normal good state of health at bedtime, but when they went to investigate noises they heard coming from her room they found her having “a seizure.” They picked her up to put her on the floor and noticed that she was very warm. Her tonic-clonic activity resolved, and by the time they have reached the emergency room she appears to be back to her normal state of good health. Which of the following statements is supportive of this child’s having had a simple febrile seizure?
40. About 12 days after a mild upper respiratory infection, a 12-year-old boy complains of weakness in his lower extremities. Over several days, the weakness progresses to include his trunk. On physical examination, he has the weakness described and no lower extremity deep tendon reflexes, muscle atrophy, or pain. Spinal fluid studies are notable for elevated protein only. The most likely diagnosis in this patient is:
41. A 5-year-old boy has severe pharyngitis and culture is positive for group A streptococci. Of the following suppurative and nonsuppurative complications of group A streptococcal pharyngitis and skin infections, which is associated only with pharyngeal infections?
42. A 15-year-old female has a 1 year history of secondary amenorrhea. She is an avid gymnast and has an intense fear of becoming fat. Her weight is at 80% of ideal body weight. For what long-term irreversible complication is this patient at greatest risk?
43. A 6-week-old child is being evaluated for a fever of unknown etiology. As part of the laboratory evaluation, a urine specimen was obtained that grew Escherichia coli with a colony count of 2000/μL. These findings would be definite evidence of a urinary tract infection if the sampled urine
Questions 44-46: For each statement choose the single most appropriate age from the list of options proposed
44. Dresses and undresses almost independently
47. A full term new born becomes jaundiced 14 hours after delivery. His blood results confirm indirect bilirubinaemia and metabolic acidosis. His parents are both rhesus negative. What is the most likely diagnosis?
48. An infant was referred for heart failure and cyanosis. On examination, there was elevated jugular venous pressure, hepatomegaly, pansystolic murmur at the lower left sternal edge and third heart sound. Chest radiography showed a large globular heart. ECG showed right bundle branch block. What is the most likely diagnosis?
49. A 12 year old girl presents with marked oedema. Blood tests show hypo-albuminaemia. Urine shows heavy proteinuria. What is the most likely diagnosis?
50. A 10 year old boy presents with nocturnal enuresis, easy fatiguability and poor progress at school. On examination he looks short and is normotensive. Blood tests show hypokalaemic hypochloraemic alkalosis. 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. A 78-year-old man with a history of coronary artery disease and an asymptomatic reducible inguinal herniarequests an elective hernia repair. You explain to him that valid reasons for delaying the proposed surgeryinclude
52. Following celiotomy, normal bowel motility can ordinarily be presumed to have returned
53. The preoperative characteristics of patients likely to experience postoperative ischemia after non-cardiac surgery include
54. During blood transfusion, clotting of transfused blood is associated with
55. With regard to wound healing, which one of the following statements is correct?
56. Which of the following is true with regard to wound contraction?
57. A 27-year-old man sustains a single gunshot wound to the left thigh. In the emergency room he is noted to have a large hematoma of his medial thigh. He complains of paresthesias in his foot. On examination there are weak pulses palpable distal to the injury and the patient is unable to move his foot. The appropriate initial management of this patient would be
58. After the first postoperative year of cardiac transplantation, the most common cause of death is
59. Which of the following statements is true of the major histocompatibility complex (MHC) proteins?
60. A 55-year-old man complains of chronic intermittent epigastric pain, and gastroscopy demonstrates a 2-cm ulcer of the distal lesser curvature. Endoscopic biopsy yields no malignant tissue. After a 6-week trial of H 2 blockade and antacid therapy, the ulcer is unchanged. Proper therapy at this point is
61. Which of the following statements is true regarding the effects of colon resection?
62. A previously healthy 20-year-old man is admitted to a hospital with acute onset of left-sided chest pain. The electrocardiographic findings are normal but chest X-ray shows a 40% left pneumothorax. Treatment consists of which of the following procedures?
63. Two days after admission to the hospital for a myocardial infarction, a 65-year-old man complains of severe, unremitting midabdominal pain. His cardiac index is 1.6. Physical examination is remarkable for an absence of peritoneal irritation or distention despite the patient’s persistent complaint of severe pain. Serum lactate is 9 (normal less than 3). In managing this problem you should
64. The recommended treatment for stage A (superficial and submucosal) transitional cell carcinoma of the bladder is
65. Optimal management of bilateral undescended testicles in an infant is
66. Genitourinary tuberculosis in a male patient is suggested by which of the following findings?
67. Meniscal tears usually result from which of the following circumstances?
68. Which nerve is most at risk in the injury in the accompanying radiograph?
69. In contrast to closed reduction, open reduction of a fracture:
70. While watching a golf tournament, a 37-year-old man is struck on the side of the head by a golf ball. He is conscious and talkative after the injury, but several days later he is noted to be increasingly lethargic, somewhat con-fused, and unable to move his right side.
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 36-year-old G0 who has been epileptic for many years is contemplating pregnancy and wants to go off her anticonvulsant medications because she is concerned regarding the adverse effects that these medications may have on her unborn fetus. All of the following statements are true regarding epilepsy and pregnancy except
72. Velamentous insertion of the cord is associated with an increased risk for
73. Following a cesarean birth, contraindications for a trial of labor in a subsequent pregnancy include
Questions 74-75 Page 391 of 463 An 18-year-old G2P1001 with a last menstrual period of May 7 presents for her first obstetrical (OB) visit at 10 weeks. The patient had a previous pregnancy complicated by gestational diabetes and delivered a 4.05kg baby boy via cesarean section after a long labor.
74. All of the following should be performed at each prenatal visit except
75. What is this patient’s estimated date of confinement?
76. A patient at 17 weeks gestation is diagnosed as having an intrauterine fetal demise. She returns to your office 5 weeks later and has not had a miscarriage, although she has had some occasional spotting. This patient is at increased risk for
77. Which of the following statements concerning appendicitis in pregnancy is true?
78. Which of the following statements concerning hepatitis infection in pregnancy is true?
79. During the evaluation of secondary amenorrhea in a 24-year-old woman, hyperprolactinemia is diagnosed. Which of the following conditions could cause increased circulating prolactin concentration and amenorrhea in this patient?
80. A 22-year-old primiparous woman is in premature labor at 30 weeks’ gestation. Despite administration of tocolytic agents, it seems she will deliver soon. Pulmonary maturity might be enhanced by the administration of which of the following drugs?
81. An 18-year-old nullipara has suddenly stopped menstruating. She recently lost 8.6 kg when she started longdistance running. The laboratory test most consistent with her cause of secondary amenorrhea is which of the following?
82. A 35 year old woman presents with a discrete breast lump that persists after her next period. What is the single most appropriate management?
83. A 25 year old primipare fails to progress in the first stage of labour. What is the single most appropriate management
84. A 25 year old woman would like to know the mode of action of the mini-pill. What is the single best answer?
85. A 20 year old woman presents with heavy periods. She states her periods are irregular. She has a new boyfriend. Her smear test is up-to-date and normal. What is the single most appropriate management?
86. A 30 year old woman complains of 7 months of amenorrhoea, facial hair and acne. She has put on 2kg in the past month. What is the single most likely diagnosis?
87. A 40 year old woman requests contraception. She has always had heavy painful periods. She has 3 children. She is needle phobic and has a busy schedule. What is the single most appropriate form of contraception?
88. A 35 year old multiparous woman with a pregnancy of 27 weeks presents with painless bright red per vaginal bleeding and hypotension. What is the single most likely diagnosis?
89. A 31 year old woman has delivered with a complete placenta praevia by caesarian section. Two hours later, she is noted to have significant post partum haemorrhage
90.A 40 year old woman presents with a 3-month history of dyspareunia and post-coital bleeding. She has been a smoker for 20 years. She has had four normal deliveries and a miscarriage in the past. Her last smear was 3 years ago and showed mild dyskariosis.
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. Which of the following measures is used frequently as a denominator to calculate the incidence rate of a disease?
92. In the study of the cause of a disease, the essential difference between an experimental study and an observational study is that in the experimental investigation
Questions 93-94 The incidence rate of lung cancer is 120/100,000 person-years for smokers and 10/100,000 person-years for nonsmokers. The prevalence of smoking is 20% in the community.
93. What is the relative risk of developing lung cancer for smokers compared with nonsmokers?
94. What percentage of lung cancer can be attributed to smoking?
95. You are preparing a report to present to the Public Health Council on the declining rates of gonorrhea in your state in both men and women over the last 10 years. Which type of graph would best illustrate the data?
96. Immunization of preschool children with diphtheria toxoid results in
Questions 97-98 An 18-year-old sexually active college student presents with complaints of lower abdominal pain and irregular bleeding for five days. She has no fever. She uses oral contraceptives as method of birth control. Upon examination, the cervix is friable, there is cervical motion tenderness and adnexal tenderness. The pregnancy test is negative.
97. Which is the most likely etiologic agent responsible for these findings?
98. She tells you that she had a similar episode two years ago. What is her risk of infertility following this second clinical episode of pelvic inflammatory disease?
99. A 10-year-old boy with sickle cell disease presents with headache, anorexia, and fever. He complains of pain in the right tibia and local inflammation is noted. Osteomyelitis is diagnosed. The most likely etiologic agent is
100. Which of the following is NOT a medical ethics basic principle?
