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CARDIOLOGY

1. Which of the following is not a known side effect of the thiazide diuretics?
A. hypokalemia
B. Impotence
C. Hypercalciuria
D. Gout
E. Altered plasma-lipid concentrations

2. Diabetes is associated with all of the following in the elderly except:


A. cerebrovascular accident
B. cognitive decline
C. fall risk
D. myocardial infarction
E. urinary incontinence

3.Which of the following is not a common cause of persistent cough lasting more than 3 months
in a nonsmoker?
A. Asthma
B. Gastroesophageal reflux disease
C. Lisinopril
D. Mycoplasma infection
E. Postnasal drip

4.A 78-year-old male presents to the clinic complaining that every time he shaves with a
straight razor, he passesout. His symptoms have been occurring for the last 2 months.
Occasionally, when he puts on a tight collar, he passes out as well. The loss of consciousness is
brief, he has no associated prodrome, and he feels well afterward. His past medical history is
notable for hypertension and hypercholesterolemia. His only medication is
hydrochlorothiazide.
On physical exam his vital signs are normal, and his cardiac exam is normal with the exception
of a fourth heart sound. Which of the following is the most appropriate next diagnostic test?
A. Stress echocardiography
B. Adenosine thallium scan
C. Computed tomogram of the neck
D. Carotid sinus massage
E. Tilt table test

5.You are called to the bedside to see a patient with Prinzmetal’s angina who is having chest
pain. The patient had a cardiac catheterization 2 days prior showing a 60% stenosis of the right
coronary artery with associated spasm during coronary angiogram. At the patient’s
bedside,which finding is consistent with the diagnosis of Prinzmetal’s angina?
A. Chest pain reproduced by palpation of the chest wall
B. Nonspecific ST-T-wave abnormalities
C. Relief of pain with drinking cold water
D. ST-segment elevation in II, III, and aVF
E. ST-segment depression in I, aVL, and V6

6.Which of the following conditions is not associated with sinus bradycardia?


A. Brucellosis
B. Leptospirosis
C. Hypothyroidism
D. Advanced liver disease
E. Typhoid fever

7.All of the following are common consequences of congenital heart disease in the adult except
A. Eisenmenger syndrome
B. erythrocytosis
C. infective endocarditis
D. pulmonary hypertension
E. stroke

8. Acute hyperkalemia is associated with which of the following electrocardiographic changes?


A. QRS widening
B. Prolongation of the ST segment
C. A decrease in the PR interval
D. Prominent U waves
E. T-wave flattening

9.All of the following clinical findings are consistent with severe mitral stenosis except
A. atrial fibrillation
B. opening snap late after S2
C. pulmonary vascular congestion
D. pulsatile liver
E. right-ventricular heave

10. All the following patients should be evaluated for secondary causes of hypertension except
A. a 37-year-old male with strong family history of hypertension and renal failure who presents
to your office with a blood pressure of 152/98
B. a 26-year-old female with hematuria and a family history of early renal failure who has a
blood pressure of 160/88
C. a 63-year-old male with no past history with a bloodpressure of 162/90
D. a 58-year-old male with a history of hypertension since age 45 whose blood pressure has
become increasingly difficult to control on four antihypertensive agents
E. a 31-year-old female with complaints of severe headaches, weight gain, and new-onset
diabetes mellitus with a blood pressure of 142/89
11.A patient is found to have a holosystolic murmur on physical examination. With deep
inspiration, the intensity of the murmur increases. This is consistent with which of the
following?
A. Atrial-septal defect
B. Austin Flint murmur
C. Carvallo’s sign
D. Chronic mitral regurgitation
E. Gallavardin effect

12. A 37-year-old male with Wolff-Parkinson-White syndrome develops a broad-complex


irregular tachycardia at a rate of 200 beats per minute. He appears comfortable and has little
hemodynamic impairment. Useful treatment at this point might include
A. Digoxin
B. Amiodarone
C. Propranolol
D. Verapamil
E. Direct-current cardioversion

13.All the following disorders may be associated with thoracic aortic aneurysm except
A. Osteogenesisimperfecta
B. Takayasu’s arteritis
C. Ehlers-Danlos syndrome
D. ankylosing spondylitis
E. Klinefelter’s syndrome

14. All the following may cause elevation of serum troponin except
A. congestive heart failure
B. myocarditis
C. myocardial infarction
D. pneumonia
E. pulmonary embolism

15.Which of the following congenital cardiac disorders will lead to a left-to-right shunt,
generally with cyanosis?
A. Anomalous origin of the left coronary artery from the pulmonary trunk
B. Patent ductusarteriosus without pulmonary hypertension
C. Total anomalous pulmonary venous connection
D. Ventricular septal defect
E. Sinus venosus atrial septal defect

16.All the following are associated with a high risk of stroke in patients with atrial fibrillation
except
A. diabetes mellitus
B. hypercholesterolemia
C. congestive heart failure
D. hypertension
E. age over 65

17.A 54-year-old man with hypercholesterolemia and poorly controlled hypertension is


admitted to the coronary care unit after coming to the emergency room with sudden chest
pain. A coronary catheterization is performed, and complete occlusion of the posterior
descending artery is identified. Percutaneous intervention fails and the patient is medically
managed. Two days later he appears to be acutely ill. Physical examination reveals a new
murmur. Which of the following would account for an early decrescendo systolic murmur in
this case?
A. Acute mitral regurgitation
B. Hypertrophic cardiomyopathy
C. Chronic mitral regurgitation
D. Severe aortic stenosis
E. Ventricular septal rupture

18. A 49-year-old male is found to have persistently elevated total cholesterol and low-density
lipoprotein (LDL) despite lifestyle modification. You prescribe an HMG-CoA reductase inhibitor
to reduce the risk of coronary events. This medication will exert all the following beneficial
effects except
A. direct action on atheroma progression
B. improvement in endothelial-dependent vasomotion
C. long-term reduction of serum LDL
D. regression of existing coronary stenosis
E. stabilization of existing atherosclerotic lesions

19. Dipyridamole is often used during nuclear cardiac stress tests. Based on the
pathophysiology of myocardial ischemia and the mechanism of action of dipyridamole, in which
circumstance might the stress test underestimate the degree of ischemic tissue?
A. Three-vessel high-grade obstruction
B. Bradycardia
C. Left bundle branch block
D. Osteoarthritis
E. Right coronary artery 99% occlusion

20. All of the following are potential causes of tricuspid regurgitation except
A. congenital heart disease
B. infective endocarditis
C. pulmonary arterial hypertension
D. rheumatic heart disease
E. all will cause tricuspid regurgitation

21.A 28-year-old female has hypertension that is difficult to control. She was diagnosed at age
26. Since that time she has been on increasing amounts of medication. Her current regimen
consists of labetalol 1000 mg bid, lisinopril 40 mg qd, clonidine 0.1 mg bid, and amlodipine 5 mg
qd. On physical examination she appears to be without distress. Blood pressure is 168/100, and
heart rate is 84 beats per minute. Cardiac examination is unremarkable, without rubs, gallops,
or murmurs. She has good peripheral pulses and has no edema. Her physical appearance does
not reveal any hirsutism, fat maldistribution, or abnormalities of genitalia. Laboratory
studiesreveal a potassium of 2.8mEq/dL and a serum bicarbonate of 32 mEq/dL. Fasting blood
glucose is 114 mg/dL. What is the likely diagnosis?
A. Congenital adrenal hyperplasia
B. Fibromuscular dysplasia
C. Cushing’s syndrome
D. Conn’s syndrome
E. Pheochromocytoma

22.A patient is noted to have a crescendo-decrescendo mid-systolic murmur on examination.


The murmur is loudest at the left sternal border. The patient is asked to squat, and the murmur
decreases in intensity. The patient stands and the murmur increases. Finally, the patient
isasked to perform a Valsalva maneuver and the murmur increases in intensity. Which of the
following is most likely to be the cause of this murmur?
A. Aortic stenosis
B. Chronic mitral regurgitation
C. Hypertrophic cardiomyopathy (HOCM)
D. Mitral valve prolapse
E. Pulmonic stenosis

23. Which of the following disorders is not associated with ventricular tachycardia as a cause of
syncope?
A. Hypertrophic obstructive cardiomyopathy
B. Prior myocardial infarction
C. Atrial myxoma
D. Aortic valvular stenosis
E. Congenital long QT syndrome

24. Normal sinus rhythm is restored with electrical cardioversion. A 12-lead electrocardiogram
is notable for a prolonged QT interval. Besides stopping the offending drug, the most
appropriate management for this rhythm disturbance should include intravenous
administration of which of the following?
A. Amiodarone
B. Lidocaine
C. Magnesium
D. Metoprolol
E. Potassium

25.You are evaluating a patient with a wide-complex tachycardia. The patient has a history of
Wolff-Parkinson-White (WPW) syndrome. Which medication is the most effective for treating
this patient’s tachycardia?
A. Adenosine
B. Digoxin
C. Diltiazem
D. Procainamide
E. Verapamil

26. A 60-year-old male patient on aspirin, an angiotensin-convertingenzyme inhibitor, nitrates,


and a beta blocker, who is being followed for chronic stable angina, presents to the ER with a
history of two or three episodes of more severe and long-lasting anginal chest pain each day
over the past 3 days. His ECG and cardiac enzymes are normal. Which of the following is the
best course of action?
a. Admit the patient and begin intravenous digoxin
b. Admit the patient and begin intravenous heparin
c. Admit the patient and give prophylactic thrombolytic therapy
d. Admit the patient for observation with no change in medication
e. Increase the doses of current medications and follow closely as an outpatient

27. You are helping with school sports physicals and see a 13-year-old boy who has had some
trouble keeping up with his peers. He has a cardiac murmur, which you correctly diagnose as a
ventricular septal defect based on which of the following auscultatory findings?
a. A systolic crescendo-decrescendo murmur heard best at the upper right sternal border with
radiation to the carotids; the murmur is augmented with transient exercise
b. A systolic murmur at the pulmonic area and a diastolic rumble along the left sternal border
c. A holosystolic murmur at the mid-left sternal border
d. A diastolic decrescendo murmur at the mid-left sternal border
e. A continuous murmur through systole and diastole at the upper left sternal border

28. A 30-year-old female presents with a chief complaint of palpitations. A 24-h Holter monitor
is obtained and shows occasional unifocal PVCs and premature atrial contractions. Which of the
following is the best antiarrhythmic management in this patient?
a. Anxiolytic therapy
b. Beta blocker therapy
c. Digoxin
d. Quinidine
e. Reassurance, no medication

29. In the ICU, a patient suddenly becomes unresponsive, pulseless, and hypotensive, with
cardiac monitor indicating ventricular tachycardia. The crash cart is immediately available. The
first therapeutic step should be?
a. Amiodarone 150 mg IV push
b. Lidocaine 1.5 mg/kg IV push
c. Epinephrine 1 mg IV push
d. Defibrillation at 200 joules
e. Defibrillation at 360 joules
30. A 55-year-old female presents to the ER with lethargy and blood pressure of 250/150. Her
family members indicate that she was complaining of severe headache and visual disturbance
earlier in the day. They report a past history of asthma but no known kidney disease. On
physical exam, retinal hemorrhages are present. Which of the followingis the best approach?
a. Intravenous labetalol therapy
b. Continuous-infusion nitroprusside
c. Clonidine by mouth to lower blood pressure slowly but surely
d. Nifedipine sublingually to lower blood pressure rapidly
e. Further history about recent home antihypertensives before deciding current therapy

31. An asymptomatic 30-year-old female postdoc was noted by her gynecologist to have a
cardiac murmur. She was referred for an echocardiogram, with results reported to her as
showing mitral valve prolapse. The patient desires more information and now comes to you.
Which of the following is true about her condition?
a. Displacement of one or both mitral valve leaflets posteriorly into the left atrium occurs
during systole
b. Migration of the systolic click and systolic murmur toward the first heart sound will occur
during squatting
c. Prophylactic beta blocker therapy is indicated
d. Significant mitral regurgitation is likely to occur (>50% chance) sometime in her life
e. Restriction of vigorous exercise is advised to reduce the risk of sudden cardiac death

32. Which ONE of the following is MOST likely to be found in apatient with longstanding
constrictive pericarditis?
A A wide pulse pressure
B A rise in systolic pressure on inspiration
C Pulsusalternans
D A fall in venous pressure on inspiration
E Ascites

33. A 54-year-old male, non-smoker, presents with chest pain. WhichONE of the following
features MOST suggests a non-cardiacetiology?
A.A fall in the ejection fraction on exercise echocardiography
B.Pain occurring at the start of exercise which then improvesduring exercise
C.Pain relieved by glyceryltrinitrate within 5 minutes
D.A normal resting ECG
E.Up-sloping ST segment depression occurring during exerciseTesting

34.A 46-year-old woman presents with hypertension.The bloodpressure (BP) is 170/108 mmHg,
plasma creatinine 190 mmol/Land there is marked left ventricular hypertrophy on the
restingECG.The plasma renin activity is <10 mU/L. She is on nomedication other than the
combined contraceptive pill. WhichONE of the following statements is TRUE?
A.Blood pressure control should lead to regression of leftventricular hypertrophy
B.Angiotensin converting enzyme (ACE) inhibitor therapy iscontraindicated
C.Bendroflumethiazide (bendrofluazide) would be anappropriate choice of antihypertensive
agent
D.‘White coat’ hypertension is a likely possibility
E.Estrogen-containing contraceptive therapy is not contraindicated

35. Which ONE of the following abnormalities is MOST likely to befound in a patient diagnosed
with syndrome X(metabolic syndrome)?
A.hypouricaemia
B.hypercholesterolaemia
C.haematuria
D.hypoinsulinaemia
E.hypertriglyceridaemia

36. A 58-year-old man who suffered a myocardial infarction 5 yearsago presents to the
outpatient clinic with tiredness, worseningshortness of breath on exercise, and swollen ankles.
Anteriorwall hypokinesia is present on echocardiography and the ejectionfraction is 40%.
Which ONE of the following drug therapies isMOST likely to improve survival?
A.Furosemide (furosemide)
B.Digoxin
C.Isosorbidemononitrate
D.Spironolactone
E.Verapamil

37. Which ONE of the following statements about disordersassociated with a bicuspid aortic
valve is TRUE?
A.The finding occurs more often in females than males
B.No association with an abnormal origin to the coronaryarteries
C.No association with coarctation of the aorta
D.A decreased risk of aortic dissection
E.An increased risk of endocarditis

38. Which ONE of the following statements concerning atrialmyxomas is TRUE?


A.They are usually found to be malignant on histopathology
B.They are the commonest benign tumour in adolescents
C.They are most often located in the right atrium
D.Often produce thromboembolic events
E.Typically associated with a soft first heart sound

39. A 67-year-old Caucasian man presents within 4 hours of theonset of crushing, central chest
pain. The ECG findings indicate3 mm ST elevation in the anterior chest leads. Which ONE of
thefollowing plasma concentrations is MOST likely to be elevated atpresentation?
A.Creatinine kinase–MB fraction
B.Lactate dehydrogenase
C.Troponin I
D.Aspartate transaminase
E.Troponin T

40. A 76-year-old woman with no significant past medical history isfound to be


asymptomatically hypertensive. Which ONE of thefollowing statements is TRUE?
A.Both systolic and diastolic pressures are likely to be elevated
B.Plasma renin is likely to be elevated
C.Secondary hypertension is more likely than in youngerpatients
D.Treatment of the high BP should reduce the risk of stroke
E.Treatment of the high BP is unlikely to reduce the risk ofatherosclerosis

41. Which ONE of the following cardiac findings in an asymptomaticsubject requires permanent
endocardial pacing?
A.First degree AV block
B.Previous history of recurrent vasovagal syncope
C.Left bundle branch block occurring after myocardial infarction
D.Sick sinus syndrome
E.Third degree AV block following coronary artery bypass surgery

42. A 76-year-old woman presents with a history of syncopal episodes and on


echocardiography, she is found to have severeaortic stenosis. Which ONE of the following
features is MOSTlikely to be found on examination?
A.Pulsus bisferiens
B.A widely split second heart sound
C.A thrill over the right anterior second intercostal space
D.A wide pulse pressure
E.Diastolic murmur

43. In a patient presenting with a supraventricular tachycardia,which ONE of the following is


LEAST likely to be responsible?
A Mitral valve prolapse
B Lown–Ganong–Levine syndrome
C Flecainide therapy
D Lange–Nielsen syndrome
E Digoxin toxicity

44. A 24-year-old man is admitted to hospital having collapsed. Hehas a previous history of
blackouts which had been attributed tovasovagal syncope. Clinical examination was
unremarkable andthe resting ECG was normal except for a prolonged QT interval.Which ONE of
the following suggests the MOST likely cause of the syncopal episodes?
A.Use of beta blocker therapy
B.Serum potassium 5.6 mmol/L
C. Family history of premature sudden death
D.Congenital lymphoedema of the lower limbs
E.Resting tachycardia

45. Which ONE of the following features suggests an alternative oradditional diagnosis to that
of severe mitral stenosis?
A Right ventricular hypertrophy
B Left ventricular dilatation
C Dilated left atrium
D Tricuspid regurgitation
E Absence of a diastolic murmur at rest

46. At an insurance medical examination, a 50-year-old male is foundto be a heavy smoker with
a blood pressure of 170/108 mmHg,body mass index 37, serum cholesterol 7.5 mmol/L andHDL-
cholesterol 1.3 mmol/L. Which ONE of the followingmeasures is likely to have the greatest
impact on reducing hiscardiovascular risk?
A Reducing his blood pressure to 140/85 mmHg
B Reducing his total cholesterol by 1.5 mmol/L
C Stopping smoking
D Taking aspirin 75 mg daily
E Losing 8 Kg in weight

47. In a patient with a wide-complex tachycardia, which ONE ofthe following ECG findings
MOST suggests a supraventriculartachycardia?
A.AV dissociation
B.Negative chest lead QRS concordance
C.QRS axis -60° to -180°
D.Fusion beats
E.QRS duration 140 milliseconds

48. Which ONE of the following is the LEAST LIKELY to beresponsible for the finding of impaired
left ventricular fillingobserved on echocardiography?
A.Hypertension
B.Hypertrophic cardiomyopathy
C.Constrictive pericarditis
D.Chronic alcohol intake
E.Amyloidosis

49. A-20-year old is found to have hypertrophic cardiomyopathy onechocardiography. Which


ONE of the following disorderssuggests that the echocardiographic changes are likely to be
dueto an additional and unrelated diagnosis?
A.Friedreich’s ataxia
B.Fabry’s disease
C.Noonan’s syndrome
D.Pompe’s disease
E.Devic’s syndrome
50. Which ONE of the following findings is most likely to be found ina 30-year-old woman
presenting with an acute myocarditis?
A.Shortness of breath at rest
B.Sinus bradycardia
C.ST segment depression
D.A pericardial effusion on echocardiography
E.A raised serum lactate dehydrogenase level

51. Which ONE of the following features suggests an alternativediagnosis to that of patent
ductusarteriosus?
A.Prominent vascular markings on a chest radiograph
B.Disappearance of the continuous supraclavicular murmur inthe supine position
C.A collapsing pulse
D.Right bundle branch block
E.A mid-diastolic murmur in the mitral area

52. On auscultation, a patient is found to have splitting of thesecond heart sound which
increases during expiration. WhichONE of the following disorders suggests that an
alternativediagnosis is likely to be present to explain the finding?
A.Severe hypertension
B.Right bundle branch block
C.Acute unstable angina
D.Aortic stenosis
E.Hypertrophic obstructive cardiomyopathy

53. Which ONE of the following statements about Kawasaki diseaseis TRUE?
A.It is more common in girls
B.The incidence in Japan is decreasing
C.Cervical lymphadenopathy is rare
D.Aneurysms are restricted to the coronary arteries
E.Polymorphous exanthema is typical

54. Which ONE of the following statements abouthyperlipoproteinaemia is TRUE?


A.The children of patients with familial type IIahyperlipoproteinaemia have a 25% chance of
inheritingthe trait
B.Chylomicrons consist primarily of cholesterol
C.Plasma cholesterol is reduced in the nephrotic syndrome
D.Long-term gemfibrozil therapy decreases the incidence ofcardiac events
E.Plasma cholesterol decreases with age

55. A 28-year-old man presents with a fever and breathlessness andis found to have a diastolic
murmur along the left sternal edge.The echocardiogram reveals evidence of significant
leftventricular dysfunction and aortic regurgitation with vegetationson the aortic valve. Which
ONE of the following statementsconcerning the investigation and management is TRUE?
A. Alpha-haemolyticstreptococci are likely to be present onblood cultures
B Tetracycline therapy is indicated prior to the results of bloodcultures
C Diffuse glomerulonephritis usually leads to irreversible renalfailure
D Valve replacement should be deferred until 4 weeks ofantibiotic therapy is given
E Blood cultures are unlikely to be positive except during peaksof pyrexia

56. In a patient with tricuspid incompetence, which ONE of thefollowing findings is the MOST
likely to be present?
A.Giant ‘a’ waves in the neck veins
B.A soft pulmonary component to the second heart sound
C.Evidence of a right ventricular heave
D.An increased risk of pulmonary embolism
E.A murmur which decreases with inspiration

57. Which ONE of the following statements about a 40-year-oldman presenting with upper limb
hypertension and rib notchingis TRUE?
A.Constriction of the aorta is most likely to be proximal to theleft subclavian artery
B.An association with pulmonary stenosis would be anexpected finding
C.Marfan’s syndrome is a recognized association
D.A diastolic murmur is characteristic of theanomaly
E.There is likely to be an increased risk of cerebrovascular accidents

58. Which ONE of the following statements about theelectrocardiogram is TRUE?


A.Hypokalaemia produces flattened T waves
B.Right ventricular hypertrophy causes an anticlockwise rotation
C.Pathological Q waves are usually an early feature of malignant hypertension
D.A QT interval of 500 milliseconds is normal, given a heart rate80 beats/min
E.Mobitz type II AV block shows progressive lengthening of thePR interval

59. In a man presenting with acute chest pain and ECG evidence ofacute myocardial infarction,
which ONE of the following featuresindicates a poorer prognosis?
A.Atrial fibrillation at onset
B.Ventricular fibrillation occurring on day 5 post-infarction
C.Left ventricular ejection fraction in range 40–50
D.Patient aged 75 or over
E.Inferior rather than an anterior infarction

60. Which ONE of the following statements about the cardiacsilhouette on a routine chest X-ray
is TRUE?
A.Left atrial size can be accurately assessed
B.The cardio-thoracic ratio is usually abnormal in rightventricular hypertrophy
C.The cardio-thoracic ratio is typically increased in chronichypoadrenalism
D.Estimated LV size correlates poorly with the severity ofhypertensive heart disease
E.The pulmonary arteries are often prominent in normal adolescents
61. In the assessment of a cardiac catheterization study, which ONEof the following statements
is TRUE?
A.A gradient of 20 mmHg across the aortic valve usuallyindicates severe stenosis
B.Pulmonary artery oxygen saturation is independent of thecardiac output
C.The mortality from coronary angiography is approximately5%
D.In constrictive pericarditis, end-diastolic pressures are notequal in both ventricles
E.A left ventricular end-diastolic pressure of 25 mmHg indicatesa myocardial abnormality in the
absence of valve disease

62. In atrial tachyarrhythmias, which ONE of the followingstatements is TRUE?


A.The delta wave in Wolff–Parkinson–White syndrome is due tomyocardial activation via an
additional conduction pathway
B.Ventricular pacing is the best way to control atrialtachycardias
C.Atrial fibrillation excludes the diagnosis ofWolff–Parkinson–White syndrome
D.Polyuria suggests a ventricular rather than a supraventricularfocus
E.Atrial tachycardias are rarely as distressing to the patient asventricular tachycardias

63. Routine auscultation of a young, asymptomatic marathon runnerat an insurance medical


examination reveals a systolic murmur.The murmur is best heard between the left sternal edge
and theapex without obvious radiation to the neck or axilla. Which ONEof the following
statements about the murmur is TRUE?
A.The murmur is likely to be due to a bicuspid aortic valve
B.If the murmur radiates to the third left interspace, tricuspidincompetence is likely
C.The severity of mitral incompetence is best assessed bypulmonary wedge pressures
D.A loud fourth heart sound suggests severe mitralincompetence
E.Mitral valve prolapse is the likeliest explanation

64. Which ONE of the following statements about congenitalventricular septal defects (VSD), is
TRUE?
A.In Eisenmenger syndrome, there is a left- to-right shunt
B.A large VSD usually closes spontaneously
C.If endocarditis develops, the left ventricular cavity is usuallyinvolved
D.The murmur typically radiates to the carotids
E.The defect typically involves the membranous part of the septum

65. An elderly hypertensive man presents with a 2-hour history oftearing, central chest pain
radiating to his back.The ECG andplasma troponin are both normal. Which ONE of the following
isMOST consistent with a diagnosis of aortic dissection?
A.The presence of a purely systolic murmur suggesting aorticstenosis
B.Pain which increases gradually over several hours after onset
C.Persistent bradycardia
D.Absence of any past history of hypertension
E.Pleural effusion on chest X-ray
66. A 22-year-old is admitted with a fever and arthropathy. WhichONE of the following features
suggests an alternative diagnosisto that of rheumatic fever?
A.Recent group A beta-haemolytic streptococcal infection
B.A short rumbling diastolic murmur
C.Erythema marginatum sparing the face
D.An elevated ESR
E.Symmetrical, small joint polyarthropathy

67. In which ONE of the following disorders would the developmentof a congestive
cardiomyopathy suggest the presence of analternative, unrelated diagnosis?
A.Thyrotoxicosis
B.Chronic alcohol abuse
C.Viral myocarditis
D.Advanced HIV disease
E.X-linked muscular dystrophy

68. In which ONE of the following disorders is the development ofpulmonary hypertension
primarily due to an increase inpulmonary blood flow?
A.Chronic bronchitis and emphysema
B.Mitral stenosis
C.Multiple pulmonary emboli
D.Fibrosingalveolitis
E.Ostium primum atrial septal defect

69. A 45-year-old man is being considered for coronary artery bypasssurgery. Which ONE of the
following criteria is the MOSTappropriate indication for surgery rather than
percutaneouscoronary intervention?
A.Asymptomatic airline pilot with an abnormal exercise ECG
B.Symptomatic patient with left main coronary artery stenosis
C.Symptomatic but untreated angina
D.Triple vessel disease with severe left ventricular failure
E.Symptoms of angina with normal coronary angiography

70. A 24-year-old woman presents with a history of episodicbreathlessness and palpitation


associated with weight gain, mildhypertension and painless diarrhea. On clinical examination,
sheappears Cushingoid and tremulous.The electrocardiogram isnormal. Which ONE of the
following is the MOST likely cause?
A.Excessive consumption of coffee
B.Phaeochromocytoma
C.Alcohol abuse
D.Carcinoid syndrome
E.Wolff–Parkinson–White syndrome

71. A patient is seen in the review clinic after having had a mitralvalve replacement with a
Starr–Edwards ball valve prostheticvalve. Which ONE of the following statements is TRUE?
A.The patient is no longer at risk from endocarditis
B.The left atrial size returns to normal
C.X-ray screening is useful in assessing postoperative valvefunction
D.A reduction in the intensity of the valve click is unlikely to beof any significance
E.Concomitant omeprazole therapy will reduce the efficacy ofwarfarin therapy

72. The most correct statement regarding thrombolytic therapy in acute myocardial infarction
(MI) is:
A. Patients under age 65 years benefit more than elderly MI victims
B. No benefits have been realized when therapy has been instituted more than 6 hours after
onset of chest pain
C. Thrombolytic therapy has improved the prognosis of patients with prior coronary artery
bypass graft (CABG)
D. Patients with non-Q-wave MI have benefited from thrombolytic therapy as well as patients
who sustain Q-wave MIs.
E. Significant reduction in mortality has been realized when therapy is administered within 3
hours of onset of chest pain

73. Which of the following statements regarding the use of heparin in patients with myocardial
infarction (MI) is (are) true?
A. Heparin therapy is now used almost routinely with thrombolytic therapy during the acute
phase of MI treatment, providing certain criteria are met
B. Heparin is recommended whenever there is echocardiographic evidence of left ventricular
thrombi
C. Heparin should be administered (unless contraindicated) to all patients with acute anterior
wall MI.
D. Heparin is contraindicated in patients with uncontrolled hypertension
E. All of the above

74. Which of the following is a (are) contraindication(s) to the use of thrombolytic therapy in
patients with acute myocardial infarction (MI)?
A. Active gastrointestinal bleeding
B. Recent surgery (2 weeks postoperatively)
C. History of cerebrovascular accident
D. Atrial fibrillation or mitral stenosis
E. All of the above

75. Which of the following statements regarding patients admitted to the Coronary Care Unit
(CCU) after presumed myocardial infarction (MI) is (are) true?
A. Patients with suspected MI should have the left ventricular ejection fraction measured
before leaving the unit
B. Patients without additional complications should have a submaximal exercise tolerance test
with thallium-201 imaging on the fourth or fifth hospital day.
C. Patients with negative submaximal stress tests should have a maximal exercise stress test
performed after 4 to 6 weeks.
D. All of the above
E. A and C

76. Which of the following is (are) significant feature(s) of the pathophysiology of myocardial
infarction (MI)?
A. Endothelial cell wall damage
B. Coronary atherosclerosis
C. Thromboxane A2 production
D. All of the above
E. A and B

77. Which of the following is (are) true concerning aspirin in the treatment of acute Myocardial
infarction (MI)?
A. Aspirin may serve as a substitute for streptokinase or t-PA
B. Aspirin may serve as a substitute for heparin
C. Aspirin may serve as a substitute for beta-blockers
D. All of the above
E. None of the above

78. Which of the following statements regarding thrombolytic therapy is (are) false?
A. Thrombolytic therapy limits myocardial necrosis
B. Thrombolytic therapy preserves left ventricular function
C. Thrombolytic therapy reduces mortality
D. All of the above statements are false
E. None of the above statements is false

79. Which of the following statements concerning arrhythmias and antiarrhythmic drugs in
patients who have sustained an Myocardial infarction (MI) is (are) true?
A. Premature ventricular contractions (PVCs) are common and should be treated with lidocaine
B. Sustained runs of ventricular tachycardia frequently progress to ventricular fibrillation
C. Prophylactic lidocaine is recommended to prevent dysrhythmias in all patients who have
sustained an MI
D. None of the above
E. All of the above

80. One of the major patient concerns after Myocardial infarction (MI) is the risk of a second or
subsequent attack. In which of the following circumstances is the risk of reinfarction and/or
mortality following MI significantly increased?
A. left ventricular ejection fraction of 40%
B. Exercise-induced ischemia
C. non-Q-wave infarction (subendocardial infarction)
D. A and B
E. All of the above

81. Which of the following medications has (have) been shown to be of benefit in some post-MI
(myocardial infarction) patients?
A. beta-blockers
B. Calcium channel blockers
C. Aspirin
D. A and C
E. All of the above

82. Which of the following statements concerning rehabilitation of the patient after myocardial
infarction (MI) is (are) true?
A. Sexual intercourse should not resume for at least 3 months
B. Patients who have sustained MI should stay off work for at least 4 months
C. Patients who have sustained MI may gradually increase activity over 6 to 8 weeks
D. No significant psychological distress regarding MI has been shown to occur
E. All of the above

83. The major pathophysiological difference between (a) unstable angina and non-Q-wave or
non-transmural infarction and (b) transmural infarction is:
A. The presenting signs and symptoms of the attack
B. The duration and completeness of the occlusion
C. The risk factor profile
D. The male-female ratio
E. The degree of injury pattern surrounding the true ischemic are(s)

84. The best single confirmatory investigation for acute myocardial infarction (MI) is:
A. the ECG
B. The height of ST-segment elevation in the affected area (in millimeters) and the depth of ST
segment depression in the reciprocally affected leads (in millimeters)
C. The creatinine kinase isoenzyme MB fraction
D. The presence of dysfunctional heart muscle as demonstrated by echocardiography
E. Measurement of radiolabeled antimyosin antibody fragments

85. Sudden death as a result of myocardial infarction (MI) is almost always caused by:
A. Third-degree heart block resulting from infarction of the atrioventricular node
B. Ventricular tachycardia
C. Ventricular fibrillation
D. Ventricular standstill
E. None of the above.
86.Which of the following statements regarding shock and its treatment in acute MI is (are)
true?
A. The acute MI patient may develop shock secondary to hypovolemic hypotension
B. The acute MI patient may develop shock secondary to persistent hypotension and a poor
cardiac index
C. Both forms of shock respond well to treatment with intravenous fluids (Ringer’s lactate or
normal saline solution)
D. A and B only
E. All of the above

87. Coronary reperfusion with thrombolytic agents has been shown to be of benefit when the
onset of the pain occurs up to how many hours (maximum) before the initial assessment?
A. 4
B. 6
C. 12
D. 24
E. 48

88. Which of the following medications increases insulin sensitivity?


a. ACE inhibitors
b. Thiazide diuretics
c. Calcium channel blockers
d. Beta blockers
e. Nitrates

89. Which of the following is not a common cause for adverse drug events in the elderly?
a. Increased number of concomitant medications
b. Noncompliance
c. Prescription error
d. Increased volume of distribution
e. Cognitive decline

90.Most complications of cardiac drugs can be classed generally as:


a. Dose-dependent
b. Allergic
c. Drug-drug interactions
d. Dose-independent only
e. Idiosyncratic

91. Renal insufficiency impacts the use of the following beta blockers, except:
a. Nadolol
b. Metoprolol
c. Sotalol
d. Acebutolol
e. Atenolol

92.All of the following are effects of loop diuretics, eg, furosemide, except which of
the following?
a. Hypomagnesemia
b. Ototoxicity
c. Hypercalcemia
d. Venodilation
e. Loop diuretics are the most effective diuretic agents

93. Regarding adverse effects with ACE inhibitors, all the following occur, except:
a. Cough and angioedema with enalapril
b. Proteinuria with captopril
c. Hyperkalemia with perindopril
d. Neutropenia or rash with enalapril
e. Teratogenicity with Lisinopril

94. Concerning beta blockers, which of the following is incorrect?


a. Beta blockers are less effective in reducing coronary events in hypertensive
men who smoke
b. Propranolol is contraindicated in patients with severe depression
c. Selective beta blockers should be avoided in patients with peripheral vascular
disease
d. Beta blockers should be avoided in patients with significant asthma
e. Propranolol and bisoprolol doses should be reduced in patients with low
plasma proteins

95. ACE inhibitors have which of the following actions?


a. Increase degradation of bradykinin
b. Decrease degradation of bradykinin
c. Increase production of bradykinin
d. Increase kallikrein production
e. Impair the conversion of prekallikrein to kallikrein

96. Which of the following agents is least likely to cause hyperkalemia?


a. Spironolactone
b. Amiloride
c. Captopril
d. Ethacrynic acid
e. Losartan
97. Which of the following agents is most efficacious in the conversion of acute atrial fibrillation
into sinus rhythm?
a. Metoprolol
b. Digoxin
c. Amiodarone
d. Diltiazem
e. Esmolol

98. NO regulates which of the following processes?


a. Vasodilation
b. Platelet aggregation
c. Matrix synthesis
d. Smooth muscle cell migration
e. All of the above

99. The diagnosis of primary aldosteronism requires each of the following except:
a. Hypertension
b. Hypokalemia (salt replete)
c. Increased 24-hr urinary aldosterone rate
d. Normal renal arteries
e. Suppressed plasma renin activity

100. Which of the following statements regarding differential diagnosis of chest pain is false?
A. The patient may have suffered from myocardial infarction (MI)
B. The patient’s chest pain may be caused by angina pectoris
C. The patient’s chest pain may be caused by esophageal motor disorder
D. The administration of sublingual nitroglycerin is a very sensitive test to distinguish angina
pectoris from esophageal causes
E. The patient should be admitted to the Coronary Care Unit until the origin of the pain is firmly
established

101.The patient is admitted for observation to the hospital. His chest pain subsides with
intravenous nitroglycerin. His creatinine kinase isoenzyme MB (CK-MB) fraction is normal.
Which of the following investigations is not indicated at this time?
A. An exercise tolerance test
B. Coronary angiography
C. An upper gastrointestinal series
D. A plasma lipid profile
E. A fasting blood sugar level

102. Which of the following medications would not be indicated as a first-line therapy for the
treatment of angina pectoris?
A. Diltiazem
B. Propranolol
C. Isosorbidedinitrate
D. Prazosin
E. Heparin

103. In which of the following patients would percutaneous coronary angioplasty most likely be
used?
A. A patient with left main stem disease
B. A patient with triple-vessel disease
C. A patient with a ventricular aneurism
D. A patient with one-vessel disease
E. Any of the above are good indications for percutaneous coronary angioplasty

104. Which of the following is least likely to be used as a combination therapy in patients with
angina pectoris?
A. Nitroglycerin-atenolol-nifedipine
B. Nitroglycerin-enalapril-nifedipine
C. Nitroglycerin-propranolol- verapamil
D. Nitroglycerin-metoprolol-diltiazem
E. Nitroglycerin-propranolol-nifedipine

105. Which of the following drugs is considered the most potent vasodilator?
A. Nifedipine
B. Verapamil
C. Metoprolol
D. Atenolol
E. Propranolol

106. Coronary artery bypass graft (CABG) surgery may be indicated as the treatment of choice
for angina pectoris with which of the following angina patients?
A. A patient with triple-vessel disease
B. A patient with one-vessel disease
C. A patient with two-vessel disease
D. CABG may be first-line therapy in any of the above
E. B or C

107. Which of the following investigations should be performed on a patient with possible
angina pectoris?
A. Complete blood count
B. Chest x-ray
C. Fasting lipid profile
D. Thyroid function testing
E. All of the above
108. The pathophysiology of angina pectoris is best explained by which of the following?
A. significantly increased peripheral vascular resistance
B. A balance between oxygen supply and oxygen demand
C. An imbalance of oxygen supply and oxygen demand plus or minus coronary artery spasm
D. Significant peripheral venous and arterial vasoconstriction
E. None of the above

109. Which of the following criteria indicate(s) a diagnosis of unstable angina pectoris?
A. new onset angina (2 months) that is either severe or frequent (three episodes daily) or both
B. Patients with accelerating angina
C. Patients with angina at rest
D. B and C
E. All of the above

110. What is the single most important risk factor for coronary artery disease?
A. An elevated HDL level
B. An elevated triglyceride level
C. An elevated LDL level
D. A depressed HDL level
E. An elevated total blood cholesterol level

111. An elevated triglyceride level is most closely associated with serum concentration of which
of the following?
A. LDL cholesterol
B. HDL cholesterol
C. Very low-density lipoprotein cholesterol
D. Total blood cholesterol
E. Apoprotein E

112. Which of the following is the treatment of choice for hypercholesterolemia?


A. Gemfibrosil
B. Colestipol
C. Nicotinic acid
D. Lovastatin
E. None of the above

113. What is the drug class of choice for the management of mild to moderate elevations of
plasma LDL?
A. The fibric acid derivatives
B. The nicotinic acid derivatives
C. HMG-CoA reductase inhibitors
D. The bile acid sequestrants
E. Any of the above
114. The patient with hypertension and atherosclerosis is taking hydrochlorothiazide and
propranolol. Which of the following statements is true concerning the effect of these drugs on
plasma lipoproteins?
A. hydrochlorothiazide has no effect on plasma lipoproteins
B. Propranolol has no effect on plasma lipoproteins
C. Neither hydrochlorothiazide nor propranolol has any effect on plasma lipoproteins
D. Both hydrochlorothiazide and propranolol can adversely affect plasma lipoproteins
E. The effect of both drugs are idiosyncratic on plasma lipoproteins, not dose dependent

115. A 56-year-old male wit hyperlipidemia needs a beta-blocker to help control hypertension.
Which of the following would be the agent of choice?
A. Propranolol
B. Metoprolol
C. Atenolol
D. Nadolol
E. Acebutolol

116. Which of the following is and (are) independent risk factor(s) for coronary artery disease?
A. Increased LDL concentration
B. Decreased HDL concentration
C. Increased TC concentration
D. Increased triglyceride concentration
E. All of the above

117. Which of the following antihypertensive drugs does (do) not have an adverse effect on
plasma lipids?
A. hydrochlorothiazide
B. Fosinopril
C. Atenolol
D. Nifedipine
E. B and D

118. Which of the following statements is (are) true regarding fish oil supplements?
A. Fish oil have been shown to lower plasma triglyceride levels
B. Fish oils inhibit platelet aggregation
C. Fish oils have been shown to increase HDL levels
D. Fish oils may decrease blood pressure and blood viscosity
E. All of the above are true

119.What is the drug of choice for the treatment of hypertriglyceridemia?


A. Nicotinic acid
B. Gemfibrosil
C. Lovastatin
D. Cholestyramine
E. None of the above

120. Which of the following is a (are) secondary cause(s) of hyperlipidemia?


A. Diabetes mellitus
B. Alcohol
C. Oral contraceptives
D. All of the above
E. None of the above

121. Chylomicrons are most closely associated with which of the following?
A. LDL
B. HDL
C. VLDL
D. Medium-density lipoproteins (MDL)
E. Chylomicrons are associated with all of the above

122. Regarding the home monitoring of cholesterol, which of the following statements is true?
A. Home monitoring is recommended for patients with very high cholesterol levels
B. Home cholesterol monitoring is sensitive
C. Home cholesterol monitoring is specific
D. Home cholesterol monitoring is both sensitive and specific
E. None of the above

123. The non-pharmacological treatment of choice for congestive heart failure may include
which of the following?
A. salt restriction
B. Fat restriction
C. Water restriction
D. All of the above
E. None of the above

124. Which of the following is (are) the current indication(s) for the use of digitalis in
congestive heart failure?
A. A dilated left ventricle
B. S3 or S4 gallop
C. Decreased ejection fraction
D. C and D
E. All of the above

125. In evaluating a patient for systolic dysfunction the most important charachteristic found
on echocardiogram is:
A. Myocardial hypertrophy
B. Valvular heart disease
C. Corpulmonale
D. Low ejection fraction
E. Wall motion abnormalities

Q7.126. Which is the drug of first choice for the management of systolic dysfunction?
A. Thiazide diuretic
B. Loop diuretic
C. Vasodilator
D. beta-blocker
E. ACE-inhibitor

127. Which is the drug of first choice for moderate to severe cases of diastolic dysfunction?
A. Thiazide diuretic
B. Loop diuretic
C. Vasodilator
D. beta-blocker
E. ACE-inhibitor

128. True statements concerning the use of beta-blockers in the treatment of diastolic
dysfunction include which of the following?
A. beta-blockers result in an improved ejection fraction and fewer hospitalizations
B. beta-blockers protect the myocardium from adrenergic stimulation
C. All beta-blockers are shown to decrease overall mortality
D. All are true
E. Only A and B are true

129. What is the single most important treatment for increasing both the quality and the
quantity of remaining life for patients with severe systolic dysfunction?
A. beta-blocker
B. loop diuretic
C. ACE-inhibitor
D. Calcium channel blocker
E. Any of the above

130. Which of the following drugs decrease(s) mortality in the treatment of systolic
dysfunction?
A. ACE-inhibitors
B. Hydralazine and nitrates combined
C. Carvedilol
D. Diuretics
E. A, B, and C

131. The initial diagnostic work-up of a patient with hypertension should include which of the
following?
A. Electrolytes
B. Blood urea nitrogen
C. Creatinine
D. 24 hour urine for vanillylmandelic acid (VMA) and metanephrine
E. All of the above

132. Which of the following drugs is (are) useful for the treatment of hypertensive emergencies
and urgencies?
A. Intravenous labetalol
B. Oral clonidine
C. Oral or sublingual nifedipine
D. All of the above
E. None of the above

133. A 50 year-old male is being treated for hypertension with a low-salt diet,
hydrochlorothiazide 25 mg/day, and propranolol 120 mg bid. His blood pressure at present is
180/100 mm Hg. Which of the following would be a reasonable third-line agent for the
treatment of this patient’s blood pressure?
A. Atenolol
B. Metoprolol
C. Labetolol
D. Furosemide
E. Enalapril

134. What is the most common side effect of ACE-inhibitors?


A. Cough
B. Constipation
C. Headache
D. Skin rash
E. Depression

135. What is the most common side effect of propranolol?


A. Cough
B. Constipation
C. Headache
D. Skin rash
E. Depression

136. What is the most commonly encountered “premature contraction”?


A. Ventricular premature beat
B. Atrial premature beat
C. Atrial flutter
D. Atrial fibrillation
E. None of the above
137. Most atrial premature beats discovered on clinical examination are:
A. Associated with chronic obstructive pulmonary disease (COPD)
B. Completely benign
C. Associated with valvular heart disease
D. Associated with an increase in cardiovascular mortality
E. None of the above

138. Most ventricular premature beats discovered on clinical examination are:


A. Associated with COPD
B. Completely benign
C. Associated with valvular heart disease
D. Associated with an increase in cardiovascular mortality
E. None of the above

139. A 51-year-old male comes to the Emergency Department with an acute episode of chest
pain He has a history of atrial fibrillation. On examination, his blood pressure is 80/60 mm Hg
and his ventricular rate is approximately 160 bpm. He is in acute distress. His respiratory rate is
32 breaths/min/ His ECG shows atrial fibrillation with a rapid ventricular response. What should
your first step in management be?
A. Digitalize the patient
B. Give the patient intravenous verapamil
C. Give the patient intravenous procainamide
D. Cardiovert the patient with a direct current
E. Start rapid intravenous hydration

140. What is the recommended treatment for paroxysmal supraventricular tachycardia with
hemodynamic compromise?
A. Synchronized cardioversion
B. DC countershock (cardioversion)
C. Intravenous adenosine
D. Intravenous verapamil
E. Intravenous digoxin

141. Patients with chronic atrial fibrillation are at increased risk for which of the following
conditions?
A. Acute myocardial infarction
B. Ventricular tachycardia
C. Sudden cardiac death
D. Cerebrovascular accident
E. Ventricular fibrillation

142. Which of the following statements regarding the medical treatment of atrial premature
beats with antiarrhythmic drugs is true?
A. The benefit outweighs the risk
B. The risk outweighs the benefit
C. The risk and the benefit are equal
D. The risk and benefit depend on patient
E. There is no evidence for that

143. Which of the following statements regarding the medical treatment of ventricular
premature beats with antiarrhythmic drugs is true?
A. The benefit outweighs the risk
B. The risk outweighs the benefit
C. The risk and the benefit are equal
D. The risk and benefit depend on patient
E. There is no evidence for that

PULMONOLOGY
1.A patient is evaluated in the emergency department for peripheral cyanosis. Which of the
following is not a potential etiology?
A. Cold exposure
B. Deep venous thrombosis
C. Methemoglobinemia
D. Peripheral vascular disease
E. Raynaud’s phenomenon

2.Which of the following associations correctly pairs clinical scenarios and community-acquired
pneumonia (CAP) pathogens?
A. Aspiration pneumonia: Streptococcus pyogenes
B. Heavy alcohol use: atypical pathogens and Staphylococcus aureus
C. Poor dental hygiene: Chlamydia pneumoniae, Klebsiellapneumoniae
D. Structural lung disease: Pseudomonas aeruginosa, S. aureus
E. Travel to southwestern United States: Aspergillusspp

3.All the following drugs can cause eosinophilic pneumoniaexcept


A. nitrofurantoin
B. sulfonamide
C. nonsteroidal anti-inflammatory drugs (NSAIDs)
D. isoniazid
E. amiodarone
4. A 26-year-old man presents to the clinic with 3 days of severe sore throat and fever. All of
the following support the diagnosis of streptococcal pharyngitis except
A. cough
B. fever
C. pharyngeal exudates
D. positive rapid streptococcal throat antigen test
E. tender cervical lymphadenopathy

5. A 63-year-old male with a long history of cigarette smoking comes to see you for a 4-month
history of progressive shortness of breath and dyspnea on exertion. The symptoms have been
indolent, with no recent worsening. He denies fever, chest pain, or hemoptysis. He has a daily
cough of 3 to 6 tablespoons of yellow phlegm. The patient says he has not seen a physician for
over 10 years. Physical examination is notable for normal vital signs, a prolonged expiratory
phase, scattered rhonchi, elevated jugular venous pulsation, and moderate pedal edema.
Hematocrit is 49%. Which of the following therapies is most likely to prolong his survival?
A. Atenolol
B. Enalapril
C. Oxygen
D. Prednisone
E. Theophylline

6. A 23-year-old male is climbing Mount Kilimanjaro. He has no medical problems and takes no
medications. Shortly after beginning the climb, he develops severe shortness of breath. Physical
examination shows diffuse bilateral inspiratory crackles. Which of the following is the most
likely etiology?
A. Acute interstitial pneumonitis
B. Acute respiratory distress syndrome
C. Cardiogenic shock
D. Community-acquired pneumonia
E. High-altitude pulmonary edema

7.Which of the following organisms is unlikely to be found in the sputum of a patient with cystic
fibrosis?
A. Haemophilusinfluenzae
B. Acinetobacter baumannii
C. Burkholderiacepacia
D. Aspergillusfumigatus
E. Staphylococcus aureus

8.A 67-year-old female is admitted to the hospital with a hip fracture after a fall. Which of the
following regimens constitutes appropriate venous thromboembolism prophylaxis for this
patient?
A. Intermittent pneumatic compression devices
B. Subcutaneous unfractionated heparin
C. Subcutaneous low-molecular-weight heparin
D. Warfarin, with a target international normalized ratio (INR) of 1.5 to 2.0
E. A and B

9.Which of the following is true regarding hypovolemic shock?


A. Loss of 20–40% of the blood volume leads to shock physiology.
B. Loss of <20% of the blood volume will manifest as orthostasis.
C. Oliguria is a crucial prognostic sign of impending vascular collapse.
D. Symptoms of hypovolemic shock differ from those of hemorrhagic shock.
E. The first sign of hypovolemic shock is mental obtundation.

10.The most common cause of a pleural effusion is


A. cirrhosis
B. left ventricular failure
C. malignancy
D. pneumonia
E. pulmonary embolism

11.Secondhand tobacco smoke has been associated with which of the following?
A. Increased risk of lung cancer
B. Increased prevalence of respiratory illness
C. Excess cardiac mortality
D. A and B
E. All of A, B, and C

12. A patient with low-grade fever and weight loss has poor excursion onthe right side of the
chest with decreased fremitus, flatness to percussion, and decreased breath sounds all on the
right. The trachea is deviated to the left. Which of the following is the most likely diagnosis?
a. Pneumothorax
b. Pleural effusion
c. Consolidated pneumonia
d. Atelectasis
e. Chronic obstructive lung disease

13. 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. Which of the following is the most likely etiologic
agent?
a. Streptococcus pneumoniae
b. Haemophilusinfluenzae
c. Legionella
d. Anaerobes
e. Mycoplasma pneumonia

14. A 30-year-old male is admitted to the hospital after a motorcycle accident that resulted in a
fracture of the right femur. The fracture is managed with traction. Three days later the patient
becomes confused and tachypneic. A petechial rash is noted over the chest. Lungs are clear to
auscultation. Arterial blood gases show PO2 of 50, PCO2 of 28, and pH of 7.49. Which of the
following is the most likely diagnosis?
a. Unilateral pulmonary edema
b. Hematoma of the chest
c. Fat embolism
d. Pulmonary embolism
e. Early Staphylococcus aureuspneumonia

15. An anxious young woman who is taking birth control pills presents to the emergency room
with shortness of breath. The absence of which of the following would make the diagnosis of
pulmonary embolus unlikely?
a. Wheezing
b. Pleuritic chest pain
c. Tachypnea
d. Hemoptysis
e. Right-sided S3 heart sound

16. A 30-year-old athlete with asthma is also a cigarette smoker. Which of the following is
characteristic of asthma but not other obstructive lung disease?
a. Hyperinflation is present on chest x-ray
b. Airway obstruction is reversible
c. Hypoxia occurs as a consequence of ventilation-perfusion mismatch
d. The FEV1/FVC ratio is reduced
e. Exacerbation often occurs as a result of an upper respiratory tract infection

17. A 60-year-old male has had a chronic cough for over 5 years with clear sputum production.
He has smoked one pack of cigarettes per day for 20 years and continues to do so. X-ray of the
chest shows hyperinflation without infiltrates. Arterial blood gases show a pH of 7.38, PCO2 of
40 mmHg, and PO2 of 65 mmHg. Spirometry shows an FEV1/FVC of 65%. Which of the
following is the most important treatment modality for this patient?
a. Oral corticosteroids
b. Home oxygen
c. Broad-spectrum antibiotics
d. Smoking cessation program
e. Predisone orally

18. A 50-year-old male with emphysema and a chest x-ray that has shown apical blebs develops
the sudden onset of shortness of breath and left-sided pleuritic chest pain. Pneumothorax is
suspected. Which of the following physical examination findings would confirm the diagnosis?
a. Localized wheezes at the left base
b. Hyperresonance of the left chest with decreased breath sounds
c. Increased tactile fremitus on the left side
d. Decreased breath sounds on the left side with deviation of the trachea to the left
e. Dry crackles at both bases

19. A homeless alcoholic presents to your emergency department complainingof cough, rigors,
pleuritic chest pain, and difficulty breathing. Chestradiograph shows a right upper-lobe
pneumonia. What organism must beconsidered?
A.Klebsiella pneumoniae
B. Escherichia coli
C.Haemophilusinfluenzae
D. Pneumococcus
E. Group A streptococcus

20. Which of the following pulmonary infections is MOST commonly associatedwith rust
coloured sputum?
A.Klebsiella
B. Staphylococcus
C. Group A streptococcus
D. Pneumococcus
E. Escherichia coli

21. Which of the following organisms is resistant to antibiotics that act on the cellwall?
A. Streptococcus pneumoniae
B.Klebsiellapneumoniae
C. Mycoplasma pneumoniae
D. Pseudomonas
E. Escherichia coli

22. A foreign body lodged in the distal one third of the airway can cause all ofthe following
EXCEPT
A. recurrent pneumonia
B. inspiratory wheezing
C. air trapping on the affected side
D. elevation of the affected diaphragm on decubitus film
E.athelectasis

23. All of the following are true concerning lung abscesses EXCEPT
A. lung abscesses are usually polymicrobial with 60% containing anaerobes
B. mortality is 10%
C. penicillin G or clindamycin are acceptable treatments
D outpatient management with oral antibiotics is acceptable in non-immunocompromised
patients
E lung abscess could be complication of pneumonia
24. Which is the earliest sign of pulmonary edema on chest radiograph?
A. Alveolar edema
B. Upper lobe diversion of vessels
C. Interstitial edema
D.Kerley B lines
E.None of the above

25. Which is FALSE in regard to spontaneous pneumothorax


A. most common in men between 20–40 years of age
B. If tension is present, the trachea is deviated to the side of the collapsed lung
C. women can have recurrent spontaneous pneumothorax during menses
D. smokers are at increased risk
E.none of the above statements is false

26. Which of the following is MOST helpful in the diagnosis of a tensionpneumothorax?


A. Chest radiograph showing mediastinal shift
B. Tracheal deviation toward the affected side
C. Bradycardia
D. Distended neck veins
E.Chest pain

27. Which of the following is MOST correct with respect to massive haemoptysis?
A. Greater than 200 ml in 24 hours
B. Patient should be placed in reverse Trendelenburg
C. Controlled hypotension should be induced to prevent further bleeding
D. Patient should lie with bleeding side down
E.None of the above

28. Which of the following is true regarding pulmonary aspiration?


A. Broad spectrum antibiotics are indicated
B. Steroid therapy should begin at once to decrease acid destruction
C. All patients should be immediately intubated and suctioned
D. Bronchodilators are useful to treat bronchospasm
E.None of the above

29. Which features best characterizes Pneumocystis carinii pneumonia (PCP)?


A.It is readily isolated and cultured in affected individuals
B. It usually presents as lobar pneumonia
C. It is a bacterial infection that responds well to intravenous sulfa-trimethoprim
D. Tuberculosis and atypical mycobacterium infection must be ruled out if PCPis suspected
E.It is common in elderly patients
30. Pneumonia due to an unusual or atypical organism should be considered inpatients with all
of the following conditions EXCEPT
A.uraemia
B. splenectomy
C. steroid treatment
D. hyperthyroidism
E.HIV/AIDS patients

31. Which of the following scintigraphic findings is most sensitive in diagnosing pulmonary
embolism?
A. No perfusion defects
B. Two or more medium to large perfusion defects with no V/Q mismatch
C. Two or more medium to large perfusion defects with V/Q mismatch
D. A single medium or large perfusion defect with V/Q mismatch
E. None of the above

32. On clinical examination of a patient with the precursor condition leading to pulmonary
embolism diagnosis which of the following statements is true?
A. Clinical examination is diagnostic in every case
B. Clinical examination is, in most cases, diagnostic
C. Clinical examination is of some value but has low sensitivity and low specificity
D. Clinical examination is of no value
E. Nobody really knows for sure

33. Which of the following blood gas combinations occurs most commonly in pulmonary
embolism?
A. Decreased PO2 and decreased PCO2
B. Decreased PO2 and increased PCO2
C. Increased PO2 and increased PCO2
D. Increased PO2 and decreased PCO2
E. None of the above

34. What is the most common cause of morbidity and mortality among hospitalized immobile
patients?
A. Myocardial infarction
B. Cerebrovascular accident
C. Deep venous thrombosis (DVT)/pulmonary embolism
D. Nosocomial infection
E. None of the above

35. What is (are) the drug(s) of choice for patients with a documented pulmonary embolus?
A. Continuous intravenous heparin
B. Intermittent intravenous heparin
C. Intermittent subcutaneous heparin
D. Any of the above
E. None of the above

36. Which of the following is a (are) risk factor(s) for pulmonary embolism?
A. Prolonged immobilization
B. Long leg fractures
C. Pregnancy
D. Malignancy
E. All of the above

37. What would be the diagnostic procedure of choice for the patient with pulmonary
embolism in the outpatient setting?
A. Pulmonary angiography
B. Pelvic vein ultrasound
C. Impedance plethysmography
D. V/Q scan
E. Magnetic resonance imaging (MRI) scan

38. What is the diagnostic procedure of choice for a patient who comes to the Emergency
Department with “a swollen leg” and has one or more of the risk factors for pulmonary
embolism?
A. Pulmonary angiography
B. Pelvic vein ultrasound
C. Impedance plethysmography
D. V/Q scan
E. MRI scan

39. Which of the following is (are) specific recommendation(s) regarding Deep Vein Thrombosis
(DVT) prophylaxis?
A. Patients at moderate risk for any reason should receive low-dose heparin or intermittent
pneumatic compression
B. Patients undergoing neurosurgical procedures should be treated with pneumatic
compression
C. Patients undergoing urologic procedures should be treated with pneumatic compression
D. Patients undergoing surgery for hip fractures should receive warfarin to a PTT of 1.2 to 1.5
times that of control
E. All of the above

40. What is the most likely cause of Chronic Obstructive Pulmonary Disease (COPD)?
A. Right-sided heart failure
B. Corpulmonale
C. Cigarette smoking
D. Obstructive sleep apnea
E. Hypercarbia

41. Which of the following statements regarding COPD is (are) true?


A. The disease develops in 10% to 15% of cigarette smokers
B. Cigarette smokers in whom this disease develops usually report the onset of cough with
expectoration 10 to 12 years after smoking began
C. Dyspnea is noted initially only on extreme exertion; as the condition progresses, it becomes
more severe and occurs with mild activity
D. Pneumonia, pulmonary hypertension, corpulmonale, and chronic respiratory failure
characterize the late stages of the disease;
E. All of the above are true

42. Which of the following is an (are) established risk factor(s) for chronic obstructive
pulmonary disease (COPD)?
A. Smoking
B. Atopy
C. Elevated levels of IgE
D. Bronchial hyperresponsiveness
E. All of the above

43. Which of the following is an (are) accurate statement(s) regarding the role of bacteria in
chronic bronchitis?
A. The delay in mucociliary clearance allows inhaled bacteria to colonize the normally sterile
airways and to multiply, leading to further infectious exacerbations
B. Hemophylus influenza, Streptococcus pneumonia and Moraxella catarrhalis account for 75%
of all exacerbations of chronic bronchitis
C. Bacteria may act synergistically with tobacco smoke to impede mucociliary clearance and
oallow organisms to colonize the airways further.
D. Nicotine stimulates the growth of H.influenzae
E. All of the above

44. Which of the following is a (are) consideration(s) in the diagnosis of chronic bronchitis?
A. Asthma
B. Postnasal drip from sinusitis
C. Chronic angiotensin-converting enzyme (ACE) inhibitor therapy
D. A and B
E. All of the above

45. Which of the following statements regarding smoking cessation and COPD is (are) true?
A. Cessation of smoking dramatically reduces symptoms in established COPD patients
B. Coughing stops in 80% of patients with COPD
C. Coughing stops in over 50% of patients with COPD within 4 weeks
D. All of the above
E. None of the above

46. Which of the following drugs is (are) the most effective for long-term pharmacologic
management in a patient with chronic bronchitis?
A. An inhaled beta-agonist
B. An inhaled anticholinergic agent
C. An inhaled corticosteroid
D. Oral prednisone
E. A, B, and C are considered to be equally efficacious
47. Which of the following drugs is (are) recommended as routine symptomatic management
for a patient with chronic bronchitis?
A. An inhaled beta-agonist
B. An inhaled anticholinergic agent
C. An inhaled corticosteroid
D. A and B
E. All of the above

48. Which of the following organisms has (have) been implicated in the pathogenesis of acute
exacerbations of chronic bronchitis and has exhibited resistance in vivo to ampicillin?
A. H.influenzae
B. S.pneumoniae
C. M.catarrhalis
D. A and B only
E. All of the above

49. An elderly patient in a long-term care facility develops influenza A pneumonia despite both
vaccination and amantadine prophylaxis. What is the organism most likely to complicate
influenza pneumonia?
A. S. pneumoniae
B. H. influenza
C. Chlamydia trachomatis
D. Chlamydia pneumoniae
E. M. pneumoniae

50. What is the most common cause of community-acquired pneumonia?


A. M.pneumoniae
B. H.influenzae
C. S. pneumoniae
D. Staphylococcus aureus
E. Viral pneumonia

51. What is the most common cause of nosocomial pneumonia?


A. M. pneumoniae
B. Aerobic gram-negative bacteria
C. S. pneumoniae
D. H. influenza
E. Viral Pneumonia

52. Which of the following is (are) included in the definition of asthma?


A. Reversible airway obstruction
B. Bronchial airway inflammation
C. Bronchial airway hyperresponsiveness to various stimuli
D. All of the above
E. None of the above

53. On a pathophysiological basis, asthma is primarily:


A. A bronchoconstricting process
B. An allergenic stimulus process
C. An inflammatory process
D. A bronchial hyperreactivity process
E. An IgE-mediated antigen-antibody reaction

54. Triggering the release of substances from the cell most responsible for the beginning of the
airway’s response leads to activation of which of the following?
A. Neutrophils
B. Eosinophils
C. Mononuclear cells
D. B and C
E. All of the above

55. The reversible airflow obstruction seen in asthma results from which of the following?
A. Bronchoconstriction
B. Mucous plug formation
C. Edema
D. A and B
E. All of the above

56. Which of the following is (are) a clinical hallmark of asthma?


A. Cough
B. Nocturnal dyspnea
C. Wheezing
D. Shortness of breath
E. A, C, and D

57. A 24-year-old woman develops wheezing and shortness of breath when she is exposed to
cold air or when she is exercising. These symptoms are becoming worse. Which of the following
is the prophylactic agent of choice for the treatment of asthma in these circumstances?
A. Inhaled beta2-agonists
B. Oral aminophylline
C. Inhaled anticholinergics
D. Inhaled sodium cromoglycate
E. Oral corticosteroids

58. What is the most common abnormality seen on physical examination of an asthmatic
patient?
A. Increased respiratory rate
B. Inspiratory rales
C. Inspiratory rhonchi
D. Expiratory rales
E. Expiratory wheezes

59. A patient who comes to the Emergency Department in acute respiratory distress caused by
a severe attack of asthma should be treated with all of the following, except:
A. Warm, humidified, high-flow-rate oxygen
B. Constant bedside monitoring
C. Intravenous corticosteroids
D. Intravenous fluids
E. Intravenous antibiotics

NEPHROLOGY
1. Which of the following is the most potent stimulus for hypothalamic production of arginine
vasopressin?
A. Hypertonicity
B. Hyperkalemia
C. Hypokalemia
D. Hypotonicity
E. Intravascular volume depletion

2. A 28-year-old woman with HIV on antiretroviral therapy complains of abdominal pain in the
emergency department. Laboratory data show a creatinine of 3.2 mg/dL; her baseline
creatinine is 1.0 mg/dL. Urinalysis shows large numbers of white blood cells and red blood cells
without epithelial cells, leukocyte esterase, or nitrites. Which test is indicated to diagnose the
cause of her acute renal failure?
A. Acid-fast stain of the urine
B. Anti-GBM (glomerular base membrane) antibodies
C. Renal angiogram
D. Renal ultrasound
E. Urine electrolytes
3. You are evaluating a 40-year-old patient admitted to the hospital with cirrhosis and an upper
gastrointestinal bleed. The bleeding was treated with endoscopy and photocoagulation, and
the patient is now stable. He required two units of packed red blood cells. He was briefly
hypotensive upon admission but has remained stable for the past 5 days. He is becoming
oliguric. Laboratory data show a creatinineof 4.0 mg/dL, whereas his baseline is 0.8–1.1 mg/dL.
Sodium is 140 meq/L,BUN is 49 mg/dL. Urine sediment shows rare granular casts. His urine
sodium is 50 meq/L, urine osmolality 287 mosmol and urine creatinine is 35 mg/ dL. What is the
cause of this patient’s acute renal failure?
A. Acute interstitial nephritis
B. Acute tubular necrosis
C. Glomerulonephritis
D. Hepatorenal syndrome
E. Prerenal azotemia

4. All of these findings are consistent with a chronic unilateral urinary tract obstruction except
A. anemia
B. dysuria
C. hypertension
D. pain with micturition
E. pyuria

5. A 72-year-old male develops acute renal failure after cardiac catheterization. Physical
examination is notable for diminished peripheral pulses, livedoreticularis, epigastric tenderness,
and confusion. Laboratory studies include (mg/dL) BUN 131, creatinine 5.2, and phosphate 9.5.
Urinalysis shows 10 to 15 white blood cells (WBC), 5 to 10 red blood cells (RBC), and one
hyaline cast per high-power field (HPF). The most likely diagnosis is
A. acute interstitial nephritis caused by drugs
B. rhabdomyolysis with acute tubular necrosis
C. acute tubular necrosis secondary to radiocontrastexposure
D. cholesterol embolization
E. renal arterial dissection with prerenal azotemia

6. A 74-year-old female sees her physician for a follow- up visit for hypertension. One week ago
she wasstarted on an oral medication for hypertension. She takes no other medications. Blood
pressure is 125/80 mmHg, and heart rate is 72/min. Serum chemistries reveal a sodium of 132
meq/L. Two weeks ago serum chemistries were normal. Which of the following medications
most likely was initiated 1 week ago?
A. Enalapril
B. Furosemide
C. Hydrochlorothiazide
D. Metoprolol
E. Spironolactone
7. A patient with a diagnosis of scleroderma who has diffuse cutaneous involvement presents
with malignant hypertension, oliguria, edema, hemolytic anemia, and renal failure. You make a
diagnosis of scleroderma renal crisis (SRC). What is the recommended treatment?
A. Captopril
B. Carvedilol
C. Clonidine
D. Diltiazem
E. Nitroprusside

8. The posterior pituitary secretes arginine vasopressin (antidiuretic hormone) under which of
the following stressors?
A. Hyperosmolarity
B. Hypernatremia
C. Volume depletion
D. A and B
E. A and C

9.Each of the following features are characteristic of the nephrotic syndrome except:
A. marked proteinuria
B. hypoalbuminemia
C. edema
D. hypertension
E. hyperlipidemia

10.Hematuria is least likely to occur in:


A. papillary transitional cell carcinoma of renal pelvis, ureter or bladder
B. renal tubular adenocarcinoma
C. acute post-infectious glomerulonephritis
D. urinary lithiasis
E. minimal change disease

11.Urinalysis results include proteinuria, many red blood cells and red blood cell casts, and
1—2 white blood cells per high power field. Which of the following diseases best fits with
these findings?
A. acute cystitis
B. acute pyelonephritis
C. chronic pyelonephritis
D. acute post-streptococcal glomerulonephritis
E. minimal change disease

12.Red cell casts in the urine would be compatible with:


A. a ureteral calculus
B. a transitional cell carcinoma of the renal pelvis
C. anti-glomerular basement membrane antibody induced renal lesion
D. a foreign body in the urinary bladder
E. hypertension

13.In the usual adult type of polycystic kidneys, findings often include:
A. involvement of both kidneys
B. another family member with the disease
C. enlarged kidneys
D. renal failure late in course
E. all of the above

14.In adult polycystic disease, each of the following statements is true except:
A. The disease is familial.
B. The renal involvement is occasionally unilateral.
C. The disease is generally asymptomatic until early adult or middle life.
D. Hematuria, hypertension and palpable abdominal masses are frequent clinical findings in
symptomatic patients.
E. Disease is progressive

15.In adult polycystic disease of the kidney:


A. the disease is generally asymptomatic until early adult and middle life.
B. hematuria, hypertension and palpable abdominal masses are frequent clinical findings in
symptomatic patients.
C. nephrotic syndrome develops in adulthood
C. A and B
D. neither

16.Typical features of adult polycystic kidney disease include:


A. involvement of both kidneys
B. autosomal dominant inheritance
C. enlarged kidneys
D. cysts in the liver
E. all of the above

17.An important condition causing renal calculi is:


A. nephrotic syndrome
B. renal tumors
C. hyperparathyroidism
D. hypoparathyroidism
E. hypertension

18.The crystalloids that are major constituents in 75—85% of renal calculi are calcium plus:
A. cystine and oxalate
B. cystine and phosphate
C. oxalate and phosphate
D. oxalate and urate
E. phosphate and urate

19.Metabolic diseases leading to excessive excretion of materials which may form calculi in
the urinary tract include all of the following except:
A. hyperparathyroidism
B. oxalosis
C. gout
D. nephrotic syndrome
E. hyperparathyroidism

20.Renal calculi:
A. may be the result of gout
B. occur as a complication of hyperparathyroidism
C. are more apt to form in an alkaline urine
D. most frequently contain calcium, oxalate and phosphate
E. all of the above

21.Each of the following is characteristic of ureteral calculi except:


A. often lodge at uteropelvic junction, pelvic brim and at vesicoureteral junction
B. cause of excruciating flank pain radiating into groin and scrotum
C. originate in ureteral lumen due to chronic ureteritis
D. associated with hematuria
E. may lead to hydronephrosis

22.Morphologic changes seen with chronic pyelonephritis are:


A. interstitial chronic inflammatory cellular infiltrate
B. pericapsular glomerular fibrosis
C. protein casts in renal tubules
D. hyalinized glomeruli
E. all of the above

23.Which of the following is most helpful in differentiating acute pyelonephritis from lower
urinary tract infection?
A. proteinuria
B. hypertension
C. white cell casts in urine
D. glomerular immune-complex deposition
E. None of the above

24. A 38-year-old mother of five children died in an automobile accident. At postmortem,


both kidneys revealed irregular U-shaped depressions on their surfaces. Microscopically,
there was periglomerular fibrosis, collections of lymphocytes and plasma cells in the
interstitium with focal scarring. The tubules were focally dilated and contained
eosinophilicproteinaceous material. Some tubules contained epithelial cells and neutrophils.
The best diagnosis is:
A. chronic glomerulonephritis
B. malignant nephrosclerosis
C. papillary necrosis
D. polycystic kidney disease
E. chronic pyelonephritis

25.The organism most frequently implicated as the cause of acute pyelonephritis is:
A. Pseudomonas species
B. Escherichia coli
C. beta hemolytic streptococci
D. Proteus species
E. Streptococcus fecalis

26.Each of the following is true of acute poststreptococcal glomerulonephritis except:


A. becomes rapidly progressive glomerulonephritis in 50% of children
B. is a proliferative glomerulonephritis
C. preceded by infective episode
D. shows dome-shaped subepithelial humps
E. usually affects children

27.The majority of patients with acute post-streptococcal glomerulonephritis:


A. die from congestive heart failure in a few weeks
B. die from renal failure in a few weeks
C. pass through a latent period but eventually develop chronic glomerulonephritis
D. progress through subacute phase to chronic glomerulonephritis
E. recover completely

28.Which is not a feature of Kimmelstiel-Wilson disease?


A. occurs in diabetes
B. nodular glomerulosclerosis
C. hyalinization of efferent arteriole
D. subepithelial glomerular deposits
E. thickened basement membrane

29.Ahistopathologic glomerular lesion which, when present, strongly suggests diabetes


mellitus is:
A. absence of foot processes as the only EM finding
B. extensive crescent formation
C. linear Ig G and C3 on immunofluorescence
D. splitting of basement membrane
E. nodular glomerulosclerosis
30.Membranousglomerulopathy and post-streptococcal glomerulonephritis are similar in that
they both:
A. are self-limiting and transient renal diseases
B. are commonly associated with the nephrotic syndrome
C. are most commonly seen in children
D. have glomerular immune complex deposits
E. occur most frequently following an infectious disease

31.A 12-year-old boy with septicemia develops hematuria, hypertension, and oliguria.
Microscopic examination reveals enlarged glomeruli with diffuse mesangial and endothelial
hypercellularity. The best diagnosis is:
A. acute cortical necrosis
B. acute proliferative glomerulonephritis
C. membranoproliferative glomerulonephritis
D. rapidly progressive glomerulonephritis
E. Acute pyelonephritis

32.A patient with hemoptysis and renal failure has a renal biopsy which reveals crescentic
proliferative glomerulonephritis. Immunofluorescence reveals linear deposits of IgG and C3.
The diagnosis is:
A. acute post-infectious glomerulonephrities
B. membranous nephropathy
C. Goodpasture’s syndrome
D. minimal change disease
E. Acute pyelonephritis

33.The most characteristic feature of rapidly progressive glomerulonephritis is


A. crescent formation
B. hyaline nodules
C. sub-epithelial dense deposits
D. thickened capillary loops
E. wire-loop lesions

34.Thenephrotic syndrome is characterized by all of the following except:


A. generalized edema
B. hematuria
C. proteinuria
D. hypoproteinemia
E. hyperlipidemia

35.Nodularintercapillaryglomerulosclerosis is characteristic of:


A. lupus erythematosus
B. diabetes mellitus
C. arteriolar nephrosclerosis
D. glomerulonephritis
E. pyelonephritis

36.Minimal change disease and membranous glomerulonephritis share which of the following
characteristics?
A. nephrotic syndrome
B. IgG deposits in glomeruli
C. good prognosis with steroid therapy
D. capillary loop thickening by light microscopy
E. Goodpasturesyndrome

37.Nodulargomerulosclerosis is characteristic of:


A. arteriolar nephrosclerosis
B. diabetes mellitus
C. minimal change disease
D. lupus erythematosus
E. pyelonephritis

38.Deposition of IgG on or in the glomerular basement membrane can be seen in all of the
following except:
A. acute post-streptococcal glomerulonephritis
B. minimal change glomerulonephritis
C. lupus erythematosis glomerulonephritis
D. Goodpasture’s syndrome
E. membranous nephropathy

39.A patient with minimal change disease is least likely to have:


A. hypoproteinemia
B. edema
C. massive albuminuria
D. hypertension
E. hyperlipemia

40.A renal disease characterized by the presence of anti-glomerular basement membrane


antibodies is:
A. Goodpasture’s disease
B. post-streptococcal glomerulonephritis
C. focal glomerulonephritis
D. malignant nephrosclerosis
E. minimal change disease

41.Nephrotic syndrome is characterized by:


A. hematuria, proteinuria, hypertension
B. pyuria, oliguria, hematuria
C. hematuria, azotemia, hypertension
D. proteinuria, edema, hyperlipidemia
E. bacteriuria, azotemia, hypertension

42.Necrotizingpapillitis is associated with:


A. acute glomerulonephritis
B. arteriolar nephrosclerosis
C. diabetes mellitus
D. multiple myeloma
E. toxemia of pregnancy

43.Which renal vascular disease best fits the following description? The essential lesion is
sclerosis of small arteries and arterioles. The effects of the vascular changes are reflected in
the glomeruli, which early show a thickening of capillary basement membranes, and, later,
varying degrees of hyalinization and atrophy. The atrophy of the glomeruli and associated
tubules produces the renal shrinkage.
A. atherosclerosis
B. arteriolosclerosis
C. malignant hypertension
D. Kimmelstiel-Wilson disease
E. polyarteritisnodosa

44.Benignnephrosclerosis is characterized morphologically by:


A. fibrinoid necrosis of afferent arterioles with ischemic atrophy of nephrons
B. hyalinization of afferent arterioles with ischemic atrophy of nephrons
C. diffuse thickening of the glomerular capillary basement membranes leading to
glomerulosclerosis
D. deposition of basement membrane-like material within the glomerular mesangium leading
to glomerulosclerosis
E. None of the above

45.Renal cortical petechiae are a common finding in:


A. benign nephrosclerosis
B. malignant nephrosclerosis
C. acute pyelonephritis
D. A and B
E. neither

46.In all of the following diseases, glomerular damage is due to deposition of circulating
immune complexes except for:
A. systemic lupus erythematosis
B. membranous glomerulonephritis (MGN)
C. acute post-streptococcal glomerulonephritis (PSGN)
D. minimal change disease
E. Goodpasture’s disease

47.Polycystic disease of the kidney is characteristically associated with:


A. double ureter
B. the nephrotic syndrome
C. nephrolythiasis
C. both
D. neither

48.An irritable female infant, age 2 years, has a fever of 104° F and bloody urine. Microscopic
examination of the urine reveals red blood cells and neutrophils but no casts. The most likely
diagnosis is:
A. sarcoma botryoides
B. acute cystitis
C. urinary stone
D. acute glomerulonephritis
E. polycystic kidney

49.A 20-year-old patient has long standing microscopic hematuria and hypertension around
180/95. Which of the following conditions would be least likely in your differential diagnosis?
A. trauma
B. chronic glomerulonephritis
C. minimal change disease
D. diabetic glomerulosclerosis
E. congenital polycystic kidneys

50.A 2-year-old child presents with huge abdominal mass (or masses), hematuria,
hypertension and abdominal pain. Which of the following is the least likely diagnosis?
A. Wilm’s tumor
B. neuroblastoma
C. polycystic kidney(s)
D. hydronephrosis
E. renal adenocarcinoma

51.A 50-year-old male develops acute renal failure with dark urine one week after a flu-like
illness. A renal biopsy is likely to reveal:
A. renal infarction
B. crescentic glomerulonephritis
C. myeloma kidney
D. amyloidosis
E. acute tubular necrosis

52.Polycystic disease of the kidney is characteristically associated with:


A. amyloidosis
B. the nephrotic syndrome
C. both
D. neither
E. nephrolithiasis

53.Most children with poststreptococcal glomerulonephritis:


A. develop nephrotic syndrome
B. progress to chronic glomerulonephritis
C. develop hypertensive cardiovascular disease
D. recover spontaneously
E. have B strep bacteria in their urine

54.Which of the following conditions does not predispose to urolithiasis?


A. hydronephrosis
B. chronic pyelonephritis
C. hypercalcemia
D. hydrocele
E. cystitis

55.Which of the following conditions does not predispose to urolithiasis?


A. hypercalcemia
B. hydronephrosis
C. chronic pyelonephritis
D. spermatocele
E. benign prostatic hypertrophy

56.Ischemic acute tubular necrosis occurs most commonly in association with:


A. septic shock
B. ruptured aneurysm
C. carcinoma of prostate
D. hydronephrosis and pyelonephritis
E. malignant hypertension

57.Thenephrotic syndrome is primarily due to:


A. diabetic glomerulosclerosis
B. toxic necrosis of renal tubular epithelium
C. increased permeability of the glomerular filtration barrier
D. narrowing of the afferent arteriole
E. None of the above

58.A 22-year-old pregnant female has flank pain and fever. Her urine contains white blood
cell casts. It can be safely assumed that she has at least:
A. chronic glomerulonephritis
B. analgesic nephritis
C. acute pyelonephritis
D. ectopic pregnancy
E. pre-eclampsia (toxemia of pregnancy)

59.A 45-year-old male complains of costovertebral angle pain and shortness of breath. A
chest x-ray reveals “cannon ball” metastases in the lungs. Fresh RBC are found in the urine.
The gall bladder was removed for stones 2 years previously. Physical exam is otherwise
normal. In this patient, which of the following is least likely to be present?
A. hypertension
B. a red blood cell count of greater than 6 million (polycythemia)
C. elevated prostatic acid phosphatase
D. feminization
E. hypercalcemia

60.A 48-year-old male has hemoptysis, microscopic hematuria, and a mass at the upper pole
of the right kidney. The most likely diagnosis is:
A. Goodpasture’s syndrome
B. Cushing’s syndrome
C. primary aldosteronism
D. renal adenocarcinoma
E. hepatocellular carcinoma

61.The most common organism associated with acute pyelonephritis is:


A. Staphylococcus aureus
B. chlamydia
C. beta-hemolytic streptococci
D. Campylobacter
E. E. coli

62.Which of the following glomerular disorders is not apparently immunologically mediated?


A. systemic lupus erythematosisglomerulopathy
B. poststreptococcal glomerulonephritis
C. allergic pupura
D. diabetic nephropathy
E. rapidly progressive glomerulonephritis

63.The most common appearance of the glomeruli in adults with the nephrotic syndrome is:
A. proliferative glomerulonephritis
B. membranous glomerulonephritis
C. rapidly progressive “crescentic” glomerulonephritis
D. normal appearing glomeruli
E. wire loops
64.A urine sediment has many RBC, several RBC casts, and few WBC. The patient probably
does not have:
A. acute post-streptococcal glomerulonephritis
B. lupus glomerulonephritis
C. renal involvement with polyarteritis
D. acute pyelonephritis
E. malignant hypertension

65.Which is the most characteristic feature in the urine sediment of patients with post-
streptococcal glomerulonephritis?
A. epithelial casts
B. white cell casts
C. red blood cells and casts
D. marked proteinuria
E. None of the above

66.The most common cause of chronic renal failure is:


A. diabetes mellitus
B. acute tubular necrosis
C. chronic glomerulonephritis
D. renal tubular adenocarcinoma
E. None of the above

67. Which of the following is pathognomic of acute poststreptococcal glomerulonephritis?


A. Macroscopic hematuria
B. Microscopic hematuria
C. Eosinophilia in the urine
D. Red blood cell casts
E. proteinuria 1.0 g/24 hr

68. What is the treatment of choice for acute poststreptococcal glomerulonephritis?


A. Penicillin
B. Gentamicin
C. Prednisolone
D. A and B
E. None of the above

69. Which of the following statements concerning prognosis of acute poststreptococcal


glomerulonephritis is (are) true?
A. Most patients with this disorder eventually develop end-stage renal failure
B. The prognosis depends on how aggressively the antecedent streptococcal infection is treated
C. Most patients with the acute disease recover completely within 1 to 2 years
D. 5% to 20% of patients with this acute disease end up with progressive renal disease
E. C and D
70. Which of the following subtypes of acute glomerulonephritis is associated with group A
beta-hemolytic streptococcus?
A. minimal change
B. Focal segmental sclerosis
C. Membraneous
D. Diffuse proliferative
E. Crescentic

71. Which of the following subtypes of acute poststreptococcal glomerulonephritis is most


closely associated with nephrotic syndrome?
A. Minimal change
B. Focal segmental sclerosis
C. Membranous
D. Diffuse proliferative
E. Crescentic

72. What is the most common cause of chroic renal failure?


A. Glomerulonephritis (acute to chronic)
B. Chronic pyelonephritis
C. Diabetes mellitus
D. Hypertensive renal disease
E. Congenital anomalies

73. What is the least common cause of chronic renal failure among the following causes?
A. Glomerulonephritis (acute to chronic)
B. Chronic pyelonephritis
C. Hypertensive renal disease
D. Diabetes mellitus
E. Congenital anomalies

74. Which of the following antihypertensive agents is contraindicated in patients with chronic
renal disease?
A. Hydrochlorothiazide-triamterene
B. Furosemide
C. Prazosin
D. Nifedipine
E. alpha-methyldopa

75. What is the major cause of death in patients with chronic renal failure?
A. Uremia
B. Malignant hypertension
C. Hyperkalemia-induced arrhythmias
D. Myocardial infarction
E. Subarachnoid hemorrhage

76. What is the anemia usually associated with chronic renal failure?
A. Hypochromic
B. Macrocytic
C. Normochromic: normocytic
D. Microcytic
E. Hypochromic: microcytic

77. Which of the following may be indicated in the treatment of a patient with chronic renal
failure?
A. Limitation of dietary protein
B. Sodium supplementation
C. Calcium supplementation
D. A and B
E. All of the above

78. Which of the following is (are) associated with nephrotic syndrome?


A. Proteinuria, 3,5 g/day
B. Edema
C. Hypoalbuminemia
D. Hypercholesterolemia
E. All of the above

79. Which of the following statements regarding nephrotic syndrome is false?


A. Most patients with nephrotic syndrome progress to chronic renal failure
B. Some cases of nephrotic syndrome are drug induced
C. Hodgkin’s disease may lead to nephrotic syndrome
D. Preeclamptic toxemia ay lead to nephrotic syndrome
E. None of the above statements is false

80. Which of the following statements regarding diabetes mellitus and chronic renal failure is
true?
A. Diabetes mellitus is an uncommon cause of chronic renal failure
B. Diabetes mellitus type I is a more common cause of chronic renal failure than diabetes
mellitus type 2.
C. Diabetes mellitus type 2 is a more common cause of chronic renal failure than diabetes
mellitus type 1
D. Diabetes mellitus type 2 does not lead to chronic renal failure
E. Diabetes mellitus type 1 does not lead to chronic renal failure

81. The treatment of nephrotic syndrome includes which of the following?


A. corticosteroids
B. Loop diuretics
C. Thiazide diuretics
D. Protein restriction
E. All of the above

82. A 30 year old male comes to the Emergency Department with acute onset of severe right-
side flank pain. The pain radiates down into the groin and testicle and is associated with
hematuria, urinary frequency, urgency and dysuria. On examination, the patient is in acute
distress. He has significant right costovertebral angle tenderness. The rest of the abdominal
examination is normal. The patient is afebrile.
What is the most likely diagnosis in this patient?
A. Renal colic
B. Acute pyelonephritis
C. Cute pyelitis
D. Atypical appendicitis
E. None of the above

83. What is the most typical composition of a kidney stone?


A. Calcium oxalate
B. Mixed calcium oxalate/calcium phosphate
C. Calcium phosphate
D. Struvite
E. Uric acid

84. Which of the following abnormalities is (are) usually associated with calcium oxalate
stones?
A. Hypercalciuria
B. Hyperuricuria
C. Hypocitraturia
D. All of the above
E. None of the above

85. What is the drug of choice for the management of idiopathic hypercalciuria?
A. Cellulose sodium phosphate
B. An orthophosphate
C. Potassium citrate
D. Hydrochlorothiazide
E. Pyridoxine

86. What is the most important component of diagnostic workup in a patient with a kidney
stone?
A. Serum calcium/serum uric acid
B. Serum creatinine
C. Intravenous pyelography
D. 24 hour urine for volume, calcium, uric acid, citrate, oxalate, sodium, creatinine, and pH
E. serum parathyroid hormone

87. Which of the following statements regarding uric acid stones is (are) correct?
A. Uric acid stones are formed in patients who are found to have acidic urine
B. Uric acid stones are formed in patients with increased uric acid secretion
C. The initial treatment for patients with uric acid stones is alkalinization of the urine
D. Patients with recalcitrant uric acid stones should be treated with allopurinol
E. All of the above statements are correct

88. Which of the following statements regarding the treatment of nephrolithiasis is (are) true?
A. Extracorporeal shock wave lithotripsy (ESWL) has become widely used for the treatment of
renal stones
B. Ureteral stones, unless large, are best managed by awaiting their spontaneous passage
C. ESWL has shown its greatest benefit in patients with stones less than 2 cm in diameter
D. All of the above statements are true
E. None of the above statements is true

89. Which of the following is (are) part o the differential diagnosis of renal colic?
A. Acute pyelonephritis
B. Renal adenocarcinoma
C. Papillary necrosis
D. All of the above
E. None of the above

90. What is the treatment of choice for metabolic stone formation?


A. Hydrochlorothiazide
B. sodium potassium citrate
C. Pyridoxine
D. Organophosphate
E. None of the above

91. Magnesium-ammonium phosphate stones are usually secondary to urinary tract infection
with which of the following?
A. Escherichia coli
B. Proteus species
C. Klebsiella
D. Enterococcus
E. Enterobacter
GASTROENTEROLOGY
1. A 46-year-old man is admitted to the hospital forupper gastrointestinal (GI) bleeding. He has
a known historyof peptic ulcer disease, for which he takes a protonpumpinhibitor. His last
admission for upper GI bleedingwas 4 years ago. After fluid resuscitation, he is
hemodynamicallystable and his hematocrit has not changed inthe past 8 h. Upper endoscopy is
performed. Which of thefollowing findings at endoscopy is most reassuring thatthe patient will
not have a significant rebleeding episodewithin the next 3 days?
A. Adherent clot on ulcer
B. Clean-based ulcer
C. Gastric ulcer with arteriovenous malformations
D. Visible bleeding vessel
E. Visible nonbleeding vessel

2. Which of the following statements about alcoholicliver disease is not true?


A. Pathologically, alcoholic cirrhosis is often characterizedby diffuse fine scarring with small
regenerativenodules.
B. The ratio of AST to ALT is often higher than 2.
C. Serum aspartate aminotransferase levels are oftengreater than 1000 U/L.
D. Concomitant hepatitis C significantly accelerates thedevelopment of alcoholic cirrhosis.
E. Serum prothrombin times may be prolonged, butactivated partial thromboplastin times are
usuallynot affected.

3. All of the following necessitate sending bacterialstool cultures in patients with diarrhea for 2
days severeenough to keep them home from work except
A. age >75
B. bloody stools
C. dehydration
D. recent lung transplantation
E. temperature >38.5°C

4. All the following are causes of diarrhea except


A. diabetes
B. hypercalcemia
C. hyperthyroidism
D. irritable bowel syndrome
E. metoclopramide

5. All the following are associated with an increasedrisk for cholelithiasisexcept


A. chronic hemolytic anemia
B. obesity
C. high-protein diet
D. pregnancy
E. female sex
6. A 76-year-old man complains of frequent small stoolsthat are not abnormally liquid or hard.
There is some painwith passing the stool. He has no abdominal pain, nausea,melena, vomiting,
or fever. He has approximately eight toten bowel movements per day, which interferes with
hisquality of life, though there is no fecal incontinence. What isa possible diagnosis to explain
his complaints?
A. Hypothyroidism
B. Neuromuscular disorder
C. Proctitis
D. Ulcerative colitis
E. Viral gastroenteritis

7. Which of the following proteins does not cause secretionof gastric acid?
A. Acetylcholine
B. Caffeine
C. Gastrin
D. Histamine
E. Somatostatin

8. A 62-year-old female has a 3-month history of diffusecrampy abdominal pain and watery
diarrhea and haslost 14 lb over this period. There is no prior history of abdominalor gynecologic
disease. She is on no regular medications,is a nonsmoker, and does not consume
alcohol.Colonoscopy reveals normal colonic mucosa. Biopsies of thecolon reveal inflammation
with extensive subepithelial collagendeposition and lymphocytic infiltration of the
epithelium.Which of the following is the most likely diagnosis?
A. Collagenous colitis
B. Crohn’s disease
C. Ischemic colitis
D. Lymphocytic colitis
E. Ulcerative colitis

9. A 29-year-old woman comes to see you in clinic becauseof abdominal discomfort. She feels
abdominal discomforton most days of the week, and the pain varies in locationand intensity.
She notes constipation as well as diarrhea, butdiarrhea predominates. In comparison to 6
months ago, shehas more bloating and flatulence than she has had before.She identifies eating
and stress as aggravating factors, and herpain is relieved by defecation. You suspect irritable
bowelsyndrome (IBS). Laboratory data include: white blood cell(WBC) count 8000/μL,
hematocrit, 32%, platelets, 210,000/μL, and erythrocyte sedimentation rate (ESR) of 44 mm/h.
Stool studies show the presence of lactoferrin but no blood.Which intervention is appropriate
at this time?
A. Antidepressants
B. Ciprofloxacin
C. Colonoscopy
D. Reassurance and patient counseling
E. Stool bulking agents
10. A patient with known peptic ulcer disease presentswith sudden abdominal pain to the
emergency department.She is thought to have peritonitis but refuses an abdominalexamination
due to the discomfort caused byprevious examinations. Which of the following maneuvers will
provide reasonably specific evidence of peritonitiswithout manual palpation of the abdomen?
A. Bowel sounds are absent on auscultation.
B. Forced cough elicits abdominal pain.
C. Hyperactive bowel sounds are heard on auscultation.
D. Pain is elicited with gentle pressure at the costovertebralangle.
E. Rectal examination reveals heme-positive stools

11. A 45-year-old male says that for the last year he occasionally has regurgitated particles
from food eaten several days earlier. His wife complains that his breath has been foul-smelling.
He has had occasional dysphagia for solid foods. The most likely diagnosis is
A. gastric outlet obstruction
B. scleroderma
C. achalasia
D. Zenker’s diverticulum
E. diabetic gastroparesis

12. Chronic active hepatitis is most reliably distinguishedfrom chronic persistent hepatitis by
the presence of
A. extrahepatic manifestations
B. hepatitis B surface antigen in the serum
C. antibody to hepatitis B core antigen in the serum
D. a significant titer of anti-smooth-muscle antibody
E. characteristic liver histology

13. All the following are causes of bloody diarrhea except


A. Campylobacter
B. Cryptosporidia
C. Escherichia coli
D. Entamoeba
E. Shigella

14. What is the most common cause of dysphagia?


A. Achalasia
B. Esophageal spasm
C. A lower esophageal ring (Schatzki ring)
D. Nonspecific motor disorders
E. An esophageal stricture

15. What is malignant dysphagia usually related to?


A. A squamous cell carcinoma related to Barret’s esophagus
B. An adenocarcinoma related to Barret’s esophagus
C. A squamous cell carcinoma unrelated to Barret’s esophagus
D. An adenocarcinoma unrelated to Barret’s esophagus
E. None of the above

16. What is the drug of choice in the treatment of achalasia?


A. A nitroglycerin derivative
B. A calcium channel blocker
C. A benzodiazepine
D. An antacid
E. Any of the above

17. Achalasia is characterized by which of the following?


A. Transient relaxation of the lower esophageal sphincter
B. Decreased resting pressure of the lower esophageal sphincter
C. Abnormal production of H in the stomach leading to acid-induced damage in the lower and
middle esophagus.
D. Loss of peristalsis and relaxation of the lower esophageal sphincter
E. None of the above

18. Esophageal spasm is best characterized by which of the following:


A. A loss of peristalsis and relaxation of the lower esophageal sphincter
B. Increased resting pressure of the lower esophageal sphincter
C. An increased percentage of simultaneous waves with some discoordinated peristalsis
D. Transient contraction of the lower esophageal sphincter
E. None of the above

19. Which of the following may be indicated in the management of the acute phase of
ulcerative colitis?
A. Steroid enema
B. Oral corticosteroids
C. Parenteral corticosteroids
D. A and B
E. All of the above

20. Which of the following statements regarding the use of sulfasalazine for the treatment of
ulcerative colitis is false?
A. Sulfasalazine is structurally related to both aspirin and sulfa drugs
B. Sulfasalazine is effective in maintaining remission is this condition as well as in the acute
treatment of mild disease
C. Sulfasalazine may impair folic acid metabolism
D. All of the above are false
E. None of the above statements is false
21. Which of the following is a (are) complication(s) of the disease described?
A. Toxic megacolon
B. Colonic cancer
C. Colonic strictures
D. Iritis
E. All of the above

22. Which of the following investigations is the most sensitive test for confirming the diagnosis
of Crohn’s diseases?
A. Sigmoidoscopy
B. Colonoscopy
C. Barium enema
D. Computed tomography (CT) scan of the abdomen
E. Magnetic resonance imaging (MRI) scan of the abdomen

23. Which of the following drugs is the most appropriate initial therapy in the acute phase of
Crohn’s disease?
A. Prednisone
B. Sulfasalazine
C. Metronidazole
D. 6-mercaptopurine
E. Azathioprine

24. Sulfasalazine is effective in which of the following subtypes of Crohn’s disease?


A. Crohn’s colitis
B. Crohn’sileocolitis
C. Crohn’s disease of the small bowel
D. A and B
E. All of the above

25. Which of the following is (are) associated with Crohn’s disease?


A. Skip lesions on x-ray
B. Thumbprinting on x-ray
C. Ineffective surgical treatment
D. None of the above
E. A, B, and C

26. Which of the following statements regarding complications of Crohn’s disease is false?
A. Rectal fissures, rectocutaneous fistulas, and perirectal abscesses are common complications
of this condition
B. Arthritis is sometimes seen as a complication of Crohn’s disease
C. Erythema nodosum and pyodermagangrenosum are sometimes found with this condition
D. Patients with this condition are not at increased risk of colorectal cancer
E. None of the above statements is false.
27. What is the pathophysiology of celiac sprue?
A. An immunologic disorder of the small bowel mucosa
B. A disaccharide deficiency of the small intestinal mucosa
C. A deficiency of pancreatic exocrine
D. Secondary contamination of the small intestine by coliform bacteria
E. None of the above

28. Which of the following drugs show(s) effectiveness against H.Pylori?


A. Bismuth subsalicylate
B. Metronidazole
C. Amoxicillin
D. B and C
E. All of the above

29. What is the mode of action of omeprazole?


A. An H1 receptor antagonist
B. An H2 receptor antagonist
C. A proton pump inhibitor
D. A cytoprotective agent
E. An anticholinergic agent

30. Which of the following drugs is classified as an H2 receptor antagonist?


A. Cimetidine
B Ranitidine
C. Famotidine
D. A and B
E. All of the above

31. Which of the following statements regarding the role of drugs in the development of peptic
ulcer is (are) true?
A. The incidence of this condition in patients taking indomethacin or other NSAIDs is increased
B. The use of dexamethasone is a risk factor for this condition
C. Aspiring may precipitate this condition
D. Some NSAIDs seem more likely to precipitate peptic ulcer than others
E. All of the above are true

32. Which of the following statements regarding cimetidine is (are) true?


A. Cimetidine is an H2 receptor antagonist
B. Cimetidine and antacids are no more effective than cimetidine alone in the treatment of
peptic ulcer
C. Exacerbation of peptic ulcer is common
D. Cimetidine may interfere with warfarin metabolism
E. All of the above are true

33. Which of the following statements regarding the diagnosis and treatment of gastric ulcers is
(are) true?
A. The pain of gastric ulcers in contrast with duodenal ulcers is sometimes aggravated rather
than relieved by food
B. Anorexia, nausea, and vomiting are more common in patients with a gastric ulcer than in
those with a duodenal ulcer
C. Endoscopy should follow the identification of a gastric ulcer on a gastrointestinal series
D. The healing rate and the time to heal for gastric ulcers are generally longer than for
duodenal ulcers
E. All of the above

34. The ascites associated with cirrhosis should generally be treated by which of the following?
A. Sodium restriction
B. Water restriction
C. Spironolactone
D. A and C
E. A, B, and C

35. Which of the following tests is the most sensitive in confirming the diagnosis of hepatitis A?
A. Anti-hepatitis A virus (HAV)-immunoglobulin G (IgG)
B. Anti-HAV-immunoglobulin M (IgM)
C. HAV core antigen
D. Anti-hepatitis B core antigen (HBcAg)
E. Anti-hepatitis C virus (HCV)

36. Initial screening for hepatitis B should include which of the following?
A. Anti-hepatitis B surface antigen (HBsAg) and anti-HBc
B. Hepatitis B early antigen (HBeAg) and anti-HBe
C. HBsAg and anti-HBs
D. HBsAg and anti-HBc
E. anti-HBe and anti-HBc

37. Which of the following laboratory tests is (are) usually abnormal in a patient with acute viral
hepatitis?
A. serum AST
B. serum bilirubin
C. serum ALT
D. serum alkaline phosphatase
E. All of the above

38. Clinical manifestations of cirrhosis include which of the following?


A. Fatigue
B. Jaundice
C. Splenomegaly
D. Hypoalbuminemia
E. All of the above

39. Indications for the use of hepatitis B vaccine include which of the following?
A. Heath care personnel
B. Hemodialysis patients
C. All children
D. A and B only
E. All of the above

40. Which of the following types of viral hepatitis is (are) associated with the development of
chronic active hepatitis?
A. hepatitis B
B. hepatitis C
C. hepatitis A
D. A and B only
E. All of the above

41. The pathophysiology of alcoholic cirrhosis includes which of the following?


A. macronodular and micronodular fibrosis
B. Nodular regeneration
C. Increased portal vein pressure
D. Increase in hepatic size followed by a decrease
E. All of the above

42. Which of the following has (have) been suggested as treatment for complications of
cirrhosis of the liver?
A. Prednisone
B. Propranolol
C. Colchicine
D. Propylthiouracil
E. All of the above

43. Which of the following is (are) a complication of alcoholic cirrhosis?


A. Hypersplenism
B. Hepatic encephalopathy
C. Congestive gastropathy
D. Spontaneous bacterial peritonitis
E. All of the above

44. Treatment of the ascites accompanying cirrhosis may include which of the following?
A. Spironolactone
B. Hydrochlorothiazide
C. Furosemide
D. All of the above
E. A and B only

45. Which of the following statements regarding irritable bowel disease is false?
A. The typical location of the abdominal pain is the lower abdomen
B. Defecation frequently relieves the pain
C. There is often a perception of incomplete emptying of the rectum
D. Bowel action is often irregular
E. Very severe abdominal tenderness is a hallmark of the disease

46. What is the most likely cause of the irritable bowel disease?
A. A mass lesion in the area of the sigmoid colon
B. A low-grade chronic inflammation of the entire small and large bowel
C. An autoimmune phenomenon
D. A decreased ability to digest certain foods
E. None of the above

47. Which of the following would be most unlikely in a patient with irritable bowel disease?
A. Alternating diarrhea and constipation
B. Increased pain at times of stress
C. Pain on awakening from sleep
D. Abdominal bloating
E. Increased passage of flatus

48. Which of the following investigations is not indicated in irritable bowel disease?
A. A complete blood count
B. An erythrocyte sedimentation rate (ESR)
C. Electrolytes
D. Abdominal ultrasound
E. Thyroid function studies

49. Which of the following may have to be considered in the differential diagnosis of irritable
bowel disease?
A. Colonic adenocarcinoma
B. Fecal impaction
C. Celiac disease
D. Endometriosis
E. All of the above

50. Which of the following conditions (symptoms) is not associated with irritable bowel
disease?
A. Gastroesophageal reflux disease
B. Cholelithiasis
C. Noncardiac chest pain
D. Depression
E. Fatigue

51. Which of the following statements concerning irritable bowel disease is (are) true?
A. This condition is the most common reason for referral from physician toa gastroenterologist
B. This condition is slightly more common in men
C. The symptoms associated with this condition are more common in young adults than in older
adults
D. This condition has been associated with a specific biochemical abnormality in some patients
E. All of the above statements are true

52. Which of the following is the most important component of the management of irritable
bowel disease?
A. Single-agent pharmacologic therapy
B. Multiple-agent pharmacologic therapy
C. A therapeutic physician-patient relationship
D. A focused diet
E. A diet elimination trial: eliminating one food at a time until the responsible food is found

53. Which of the following medications should not be used in the treatment of irritable bowel
disease?
A. Psyllium
B. Loperamide
C. Cholestyramine
D. Codeine phosphate
E. Desipramine

54. A 43 year old female comes to your office with a 3-hour history of right upper quadrant
pain. The pain is described as spasmodic and sharp. It radiates through to the back. The patient
describes several episodes of this pain within the past 6 months. Nausea and vomiting
accompany most of these episodes. Fever and chills are usually absent. The pain usually comes
on after meal. On examination there are no abdominal masses or tenderness. The chest is clear
and the cardiovascular system is normal. The patient’s blood pressure is 140/70 mm Hg. The
patient has no drug allergies and is on no medications at the present time. What is the most
likely diagnosis in this patient?
A. Acute cholecystitis
B. Biliary colic
C. Acute pancreatitis
D. Ileocecal appendicitis
E. Crohn’s disease

55. Which of the following investigations is more informative NS cost-effective to diagnose


gallstones?
A.A white blood cell count
B. An oral cholecystogram
C. An abdominal ultrasound
D. An electrocardiogram
E. CT of abdomen

56. Regarding the use oral dissolution therapy in gallstone disease, which of the following
statements is (are) true?
A. Oral dissolution therapy is an excellent option for most patients
B. Few if any gallstones that are dissolved with oral dissolution reoccur
C. The preferred agent for oral dissolution therapy is ursodiol
D. Oral dissolution therapy should not be combined with extracorporeal shock wave lithotripsy
(ESWL)
E. Oral dissolution therapy works best in patients with large gallstones

57. Which of the following statements regarding the treatment of asymptomatic gallstones is
most accurate?
A. Asymptomatic gallstones should be treated with cholecystectomy
B. Asymptomatic gallstones should not be treated
C. Whether or not asymptomatic gallstones should be treated depends on the presence or
absence of comorbid conditions
D. Asymptomatic gallstones should or should not be treated;
E. Asymptomatic gallstone treatment has radically changed since the introduction of
laparascopic cholecystectomy

58. What is the most common complication during laparoscopic cholecystectomy?


A. Excessive bleeding
B. Small bowel perforation
C. Injury to the biliary tract system
D. Inability to remove the gallbladder through the laparoscope
E. Liver laceraition
59. Which of the following statement(s) is (are) true of laparoscopic cholecystectomy?
A. Laparoscopic cholecystectomy provides a safe and effective treatment for most patients with
symptomatic gallstones; it is the treatment of choice
B. Laparoscopic cholecystectomy provides distinct advantages over open cholecystectomy
C. Laparoscopic cholecystectomy can be performed at a treatment cost equal to or slightly less
than that for open cholecystectomy
D. During laparoscopic cholecystectomy when the anatomy is obscured because of excessive
bleeding or other problems, the operation should be converted promptly to open
cholecystectomy
E. All of the above statements are true

60. What is (are) the essential diagnostic feature(s) of acute pancreatitis?


A. Abrupt onset of epigastric pain with radiation to the back
B. Nausea and vomiting
C. Elevated serum amylase
D. All of the above
E. None of the above

61. Which of the following statements about acute pancreatitis is (are) true?
A. Many cases of this disease are associated with a pathologic condition of the biliary tract
B. strong evidence suggests a link between this disease and alcohol
C. The chronic condition of this disease is more likely to be associated with alcohol abuse rather
than biliary tract disease
D. All of the above statements are true
E. None of the above statements is true

62. Which of the following is (are) complications of acute pancreatitis?


A. Ascites
B. Pleural effusion
C. Abscess formation
D. All of the above
E. None of the above

RHEUMATOLOGY
1. A 73-year-old woman with a medical history of obesityand diabetes mellitus presents to your
clinic complaining of right knee pain that has been progressive and is worse with walking or
standing. She has taken over the-counter nonsteroidalanti-inflammatory drugs without relief.
She wants to know what is wrong with her knee and what may have caused it. X-rays are
performed and reveal cartilage loss and osteophyte formation. Which of the following
represents the most potent risk factor for the development of osteoarthritis?
A. Age
B. Gender
C. Genetic susceptibility
D. Obesity
E. Previous joint injury

2. A patient presents with 3 weeks of pain in the lower back. All the following are risk factors
for serious causes of spine pathology except
A. age more than 50 years
B. urinary incontinence
C. duration of pain more than 2 weeks
D. bed rest without relief
E. history of intravenous drug use

3. Which of the following joints are typically spared in osteoarthritis (OA)?


A. Ankle
B. Cervical spine
C. Distal interphalangeal joint
D. Hip
E. Knee

4. What is the most common extraarticular manifestation of ankylosing spondylitis?


A. Anterior uveitis
B. Aortic regurgitation
C. Cataracts
D. Inflammatory bowel disease
E. Third-degree heart block

5. A 43-year-old man presents to your clinic complaining of bilateral knee pain. He states that
the pain worsens with walking and is not present at rest. He has been experiencing knee pain
for many months and has had no relief from over-the-counter analgesics. He has a history of
hypertension and obesity. Which of the following represents the best initial treatment strategy
for this patient?
A. Avoidance of walking for several weeks
B. Light daily walking exercises
C. Low-dose, long-acting narcotics
D. Oral steroid pulse
E. Weight loss

6. All the following organisms have been implicated in reactive arthritis except
A. Chlamydia trachomatis
B. Neisseria gonorrhoeae
C. Salmonella enteritidis
D. Shigelladysenteriae
E. Yersinia enterocolitica
7. A 60-year-old male complains of pain in both knees coming on graduallyover the past 2
years. The pain is relieved by rest and worsened by movement. There is bony enlargement of
the knees with mild warmth and small effusions. Crepitation is noted on motion of the knee
joint bilaterally. There are no other findings except for bony enlargement at the distal
interphalangealjoint. The patient is 167 cm tall and weighs 95 kg. Which of the following is the
best way to prevent disease progression?
a. Weight reduction
b. Calcium supplementation
c. Total knee replacement
d. Long-term nonsteroidal anti-inflammatory drug (NSAID) administration
e. Oral prednisone

8. A 45-year-old woman has pain in her fingers on exposure to cold, arthralgias, and difficulty
swallowing solid food. Of the following tests, which, if positive, would be most supportive of a
definitive diagnosis?
a. Rheumatoid factor
b. Antinucleolar antibody
c. ECG
d. BUN and creatinine
e. Reproduction of symptoms and findings by immersion of hands in cold water

9. A 43-year-old man with diabetes and cardiomegaly has had an attack of pseudogout. He
should be evaluated for which of the following?
a. Renal disease
b. Hemochromatosis
c. Peptic ulcer disease
d. Lyme disease
e. Inflammatory bowel disease

10. A 75-year-old male complains of headache. On one occasion he transientlylost vision in his
right eye. He also complains of aching in the shoulders and neck. There are no focal neurologic
findings. Carotid pulses are normal without bruits. Laboratory data show a mild anemia.
Erythrocyte sedimation rate is 85. Which of the following is the best approach to management?
a. Begin glucocorticoid therapy and arrange for temporal artery biopsy
b. Schedule biopsy and begin corticosteroids based on biopsy results and clinical
course
c. Schedule carotid angiography
d. Follow ESR and consider further studies if it remains elevated
e. Start aspirin and defer any invasive studies unless further symptoms develop

11. What is the most characteristic symptom of rheumatoid arthritis?


A. Early morning joint stiffness
B. Progressive joint pain
C. Predilection for the small joints
D. Joint swelling
E. Normal cartilage despite joint pain

12. What is the most characteristic sign of rheumatoid arthritis?


A. Joint swelling
B. Bilateral (symmetrical) joint involvement
C. Erythema surrounding the affected joints
D. Joint bogginess
E. Involvement of theglenohumeral joint in all cases

13. On what is the pathophysiology of rheumatoid arthritis is based?


A. Bone destruction
B. Bone spur formation
C. Bone sclerosis
D. Symmetrical joint involvement
E. Synovial inflammation

14. In the course of the pathophysiology of rheumatoid arthritis, which of the following is most
characteristic of the disease?
A. Synovial proliferation with cartilage erosion stimulated by cytokines
B. Cartilage destruction stimulated by the proliferation of proteoglycans
C. Cartilage destruction stimulated by the enzymatic action of proteoglycans
D. Loss of the synovial membrane
E. None of the above; the pathophysiology of the disease is not known with any certainty

15. The disease described affects one particular part of the spine. What is the affected part, and
what are the affected vertebrae?
A. Cervical: C6-C7
B. Cervical: C1-C2
C. Thoracic: T7-T9
D. Lumbar: L1-L3
E. LumbarL L4-L5

16. Which anemia usually accompanies rheumatoid arthritis?


A. Microcytic: hypochromic
B. Microcytic: normochromic
C. Normocytic: normochromic
D. Macrocytic: hyperchromic
E. Normocytic: hypochromic

17. Which of the following is a (are) systemic complication(s) of rheumatoid arthritis?


A. Vasculitis
B. Pericarditis
C. Pleural effusion
D. Diffuse interstitial fibrosis of the lungs
E. All of the above

18. Felty’s syndrome is a complication of rheumatoid arthritis. Which of the following is (are)
component of Felty’s syndrome?
A. Splenomegaly
B. Neutropenia
C. Positive rheumatoid factor
D. A and B
E. All of the above

19. For rheumatoid arthritis, which of the following is a (are) proven therapeutic agent(s)?
A. Auranofin
B. Hydroxychloroquine
C. Methotrexate
D. D-penicillamine
E. All of the above

20. What is the drug of choice for the suppression of inflammation in a patient with rheumatoid
arthritis?
A. Auranofin
B. Methotrexate
C. Oral prednisone
D. Naproxen
E. D-penicillamine

21. Which of the following is not a classical radiologic feature of rheumatoid arthritis?
A. Loss of juxtaarticular bone mass
B. Narrowing of the joint space
C. Bony erosions
D. Subarticular sclerosis
E. All of the above are radiologic manifestations

22. Which of the following statements regarding the symptomatology of osteoarthritis is false?
A. Pain is the chief symptom of osteoarthritis and is usually deep and aching in character
B. Stiffness of the involved joints is common but of relatively brief duration
C. The pain of osteoarthritis is characteristically dull and aching
D. The major physical finding in osteoarthritis is bony crepitus
E. The presence of osteophytes is sufficient for the diagnosis of osteoarthritis

23. Which of the following statements concerning osteoarthritis is false?


A. This condition is the most common form of joint disease
B. 80% of the population have radiographic features of this condition in weight-bearing joints
before age 65 years
C. This condition has both primary and secondary forms
D. Narrowing of the joint space is unusual
E. Pathologically, the articular cartilage is first roughened and then finally worn away

24. A 65-year-old female with moderately severe osteoarthritis of her left hip comes to your
office requesting an exercise prescription. She wishes to “get into shape”. Which of the
following would you recommend to this patient at this time?
A. Exercise is not good for osteoarthritis; rest is much more appropriate
B. A graded exercise program consisting of brisk walking and gradually increasing the distance
to 3 to 4 km/day will probably not cause pain and will be good for her
C. A passive isotonic exercise program is preferable to an active isometric exercise program
D. Any exercise program will probably hasten her need for total hip replacement
E. Swimming is the best exercise prescription you can give her; it promotes cardiovascular
fitness and at the same time keeps pressure off the weight-bearing joints.

25. Which of the following radiographic features is (are) usually seen in osteoarthritis?
A. Narrowing of the joint spaces
B. Bony sclerosis
C. Osteophyte formation
D. Subchondral cyst formation
E. All of the above

26. Which of the following is a (are) useful treatment modality(ies) in the treatment of
osteoarthritis?
A. Weight loss in obese patients
B. Canes, crutches, and walkers
C. The application of heat to involved joints
D. NSAIDs
E. All of the above

27. Which of the following statements concerning the incidence of osteoarthritis is (are) true?
A. One third of adults age 25-75 years have radiographic evidence of osteoarthritis
B. Cartilaginous fraying is common
C. Mild synovitis may develop in response to crystals or cartilaginous debris
D. The most common sites for this disease are in the small joints of the hand, the foot, and the
knees and/or hips
E. All of the above are true

28. What is (are) the major goal(s) of therapy in the disease just described?
A. Minimize pain
B. Prevent disability
C. Delay progression
D. A and B only
E. All of the above

29. Which of the following statements regarding the use if NSAIDs in the treatment of
osteoarthritis and as given to an elderly patient is true?
A. NSAIDs are generally very safe for the treatment of the condition described in elderly
patients
B. NSAID toxicity in elderly patients is uncommon
C. NSAID toxicity in elderly patients is unlikely to be associated with renal insufficiency
D. The most common NSAID toxicity in elderly patients is gastrointestinal
E. None of the above is true

30. What is the drug of choice for the treatment of primary osteoarthritis?
A. Acetaminophen
B. Naproxen sodium
C. Diclofenac
D. Indomethacin
E. Any of the above

31. Which of the following statements regarding gout is false?


A. The disease is more common in males than in females
B. Fever is unusual
C. More than 50% of the initial attacks of this condition are confined to the first
metatarsophalangeal joint
D. Peripheral leukocytosis can occur
E. Involvement is usually asymmetric

32. What is the most common metabolic abnormality found in patients with gout?
A. Increased production of uric acid
B. Decreased renal excretion of uric acid
C. Increased production of uric acid metabolites
D. Decreased renal excretion of uric acid metabolites
E. None of the above

33. What is the pharmacologic agent of choice for the initial management gout?
A. Indomethacin
B. Colchicine
C. Acetaminophen
D. Aspirin
E. Phenylbuazone

34. The determination of the agent of choice for the prophylaxis of gout attacks is made by
which of the following?
A. A serum blood level
B. A joint fluid aspiration
C. A 24 hour urine determination of uric acid
D. A joint x-ray
E. None of the above

35. Which of the following drugs increase(s) the excretion of uric acid?
A. Sulfinpyrazone
B. Probenecid
C. Allopurinol
D. A and B only
E. All of the above

36. In patients started on prophylactic therapy, which of the following statements regarding the
use of prophylactic agents is (are) true?
A. The patient who is begun on a prophylactic agent should also be started on colchicine
B. Colchicine should be added and maintained for 3 to 6 months
C. Indomethacin can replace colchicine
D. None of the above statements are true
E. All of the above statements are true

37. Which of the following drugs would be most likely to provide significant relief in the case of
acute gout attack?
A. Oral prednisone
B. Oral dexamethasone
C. Intravenous hydrocortisone
D. Intravenous methylprednisolone
E. Intraarticular methylprednisolone acetate

38. Which of the following classes of drugs is most likely to precipitate attack of gout?
A. Thiazide diuretics
B. Calcium channel blockers
C. ACE-inhibitors
D. beta-blockers
E. Alpha-blockers

39. A27-year-old woman presents with a red rash over her cheeks, and pain and swelling in
both knees as well as several small joints in her hands. She notes that the rash is worse with sun
exposure. Medical evaluation reveals oral ulceration, positive ANA, and 3+ proteinuria.
Which of the following is the most likely mechanism for the renal damage in this condition?
(A) vasculitis
(B) microemboli
(C) antibasement membrane antibodies
(D) deposition of circulating immune complexes
(E) primary tubular atrophy

40. A 50-year-old man develops fatigue and painful swelling of both hands. He is also very stiff
in the morning and requires longer time to get ready for work. Physical examination reveals
erythema, swelling, and tenderness on palpation of the proximal interphalangealjoints and
MCP joints. Plain x-rays of the hand are taken. Which of the following x-ray findings is
characteristic of this condition?
(A) lossof articular cartilage and bone erosion
(B) normal
(C) osteolytic changes
(D) osteosclerotic changes
(E) osteolytic and osteosclerotic changes together

41. A 69-year-old man develops clubbing of his fingers. Which of the following is most likely
associated with this condition?
(A) RF
(B) aortic stenosis
(C) periosteal inflammation
(D) crystal-induced arthritis
(E) diffuse osteoarthritis

42. A 67-year-old man has a long history of symmetrical small joint arthritis with deformities.He
now develops shortness of breath on exertion with a dry cough, but no sputum or chest
discomfort. His heart sounds have a loud P2, and the lungs have fine bibasilar crackles. Which
of the following is the most likely diagnosis of the pulmonary condition associated with his
arthritis?
(A) pleuritis
(B) cavitating lesions
(C) intrapulmonary nodules
(D) interstitial fibrosis
(E) diffuse pneumonitis

43. A 45-year-old man has had intermittent swelling and pain in the superior part of his auricles
for several years. Mild arthritis usually accompanies these episodes. Last year he also had
redness, pain, and swelling over the bridge of his nose. Which of the following is the most
likely diagnosis?
(A) psoriatic arthritis
(B) Behçet’s syndrome
(C) Wegener’s granulomatosis
(D) relapsingpolychondritis
(E) rheumatoid arthritis

44. Which of the following features is a characteristic of Ehlers-Danlos syndrome?


(A) thickening of the skin
(B) mental retardation
(C) an increased incidence of skin carcinoma
(D) thrombocytopenia
(E) habitual dislocation of joints

45. Which of the following statements concerning the articular manifestations of RA is correct?
(A) wrists are rarely involved
(B) involvement of hands is characteristically asymmetric
(C) fever up to 38°C is common with joint involvement
(D) ulnar deviation at the wrist is common
(E) absence of morning stiffness makes RA an unlikely cause of articular symptoms

46. Which of the following is the most common location for osteoarthritis?
(A) hip
(B) base of thumb
(C) knee
(D) spine
(E) Distal interphalangealand joints of hand