!

"
#nd part 2011

(Q1)25.1 A 62-year-old man presents for a follow-up visit for severe

depression.
His symptoms have included crying episodes, insomnia, and decreased
appetite. He has suicidal ideations and states that he has a gun in his
home. He has had auditory hallucinations, saying he hears a voice telling him
that his wife is the devil. His symptoms have not been relieved by maximum
doses of sertraline (Zoloft), venlafaxine (Effexor), or citalopram (Celexa). He is
currently taking duloxetine (Cymbalta),which has also failed to improve his
symptoms. Which of the following would most likely provide the quickest relief of his
symptoms?
A. Electroconvulsive therapy (ECT)
B. Bupropion (Wellbutrin)
C. Stopping duloxetine and starting on a MAO inhibitor
D. Behavioral modification

25.1 A. This patient has psychotic depression with suicidal ideations and has not
responded to maximum doses of several antidepressants. He is more likely to respond
to electroconvulsive therapy than to counseling or a change in medication.
(Case Files Family Medicine, 2nd .pdf)

---------------------------------------------

(Q2) 27.3 A 64-year-old man is noted to have congestive heart failure because of
coronary artery disease. Over the past 2 days, he has developed progressive dyspnea
and orthopnea. On examination, he is found to be in moderate respiratory distress,
has JVD, and rales on pulmonary examination. He is diagnosed with pulmonary
edema. Which of the following agents is most appropriate at this time?
A. Hydrochlorothiazide
B. Furosemide
C. Carvedilol
D. Spironolactone
E. Digitalis

27.3 B. Furosemide, a loop diuretic, is a first-line agent in CHF exacerbation with

pulmonary edema. The other medications listed may be used in the management
of CHF, but are not indicated in an acuteexacerbation.
Case Files of family medicine 2nd

1
 (Q3)42.5 You are called to the bed side of a patient who was complaining of
chest
pain. When you get there you find the patient confused and not
answering questions. The nurse informs you that the patient was speaking
coherently only a moment before. The patient’s pulse is 180 bpm,
his systolic blood pressure is 60 mm Hg, and his diastolic cannot be
measured. He was admitted to the hospital for a condition completely unrelated
to chest pain. A rhythm strip shows ventricular tachycardia.
Which of the following is the most appropriate next step in the man-
agement of this patient?
A. Adenosine
B. Cardiology Consultation
C. Emergent electrical cardioversion
D. Negative chronotropic agent
E. 12-lead ECG

42.5 C. This patient has ventricular tachycardia with clinical deterioration and
hemodynamic instability. He needs immediate electrical cardioversion.
(Case Files Family Medicine, 2nd .pdf)

(Q4) A 29-year-old female comes to your office with a 4-day history of "unrelenting
dizziness." The dizziness is associated with nausea and vomiting. There has been no
hearing loss, no tinnitus, and no sensation of aural fullness. The patient has just
recovered from an upper respiratory tract infection. On examination, nystagmus is
present. The slow phase of the nystagmus is toward the left, and the rapid phase of
the nystagmus is toward the right. There is a significant ataxia present. What is the
most likely diagnosis in this patient?
A) vestibular neuronitis
B) acute labyrinthitis
C) benign positional vertigo
D) orthostatic hypotension
E) Meniere's disease

answer A

(Q5)Family physicians provide a care that is :

a. limited to specific age
b. designed to reduce number of patients reaching hospitals.
c. currently not a suitable type of care for saudi population.
d. given regardless of the presenting complaints
e. episodic care

2
 ------------------------------------------

(Q6) which of the following statements is correct about the family life cycle?
A) Families seen in family practice go through the complete cycle in sequence
b) transitions in family life cycle can help families and thier family physicians
anticpate and prepare for any illness or crisis.
C} Families in Saudi Arabia rarely face conflicts at any stage in their family life cycle
due to good family coherence in our society
d) Different cultural groups encountered in different parts of Saudi Arabia have the
same family life cycle
E) The last stage in the family Life cycle involves adjusting to pregnancy and the
promise of parenthood.

(Q7)Poor communication with patients during interviewing shows that

A) More than half of patients devaite from their doctors’ advice or do not follow it at
all`
B) There is no dissatisfaction about the quality of communication in many medical
interviews
C) Doctors interrupt their patients opening statements after a mean interval of La
minutes
D) Most patients understand what their doctors explain or recommend
E) more than 10% of medical students in Saudi Arabia. are not trained on
communication
skills

-----------------------------
(Q8) 41. You are seeing a 36-year-old woman with a complex medical condition. You
have explored how she views the problem, you thoroughly understand her point
of view, and you have acknowledged to the patient
that you understand her point of view. Which of the following communication tactics
best describes this approach?
a. Empathy
b. Sympathy
c. Collaboration
d. Therapeutic alliance
e. Patient centeredness

41. The answer is a. (South-Paul, pp 663–668.) Empathy involves the

three components described in the question. Sympathy does not require
acknowledgement of understanding. Collaboration refers to the doctor and
patient working together in treatment plans, as does a therapeutic alliance.
Patient-centeredness involves understanding the patient, the illness or dis-

3
 ease, its impact on his/her life, and the community to which the patient will
look for relief and treatment.
(Pretest Family)

(Q9) 52. You are taking care of a 62-year-old woman with a urinary tract infec- tion.
You prescribe trimethoprim-sulfamethoxazole (Bactrim) for her infec- tion, but
forget to ask about allergies. The next day, she returns with significant hives,
asking if Bactrim contains “sulfa,” something she is aller- gic to. Which of the
following fundamental principles of medical profes- sionalism has been violated?
a. The principle of primacy of patient welfare
b. The principle of patient autonomy
c. The principle of social justice
d. The principle of professional competence
e. The principle of honesty with patients

52. The answer is a. (Brennan, pp 243–246.) There are three fundamental

principles of professionalism. The first is the principle of primacy of patient
welfare. This is based on a dedication to serving the interest of the patient,
and deals with doing no harm. This is the principle violated in the ques-
tion. The principle of patient autonomy involves empowering patients to
make informed decisions regarding their treatment.
(Pretest Family)

(Q10) 57. You are caring for a 55-year-old man who recently has complained of
chest pain. His electrocardiogram is abnormal, and you feel he should have
a cardiac catheterization. After explaining the risks and benefits to him, he refuses
the intervention. Which of the following responses best demon- strates the
tenets of professionalism in this case?
a. Respect the patient’s choice and continue to explore his reasons for refusing
treatment
b. Explain to him that you think he is making a bad decision, and try to convince him
to change his mind
c. Consult the ethics committee of the hospital
d. Consult a psychiatrist to determine the patient’s competency
e. Discharge the patient from your practice because of the poor doctor-patient
relationship you have with him
----
57. The answer is a. (Brennan, pp 243–246.) Convincing a patient to change
his mind disregards patient autonomy. Consulting an ethics committee and evaluating
the patient’s competency are unnecessary at this point. Discharg-
ing the patient from your practice for disagreeing with you would be
inappropriate.
(Pretest Family)

4
 (Q11) 58. You are caring for a 38-year-old man with metastatic cancer. He thoroughly
understands his condition, and realizes that he has only a few months to live.
He asks that you do not tell his wife about his prognosis, as “she won’t be able to take
it.” The patient’s wife sees you in the hallway and says, “tell me the truth . . . how
is his condition?” Which of the following responses best reflects an ethically sound
course of action?
a. Tell her the truth about the situation because she has a right to know
b. Tell her the truth because you have the legal obligation to do so
c. Consult the ethics committee to help you make the decision
d. Do not tell the patient’s wife, but inform her that you will not tell her husband about
the conversation you’ve just had
e. Do not tell the patient’s wife, but make an effort to encourage an open
dialogue between her and her husband

58. The answer is e. (Brennan, pp 243–246.) Patient confidentiality demands that

you maintain safeguards related to the disclosure of patient information. This is
dictated by the patient, even if the wife is the other person in the communication triad.
(Pretest Family)

(Q12) 78. You are rounding on a 17-year-old G1P1 patient you delivered yesterday.
You are discussing contraception options with her and she asks you about “the shot”
that several of her friends have received. Regarding DMPA (Depo-Provera), you tell
her:
A. In actual use, DMPA is less effective than oral contraceptives at preventing
pregnancy.
B. It is associated with a return to normal fertility 3 months (12 weeks) after the last
injection.
C. Amenorrhea is the most common side effect after 12 months of use.
D. Breakthrough bleeding is uncommon during early use. If noted, it should be
investigated further (e.g., endometrial biopsy).
E. It is more likely to cause severe headaches than are oral contraceptives.

View Answer C. Amenorrhea is the most common side effect of DMPA, with over 80%
of women becoming amenorrheic after 5 years of use. Other side effects
include irregular or breakthrough bleeding, which occurs in 50% of
women in early use. A benefit of DMPA is that the perfect use and typical
use are the same and result in only 0.3% pregnancy use per year. The
rate for typical use of oral contraceptive pills is 4% to 5%. The average
length to return to fertility is 5 to 8 months after DMPA, but it can take 1
year. The estrogenic component of OCPs is associated with vascular
headaches and therefore DMPA is unlikely to contribute to migraines. In
addition, women with seizure disorder can experience a reduction in
seizure frequency. (Family_Medicine_Certification_Review.pdf)

-------------------------------------------------------

5
 (Q13) a 26 year old primigravida presents to the ed at 32 weeks gestation with
epigastric pain.Her BP is 150/100, but the other vital signs are abnormal.while the
nurse is performing his assessment in the room, the patient begins to seize.the next
best step in management is :
(A) Hydralazine 10 mg IV push.
(B) Lorazepam 2 mg per minute IV push.
(C) Phenytoin 20 mg per kg IV.
(D) Magnesium 6 g slow IV push.
(E) Labetalol 20 mg slow IV push
Answer D
1000 questions help in Emergency Medicine
-------------------------------------------------

(Q14) 251. A 40-year-old cigarette smoker complains of epigastric

pain, localized, nonradiating, and described as burning. The pain is partially
relieved by eating. There is no weight loss. There has been no use of
nonsteroidal antiinflammatory agents. The pain has
been worsening over several months. The most sensitive way to
make a specific diagnosis is
a. Barium x-ray
b. Endoscopy
c. Serologic test for Helicobacter pylori
d. Serum gastrin

251. The answer is b. (Stobo, 23/e, pp 452–457.) Localized epigastric

burning pain relieved by eating requires evaluation for peptic ulcer disease.
Upper gastrointestinal duodenoscopy provides the best sensitivity and
specificity; barium swallow is less expensive, but is less sensitive and less
accurate in defining mucosal disease. Patients with refractory or recurrent
disease should have serum gastrin levels measured to rule out gastrinoma.
A positive test for H. pylori would only indicate previous exposure.
(Pretest Medicine)

(Q15) 422. A 17-year-old girl noted a 2-cm, annular, pink, scaly lesion on her
thigh. In the next two weeks she developed several smaller, oval, pink lesions
with a fine collarette of scale. They seem to run in the body folds and mainly
involve the trunk, although a few are on the upper arms and thighs. There is
no adenopathy and no oral lesions. The
most likely diagnosis is
a. Tinea versicolor
b. Psoriasis
c. Lichen planus
d. Pityriasis rosea
e. Secondary syphilis

6
 422. The answer is d. (Freedberg, 5/e, pp 541–545.) The description of
this papulosquamous disease is that of a classic case of pityriasis rosea. Thisdisease
occurs in about 10% of the population. It is usually seen in young
adults on the trunk and proximal extremities. There is a rare inverse form
that occurs in the distal extremities and occasionally the face. Pityriasis
rosea is usually asymptomatic, although some patients have an early, mild,
viral prodrome (malaise and low-grade fever), and itching may be signifi- cant.
Drug eruptions, fungal infections, and secondary syphilis are often confused
with this disease. Fungal infections are rarely as widespread and sudden
in onset; potassium hydroxide (KOH) preparation will be positive.
Syphilis usually has adenopathy, oral patches, and lesions on the palms and
soles (a VDRL test will be strongly positive at this stage). Psoriasis, with its
thick, scaly red plaques on extensor surfaces, should not cause confusion.
A rare condition called guttate parapsoriasis should be suspected if the rash
lasts more than two months, since pityriasis rosea usually clears sponta-
neously in six weeks.
(Pretest Medicine)

(Q16) 423. A 45-year-old man with Parkinson’s disease has macular areas of
erythema and scaling behind the ears and on the scalp, eyebrows, glabella,
nasal labial folds, and central chest. The diagnosis is
a. Tinea versicolor
b. Psoriasis
c. Seborrheic dermatitis
d. Atopic dermatitis
e. Dermatophyte infection

423. The answer is c. (Freedberg, 5/e, pp 1482–1487.) The patient has the
typical areas of involvement of seborrheic dermatitis. This common der-
matitis appears to be worse in many neurological diseases. It is also very
common and severe in patients with AIDS. In general, symptoms are worse
in the winter. Pityrosporum ovale appears to play a role in seborrheic der-
matitis and dandruff, and the symptoms improve with the use of certain
antifungal preparations (e.g., ketoconazole) that decrease this yeast. Mild
topical steroids also produce an excellent clinical response.
(Pretest Medicine)

7
 (Q17) 405. A 21-year-old female presents with an annular pruritic rash on her
neck.She explains that the rash has been present for the past 3 weeks and that
herroommate had a similar rash not long ago. Physical examination is remarkablefor a
20-mm scaling, erythematous plaque with a serpiginous border. Which of the following
is the most appropriate initial treatment for this condition?
a. Griseofulvin
b. Oral cephalexin
c. Topical mupirocin ointment
d. Topical ketoconazole
e. Hydrocortisone cream

405. The answer is d. (Fauci, pp 318, 1263-1265.) Tinea corporis (ring-

worm) is a dermatophyte that causes a superficial infection of the skin.
Tinea corporis clinically presents as an erythematous scaly plaque with a
central clearing and serpiginous border. It is usually acquired through contact
with an infected individual or animal. Initial treatment involves appli-
cation of topical antifungals such as ketoconazole, clotrimazole, miconazole,
toconazole, econazole, naftifine, terbinafine, or ciclopirox olamine cream.
More severe infection that is unresponsive to topical therapy, or one involving
the scalp, nails, or beard area, should be treated systematically with oral grise-
ofulvin, itraconazole, or terbinafine. Cephalexin and mupirocin are antibacte-
rial agents used for superficial infections of the skin caused by Staphylococcus
aureus such as folliculitis or impetigo. Hydrocortisone is a weak corticos-
teroid that can actually exacerbate a fungal infection. Potassium hydroxide
(KOH) skin prep would confirm the diagnosis.
(Pretest Medicine)

(Q18 ) 32. A 25-year-old G2P2 female presents to your office 2 weeks

postpartum after delivering a 3,325-g male infant. She is concerned about
her breast milk supply. She did not have any difficulties with milk supply with
her first child. She breast-fed the baby 10 times in the last 24 hours. His
weight in the office today is 3,100 g. Which of the following is a cause of
decreased milk production?
A. Breast engorgement
B. Use of a breast pump
C. Exclusive breast-feeding
D. Frequent breast-feeding
E. Retained placental tissue
View Answer
E. Breast pumps are an extremely effective method to stimulate or increase
milk production. Pumping can be achieved by hand, with a handheld pump, or
with an electric pump. In all three methods, the pumping should simulate the

8
 suck of an infant, which is a rate of one suck per second or 60 sucks per minute.
Pacifier use, as well as the use of bottles, decreases breast-feeding success. The
action of the infant's tongue is different when sucking from a bottle or pacifier than from
the human breast. Other causes of decreased breast milk supply are stress, infrequent
feeding, and retained placenta. This last one can be a common cause of poor milk
supply because lactogenesis is stimulated by the delivery of the complete placenta and
subsequent rapid decrease in progesterone. A newborn should be nursing 8 to 12
times a day, with multiple soaked diapers and frequent stooling. As a guideline, an
infant should regain birth weight by 2 weeks.
(Family_Medicine_Certification_Review.pdf)

(Q19) 486. A 60-year-old white female presents for an office visit. Her mother
recently
broke her hip, and the patient is concerned about her own risk for osteo- porosis.
She weighs 165 lb and is 5 ft, 6 in. tall. She has a 50-pack-year his- tory of
tobacco use. Medications include a multivitamin and levothyroxine 50 µg/d. Her
exercise regimen includes mowing the lawn and taking care
of the garden. She took hormone replacement therapy for 6 years after
menopause, which occurred at age 49.
In counseling this patient about osteoporosis, you should advise her that
she might benefit from
a. Fluoride supplementation
b. Calcium supplementation
c. Continuing her current exercise routine
d. Restarting hormone replacement therapy

486. The answer is b. (Braunwald, 15/e, pp 2194, 2232–2234.) Post-

menopausal women not on estrogen replacement should achieve a daily
intake of calcium at 1200 mg of elemental calcium. The average woman in
the United States receives 600 to 700 mg from diet alone. The current rec-
ommendation is that women consume 1200 mg oral calcium supplement in
two or three divided doses. Although fluoride is an osteoclast inhibitor,
early studies revealed an increased fracture rate with fluoride supplementa-
tion for prevention or treatment of osteoporosis. Fluoride does not have a
proven role in the prevention or treatment of osteoporosis. The current
exercise regimen recommended is weight-bearing activities such as walking,
dancing, tennis, or jogging three to five times per week. This patient is not
performing adequate weight-bearing exercise. There is no indication at this
time that the patient should restart hormone replacement therapy without
further diagnostic testing. If this patient is diagnosed with osteoporosis,
treatment options such as the bisphosphonates, calcitonin, selective estro-
gen modulators (SERMs), or hormone replacement therapy are available.

(pretest\Medicine.pdf pretest medicine 2004)

9
 (Q20) 439. A 35-year-old nurse with a diagnosis of bipolar disorder has
been stable on lithium therapy for two years. For the past three
months, she has been easily fatigued, more sensitive to cold, and
excessively sleepy for several weeks. Her hair is dry and brittle and her face
is puffy. Her medical workup will probably show
a. An elevated TSH
b. Abnormal liver functions
c. Leukopenia
d. A blunted cortisol response to ACTH
e. Hypocholesterolemia

(439. The answer is a. (Schatzberg, 2/e, p 404.) The patient in the vignette presents
with several signs and symptoms of hypothyroidism. Lithium negatively affects
everal thyroid functions, including TSH activity, thyroid hormone synthesis and release,
and peripheral metabolism of thyroxin. Although 30% of patients on lithium have an
levated TSH, the prevalence of clinical hypothyroidism is estimated to be 5% and
more common in women.)
(pretest psychiatry 2001)

(Q21) A 17-year-old female fell asleep with her contact lenses in her eyes last
evening. This morning she notes quite a bit of eye pain and photophobia. You evert
the eyelids
and find no evidence of a foreign body. When you stain her eye, you find a
corneal ulcer. The treatment for this patient is:
A) Debridement with a burr and systemic antibiotics.
B) Debridement with a cotton swab and systemic antibiotics.
C) Topical antibiotics, cycloplegia, and referral to ophthalmology.
D) Copious irrigation, systemic antibiotics, and cycloplegia.

(Family practice examination and board review P19)

(Q22) 144. The mother of a 2-week-old infant reports that since birth, her infant
sleeps most of the day; she has to awaken her every 4 hours to feed, and she will
take only an ounce of formula at a time. She also is concerned that the infant has
persistently hard, pellet-like stools. On your examination you find an infant with
normal weight and length, but with an enlarged head.
The heart rate is 75 beats per minute and the temperature is 35°C (95°F).
The child is still jaundiced. You note large anterior and posterior fontanelles, a
distended abdomen, and an umbilical hernia. This clinical presentation is likely a
result of which of the following?
a. Congenital hypothyroidism
b. Congenital megacolon (Hirschsprung disease)
c. Sepsis
d. Infantile botulism
e. Normal development

10
 144. The answer is a. (Hay et al, pp 947-950. Kliegman et al, pp 2319-2325.
McMillan et al, pp 421-422, 2126-2128. Rudolph et al, pp 2065-2070.) The clini-
cal findings of congenital hypothyroidism are subtle, and may not be present
at all at birth; this is thought to be a result of passage of some T 4 transplacen-
tally. Infants with examination findings will usually have an umbilical hernia
and a distended abdomen. The head may be large, and the fontanelles will be
large as well. The child may be hypothermic and have feeding difficulties;
constipation and jaundice may be persistent. Skin may be cold and mottled,
and edema may be found in the genitals and extremities. The heart rate may be
slow, and anemia may develop. As these findings may be subtle or nonexis-
tent, neonatal screening programs are extremely important for early diagnosis
of these infants.
Sepsis can cause hypothermia and poor feeding, but the 2-week time
makes this choice unlikely. Hirschsprung disease may cause chronic con-
stipation and abdominal distension, but not the other findings. Botulism
can cause a flaccid paralysis and poor feeding, but the large fontanelles and
umbilical hernia are not caused by this infection.(pretest\pretest Pediatrics 12th.pdf)
((pretest\pretest Pediatrics 12th.pdf))

(Q23) 13. A 6-year-old boy is often teased at school because he has stooled in his
underwear almost daily for the last 3 months. He was toilet trained at 2 years of age
without difficulty, but over the last 2 years he had developed ongoing constipation.
His family is frustrated because they cannot believe him when he says “I didn’t
know I had to go.” He is otherwise normal; school is going well, and his home life is
stable. His only finding on examination is significant for stool in the rectal vault. The
plain radiograph of his abdomen is shown.
Initial management of this problem should include which of the following?
a. Barium enema and rectal biopsy
b. Family counseling
c. Time-out when he stools in his underwear
d. Clear fecal impaction and short-term stool softener use
e. Daily enemas for 4 weeks
((pretest\pretest Pediatrics 12th.pdf))

13. The answer is d. (Hay et al, pp 206-207. Kliegman et al, pp 114-115.

McMillan et al, pp 672-674, 1920-1923. Rudolph et al, pp 1368-1370.) Enco-
presis is defined as the passage of feces in inappropriate locations after bowel
control would be expected (usually older than 4 years). Encopresis is seen
both with chronic constipation and overflow incontinence (retentive enco-
presis), and without constipation (nonretentive encopresis). Retentive enco-
presis is more common, and is the source of this child’s problem. There is
leakage of liquid stool around a large fecal impaction, resulting in fecal soiling.

11
 The radiograph demonstrates a dilated, stool-filled colon consistent with retentive
encopresis. Treatment involves clearing the fecal mass, maintaining soft stools for a
short period of time with mineral oil or stool softeners (3-6 months), and behavioral
modification. Most children will grow out of this condition.Time-out would be ineffective,
because these children usually have dysfunctional anal sphincters and little control
over the problem; they do not knowthey are soiling their clothes until it is too late. Daily
enemas could potentially be harmful. A rectal biopsy would help diagnose
Hirschsprung disease, but the story presented is not consistent with that diagnosis.

(Q24) 3. A child is brought to your clinic for a routine examination. She can put on
a T-shirt but requires a bit of help dressing otherwise. She can copy a circle well but
has difficulty in copying a square. Her speech is understandable and she knows four
colors. She balances proudly on each foot for 2 seconds but is unable to hold the
stance for 5 seconds. Which of the following is the most likely age of this child?
a. 1 year
b. 2 years
c. 3 years
d. 4 years
e. 5 years

3. The answer is d. Four- and five-year-old childrenbegin to be able to copy a square;

children younger than this age have difficulty with this task. By 4 years of age the
language should be fully understandable and children begin to be able to name four
colors, define five words, and know three adjectives. A 4-year-old can stand on each
leg for 2 seconds, and by 5 years of age that skill can be maintained for at least 5
seconds. A 4-year-old may require some help with some clothing, but by 5 years of
age they are able to dress themselves independently
(pretest Pediatrics 12th.pdf)

(Q25) 5. A previously healthy 4-year-old child pictured below presents to the

emergency room (ER) with a 2-day history of a brightly erythematous rash and
temperature of 40°C (104°F). The exquisitely tender, generalized rash is
worse in the flexural and perioral areas. The child is admitted and over the next
day develops crusting and fissuring around the eyes, mouth, and nose.
The desquamation of skin shown in the photograph occurs with gentle traction. Which
of the following is the most likely diagnosis?
a. Epidermolysis bullosa
b. Staphylococcal scalded skin syndrome
c. Erythema multiforme
d. Drug eruption
e. Scarlet fever

12
 ((pretest\pretest Pediatrics 12th.pdf))

(Q26) 249. A 5-month-old child regularly regurgitates a large portion of her feeds.
A pH probe study showed significant periods of low esophageal pH. The child has
normal growth and no other significant past medical history. Which of the following
is the best management at this point?
a. Barium swallow and upper GI series
b. Oral reflux medications
c. Esophageal manometry
d. Close observation only
e. Surgical correction with fundoplication

249. The answer is d. (Hay et al, pp 605-606. Kliegman et al, pp 1547-

1550. McMillan et al, pp 382-383. Rudolph et al, pp 1390-1393.) Barium swalãow and
upper GI series are helpful in detecting anatomic abnormalities such as antral web,
pyloric stenosis, malrotation, and annular pancreas. To confirm the presence of
gastroesophageal reflux (GER), the best test is the
esophageal pH probe, which measures the frequency and duration of falls
in pH, thereby indicating acid reflux. Esophageal manometry is used to
identify poor tone of the lower esophageal sphincter. In this child, who is
growing well and developing properly and has no other medical problems
such as reflux-induced apnea or bradycardia or aspiration pneumonia, pharma-
cologic treatment is not necessary, as most infants will outgrow this common
problem of esophageal reflux. Surgical correction is reserved for infants with
poor weight gain or reflux-associated apnea and bradycardia who have failed
((pretest\pretest Pediatrics 12th.pdf))

(Q27 ) 281. A 17-year-old boy is brought to the emergency department by his parents
with the complaint of coughing up blood. He is stabilized, and his hemo- globin and
hematocrit levels are 11 mg/dL and 33%, respectively. During
his hospitalization, he is noted to have systolic blood pressure persistently greater
than 130 mm Hg and diastolic blood pressure greater than 90 mm Hg. His
urinalysis is remarkable for hematuria and proteinuria. You are suspi- cious the
patient has which of the following?
a. Hemolytic-uremic syndrome
b. Goodpasture syndrome
c. Nephrotic syndrome
d. Poststreptococcal glomerulonephritis
e. Renal vein thrombosis

281. The answer is b. (Hay et al, pp 529-530. Kliegman et al, p 2180.

McMillan et al, p 1439. Rudolph et al, p 1998.) The patient in the question has
a classic description of Goodpasture syndrome, a rare disease in children.The
pulmonary hemorrhage can be life threatening and the renal function
progressive. Diagnosis is suggested by kidney biopsy and finding antibodies

13
 to the glomerular basement membrane.
Hemolytic-uremic syndrome presents in a child with fever, bloody diar-
rhea, and progression toward renal failure but not respiratory symptoms.
Nephrotic syndrome presents with edema, hypertension, and proteinuria;
respiratory symptoms related to congestive heart failure (and not pulmonary
hemorrhage) might be seen. Poststreptococcal glomerulonephritis can result
in hematuria, but the respiratory symptoms associated with the condition
would be related to congestive heart failure and not to pulmonary hemor-
rhage. Renal vein thrombosis might result in hematuria but would not be
expected to have pulmonary findings.
pharmacologic therapy.
((pretest\pretest Pediatrics 12th.pdf))

(Q28) A 59-year-old man with a known history of COPD presents with wors-
ening dyspnea. On examination he is afebrile. His breath sounds are decreased
bilaterally. He is noted to have jugular venous distension (JVD) and 2+ pitting
edema of the lower extremities. Which of the
following is the most likely cause of his increasing dyspnea?
A. COPD exacerbation
B. Pneumonia
C. cor pulmonale
D. Pneumothorax
C. JVD and lower extremity edema are suggestive of cor pulmonale,
which is right heart failure due to chronically elevated pressures in
the pulmonary circulation. Right heart failure causes increased right
atrial pressures and right ventricular end diastolic pressures, which
then lead to liver congestion, jugular venous distension, and lower
extremity edema.
Case files of Family medicine

(Q29) 8. A mother calls you on the telephone and says that your 4-year-old son bit
the hand of her 2-year-old son 48 hours previously. The area around the injury has
become red, indurated, and swollen, and he has a temperature of 39.4°C (103°F).
Which of the following is the most appropriate response?
a. Arrange for a plastic surgery consultation at the next available appointment.
b. Admit the child to the hospital immediately for surgical debridement and
antibiotic treatment.
c. Prescribe penicillin over the telephone and have the mother apply warm soaks
for 15 minutes four times a day.
d. Suggest purchase of bacitracin ointment to apply to the lesion three times a day.
e. See the patient in the ER to suture the laceration.

14
 8. The answer is b. Human bites can pose a significant problem. They can become
infected with oropharyngeal bacteria, including S aureus, Streptococcus viridans,
Bacteroides spp., and anaerobes. A patient with an infected
human bite of the hand requires hospitalization for appropriate drainage pro-
cedures, Gram stain and culture of the exudate, vigorous cleaning, debridement,
and appropriate antibiotics. The wound should be left open and allowed to
heal by secondary intention (healing by granulation tissue rather than closure
with sutures).
((pretest Pediatrics 12th.pdf))
-----------------------------------------------------

(Q30) 112. A mother wishes to breast-feed her newborn infant, but is

worried
about medical conditions that would prohibit her from doing so. You coun- sel her
that of her listed conditions, which of the following is a contraindica- tion to breast-
feeding?
a. Upper respiratory tract infection
b. Cracked and bleeding nipples
c. Mastitis
d. Inverted nipples
e. HIV infection

112. The answer is e. There are few contraindications to breast-feeding. Active

pulmonary tuberculosis and HIV are two examples of infectious contraindications in
developed countries, as well as malaria, typhoid fever, and septicemia. In
underdeveloped countries, the risk of infectious diarrhea due to use of contaminated
water to mix formula or the unavailability of formula can preclude this recommendation.
All medications taken by the mother will be secreted in breast milk, but usually not in
amounts significant enough to affect the infant. Mothers taking antineoplastic agents
should not breast-feed. Mothers with mastitis can continue to breast-feed; frequent
feedings may help the condition by preventing engorgement. Mothers with mild viral
illness may also continue to breast-feed. Cracked or bleeding nipples may make
breast-feeding uncomfortable, but are not contraindications. Inverted nipples
usually can be remedied, and only rarely prohibit breast-feeding.
((pretest\pretest Pediatrics 12th.pdf))
------------------------------------------------
(Q31) 45. A 42-year-old woman presents to your office. Her life appears chaotic and
she transfers many of her dysfunctional feelings and conflicts to you her physician.
She is at times paranoid, depressed, and angry. She has a history of multiple
unstable interpersonal relationships. The most likely diagnosis is
A) borderline personality disorder
B) antisocial behavior
C) narcissistic disorder
D) histrionic disorder
E) none of the above

15
 View Answer

Answer and Discussion

The answer is A. Treating borderline personality disorder can be difficult and

challenging. Because of their instability in the multiple areas of interpersonal
relationships, self image, affects, and impulsivity, these affected patients can present
with a wide range of symptoms, including depression, anger, paranoia, extreme
dependency, self mutilation, and alternating idealization and devaluation of the
physician. Their lives tend to be chaotic. They transfer many of their dysfunctional
feelings and conflicts to the treating physician and the medical encounter. A detached
professional stance and clear limit setting in terms of availability, appointment
frequency, appropriate behavior, and medication use are necessary to manage these
patients successfully. It is important to monitor one's own feelings, and to refrain from
responding
Bratton Family medicine

------------------------------------

(Q32) A 70-year-old female with chronic paranoid schizophrenia presents to the ER

acutely confused with visual hallucinations. Her skin is warm and dry and her heart
rate is 110 beats per minute. Her group home nurse tells you that the patient had
been complaining of having a dry mouth and having difficulty initiating urination
this past week.
11. Which of the following is the most likely cause for this presentation?
(A) psychotic exacerbation of schizophrenia
(B) urinary tract infection
(C) Alzheimer dementia
(D) anticholinergic delirium
(E) myocardial infection

11. (D) Acute confusion with visual hallucina-

tions would be characteristic of a delirium.
Warm and dry skin, tachycardia, dry mouth,
constipation, and urinary retention are anti-
cholinergic side effects. Many antipsychotics
are anticholinergic, and when Parkinsonian
EPS present, anticholinergic medicines are
often added to reverse these side effects. These
anticholinergic effects can be additive and can
cause delirium.
) lange Q & A\Lange Q & A. USMLE Step 2 CK.pdf p166

-------------------------------------------

16
 (Q33) 208. A 7-year-old is prescribed a phenothiazine for nausea and
vomiting. He develops torticollis and facial muscle spasms. The most
appropriate management would be to administer
(A) diazepam
(B) diphenhydramine
(C) epinephrine
(D) naloxone
(E) steroids

208. (B) Infants and children are especially sensitive to phenothiazines.

Extrapyramidal signs (spasmodic torticollis, hyperirritability, tremors, dysphagia,
opisthotonus, etc) may occur after relatively small doses. Higher doses
may result in hypotension, seizures, coma, and death. Diphenhydramine reverses
only the extrapyramidal signs. Diazepam would
be indicated only if the patient develops sei-
zures. Naloxone is used to reverse the effects
of opiates. Epinephrine is used for anaphy-
lactic reactions. (Ellenhorn, pp 89–92)
_Appleton_&_Lange's_Review_for_the_Step_2.pdf

-----------------------------------------

(Q34) 16- A student is worried that she may not be able to take her final University
examinations in three months time because she says she becomes faint and dizzy
when she does examinations.What is the most appropriate course of action?
1) Advise her to withdraw from examinations on medical grounds [0]
2) 24 hour ECG monitoring [0]
3) Arrange counselling, with relaxation training [100]
4) Prescribe diazepam [0]
5) Prescribe fluoxetine [0] mrcp question
MRCP
---------------------------------------------------

(Q35) 21- A 63-year-old man was found collapsed. A Department of Psychiatry

outpatientCard was found in his jacket, together with a bottle of procyclidine tablets. He
wasfebrile (38.2°C), conscious but unresponsive to commands. The blood pressure
was160/105 mmHg and there was marked muscle rigidity.What is the most likely
diagnosis?
1) acute catatonic schizophrenia [0]
2) bacterial meningitis [0
3) cerebral malaria [0]
4) neuroleptic malignant syndrome [100]
5) procyclidine overdose [0]

MRCP

17
 ------------------------------
(Q36) 39. A 15 year old comes to you for a football physical. which finding below in
this childs history would preclude him from a contact sport?
A. sickle cell disease
B. Asthma
C. A heart mumur
D. patient has one kidney

answer d

-----------------------------------------

(Q37) 43) The classical “epidemiological triad” of disease causation consists of

factors which fall into which of the following categories:
a) host, reservoir, environment
b) host, vector, environment
c) host, agent, environment
d) reservoir, agent, vector
e) host, age, environment
MCCQE

(Q38) I-20. Which of the following class of medicines has been

linked to the occurrence of hip fractures in the elderly?
A. Benzodiazepines
B. Opiates
C. Angiotensin-converting enzyme inhibitors
D. Beta blockers
E. Atypical antipsychotics

answer A
Harrison self assessment

(Q39) I-21. Patients taking which of the following drugs should be

advised to avoid drinking grapefruit juice?
A. Amoxicillin
B. Aspirin
C. Atorvastatin
D. Prevacid
E. Sildena?l

answer C

Harrison self assessment

----------------------------

18
 (Q40) A 72 year old man presents with an acutely painful right knee. On examination,
he had a temperature of 37°C with a hot, swollen left knee. Of releavance amongst his
investigations, was his white cell count which was 12.6 x109/l and a knee X-ray
revealed reduced joint space and calcification of the articular cartilage. Culture
of aspirated fluid revealed no growth. What is the most likely diagnosis?

Available marks are shown in brackets

1)gout
2)Psoriatic monoarthropathy
3)Pseudo-gout [100]
4)rheumatoid arthritis
5)septic arthritis
(MRCP)

(Q41) 2) A 42-year-old carpenter presents with wrist pain and grip weakness. On
exam he is found to have pain over the radial aspect of the wrist that is aggravated by
flexing the thumb and applying ulner flexion. The most likely diagnosis is :
a) Carpal tunnel syndrome.
b) Scaphoid fracture.
c) De Quervain's tenosynovitis.
d) Boxer's fracture.
e) Hamate fracture.

Answer C.
Bratton Family medicine

(Q42) 53) A young mother is very focused on the health of her 16 month-old. She
keeps her house immaculate for fear that dirt will harm her baby, she checks the lock
on the door at least ten times before retiring to bed, and she has to get up and check
that her child is still breathing at least 3 times every night.
She knows that her fears are irrational but persists with these behaviors. The most
likely diagnosis is:
a) paranoid delusions not otherwise specified
b) post-partum depression
c) obsessive compulsive disorder
d) generalized anxiety disorder
e) paranoid personality disorder

Answer C
mccqe 2004

19
 (Q43) 328. After undergoing surgical resection for carcinoma of the
stomach, a 60-year-old male has developed numbness in his feet.
On exam he has lost proprioception in the lower extremities and has a
wide-based gait and positive Romberg. A peripheral blood smear shows
macrocytosis and hypersegmented polymorphonuclear leuko- cytes. The
neurologic dysfunction is secondary to
a. Folic acid
b. Thiamine
c. Vitamin K
d. Vitamin B 12

328. The answer is d. (Fauci, 14/e, pp 653–659.) These neurologic

deficits occur with vitamin B 12 deficiency. This patient has a deficit of
intrinsic factor after gastric surgery. Folic acid deficiency causes a mega-
loblastic anemia, but not neurologic deficits. (pretest medicine)

Pretest Medicine 2004

(Q44) 11) A 29-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to

the labor and delivery ward with frequent painful contractions. Her prenatal course was
significant for a urine culture that showed 100,000 colony-forming units/milliliter of
Group-B streptococci and asthma, for which she uses an albuterol inhaler.
Examination shows that she is contracting every 2 minutes and her cervix is 5
centimeters dilated and 100% effaced. Which of the following medications should this
patient be treated with during labor and delivery?
A. Betamethasone
B. Folic acid
C. Magnesium sulfate
D. Oxytocin
E. Penicillin

Explanation:
The correct answer is
E. The Group B Streptococcus (GBS) is a bacterium that is a part of the normal
bacterial colonization of many women. During pregnancy, as many as 20-40% of
women will be colonized with GBS. Most babies born to colonized mothers will not
develop infection
(50-Mcqs-Gynae-w-Answers)

20
 (Q45) A 24-year-old black male presents to the ED complaining of fever, chills,
and dyspnea. He has chest painthat is respirophasic (pleuritic) in nature. He is noted
to be tachypneic with a respiratory rate of 36 and an oxygen saturation of 90%. He
has a history of sickle cell anemia and has had a number of sickle-cell crises in the
past. He is up to date on immunizations, including S. pneumonia and Haemophilus
influenza vaccines. The patient’s current symptoms are MOST suggestive of:
A) Pneumothorax.
B) Pulmonary embolism.
C) Acute chest syndrome.
D) Sickle cell-related pericarditis.

Discussion
The correct answer is C.
(Family practice review p22)

(Q46) 427. A 19-year-old man is diagnosed with paranoid schizophrenia. He has

command auditory hallucinations and persecutory delusions, but is also apathetic and
withdrawn, with a flat affect. Which of the following medications is most likely to treat
both the positive and the negative symptoms of this patient?
a. Chlorpromazine
b. Fluphenazine
c. Olanzapine
d. Quetiapine
e. Trifluoperazine

answer c

pretest psychiatry

(Q47) the most difficult mode of transmission to prevent is:

a) person-to-person spread
b)droplet spread
c) vector spread
d) vehicle spread
e) airborne spread

Preventive medicine and public health

21
 (Q48) 425. A 33-year-old fair-skinned woman has telangiectasias of the
cheeks and nose along with red papules and occasional pustules.
She also appears to have a conjunctivitis because of dilated scleral vessels. She
reports frequent flushing and blushing. There is a family history of this condition.
The diagnosis is
a. Carcinoid syndrome
b. Porphyria cutanea tarda
c. Lupus vulgaris
d. Acne rosacea
e. Seborrheic dermatitis

Pretest Medicine

(Q49) A 26-year-old professional football player is brought to your clinic after being
hit on the lateral side of the left knee. His knee buckled, and he is now in 'severe
pain.
On examination, there is swelling over the medial aspect of the left knee. There is
laxity when a valgus stress test is performed on the knee. There is a negative
Lachman's test and McMurray's test.
What is the most likely injury in this patient?

A. Lateral meniscus tear

B. Medial meniscus tear
C. Lateral collateral ligament sprain
D. Medial collateral ligament sprain
E. Tibial plateau fracture

(Q50)
1. A 43-year-old male comes to your office for assessment of hearing loss. He
has had hearing difficulties for the past 4 years.
On examination, the Weber tuning fork test lateralizes to the left ear. The
Rinne tuning fork test is positive: (AC>BC). ' This suggests which one of the
following hearing losses?

(A) A right-sided conductive hearing loss

(B) A left-sided conductive hearing loss
(C) A right-sided sensorineural hearing loss
(D) A left~sided sensorineural hearing loss
(E) B or c

Same this question but with recent viral infection and right hearing loss . rinne test
was not mentioned .

22
 (Q51) 44. Which of the following medications is contraindicated to treat
hypertension in pregnancy?
A. Methyldopa (Aldomet)
B. Nifedipine (Procardia)
C. Labetalol (Normodyne)
D. Hydralazine
E. Captopril (Capoten)

View Answer
E. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers
are contraindicated during pregnancy because of the risk of renal agenensis in
the fetus. Nifedipine may be used for hypertension and is also used in some
cases for treatment for preterm labor. It may not be used concurrently with
magnesium sulfate due to the risk of pulmonary edema. Labetalol is commonly
used for treatment of acutely elevated pressures associated with pre-eclampsia
and is gaining popularity as a first-line drug. Methyldopa is still considered the
first-line therapy because it has the longest track record and proven safety.
Hydralazine intravenously is often used acutely to lower blood pressure.

Family_Medicine_Certification_Review

(Q52) 58. After examining a patient at 32 weeks gestation, you note that her
fundal height is only 28 cm, the same as her last visit. Your immediate
plan includes:
A. Send the patient for an urgent ultrasound to determine biometric
measurements of the fetus.
B. Have the patient increase her dietary fat and return to the office in 1
week for a recheck.
C. Measure both parents’ heights and extrapolate appropriate fetal growth.
D. Admit the patient to the hospital for a non-stress test and biophysical
profile.
E. Consider induction after steroid administration.

View Answer
A. Intrauterine growth restriction occurs in up to 5% of the pregnant
population. Most of these infants are simply small for gestational age, but this
is a retrospective diagnosis once all the pathologic causes are ruled out. This
mother needs an urgent ultrasound to look at the fetal measurements. Since
asymmetrical growth restriction is most ominous, important measures are the
biparietal measurement, head circumference, abdominal circumference, and
femur length. Brain growth is preserved at the expense of abdominal organs,
namely the liver, so the proportion of the head circumference to abdominal
circumference will be elevated. If oligohydramnios is also present, it increases
the risks to the fetus. Management of IUGR depends on the cause but usually
includes treating underlying disease, improved nutrition, and bed rest.
Antenatal testing should be instituted, consisting of non-stress testing twice

23
 weekly. If that is abnormal, a biophysical profile should be performed. The
decision to deliver is based on the risk of prematurity versus the risk of
persistent hypoxia.

Family_Medicine_Certification_Review

(Q53) 6. Which of the following is an absolute contraindication to the use

of oral contraceptive pills?
A. Personal history of smoking in a woman younger than 35 years of age
B. Obesity
C. Hypertension
D. Personal history of diabetes mellitus
E. History of thrombophlebitis

View Answer
E. The absolute contradictions to the use of oral contraceptives include
thrombophlebitis or thromboembolic disorders, cerebral vascular or
coronary artery disease, breast or other estrogen-dependent neoplasms,
undiagnosed genital bleeding, cholestatic jaundice, and hepatic tumors. A
history of heavy smoking (greater than 15 cigarettes per day) in a
woman older than 35 years is an absolute contraindication. These
recommendations were based on older, higher dose pills. However, there
have been no new studies to challenge these contraindications. The
product insert clearly states that women with these conditions may not
receive oral contraceptives. Among the relative contraindications are
hypertension, surgeries that require a period of immobilization, major
injury to the lower extremity, migraines, tobacco use, diabetes mellitus,
sickle cell disease, major depression, gallbladder disease, hepatitis, and age older
than 40 years if there is an additional risk such as for coronary artery disease. These
prescribing recommendations for oral contraceptives are applicable to all delivery
systems of hormonal contraception (i.e., transdermal patches and vaginal rings).

Family_Medicine_Certification_Review

24
 (Q54) 5. The daughter of an 81-year-old widowed male presents with concerns about
her father. Recently when visiting him she noticed a lot of spoiled food in the
refrigerator, various objects misplaced around the house, and that he had stopped
balancing the checkbook. She states that he has become forgetful over the years. He
has had no personality changes or difficulties with motor activity or ambulation. He has
not seen a doctor for years and reports no significant past medical history. On
examination, he has no focal findings and a mini-mental status score of 20. You order
laboratory tests and a computed tomography scan of the brain. All tests are normal.
You tell her that your findings support a diagnosis of dementia. The most likely cause
for this patient's dementia is:
A. Multi-infarct dementia
B. Alzheimer's disease
C. Lewy body disease
D. Normal pressure hydrocephalus
E. Pick's disease

View Answer
B. A common presentation for patients with Alzheimer's disease is insidious decline in
mental function with resultant gradual loss of the instrumental activities of daily living
(e.g., preparing meals, buying groceries, and paying bills) followed by activities of daily
living (e.g., continence, feeding, and bathing). Family members visiting from out of state
may be surprised by the deficits that become apparent upon inspecting the living
environment because in many cases, patients are able to interact socially and “cover
up” their deficits. The score of 20 on the mini-mental status exam supports the
diagnosis, and the presence of an otherwise normal neurologic examination as well as
computed tomography make the other choices unlikely. The absence of movement
difficulty would argue against Lewy body disease as a cause. Normal pressure
hydrocephalus is characterized by the triad of incontinence, ataxia, and dementia.
Multi-infarct dementia presents with a more abrupt and step-wise decline in function
associated with focal neurologic deficits. Pick's disease is a type of frontotemporal
dementia. Personality change, loss of inhibition, and decreased verbalization are some
of the characteristic features.

(Q55) 302. A 35-year-old female who is recovering from Mycoplasma pneumonia

develops increasing weakness. Her Hgb is 9.0 g/dL and her MCV is 110.
Which of the following is the best test to determine whether the patient has a
hemolytic anemia?
a. Serum bilirubin
b. Reticulocyte count and blood smear
c. Mycoplasma antigen
d. Glucose phosphate dehydrogenase level
e. Liver spleen scan

302. The answer is b. (Fauci, pp 355-362, 652-662.) An elevated reticulocyte

count suggests active bone marrow response either to red blood cell loss

25
 (acute bleeding) or destruction (hemolysis). Many cases of hemolytic anemia
can be diagnosed from changes on the peripheral blood smear. Large polychro-
matophilic cells suggest reticulocytes (which can be diagnosed with a specific
reticulocyte stain). Microspherocytes suggest immune-mediated hemolysis.
Fragmented cells suggest microvascular damage. This patient likely has immune-
mediated hemolysis due to her Mycoplasma infection. This is usually asso-
ciated with IgM antibodies, which react better at temperatures less than 37°C
(98.6°F) (and thus are called cold-reacting antibodies). Although the serum
bilirubin is often elevated in hemolysis, it is less specific. The Mycoplasma
antigen test would confirm recent infection with M pneumoniae but would
not specifically explain the cause of the anemia. Evidence of G6PD deficiency
and intravascular hemolysis might be sought in certain circumstances, once
confirmation of hemolysis had been established by simpler tests. Liver spleen
scan is not used in the diagnosis of hemolysis.

PreTest Medicine 12thEdition

(Q56) Q1. An eight-year-old boy presents with mild diffuse conJunctival

injection, which started in one eye and spread to the other, and a watery
to serous discharge. He also has an upper respiratory infection
and a cough. Which one of the following is an appropriate initial
management strategy?
❏ A. Cold compresses, ocular decongestants, and artificial
tears.
❏ B. Broad-spectrum topical antibiotics.
❏ C. Referral to an ophthalmologist.
❏ D. Topical steroids.

AAFP Volume 81, Number 2 January 15, 2010.pdf

(Q57) Q4. Which one of the following types of evidence is the most
reliable to guide physician prescribing? (check one)
A. Trials reporting relative risk reduction.
B. Noninferiority trials.
C. Patient-oriented evidence that addresses whether
patients live longer or have improved quality of life.
D. Short-term clinical trials of safety before the release
of the drug.
AAFP Volume 82, Number 1 V July 1, 2010

26
 (Q58) 463. You are counseling a 33-year-old obese woman with hypertension. Which
of the following interventions would lower her systolic blood pressure the most?
a. Weight loss amounting to 10% of her total body weight
b. Adopting a diet high in fruits, vegetables, and low fat dairy products
c. Restricting dietary sodium
d. Increasing physical activity at least 30 minutes a day, most days of the week
e. Limit alcohol consumption to no more than 1 drink per day

PreTest Family Medicine 1st Edition

(Q59) 16. A mid-third trimester screening ultrasound reveals oligohydramnios. This

is most likely associated with which anomaly?
A. Esophageal atresia
B. Polycystic kidneys
C. Broncho-esophageal fistula
D. Duodenal atresia
E. Urinary tract dysplasia

View Answer
E. Oligohydramnios is almost always associated with an abnormality. It is
determined by ultrasound examination if the largest pocket of fluid is less than 2
× 2 cm. During the end of pregnancy, an amniotic fluid index (AFI) may be
determined by adding the vertical depth of the largest pocket in all four
quadrants of the uterus. An AFI less than 5 is considered oligohydramnios. This
finding is associated with disorders of the renal system, including renal
agenesis, outflow obstruction, or collecting system abnormality. It is also
associated with severe intrauterine growth restriction and fetal demise. Because
amniotic fluid plays a role in lung development, fetal movement, and possibly
nutrition, oligohydramnios portends poor prognosis if present early. If found
later in pregnancy, delivery is indicated.

Family_Medicine_Certification_Review

(Q60) 62. A 43-year-old female presents with complaints of changes in her

menstrual pattern. She notes that her past three periods have been very
light with spotting for 1 or 2 days. Which of the
following options represents a correct first response to her
concern?
A. Order a TSH level
B. Order a prolactin level
C. Perform an endometrial biopsy right away
D. Prescribe HRT
E. Order a urine pregnancy test

27
 View Answer
E. Menstrual patterns vary widely during the perimenopause. For the
perimenopausal patient with absent or decreased menses, the first step
in evaluation is to rule out pregnancy. An endometrial biopsy is indicated
for patients with menometrorrhagia in this age group because this is the
usual bleeding pattern associated with endometrial cancer. Other causes
of menstrual irregularity include thyroid disorders and prolactin secreting
tumors.
Family_Medicine_Certification_Review.pdf

(Q61) 24. Which of the following is appropriate for the care of the pregnant
woman and fetus whose prenatal lab shows a positive hepatitis B
surface antigen (HBSAg)?
A. Advise her it is not safe to breast-feed.
B. Give her hepatitis B immune globulin (HBIg) at the beginning of the
second trimester.
C. Determine if she has been immunized against hepatitis B.
D. Give her newborn HBIg within 12 hours of delivery.
E. Check for concurrent hepatitis A infection.

View Answer
D. HBIg is given to the infant and not to the mother during pregnancy. When an
infant is born to a mother with HBSAg, the infant should receive the HBIg and
the first hepatitis B vaccine within 12 hours of birth. Patients may breast-feed
with hepatitis B. In the patient with HBSAg, it is important to discover if the
patient has active hepatitis or if it is in the carrier state, as well as to
determine if she may also have hepatitis C. Patients previously immunized will
have the antibody to HBSAg. It is also wise to screen for other sexually
transmitted diseases, including HIV.

(Q62) Which structure is most commonly injured in association with a Colles'

fracture?
A. Radial nerve
B. Median nerve
C. Ulnar nerve
D. Radial artery
E. Ulnar artery

Blueprints clinical cases in emergency medicine P13

28
 (Q63) 477. A 12-year-old boy complains of pain in his left leg that is worse at
night. He has been experiencing fevers and also has a 9-lb weight loss.X-
ray demonstrates an aggressive lesion with a permeative pattern of bone lysis
and periosteal reaction. There is an associated large soft tissue
mass as well. Pathology demonstrates the tumor to be of the
round cell type.

a. Osteoma

b. Osteoid osteoma

c. Osteoblastoma

d. Osteosarcoma

e. Paget’s disease

f. Ewing’s sarcoma

Osteosarcoma, or osteogenic sarcoma, usually is seen in patients between the ages of 10 and
25 years. The distal femur is the site most frequently involved. The radiograph has a blastic, or
sunburst, appearance. The tumor is not sensitive to radiation but does respond well to
combination chemotherapy followed by surgical resection or amputation.

An osteoid osteoma typically presents with severe pain that is characteristically relieved by
aspirin. On radiograph, the lesion appears as a small lucency (usually <1.0 cm) within the
bone that is surrounded by reactive sclerosis. These lesions gradually regress over 5–10
years, but most are excised to relieve symptoms. Surgical extirpation is usually curative.

Ewing’s sarcoma is a round cell–type tumor. This is a highly malignant tumor that affects
children (age range 5–15 years) and tends to occur in the diaphyses of long bones. The spine
and pelvis can also be primary sites. There is a permeative pattern of bone lysis and periosteal
reaction often associated with a large soft tissue mass. Fever and weight loss are common.The
pain is often more pronounced at night. Treatment usually involves a combination
of radiation and systemic chemotherapy, with 5-year survivals around 50%.
Adjuvant surgery in combination with radiation and chemotherapy improves the 5-year survival
to about 75%.

pretest\Pretest Surgery 9th (2001).pdf

29
 (Q64) 207. A 24-year-old female with a past history of asthma presents to the
emergency department with an asthma exacerbation. Treatment with an inhaled
bronchodilator and ipratropium (Atrovent) does not lead to significant improvement,
and she is admitted to the hospital for ongoing management. On examination she
is afebrile, her respiratory rate is 24/min, her pulse rate is 92 beats/min, and oxygen
saturation is 92% on room air. She has diffuse bilateral inspiratory and expiratory
wheezes with mild intercostal retractions. Which one of the following should be
considered in the acute management of this patient?
A) Chest physical therapy
B) Inhaled fluticasone/salmeterol (Advair)
C) Oral azithromycin (Zithromax)
D) Oral prednisone
E) Oral theophylline

Peak flow rate 50%

Item 207
ANSWER: D
Hospital management of acute exacerbations of asthma should include inhaled short-
acting bronchodilators in all patients. Systemic corticosteroids are recommended for
all patients admitted to the hospital. The efficacy of oral prednisone has been shown
to be equivalent to that of intravenous methylprednisolone (SOR A). Oxygen should
also be considered in most patients. Antibiotics are not recommended in the treatment
of asthma exacerbations unless there is a comorbid infection. Inhaled ipratropium
bromide is recommended for treatment in the emergency department, but not in the
hospital (SOR A). Chest physical therapy and methylxanthines are not recommended
in the treatment of acute asthma exacerbations.

ABFM 2008

(Q65) A 12-year-old girl was brought to the emergency department because of

severe sore throat, muffled voice, drooling, and fatigue. She had been sick
for the past 3 days and is unable to eat because of painful swallowing. The
parents deny any history of recurrent pharyngitis.
The patient still managed to open her mouth and you were able to see an
abscess at the upper pole of the right tonsil with deviation of the uvula
toward the midline. Examination of the neck reveals enlarged
and tender lymph nodes. Which of the following is the most appropriate
management?
A. Analgesics for pain
B. Oral antibiotics
C. Nebulized racemic epinephrine
D. Incision and drainage of the abscess
E. Tonsillectomy and adenoidectomy

30
 39.4 D. This patient is suffering from peritonsillar abscess. Of the choices
listed, incision and drainage is the most appropriate. Tonsillectomy is only indicated if
there are confirmed cases of recurrent pharyngitis and peritonsillar abscess.
Case Files Family Medicine, 2nd .P415

(Q66) 243. A 37-year-old woman presents with the acute onset of a productive
cough, fever, chills, and pleuritic chest pain. A chest x-ray reveals consolida- tion of
the entire lower lobe of her right lung. She unexpectedly dies before treatment due
to a cardiac arrhythmia. Histologic examination of lung tissue taken at the time of
autopsy reveals multiple suppurative, neutrophil-rich exudates filling the bronchi,
bronchioles, and alveolar spaces. The majority
of lung tissue from her right lower lung is involved in this inflammatory
process. Hyaline membranes are not found. Which of the following is the most likely
diagnosis?
a. Bronchiectasis
b. Bronchopneumonia
c. Interstitial pneumonitis
d. Lobar pneumonia
e. Pulmonary abscess
! Pathology_PreTest_Self-Assessment_and_Review 12th edition

(Q67) A 5-week-old bottle-fed boy presents with persistent and worsening

projectile vomiting, poor weight gain, and hypochloremic metabolic alkalosis. Of
the following diagnostic modalities, which would most likely reveal the
diagnosis?
(A) ultrasound of abdomen
(B) barium enema
(C) evaluation of stool for ova and parasites
(D) testing well water for presence of nitrites
(E) serum thyroxine

Lange Q and A: USMLE Step 2 CK)

(Q68) 50. You are asked to see a 78-year-old woman prior to surgical repair of a
femoral neck fracture. Her medical problems include hypertension, osteo- porosis,
and hypothyroidism. Morphine is the only medication ordered so far.
She is comfortable at rest. Her BP is 136/82, HR 88, RR 16. Her cardiac exami-
nation is normal, and her lungs are clear. What is the best recommendation to
prevent postoperative venous thrombosis?
a. Postoperative low-dose ASA
b. Postoperative SCDs (sequential compression devices)
c. Early mobilization and ambulation
d. Postoperative subcutaneous low-molecular-weight heparin
e. Postoperative intravenous unfractionated heparin

31
 50. The answer is d. (Fauci, pp 731-735). After orthopedic injury, patients
are at high risk of development of deep vein thrombosis. Other risk factors for
DVT formation include advanced age, immobility, malignancy, hypercoagulable
states, and prior history of DVT. Appropriate options for DVT prophylaxis after
hip fracture include subcutaneous unfractionated or low-molecular-weight
heparin. SCDs (answer b) may be used in addition to chemoprophylaxis, but
SCDs by themselves are not effective in hip fracture patients. Early ambulation
is recommended as tolerated for all patients at risk for DVT, but is not enough
to fully attenuate risk after a hip fracture. Aspirin (answer a) is never recom-
mended by itself for inpatient DVT prophylaxis. Intravenous heparin is used
for DVT therapy, not prophylaxis.
" #$ % &'
ASPIRIN , CLOPIDEGREL , WARFARIN , HEPARIN
PRETEST MEDCININE 12th

(Q69) 410. A 60-year-old man had an anterior myocardial infarction 3 months ago.
He currently is asymptomatic and has normal vital signs and a normal physical
examination. He is on an antiplatelet agent and an ACE inhibitor.What other category
of medication would typically be prescribed for secondary prevention of myocardial
infarction?
a. Alpha-blocker
b. Beta-blocker
c. Calcium-channel blocker
d. Nitrates
e. Naproxen sodium

410. The answer is b. (Fauci, pp 1521-1524.) Beta-blockers are documented to lower the
risk of myocardial reinfarction, whereas calcium channel blockers may increase the risk. Alpha-
blockers have been associated with an increased risk of congestive heart failure. ACE
inhibitors are beneficial in this setting and should be continued. Despite their decades-long use
for the symptomatic treatment of angina, nitrates are not indicated for secondary
prevention of infarction. Recently, long-term use of some nonsteroidal anti-inflammatory
drugs (including naproxen sodium) has been associated with an increased risk of
myocardial infarction. PRETEST MEDICINE 12th

32
 (Q70) A 17-year-old girl is brought in by her parents because of their concerns
about her weight loss. She is petite, and a normal weight for someone her height
is 100 lbs, but she weighs 78 lbs. She reports menstrual irregularity. The patient
believes she is obese. She does not believe she has a problem. Her mother reports
that she found laxatives on her daughter’s nightstand, and heard her vomiting in
the bathroom yesterday after dinner.
21. Which of the following is the most likely diagnosis?
(A) bulimia nervosa
(B) pregnancy
(C) anorexia nervosa
(D) no diagnosis, normal presentation
(E) obesity

21. (C) Anorexia nervosa is an eating disorder that predominantly affects women in
their teens and in early adulthood. It is defined as refusal to maintain a minimal normal
weight, at least 85% of that weight considered normal for that person’s age and height,
and a morbid preoccupation with feeling obese. Common strategies to lose weight
include avoidance of all fats and carbohydrates, self-induced vomiting,
obsessive physical activity, and abuse of laxatives or diuretics or both. Despite
apparent aversion to gaining weight, anorectics frequently take very special care in
preparation and consumption of food and may delight in preparing gourmet feasts for
others. Menstrual irregularity and amenorrhea are also commonly reported but are
not essential factors in making the diagnosis. It is not yet clear whether such
menstrual problems are simply secondary to starvation or whether they reflect
a more pervasive endocrine dysfunction. Perhaps the most striking clinical
feature of this disorder is the misperception of body image. Regardless of the
method of confrontation, including use of mirrors or photographs, sufferers see
themselves as overweight. The patient often refus including developmental, family,
endocrine, and gastrointestinal disturbances have been

in exam mention BMI 17.8 without wt and ht

========================================

$ % &'

33
 $ % ( " )*+,-
(Q71) When you educate patients who have asthma or diabetes , this type of
prevention is :
(A) primary prevention
(B) secondary prevention
(C) tertiary prevention
(D) primodal prevention

(Q72) When increase the sample size , it will :

A) Decrease confidence interval
B) Increase standard error
C) Standard deviation

however. As the sample size increases, the standard error decreases, the confidence
interval decreases, and you get a much more stable estimate. The standard error and
confidence interval should therefore be used in interpreting estimates based on a
survey.

(Q73) 60 year old man k/c hemochromotsis and cirrhosis , present with RUQ pain
and o/e abdominal distension and tender over RUQ , what is your investigatation?
A) Hepatitis A
B) Hepatitis C
C) Iron level
D) Alpha fetoprotein

(Q74) 141. Three weeks ago, a 78-year-old man with coronary artery disease and
diabetes developed herpes zoster of the right lateral chest wall. He was treated within
48 hours of symptom onset with oral acyclovir. He continues to have significant pain.
What would be appropriate therapy for this patient at this point?
❑ A. Gabapentin
❑ B. Oxycodone
❑ C. Nortriptyline
❑ D. Prednisone
❑ E. Repeat course of acyclovir

Key Concept/Objecetive: To be able to choose appropriate therapy in an elderly

patient with postherpetic neuralgia Treatment options for postherpetic neuralgia
include topical anesthetics, oral analgesics, tricyclic antidepressants, and
gabapentin. Neither oral steroids nor antiviral agents are effective in the long-
term treatment of this syndrome. Although some patients need long-acting

34
 narcotics to control their pain, oxycodone would not be the initial drug of choice,
especially in the elderly, who are at higher risk for CNS effects and falls. Tricyclic
antidepressants are contraindicated in patients with active ischemic heart disease.
(Answer: A—Gabapentin) (

(Q75) Q. An ankle radiographic series is required only if there is any pain in :

a) Anterior edge of medial malleolus
b) Anterior edge of lateral malleolus
c) Base of fifth metatarsal

(Q76) 49. An autopsy heart from a 4-year-old boy with a premortem history of
cyanotic congenital heart disease displays right ventricular hyperplasia, pulmonary
stenosis, ventricular septal defect, and dextroposition of the aorta. What term best
defines this disorder?
(A) anomalous pulmonary venous drainage
(B) dextrocardia
(C) ebstein malformation
(D) transposition of the great arteries
(E) Tetralogy of Fallot
Lange Q & A. USMLE Step 1 !

(Q77) 104. A 79-year-old male is admitted to the hospital because of a sudden

inability to ambulate. He has a past history of gout. On examination his temperature
is 38.2°C (100.8°F) and he has bilateral knee effusions. His WBC count is
14,000/mm with 82% segs. His serum uric acid level is 8.5 3 mg/dL (N
<6.5). Which one of the following would be most appropriate at this point?
A) 24-hour urine collection for uric acid
B) Arthrocentesis
C) Initiation of allopurinol
D) Initiation of antibiotics
E) Initiation of furosemide (Lasix)

35
 ABFM 2008 (
)
In Hx urethral discharge and in options

A) CBC and differntial

(Q78 ) Adult male patient present with 7 days present with nasal dishcharge and face
tenderness what is your first line treatment:
A) Amoxicillin
B) Ciprofloxacin
C) Cuferoxime

(Q79 ) Female present with low mood and loss of interest , before she leave , you
should ask question about
A) Substance abuse
B) Alcholol
C) Suicide or harm other

(Q80) Patient present with sudden vision loss , What is most common cause of
sudden retinal artery occlusion
a) Embolism ??? *' )+, -. /
b) Hypertension
c) Diabetes melltus

(Q81) WHAT is most common death after myocardial infarction episode :

a) Arrhythmia

(Q82) Adult female present with numbness in the right arm after conflict with her
husband. On examination all normal , what is mot likely diagnosis :
A) Panic disorder
B) Somatization disorder
C) Conversion disorder

(Q83) Adult present with fever neck rigidity look toxic , after LP done and wait the
result , what you will give now
A) Dexamethasone
B) Ciprofloxacin
C) Ceftrixone

36
 (Q84) Patient present with epistaxis , you will do first :
a) Pinch the nose
b) Lying forward
c) Put tissue in the nose

(Q85) 237. A 5-year-old child is noted to be iron deficient. Upon questioning, his
family reports several episodes of grossly bloody (maroon) stools. Which of
the following is a likely explanation for his anemia?
a. Increased demands for iron due to accelerated growth
b. Meckel diverticulum
c. Infestation by hookworm
d. Peptic ulcer
e. Recurrent epistaxis
(

(Q86) In primary hyperparathyroidism :

A) high PTH, high calcium, and low phosphate

(Q87) 7 year old boy present with abdominal pain, lethargy and vomiting
Blood glucose was 500 ? what is your diagnosis
A) DKA

(Q88) patient dignosed with cornel abrasion and he present with still
photophobia on examination you found whit and grey edge on the site of
abrasion what will you do?
a) Reassurance and continue treatment
b) Immediate referral to ophthalmology

(Q89) Scinerio of Uveitis

(Q90) prevelance increase –

A) not cure disease
B) if incidence decrease
C) if high mortality

don’t forget prevalence = incidence x period

37
 (Q91) 100 sample for study to show difference between male and female in laboratory
values, What is appropriate test for this study is:
A) t -test
B) Chi square
C) Regression
D) Correlation

(Q92) In Fhx if u find there is hx of drug abuse and violence your first treat:
a. Check the Drug abuser
b. Check for depression
c. First of all Protect the violence and safety of victims $ .
d. Look for family dynamic

(Q93) In an epidemic outbreak one of the investigation steps should be done:

1. Verify the diagnosis $ 0 \

(Q94) about consultation selecet the right answer:

A) Frequent short consultation increase patient satisfaction
B) Pendleton model :most important thing to say to pt the last information while
heis leaving.
C) Neighbour safety netting means"you should ventilate bw pt and next one
D) Balint model personality of the doctor
E) Eric style divide patient center and doctor center

(Q95) A study with p-value 0.001 that mean :

A )5% the result will happen by chance
B) the test is not significant

(Q96) Painter with pain on shoulder and numbeness on arm , whai is most likely
diagnosis
A) Thoracic outlet syndrome

(Q97) Patient after one week after kidney transplant , what is most sign indicate
rejection of transplantation ?
A) Fever
B) Hypotension

38
 3 ' " $ .' 3 ) ' $ . ( /' - 0 1.2"

PRETEST Pediatrics 12th edition

Pretest medicine 2004
Case files Family medicine
Pretest gynecology Pretest
family medicine
Family certificate (especially obst and gyne chapters)
American journal family medicine ( 2 questions only)
American board family medicine 2010 ( 1 question only)
Family practice examination and board review
Pretest Psychaitry
MRCP
4 - $ % 5"
678 9 : - )*+,- 5 ; 6 7 8 < 7 = $ % > ? ;' - > 7

# $ "%1 $ 0" ,2 (
122. A 25-year-old male with a long history of severe asthma presents to the
emergency room with shortness of breath. He has previously required admission
to the hospital and was once intubated for asthma. Which of the following
findings on physical exam would indicate a benign course?
a. Silent chest
b. Hypercapnia
c. Thoracoabdominal paradox (paradoxical respiration)
d. Pulsus paradoxus of 5 mmHg
e. Altered mental status

122. The answer is d. (Stobo, 23/e, p 143.) It is extremely important to

accurately determine the severity of an exacerbation of asthma, since the
major cause of death from asthma is the underestimation of the severity of
a particular episode by either the patient or the physician. Silent chest is a
particularly ominous finding, because the airway constriction is so great
that airflow is insufficient to generate wheezing. Hypercapnia and thoraco-
abdominal paradox are almost always indicative of exhaustion and respira-
tory muscle failure or fatigue and generally need to be aggressively treated
with mechanical ventilation. Altered mental status is frequently seen with
severe hypoxia or hypercapnia, and ventilatory support is usually required.
An increased pulsus paradoxus may also be a sign of severe asthma, as it
increases with greater respiratory effort and generation of more negative
intrathoracic pressures during inspiration. However, a pulsus paradoxus of
up to 8 to 10 mmHg is considered normal; thus, a value of 5 mmHg would
not be indicative of a severe episode of asthma.

39
 MEQ:
Q1
53 year old man work as taxi driver , present with long history with heartburn relived by
anti acid , but before 1 week complain from vomiting one time with severe abdominal
pain , how to proceed this consultation ?

Q2
36 year old business man with frequent travel, presents with urethral discharge
purulent for 2 days, how to proceed this consultation?

Q3
Lady comes to your clinic with multiple bruises on her face and ask you to document
this against her husband , and she doesn’t want any treatment . what are the issues
raised?

Q4
King Abdullah research center request you to participate in new research about new
anti lipid drug , What factors you will consider before accept the participation ?

40
 Q1 CRQ
Safety and Efficacy of an Attenuated Vaccine
against Severe Rotavirus Gastroenteritis

Background

The safety and efficacy of an attenuated G1P[8] human rotavirus (HRV) vaccine were tested in
a randomized, double-blind, phase 3 trial.

Methods

We studied 63,225 healthy infants from 11 Latin American countries and Finland who received
two oral doses of either the HRV vaccine (31,673 infants) or placebo (31,552 infants) at
approximately two months and four months of age. Severe gastroenteritis episodes were
identified by active surveillance. The severity of disease was graded with the use of the 20-
point Vesikari scale. Vaccine efficacy was evaluated in a subgroup of 20,169 infants (10,159
vaccinees and 10,010 placebo recipients).

Results

The efficacy of the vaccine against severe rotavirus gastroenteritis and against rotavirus-
associated hospitalization was 85 percent (P<0.001 for the comparison with placebo) and
reached 100 percent against more severe rotavirus gastroenteritis. Hospitalization for diarrhea
of any cause was reduced by 42 percent (95 percent confidence interval, 29 to 53 percent;
P<0.001). During the 31-day window after each dose, six vaccine recipients and seven placebo
recipients had definite intussusception (difference in risk, −0.32 per 10,000 infants; 95 percent
confidence interval, −2.91 to 2.18; P=0.78).

Conclusions

Two oral doses of the live attenuated G1P[8] HRV vaccine were highly efficacious in
protecting infants against severe rotavirus gastroenteritis, significantly reduced the rate of
severe gastroenteritis from any cause, and were not associated with an increased risk of
intussusception.

41
 Q1 A - Comment on this graph ?

42
 Q1 B – Were patients analyzed in the groups( intention to treat) to which they were
randomized?

Q1 C - Comment if you recommend this vaccine in Saudi Arabia ?

43
 Performance of the immunochemical fecal occult blood test in
predicting lesions in the lower gastrointestinal tract
1. Tsung-Hsien Chiang, MD MSc, Yi-Chia Lee, MD PhD, Chia-Hung Tu, MD MSc, Han-
Mo Chiu, MD PhD, Ming-Shiang Wu, MD PhD

Abstract

Background: Previous studies have suggested that the immunochemical fecal occult
blood test has superior specificity for detecting bleeding in the lower gastrointestinal
tract even if bleeding occurs in the upper tract. We conducted a large population-
based study involving asymptomatic adults in Taiwan, a population with prevalent
upper gastrointestinal lesions, to confirm this claim.

Methods: We conducted a prospective cohort study involving asymptomatic people aged 18

years or more in Taiwan recruited to undergo an immunochemical fecal occult blood test,
colonoscopy and esophagogastroduodenoscopy between August 2007 and July 2009. We
compared the prevalence of lesions in the lower and upper gastrointestinal tracts between
patients with positive and negative fecal test results. We also identified risk factors associated
with a false-positive fecal test result.

Results: Of the 2796 participants, 397 (14.2%) had a positive fecal test result. The sensitivity of
the test for predicting lesions in the lower gastrointestinal tract was 24.3%, the specificity
89.0%, the positive predictive value 41.3%, the negative predictive value 78.7%, the positive
likelihood ratio 2.22, the negative likelihood ratio 0.85 and the accuracy 73.4%. The prevalence
of lesions in the lower gastrointestinal tract was higher among those with a positive fecal test
result than among those with a negative result (41.3% v. 21.3%, p < 0.001). The prevalence of
lesions in the upper gastrointestinal tract did not differ significantly between the two groups
(20.7% v. 17.5%, p = 0.12). Almost all of the participants found to have colon cancer (27/28,
96.4%) had a positive fecal test result; in contrast, none of the three found to have esophageal or
gastric cancer had a positive fecal test result (p < 0.001). Among those with a negative
finding on colonoscopy, the risk factors associated with a false-positive fecal test result were use
of antiplatelet drugs (adjusted odds ratio [OR] 2.46, 95% confidence interval [CI] 1.21– 4.98)
and a low hemoglobin concentration (adjusted OR 2.65, 95% CI 1.62–4.33).

Interpretation: The immunochemical fecal occult blood test was specific for predicting lesions
in the lower gastrointestinal tract. However, the test did not adequately predict lesions in the
upper gastrointestinal tract.

Positive Fecal occult test Negative Fecal occult test

All lesions 397 2399
Colon cancer 27 1

44
 Q2 A Draw 2x2 table for colon cancer and the test ? @ *A B -

Q2 B what is probability of positive test in patient who actually have the colon cancer ?

C= 3 / >D;7 : 7
PPV

45
 Q3 what is positive likelihood ratio for the test to detect colon cancer ?

46
 Q4

What is post test probability for topinin I to detect mycocardial infarction if positive LHR
is 10 and prevelance of disease is 50 % ?

47
 Q4 =====MCQ
1- CI ( 1.5-3) RR 2 E F ;7 =
a) The test is statistically significant
b) The test is not significant
c) It Is not important
d) Can’t tell because P value is not mentioned

2- P value = 0.2
a) It meant is statistically significant
b) That mean 20% of results is by chance

3- forest plot graph ( ), $ 6$ ) and comment on test of heterogeneity P

value = 0.01 I2= 76% that mean :
A) Heterogeneity
B) Homogeneity
C) Variable
D) Can’t tell

G ' ! " EH

.I -
L. &K ME $ % ) /" ;, J &K

.I : /
! H N )*+,- 5 " $ E', >* , ( -

48