INTERNAL MEDICINE
Instructions: Questions 1-5 : For each case below, choose the single most appropriate diagnosis from the list of options proposed.
1. A 53 year old unemployed alcoholic presents with haematemesis, a history of alcoholic liver disease and ascites. What is the single most likely diagnosis
2. A 65 year old man presents with progressive jaundice, anorexia and weight loss. What is the single most likely diagnosis?
3. A 24 year old athlete attends a routine medical insurance health assessment. His resting pulse is 48 beats/min with a regular rhythm and his blood pressure is 106/70mmHg. What is the single most likely diagnosis?
4. A 35 year old woman complains of severe pain on defecation. She is unable to tolerate digital rectal examination. She has a history of constipation. What is the single most likely diagnosis?
5. A 30 year old woman presents with 2 weeks of fever, rigors and productive rusty cough. Chest x-ray shows a left lower lobe consolidation. What is the single most likely organism?
6. An 80 year old woman is brought in by her family as they are concerned as she has been getting progressively more confused over the past few months. She is disoriented to time, place and person and often wanders the streets aimlessly. What is the single most likely diagnosis?
7. A 50 year old alcoholic presents with mild jaundice and epistaxis. What is the single most appropriate investigation?
8. A 55 year old man with new-onset dyspepsia reports no relief with antacids. What is the single most appropriate management?
9. A 55 year-old woman presents with a plaque like lesion on her lower calf and a painless ulcer on the sole of her foot. What is the single most useful investigation?
10. A 70 year old man presents with both back pain and acute renal failure. What is the single most likely diagnosis?
11. A 22 year old HIV positive individual on anti-retroviral therapy presents with Pneumocystis jeroveci pneumonia.
12. A 22 year old student with mild asthma that needs treatment for occasional early morning wheeze.
13. A 55 year old man admitted with acute myocardial infarction develops a short run of ventricular tachycardia (VT). He requires treatment for prophylaxis against recurrent ventricular tachycardia.
14. A 50 year old man presents with right sided hemiparesis. There is a bruit on neck auscultation. What is the single most appropriate investigation?
15. A 33 year old woman is found to have a solitary 2.5cm nodule in the left side of the thyroid. What is the single most definitive investigation?
16. A 63-year-old woman develops exertional angina and has had two episodes of syncope. Examination of the heart shows a systolic ejection murmur with radiation to the carotids and a soft S2. Which of the following is the most likely diagnosis?
17. 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?
18. 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?
19. 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?
20. A 63-year-old man has stools positive for occult blood. Which of the following is the most likely location of bowel cancer?
21. 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?
22. 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?
23. 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?
24. 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?
25. 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?
26. 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?
27. 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?
28. Which of the following differentiates a patch from a macule?
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. A 45 year old man is referred to you because of breathlessness. You diagnose a pleural effusion which you aspirate. You find that it is rich in eosinophils. What is the single least likely diagnosis among the following Conditions?
PAEDIATRICS
Instructions: Questions 31-35 : For each presentation below, choose the most correct answer from the list of options proposed.
31. 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?
32. An 18 month old boy presents with a hoarse barking cough and inspiration stridor. What is the single most likely micro-organism?
33. A neonate develops jaundice 6 hours after delivery. The neonate has a positive direct Coombs test and the bilirubin is 150mmol/l with a haematocrit of 48%. What is the single most likely diagnosis?
34. A 4 year old boy accidentally swallowed some tablets. On examination, pupils are pinpoint and respirations are shallow with marked hypotonia. What is the single most likely diagnosis?
35. A child due for haemophilus influenzae vaccine (Hib), DPT etc is suffering from an acute febrile illness. What is the best conduct to adopt?
36. Infant presenting a flat face, slanting eyes, simian crease, hypotonia and learning difficulties.
37. A 12 year old girl presents with a 3 day history of fever and a 3cm warm, tender and fluctuant right anterior cervical lymph node. What is the single most likely diagnosis?
38. The following results are obtained after investigating a child: Decreased haemoglobin, mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH) and mean corpuscular haemoglobin concentration (MCHC). Increased total iron binding capacity. What is the single most likely diagnosis?
39. A 6 year old boy presents with mild fever and maculopapular rash. His mother reported that the rash started on the face then became generalized. On examination, there is palpable cervical and occipital lymphadenopathy. What is the single most likely diagnosis?
40. 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 single most likely diagnosis?
41. A 12 year old girl presents with marked oedema. Blood tests show hypo-albuminaemia. Urine shows heavy proteinuria. What is the most likely diagnosis?
42. 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?
43. 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?
44. 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:
45. 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?
46. 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?
47. 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 48-50: For each statement below, choose the single most appropriate age from the list of options proposed
48. Dresses and undresses almost independently:
SURGERY-ANAESTHESIA
Instructions: Questions 51-60 : For each question or statement below, choose the correct answer from the list of options proposed.
51. Which of the following features is in keeping with a postoperative opiate overdose:
52. Postoperative atelectasis is more common in which of the following?
53. Which of the following is a classical feature of a perforated peptic ulcer:
54. Necrotizing pancreatitis:
55. In small bowel mesenteric ischaemia, the following statements are true, except:
56. A sliding type inguinal hernia:
57. An overweight 45 year old mother of four has used pads to control leakage of urine for 5 years. She has a “smoker’s” cough. She is now finding it difficult to afford the pads and asks for treatment. Which of the propositions below is correct?
58. Which one of the following is true of cerebrovascular accidents?
59. Which one of the following statements concerning fluid and electrolyte balance is correct?
60. An abdominal wound dehiscence:
61. A 78-year-old man with a history of coronary artery disease and an asymptomatic reducible inguinal hernia requests an elective hernia repair. You explain to him that valid reasons for delaying the proposed surgery include
62. Following celiotomy, normal bowel motility can ordinarily be presumed to have returned:
63. The preoperative characteristics of patients likely to experience postoperative ischemia after non-cardiac surgery include:
64. 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:
65. Which of the following statements is true regarding the effects of colon resection?
66. 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
67. Optimal management of bilateral undescended testicles in an infant is
68. Meniscal tears usually result from which of the following circumstances?
69. Which nerve is most at risk in the injury in the accompanying radiograph?
70. In contrast to closed reduction, open reduction of a fracture:
OBSTETRICS AND GYNAECOLOGY
Instructions 71-75: For each presentation below, choose the single best answer from the different options proposed.
71. A 36 year old woman is found to have blocked fallopian tubes on laparoscopy and hysterosalpingography. The uterus is normal. What is the single most appropriate next form of treatment?
72. 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?
73. A 40 year old woman is brought in emergency with shock and profuse vaginal bleeding. She had delivered her third baby at home. On examination a low transverse scar is noted. What is the single most likely diagnosis?
74. A 25 year old primipare fails to progress in the first stage of labour. What is the single most appropriate management?
75. A 16 year old girl requires contraception. She has been seeing her 17 year old steady boyfriend for one month and would like to become intimate. What is the single most appropriate form of contraception?
76. Detection of intrauterine malformation and pathology:
77. A 23 year old smoker is started on a combined oral contraceptive pill for the first time. She returns 2 months later complaining of intermenstrual bleeding.
78. An 18 year old woman presents with a 6 months history of secondary amenorrhoea, hirsutism, and weight gain of 4 kg. She has suffered from irregular periods since mensarche at the age of 13. Her BMI is 31.
79. A 21 year old student presents to emergency with severe left iliac fossa pain. Her last period was 3 weeks ago. An ultrasound shows an echogenic structure of 5cm diameter in the left fornix
80. A 45 year old woman reports a green discharge from her right nipple. She is concerned. On exam, there are no lumps and no axillary lymphadenopathy. There is redness and tenderness around the nipple. What is the single most likely diagnosis?
Questions 81-82 An 18-year-old G2P1001 with a last menstrual period on 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.
81. All of the following should be performed at each prenatal visit except
82. What is this patient’s estimated date of confinement?
83. Which of the following statements concerning appendicitis in pregnancy is true?
84. 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?
85. 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?
86. 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?
87. 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
88. 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?
89. The triple test of a 23 year old female showed that her baby was in increased risk of developing Down’s syndrome. Your next step to confirm this diagnosis will be:
90. A 28 year old obese female presents in early labour. On vaginal examination there is an “empty” pelvis. What is the single most appropriate step of management?
PUBLIC HEALTH
Instructions: Questions 91-92: For each question or statement below, choose the correct answer amongst the options proposed.
91. The ability of a test to detect people who do have the disease is called:
92. The best indicator of central value when one or more of the lowest or the highest observations are wide apart or not so evenly distributed is:
Instructions: Questions 93-96: For each of the infectious diseases of childhood below, select the most appropriate incubation period.
94. Pertussis (whooping cough) :
96. Infectious mononucleosis:
Instructions: Questions 97-100: Each item below contains a question or incomplete statement followed by suggested responses. Select the one best response to each question
97. Which of the following measures is used frequently as a denominator to calculate the incidence rate of a disease?
98. You are preparing a report to present to the Public Health Council on the declining rates of gonorrhea in your region in both men and women over the last 10 years. Which type of graph would best illustrate the data?
Questions 99-100 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.
99. Which is the most likely etiologic agent responsible for these findings?
100. 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?
