D.S.

S AIIMS PREPRATION TEST SERIES

1. A 55-year-old retired man is admitted with central chest pain which is radiating to the left arm
and jaw. The 12-lead ECG shows left bundle branch block. The cardiac enzymes are normal.
He has had three similar admissions in the last six months despite optimum treatment. Similar
ECG changes were noticed in previous records.
Which of the following will be the most appropriate action?
A) Exercise tolerance test
B) Dipyridamole-thallium scintigraphy
C) 99 mTc pyrophosphate imaging
D) Exercise thallium scintigraphy
E) Multiple gated acquisition (MUGA) scan

2. A 65-year-old male patient presents with right sided weaknessof one day duration. He is
diabetic on oral hypoglycemic agents. On examination, his BP is 150/90 mmHg, pulse
104/minute, his right upper and lower limbs are weak III/V. reflexes are normal with upgoing
right planter reflex. Brain CT showed ischemic stroke. He is a tourist and wishes to travel
back home as soon as possible.
How soon after an uncomplicated ischemic stroke may a patient undertake air travel
safely?
A) 1 week
B) 2 weeks
C) 4 weeks
D) 6 weeks
E) 8 weeks

3. A 22-year-old patient is brought to the emergency department in class III shock following
multiple penetrating stab injuries to the torso, chest and abdomen. He undergoes an
emergency thoracotomy and laparotomy. In theatre he requires a total of 30 units of blood.
Which of the following is the best statement regarding complications of massive blood
transfusion?
A) Thrombocytosis is inevitable
B) Depletion of factor XI and X is a common problem
C) Hypocalcaemia may ensue
D) Hyperkalemia is uncommon
E) Hypothermia is rare

4. You have been asked to see a 72-year-old Caucasian woman who is 52 hours following
uncomplicated laparoscopic cholecystectomy for gallstone disease. She was found
unconscious on the ward with generalized tonic-clonic seizures, requiring 20 mg diazepam.
Her sodium level is 112 mmol/L. During surgery she received 3 L of 5 per cent dextrose with
20 mmol/L potassium chloride. Her potassium and urea and creatinine are within normal
limits. There are no signs of heart failure. Her plasma osmolality is 265 mOsm/kg and her
urinary osmolality is 566 mOsm/kg. Which of the following is the most likely cause for her
low sodium?
A) Excess 5 per cent dextrose
B) Addison’s disease
C) Syndrome of inappropriate antidiuretic hormone secretion
D) Nephrotic syndrome
E) Congestive cardiac failure

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5. A 45-year-old patient is 1 week following an attack of severe acute pancreatitis. He has been
unable to start eating as this precipitates severe pain. Physical examination reveals a soft
abdomen with epigastric tenderness. Bowel sounds are scanty. He is afebrile. His amylase
in normal and C-reactive protein is 200 mg/L. Which of the following statements
regarding management of nutrition is correct?
A) No supplementary nutrition is required
B) Total parenteral nutrition should be commenced
C) Nasogastric feeding should be commenced
D) Nasojejunal feeding should be commenced
E) None of the above

6. A 35-year-old female is referred for evaluation of positive antinuclear antibodies (ANA). She is
asymptomatic. No malar rash, photosensitivoity, mouth ulcer, synovitis, or serositis is
observed. Her lab work reveals ANA 1:160 homogeneous pattern; extractable nuclear
antigens are negative. Hematologic and renal function values are normal and urinalysis is
without sediment. Her examination is unremarkable apart from a smooth nontender goiter.
The past medical history is significant for Hashimoto’s thyroiditis with hypothyroidism on
regular thyroxine. What is your next step?
A) No further intervention is warranted
B) Start oral steroids
C) Start hydroxychloroquine
D) Start NSAIDs
E) Start steroids and hydroxychloroquine

7. You are asked to evaluate a 74-year-old male with joint pain. He was recently admitted after a
bout of diverticulitis. On examination he has polyarticular synovitis, and arthrocentesis reveals
multiple intracellular uric acid (UA) crystals diagnostic of gout. Lab values: UA = 5.5 mg/dl,
WBC = 10.5x109/L, HB = 11.5, Plts = 550x109/L, and creatinine = 2.8 mg/dl. How would you
best manage this patient’s gout?
A) Oral steroids
B) Intra-articular steroids
C) Colchicine
D) NSAIDs
E) Intravenous steroids

8. A 76-year-old man with a history of hypertension and hyperlipidemia comes to the emergency
department because of an acute change in speech, binocular horizontal double vision, and
leftsided extremity weakness. On examination, the patient has weakness of the right
forehead, face, and mouth. He has a right abductor weakness on extraocular muscle testing.
He has a left-sided hemiparesis, pronator drift, increased tendon reflexes, and Babinski sign.
The rest of the neurologic examination is unremarkable. Which syndrome provides the
most accurate localization?
A) Cavernous sinus syndrome
B) Foville’s syndrome
C) Gradenigo’s syndrome
D) Millard-Gubler syndrome
 E) Pontomedullary lesion

9. A 30 year old female refereed to you with a diagnosis of asthma. Despite initial therapy with a
maximal dose of inhaled corticosteroids and B-agonists remains symptomatic with cough and
wheeze, FEV1 is 80% of predicted value and improves 8% of predicated value after
salbutamol inhaler. The most appropriate next step in the management of this patient is?
A) Give oral corticosteroids
B) Order methalcholine challenge
C) Order a nasolaryngoscopy
D) Add theophylline
E) Add a leukotriene receptor antagonist

10. A 24-year-old sexually active man, who admits to only variable use of condoms, complains of
painful vesicles and ulcers on his penile shaft that have been present for 3 days. This is his
first episode. Which of the following statements regarding the diagnosis and treatment
of primary genital site herpes simplex virus (HSV) is correct?
A) The lesions are typically indurated and sharply demarcated and rarely coalesce.
B) The prognosis is the same even if the isolate is found to be HSV type 1 (HSV-1).
C) If he has subsequent relapses, the natural course of the episode almost always will be
identical to the primary episode.
D) Confirmatory testing and serology often is not helpful in this scenario.
E) Early treatment with acyclovir or valacyclovir is curative.

11. A 76-year-old woman was found in her home with a decreased level of responsiveness. The
patient’s daughter last saw her yesterday morning, and the patient can provide no further
information. Vital signs: rectal temperature 96.6◦F, heart rate 120/min, respiratory rate 26/min,
blood pressure 84/44 mmHg, oxygen saturation 94% on room air. Your examination is
significant for signs of dehydration and a diminished mental status. Laboratory values reveal
WBC of 18.2 with 10% band forms, hemoglobin 9.6 g, hematocrit 28.8%, platelets 120,000,
sodium 128 mEq/L, potassium 3.4 mEq/L, BUN 64 mg/dL, and creatinine of 2.8 mg/dL.
Urinalysis is consistent with a urinary tract infection. Which of the following statements
regarding this patient’s condition is true?
A) The patient may benefit from cortisol administration.
B) Fluid resuscitation should be limited due to her decreased oxygen saturation and
concerns for precipitating pulmonary edema. C) A serum lactate is of limited
value.
D) The patient should be transfused with packed red blood cells (PRBC) until her hematocrit is
greater than 50%.
E) A CVP less than 8 mmHg is a good prognostic sign.

12. A final year medical student set up a website offering travel advice to colleagues travelling to
malarial areas to undertake their student electives. In his enthusiasm, he included some
inaccurate information. Which of the following pieces of advice on malaria prevention is
not appropriate?
A) Avoid travel to endemic regions if at risk of severe infection, e.g. splenectomized
B) Get vaccinated against malaria at least 4 weeks prior to the expected date of travel
C) Take daily doxycycline as anti- malarial prophylaxis
D) Use bed-nets impregnated with mosquito repellent
E) Wear loose fitting long - sleeved shirts
13. Acetaminophen overdose: Depletion in which of the metabolic substances is causing
hepatotoxicity?
A) Alcohol dehydrogenase.
B) Catalase.
C) Glutathione.
D) Glycogen.
E) Vitamin K.

14. A 49-yr-old woman who is being treated with chemotherapy after surgery for breast cancer
presents to the ER of the local hospital. She has just started taking prochlorperazine for
nausea the day before. Her husband brings her in because she is acting bizarrely over the
past 24hours with waxy flexibility and mutism. She has no previous psychiatric history. Her
physical examination, lab studies and vitals are all within normal limits. Which of the
following is the most appropriate pharmacotherapy?
A) Alprazolam
B) Benztropine
C) Haloperidol
D) Methylphenidate
E) Valproic acid

15. A 31-yr-old woman with known HIV presents to her physician with a 3-month history of watery
diarrhea, severe weakness and 22 lbs weight loss. Multiple stool tests for bacteria, parasites
and ova are repeatedly negative. Colonoscopy is normal as are the biopsies of the colon.
Which of the following is the most likely explanation for her diarrhea? A)
Cryptosporodiasis.
B) Cytomegalovirus infection.
C) Entamoeba histolytica.
D) Enterotoxigenic E.coli.
E) Shigella dysentriea.

16. A 69-yr-old patient is admitted to the neurology service following a stroke. During the next few
days the staff observes that the patient develops the clinical picture of mania. Which area of
the brain is most likely been affected by the stroke? A) Left hemispheric region including
the Broca’s area.
B) Left prefrontal cortex.
C) Midbrain.
D) Right frontal lobe.
E) Thalamus.

17. A 34-yr-old woman complains of difficulty swallowing both liquids and solids for the past 6-
months. She has a history of hypertension and Raynaud’s phenomenon. Physical
examination reveals tight skin on the face and on the dorsal surface of both hands. Which of
the following manometric findings will most likely be found in this patient?
PERSISTENCE OF PRESSURE PRESSURE IN THE LOWER
IN BODY OF ESOPHAGUS ESOPHAGEAL SPHINCTER
A) Decreased Normal
B) Decreased Increased
C) Increased Decreased
D) Decreased Decreased
E) Increased Increased
18. A 44-year-old man with advanced HIV/AIDS presents with a two week history of fever, weight
loss (8 kg) and sweats. His latest CD4 T-lymphocyte count (taken four weeks previously) was
20 cells/mm3. He had failed multiple regimens of antiretroviral therapy and was not currently
taking any prescribed medications other than co-trimoxazole as prophylaxis against
Pneumocystis carinii pneumonia. Investigations: Hb 8.2 g/dL (13.0-18.0); Total WBC 2.1
x109/L (4-11 x109); Platelets 75 x109/L (150-400 x109). A bone marrow aspirate showed
acid/alcohol fast bacilli on light microscopy. Which one of the following mycobacteria is
the most likely cause of his presenting illness?
A) Mycobacterium avium
B) Mycobacterium bovis
C) Mycobacterium chelonae
D) Mycobacterium fortuitum
E) Mycobacterium marinum

19. In asbestos related a disorder which of the following statements is correct?

A) Basal fibrotic shadowing on CXR suggests coincidental idiopathic fibrosing alveolitis
B) Increased incidence of primary lung cancer
C) Pleural effusion develops more than 20 years after causative asbestos exposure
D) Pleural plaques are recognized precursors of mesothelioma
E) The risk of malignant mesothelioma is greatly increased in smokers compared with non-
smokers

20. A 74-year-old Caucasian man with obstructive jaundice secondary to gallstones is about to
undergo urgent laparoscopic cholecystectomy and bile duct exploration following failed
endoscopic retrograde cholangiopancreatography. His latest blood tests are as follows:
Bilirubin = 180 µmol/L; Alkaline phosphatase = 700 IU/L; Alanine aminotransferase = 250
IU/L; White cell count = 18 x 109/L; Urea = 9.0 mmol/L; Creatinine = 180 µmol/L. Which one
of the following is the best statement regarding perioperative management
considerations?
A) Rehydration should be approached with caution to prevent the risk of hepatorenal
syndrome
B) The patient is at increased risk of bleeding owing to reduced absorption of clotting factors
II, VII, IX and X
C) There is a lower risk of infection so prophylactic antibiotics are not necessary
D) Analgesics are less effective so doses of opiates should be increased E) Surgery should
not be performed in a jaundiced patient

21. A 25-year-old man was an unrestrained passenger in a motor vehicle collision. After being
extracted from the car, he was taken to the emergency department. He has a broken clavicle,
a broken fibula, and a scalp laceration on the vertex. Since the collision, he has noticed
vertical diplopia. The emergency department physician orders computed tomography
(noncontrast) of the head, which does not show any intracranial abnormality, hemorrhage, or
stroke. You are consulted about the patient’s diplopia. On examination, the patient has a right
 hypertropia in primary gaze that is worse on left gaze and right head tilt. The rest of the
neurologic examination is normal. What is the most likely diagnosis?
A) Right inferior rectus muscle weakness
B) Left superior rectus muscle weakness
C) Right inferior oblique muscle weakness
D) Skew deviation
E) Right fourth nerve palsy

22. A 55-year-old female with longstanding Sjogrens syndrome (SS) presents with new onset of
lethargy, hypokalemia, and nephrocalcinosis. Her metabolic profile reveals an anion gap
metabolic acidosis, hypokalemia, and alkaline urine. A skeletal survey reveals diffuse
osteopenia. What complication has occurred?
A) Proximal type 2 renal tubular acidosis (RTA)
B) Combined Proximal and Distal RTA (Type 3)
C) Type 4 RTA
D) Distal type 1 RTA
E) Type 5 RTA

23. Raynaud’s syndrome can be caused by which one of the following anti-hypertensives?
A) α-blockers
B) Angiotensin-converting enzyme inhibitors
C) β-blockers
D) Calcium channel blockers
E) Angiotensin receptor blockers

24. Your colleague consults you with regard to a 56-year-old patient who has suffered an episode
of amaurosis fugax. From the list below, choose the most likely site of pathology which
may give rise to amaurosis fugax.
A) Vertebrobasilar artery territory
B) Carotid artery territory
C) Posterior communicating artery territory
D) Spinal artery territory
E) Anterior communicating artery territory

25. A patient on warfarin for multiple deep vein thromboses is about to undergo an emergency
laparotomy for a perforated sigmoid colon. Which of the following is the best preoperative
strategy?
A) Discontinue warfarin therapy, administer vitamin K (2–3 mg) and check the international
normalized ratio (INR) every 6–8 hours preoperatively
B) Discontinue warfarin therapy and check the INR every 6–8 hours preoperatively
C) Continue warfarin therapy as prescribed
D) Discontinue warfarin therapy, administer vitamin K (2–3 mg), check the INR every 6–8
hours preoperatively, request fresh frozen plasma to cover the procedure E) None of the
above as the surgery should be postponed

26. A 56-year-old white man asks for your advice regarding methods to reduce his risk of
coronary disease. He has hypertension and depression. Current medications are sertraline
(50 mg daily), aspirin (162 mg daily), and lisinopril (10 mg daily). He does not use tobacco.
 BMI is 34. Pulse rate is 74 per minute, and blood pressure is 115/74 mm Hg. Serum lipids:
Cholesterol Total 205 mg/dL [desirable: less than 200]; HDL 41 mg/dL [low: less than 40]; LDL
118 mg/dL [optimal: less than 100]; Triglycerides 229 mg/dL [normal: less than 150]. The
patient’s 10-year risk for atherosclerotic cardiovascular disease is 7.2%. In addition to
recommending weight loss, which of the following should you do to reduce this patient’s
risk of cardiovascular events?
A) Begin simvastatin, 40 mg daily
B) Increase of aspirin dosage to 325 mg daily
C) Addition of metoprolol, 25 mg twice daily
D) Addition of omega-3 fatty acids, 1.5 g daily
E) No changes are indicated at this time
27. A 41 year old man presented with fatigue. He has had Hodgkin lymphoma for 16 years and
has six different treatment regimens. At this time, physical examination does not show
lymphadenopathy or hepatosplenomegaly. A CBC demonstrates severe pancytopenia. What
would you do next?
A) CT of the abdomen and chest
B) Treat for recurrent Hodgkin disease
C) Flow cytometry for Paroxysmal Nocturnal Hemoglobinuria
D) Observation and to return in 3 month
E) Bone marrow biopsy with cytogenetic studies to examine for monosomy 5 translocation

28. Which of the following patients could reasonable to be offered observational follow up
(wait and watch) for their solitary pulmonary nodule?
A) 68 year old otherwise healthy man with 75 pack year smoking history quit 4 years ago
with a new 3.6 cm lobulated nodule in the right middle lobe
B) 28 year old woman without prior Chest X-Rays with a 2.6 cm round nodule in the left
upper lobe. CT scan demonstrates it is round smooth with dense central
calcification
C) 53 year old woman who smokes 1 pack of cigarettes per day with 3 cm nodule in the left
lower lobe found during work up for reflux esophagitis. It was not seen on her last xray 15
years ago, CT scan reveals it to be lobulated with smooth borders and without
calcification
D) 60 year old man with COPD, CXR revealed 3 cm scan shoed irregular marginal
calcification, no old CXR for comparison nodules

29. A 43-year-old nulligravid woman requests a second opinion regarding treatment for
osteoporosis. Osteoporosis has been diagnosed by dual-energy X-ray absorptiometry (DXA),
and she has begun to take alendronate at her physician’s recommendation. She takes
calcium supplements, 1,500 mg per day, with vitamin D, 400 IU per day. She runs
approximately 16 km (10 mile) per week and bikes 80.5 km (50 mile) every weekend. On
physicial examination, she is 1.7 m(5 ft 8 in) tall, she weighs 57.2 (126 lb), her blood
pressure level is 96/60 mm Hg, and pulse rate is 64 beats per minute. The remainder of her
examination is unremarkable. Laboratory studies, including TSH, estradiol, FSH and serum
prolactin levels, are normal. In addition, her electrolyte, human parathyroid hormone, serum
calcium, and 24-hour urinary free calcium levels obtained while she is off calcium
supplementation also are normal. To monitor her response to alendronate, the most
appropriate next step in her management is
A) Repeat DXA scan
B) Urinary N-telopeptide level
C) Lateral X-ray of spine

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 D) Urinary calcium excretion rate
E) Ultrasonography of calcaneus

30. A 35-year-old man complains of chest pain, which began following the use of cocaine 30
minutes prior to arrival. The patient describes severe substernal chest pressure, radiating to
the left arm and jaw. It is associated with shortness of breath. Initial vital signs: temperature
100.4°F, heart rate 120/min, respiratory rate 20/min, blood pressure 185/100 mm Hg, pulse
oximetry 98% on room air. An ECG is consistent with acute myocardial infarction. A drug
which is contraindicated is:
A) Oxygen
B) Aspirin
C) Lorazepam
D) Bisoprolol
E) Morphine
31. A 55-year-old man with known esophageal varices has an upper gastrointestinal bleeding
requiring six-unit blood transfusion. He becomes encephalopathic and was intubated and now
is ventilated on the ICU. He continues to bleed. The is the most appropriate action ?
A) Somatostatin
B) Propranolol
C) Endoscopic variceal banding
D) Conservative management and correction of coagulopathy
E) Gastro-esophageal balloon tamponade

32. A pregnant woman is being followed for gestational diabetes. She walks 30 minutes per day
and is following a diabetic diet. She is not gaining weight. Fasting sugars are 5 - 6.5;
postprandial, 7 - 8.5. She now has ketonuria in the mornings. What should you advise? A)
Increase caloric intake, plus begin insulin NPH 10u QHS
B) Increase caloric intake, plus begin insulin lispro ac meals
C) Increase caloric intake and exercise before breakfast
D) Increase calorie intake and postprandial exercise
E) Increase calorie intake, plus an oral agent

33. A 22-year-old man is brought to the emergency department following ingestion of six ecstasy
tablets 8 hours ago. He has been dancing at a night club since then, but is now alternately
violently agitated and listless. On examination he has tachycardia (140/min), his BP is
185/115 mmHg and rectal temperature is 40.3ºC. Initial blood tests: sodium 114 mmol/L.
Management plan will include all of the following EXCEPT:
A) Active cooling
B) Administration of sodium-containing fluid
C) Arterial blood gas analysis
D) Gastric lavage to empty the stomach
E) Intravenous benzodiazepine administration

34. A 46-year-old woman comes to the office for management of a 4-mm left middle cerebral
artery aneurysm. The aneurysm was found when the patient had magnetic resonance
angiography and imaging for evaluation of a chronic headache disorder. Medical history is
limited to chronic migraine headaches and smoking. Neurologic examination is normal. Which
of the following is the most appropriate next step in this patient’s management?

9
 A) Arteriography
B) Computed tomographic angiography
C) Follow-up magnetic resonance angiography in 6 months
D) Aneurysm clipping

35. A 74-year-old type 2 diabetic woman undergoes a bowel resection for cancer of the colon.
She is well prior to the operation with well–controlled diabetes and no other underlying disease.
The operation is successful and the patient is given postoperative insulin and IV dextrose. Two
days after the operation she becomes very agitated. Sodium 124 mmol/L (135–145); Potassium
3.3 mmol/L (3.5–5.0); Urea 3.1 mmol/L (3.0–7.0); Glucose 7.2 mmol/L (2.5–6.0); Serum
osmolality 265 mOsmol/kg (275–295); Urine osmolality 150 mOsmol/kg. The most likely cause
of the hyponatremia is:
A) Addison’s disease
B) Syndrome of inappropriate anti-diuretic hormone (SIADH)
C) Diabetic nephropathy
D) Excess insulin
E) Water overload
36. Plasma natriuretic peptides (i.e., BNP and NT-proBNP), all are true EXCEPT
A) Normal’ level means heart failure is unlikely and other causes for symptoms should be
determined.
B) Elevated natriuretic peptide levels may help confirm a suspected diagnosis of
heart failure.
C) Elevated levels alone can be used to confirm a heart failure diagnosis.
D) Elevated levels can be found in atrial fibrillation, ischaemic heart disease and
renal dysfunction.
E) Measurement of BNP or NT-proBNP is useful for establishing prognosis or disease
severity in chronic heart failure.

37. According to ACC/AHA guidelines, which treatments are recommended for all patients
with all New York Heart Association classifications of heart failure?
A) ACE inhibitors and aldosterone antagonists
B) Angiotensin receptor blockers (ARB) and diuretics
C) Aldosterone antagonists and diuretics
D) ACE inhibitors or ARBs
E) All of the above

38. Aortic dissection should be suspected in a patient with:

A) Anterior chest pain
B) Intrascapular pain
C) Diastolic hypertension with an aortic insufficiency murmur
D) All of the above
E) None of the above

39. A 40 year old woman with mild von Willebrand disease requires minor surgery for skin lesion.
The most appropriate management would include which of the following:
A) IV stored plasma during surgery
B) Cryoprecipitate every 12 hrs for one day prior and two days post surgery. 100 units of
factor VIII during surgery

10
 C) Deamino-D-arquinine vasopressin IV before surgery (DDAVP) D) Factor IX complex
given topically post operatively

40. In hepatorenal syndrome which one of the following is TRUE?

A) Is characterized by the production of small volume of iso-osmolar urine
B) Early intervention with renal replacement therapy has lead to an improvement in
patient survival
C) The renal biopsy usually shows immunoglobulin and complement deposition in the
glomeruli
D) Heavy proteinuria is common
E) May be successfully treated by performing liver transplantation.

41. Which of the following is not recommended for patients with peripheral vascular
disease in whom claudication developed?
A) Pentoxyphyline
B) Smoking cessation
C) Regular exercise
D) Anticoagulation
E) All of the above

42. According to the American Thyroid Association 2015 Guidelines in regards to differentiated
thyroid cancer, which of the following is supported by good evidence for screening a
sibling?
A) Thyroid ultrasound
B) Nuclear thyroid scan
C) TSH
D) Thyroglobulin
E) Insufficient evidence

43. You find that many of your patients that have gone to the emergency department with chest
pain have a negative set of initial cardiac enzymes. Most of those with a negative set of initial
enzymes did not have a heart attack. You decide to evaluate 100 of your patients who have
gone to the emergency department with chest pain to find out if an initial set of negative
enzymes by itself is a good predictor of those that are not having an MI. Of those 100
patients, 20 of them had acute MIs. Of those 20, 10 had a positive set of enzymes initially. Of
the 80 that did not have an acute MI, none of them had a positive set of initial enzymes. Given
this information, what is the negative predictive value of the initial set of cardiac
enzymes in your patient population?
A) 20% B) 22% C) 50%
D) 89%
E) 100%

44. A 76-year-old man receiving chemotherapy for cancer developed an abrupt onset of fever,
chills, headache, nonproductive cough, and diarrhea. A chest radiograph suggested a
diagnosis of pneumonia. The organism, isolated from sputum and blood culture, is an aquatic
saprophyte that infects amoebas outside of the body and macrophages following infection.
What is this organism?
A) Chlamydia pneumoniae
B) Legionella pneumophila

11
 C) Mycobacterium tuberculosis
D) Mycoplasma pneumoniae
E) Streptococcus pneumoniae

45. A 42-year-old man comes to the physician because of malaise, muscle and joint pain, and
temperatures to 38.4°C (101.1°F) for 3 days. Three months ago, he underwent cadaveric
renal transplantation resulting in immediate kidney function. At the time of discharge, his
serum creatinine concentration was 0.8 mg/dL. He is receiving cyclosporine and
corticosteroids. Examination shows no abnormalities. His leukocyte count is 2700/mm3, and
serum creatinine concentration is 1.6 mg/dL; serum cyclosporine concentration is in the
therapeutic range. A biopsy of the transplanted kidney shows intracellular inclusion bodies.
Which of the following is the most appropriate next step in management?
A) Increase the dosage of corticosteroids
B) Increase the dosage of cyclosporine
C) Begin amphotericin therapy
D) Begin ganciclovir therapy
E) Begin heparin therapy

46. You are called to take an action regarding the ABG results of a 70 kg patient on mechanical
ventilation which showed PH 7.42 PaCo2 30 mm Hg PaO2 50 mm Hg on the following
ventilator setting: tidal volume 700 ml, RR 15, PEEP 5 cm H2O, FiO2 1.00, your course of
action is
A) Continue the same ventilator setting
B) Decrease the ventilator rate to 10 b/min
C) Increase PEEP to 7 cm H2O
D) Decrease Tidal volume to 500 ml
E) Give 80mg of IV furosemide

47. A 59-year-old man is admitted to the hospital for shortness of breath. The patient has a long-
standing cardiac history and has suffered two non-Q wave infarctions in the past 20 months.
The patient reports bright red blood in the toilet bowl during his last bowel movement.
Laboratory data are remarkable for a hematocrit of 22%. Given the patient's known coronary
disease, his attending cardiologist recommends a blood transfusion. As appropriate, you order
2 units of appropriately matched red bloods cells in order to transfuse the patient to a target
hematocrit above 30%. While the first unit is being administered, the patient becomes febrile
and develops chest and flank pain. You are immediately summoned to his side and on arrival
you note erythema around the intravenous access site and a small volume of dark colored
urine in his Foley catheter bag. The remainder of the physical examination is unremarkable.
The most likely diagnosis is
A) Acute febrile hemolytic reaction
B) Anaphylaxis
C) Delayed hemolytic transfusion reaction
D) Pulmonary embolus
E) Transfusion associated lung injury

48. A 70-year-old man is admitted to your service for exacerbation of his congestive heart failure.
His other past medical history is significant for end-stage renal disease secondary to diabetes,
now requiring hemodialysis. On rounds the day after admission, he is somnolent with a

12
 breathing pattern that steadily increases and then decreases in size in a smooth
crescendodecrescendo pattern, followed by apneas. This patient's respiratory pattern
would NOT be seen in which of the following conditions?
A) Severe congestive heart failure
B) Hypoxia
C) Hemodialysis
D) Sleep
E) Pontine hemorrhage

49. A 17-year-old previously healthy man presents with a history of shortness of breath on
exertion, particularly during basketball season, when he sometimes needs to sit down during
practice to catch his breath. He does not notice any shortness of breath with routine activity.
There is no family history of asthma. On physical examination, he is in no respiratory
distress. His lungs are clear, with no wheezing during either tidal breathing or forced
expiration. His heart is normal. Baseline spirometry is normal. What is the next diagnostic
step?
A) Allergy testing
B) Methacholine challenge testing
C) Exercise testing with postexercise spirometry
D) Overnight oximetry
E) Repeat lung volumes and diffusing capacity

50. Which of the following auto-antibodies is associated with aggressive erosive

Rheumatoid Arthritis?
A) ANA
B) Anti-CCP (ACPA)
C) ANCA
D) Anti-SSA AB
E) Rheumatoid factors (RF)

ANSWER KEY
1. D
2. B
3. C
4. C
5. D
6. A
7. A
8. D
9. E
10. D
11. A
12. B
13. C
14. B
15. A
16. D
17. D
18. A

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 19. B
20. B
21. E
22. D
23. C
24. B
25. D
26. E
27. B
28. B
29. D
30. A
31. C
32. B
33. D
34. C
35. E
36. C
37. D
38. D
39. C
40. E
41. D
42. E
43. D
44. B
45. D
46. C
47. A
48. E
49. C
50. B

14