RITE Full Exam With Answer Key

RITE Full Exam with Answers
Table of Contents
Part 1: Cardiology (15) ......................................................................................................................................... 2
Part 2: Infectious Diseases (15) ............................................................................................................................ 9
Part 3: Pulmonary Medicine and Critical Care (15) ..............................................................................................15
Part 4: Gastroenterology (12) .............................................................................................................................20
Part 5: Endocrinology (12) ..................................................................................................................................25
Part 6: Renal Diseases (12)..................................................................................................................................30
Part 7: Oncology (7) ............................................................................................................................................34
Part 8: Hematology (7)........................................................................................................................................36
Part 9: Rheumatology (7) ....................................................................................................................................39
Part 10: Dermatology (6) ....................................................................................................................................41
Part 11: Allergology (6) .......................................................................................................................................44
Part 12: Neurology (6) ........................................................................................................................................46
RITE Full Exam with Answers Page 1 of 47

Part 1: Cardiology (15)
1 1. A 52 year old female was brought to E.R. due to sudden onset of palpitations ECG features of
and dizziness. She is Diabetic and Hypertensive. Her BP was 130/70 and HR SVT
was 170. She was hooked to the cardiac monitor with the following tracing:
What is the rhythm?

A. Supraventricular tachycardia
B. Atrial fibrillation
C. Sinus tachycardia
D. Multifocal tachycardia
Answer: A
2 A 33 year old male was rushed to the E.R. due to loss of consciousness. There was no Management
reliable informant during that time. When he was attached to cardiac monitor, the approach for
following tracing was noted: ventricular
arrhythmia
What is the initial management of this rhythm?
A. Give Atropine 0.5mg IV

B. Give Epinephrine 1mg IV
C. Cardiovert with 200J biphasic
D. Defibrillate with 200J biphasic and do CPR
Answer: D
3 A 65 year old male was brought to E.R. due to sudden onset of severe chest pain Management
associated with dyspnea, diaphoresis and generalized weakness. He was previously approach for
diagnosed with Hypertension and Diabetes but was non-compliant with his maintenance ventricular
medications. arrhythmia
At the E.R., BP was noted to be 70/40 and HR was 180. You check the patient tracing
in the cardiac monitor and it showed:
What will be your immediate intervention?

A. Do CPR immediately.
B. Defibrillate with 200 J biphasic
C. Synchronize cardioversion with 200J biphasic
D. Amiodarone 150 mg rapid IV bolus
Answer: C
4 A case of 70 year old male previously diagnosed with Diabetes, Hypertension ECG tracing of
and CKD (on twice weekly dialysis) was brought to the E.R. due to chest AV block
discomfort and light headedness.
At the E.R., BP was noted to be 80/60 and HR was 40. A 12 lead ECG was
done and it showed:
What is the ECG reading?

A. 2nd degree AV block
B. Junctional rhythm
C. 3rd degree AV block
D. High grade AV block
Answer: C
5 A 56-year-old female with a history of mitral stenosis was brought to the E.R. ECG features of
due to right sided weakness and dysarthria which resolved spontaneously after 3 AF
hours.
Indications for
On cardiac examination, you note irregularly irregular rhythm with variable S1 anticoagulation in
loudness. You ordered an ECG which showed the following: AF

Plain cranial CT scan was unremarkable, as well as her Chest X-ray. What is the
appropriate treatment approach for this patient?
A. Start the patient on digoxin

B. Start patient on dobutamine
C. Start the patient on anticoagulation
D. Do immediate cardioversion
Answer: C
6 A 19 year old male athlete was rushed to the E.R. due to sudden onset of Diagnosis of
syncope while doing his routine long run. He has no known co-morbidities. Hypertrophic
CMP
Family history revealed 3 relatives with sudden cardiac death.
The cardiac P.E. of the patient revealed a harsh and late peaking systolic ejection
murmur.
A 2D Echocardiogram was done and revealed an asymmetric hypertrophy of the

LV septum compared to the lateral wall with the mitral valve anterior leaflet
moves towards the hypertrophied septum during systole.
What is the most likely diagnosis?

A. Restrictive Cardiomyopathy
B. Idiopathic Dilated Cardiomyopathy
C. Hypertrophic Cardiomyopathy with obstruction
D. Mitral Valve Prolapse
Answer: C
7 A 35year old female was rushed to the E.R. because of progressive crushing Management of
substernal chest pain that occurred less than 10minutes ago. Prinzmetal
Angina
She has no known illness except for migraine headaches.
She became diaphoretic during the interview with a BP of 110/70, HR of 59
She was immediately given sublingual Isordil which afforded relief within 2-
3minutes.
P.E. showed tachycardia during episodes of severe angina. She had abnormal
stress test but normal coronary angiogram. The printout of the cardiac monitor
tracing showed the following:
A. upon arrival
B. at the peak of chest pain
C. 3mins after Isordil

1 2 3
What is your management for this patient?

A. Load Aspirin and/or Clopidogrel
B. Give Nitrates and/or Calcium Channel blocker
C. Immediately proceed with percutaneous coronary intervention
D. Provide supportive measures including ACE-inhibitor and Beta-blocker to
reduce the cardiac workload
Answer: B
8 A 55 year old male who is Hypertensive underwent stress test which showed a Important
positive 1.0mm horizontal ST depression in multiple leads at 5 METs. Patient considerations in
said he does not have any chest pain, dyspnea, easy fatigability or weakness. the management
of Asymptomatic
What would be your next step? (Silent) Ischemia
A. Optimize medical management with anti-platelet, RAAS inhibition, statin
therapy and beta-blockade
B. Recommend for coronary angiography to determine the need for
revascularization
C. Do more accurate non-invasive stress testing or imaging to stratify patients
risk further
D. Reassure patient that risk factor management will suffice to treat his
condition
Answer: B
9 A 65 year old female who was previously diagnosed with Hypertension and NYHA
Diabetes consulted because of chest pain. She described it as episodic and she will Functional
usually experience the pain every time she climbs up the footbridge going to the Classification of
nearby market. Angina
Using the New York Heart Association functional classification, what is the
NYHA classification of your patient?
A. I
B. II
C. III
D. IV
Answer: B

10 A 60 year old male who was diagnosed with Chronic Stable Angina with Pharmacologic
decreased ejection fraction was being maintained on Aspirin, Nitrates and management of
Statins. Patient still has recurrent episodes of angina. IHD
Which medication would you start to address this problem?

A. Verapamil
B. Metoprolol
C. Perindopril
D. No need to add new medication. Just increase the dose of nitrate.
Answer: B
11 A 62 year old female consulted at the E.R. due to one day history of severe chest Characteristic
pain with difficulty of breathing. On further history, patient expressed that she feature of specific
experienced an intense grief for the loss of her spouse for the past few days. She cause of Dilated
had no known co-morbidities. CMP
Vital signs were as follows: Pathologic

BP=80/50, HR=95, RR=31. She was afebrile. A 12-lead ECG was requested mechanism of
which showed: specific cause of
Dilated CMP
(Tako-tsubo
CMP)
Chest X-ray showed Pulmonary edema and Cardiomegaly and 2D

Echocardiography revealed a global ventricular dilation with mid to apical wall
motion akinesia and a basal segment contraction.
What is the pathologic basis of this disease?

A. Autosomal dominant pattern of inheritance with mutation in the
sarcomeric genes either MYH7 or MYBPC3
B. Intense sympathetic activation with heterogeneity of myocardial
autonomic innervation, diffuse microvascular spasm, and/or direct
catecholamine toxicity
C. Abnormal prolactin cleavage fragment, which is induced by oxidative
stress and also affects angiogenesis
D. Infiltration of abnormal substances between myocytes, storage of
abnormal metabolic products within the myocytes, or fibrotic injury
Answer: B
12 A 65 year old female who was previously diagnosed with Hypertension and Diabetes Management of
consulted due to prominent veins on both lower extremities. There was no note of Chronic Venous
edema or ulcerations. Patient said that it was also not painful. Insufficiency

As a physician, you decided to manage the patient conservatively using compression
stockings.
What will be the most suitable pressure for your patient?

A. 10-20 mmHg
B. 20-30 mmHg
C. 30-40 mmHg
D. 40-50 mmHg
Answer: B
13 A 39 year old male was brought to the E.R. due to chest discomfort. Patient claimed that Clinical and
initially, the chest discomfort was aggravated by exertion however, 5 days ago, chest laboratory
discomfort occurs even at rest. Patient also noted bipedal edema. findings in
Constrictive
Vital signs of the patient were as follows: BP=100/60, HR=104, RR=22, Temp=36.2 Pericarditis
Initial evaluation revealed the following: Presence of Kussmaul’s sign, Absence of S3,
Presence of Pericardial knock
ECG showed low voltage complexes. 2D Echocardiography revealed thickened

pericardium, pericardial calcification and exaggerated respiratory variation in flow
velocity.

A. Cardiac Tamponade
B. Constrictive Pericarditis
C. Restrictive Cardiomyopathy
D. Right Ventricular Myocardial Infarction
Answer: B
14 A 40 year old male who was previously diagnosed with Valvular Heart Disease Hemodynamic
consulted at the E.R. due to progressive dyspnea. Patient claimed that he had changes and P.E.
uncomfortable awareness of the heartbeat especially when lying down. He also findings in Aortic
experienced 2 pillow orthopnea, paroxysmal nocturnal dyspnea and diaphoresis. There Regurgitation
was also a note of grade 1 bipedal edema.
At the initial evaluation, patient presented with rapidly rising pulse that collapses
suddenly as arterial pulse falls rapidly during late systole and diastole.
Upon auscultation, there was a note of high-pitched, blowing, decrescendo, diastolic

murmur, heard best at the third intercostal along the left sternal border.
What is the most likely valvular heart pathology?
A. Aortic Stenosis
B. Aortic Regurgitation
C. Tricuspid Regurgitation
D. Mixed Mitral Regurgitation and Tricuspid Stenosis
Answer: B
15 A 56 year old male came into the E.R. due to squeezing substernal chest pain graded 6- Principles of
7/10 which was precipitated by lifting a heavy bucket of water. medical
management of
He was anxious with cold clammy hands. His vital signs were as follows: BP=130/70, CAD
HR=68, RR=22, Temperature=36.2.

Cardiac auscultation was unremarkable and he had clear breath sounds. 12-lead ECG
was done and the tracing is shown below:
Troponin-I was also done and it was 0.02ng/ml.

How will you manage this case?
A. Give analgesic and muscle relaxant
B. Proceed with emergency percutaneous coronary intervention (PCI) if the
institution is capable of such or thrombolysis if not
C. Treat medically with aspirin, nitrate, beta-blocker, low molecular weight
heparin, ACE-inhibitor and statin
D. Treat medically with nitrate, beta-blocker, low molecular weight heparin,
ACE-inhibitor and statin but hold Aspirin
Answer: C

Part 2: Infectious Diseases (15)
1 A 26 year old male, with no known comorbidities comes to the ER 1. Role and indications of
immediately after being bitten by a stray dog on the left calf while post- exposure
walking home in Tondo, Manila. The dog ran away after the incident. prophylaxis 2. Role and
Immunization history is limited to annual company-sponsored fluvax indications of passive and
and childhood MMR, DPT and BCG. On PE, patient is oriented and active vaccination
ambulatory with stable vital signs. There are deep bleeding lacerations
on the lateral left lower extremity. After cleaning the wound thoroughly
and giving antibiotics, you would:
A. Infiltrate the bite site with rabies immune globulin on day 0 plus a total of
two doses of rabies vaccine on day 0 and 3
B. Infiltrate the bite site with rabies immune globulin on day 0 plus a total of
four doses of rabies vaccine on days 0, 3, 7, and 14
C. Give rabies immune globulin IM on deltoid area on day 0 plus a total of
two doses of rabies vaccine on days 0 and 3
D. Give rabies immune globulin IM on deltoid area on day 0 plus a total of
four doses of rabies vaccine on days 0, 3, 7 and 14.
Answer: B (p. 1488-89)
2 A 42 year old male, recently diagnosed with HIV, comes to the clinic 1.Recommended
for advise regarding pneumococcal vaccinations. He recalls having vaccination in special
completed all vaccinations during childhood and has received hepatitis populations.
A and B vaccinations 3 years ago when he travelled to Africa. He has 2.Guidelines on timing
also been regularly receiving his yearly inactivated trivalent influenza and spacing of vaccines.
virus vaccine as per company policy. Your best advise is:
A. PCV 13 should be given at least 8 weeks before PPSV 23

B. PCV 13 should be given at least 1 year before PPSV 23
C. PPSV 23 should be given at least 8 weeks before PCV 13
D. PPSV 23 should be given at least 1 year before PCV 13
Answer: A (p. 1432 table 197-11)
3 A 20-year-old male is referred for fever with associated headache, body 1. WHO case definitions
malaise and anorexia. On physical examination, temperature is 38.8 °C, of dengue
blood pressure is 100/70 mm Hg, pulse rate is 102/min, and respiration infection/spectrum
rate is 19/min. There is no active mucosal bleeding but his posterior 2. Clinical
pharynx is notably injected without exudate. Examination of the lower manifestations of dengue
extremities revealed the following findings (see picture below). The based on level of severity
liver span is measured 12 cm midsternal line. There is no palpable or phases of disease
lymphadenopathy.

What is the classification of the patient’s disease?
A. Dengue without warning signs

B. Dengue with warning signs
C. Severe dengue
D. Dengue shock syndrome
Answer: B
4 A 35 year old female, known RHD, with severe MR, MS s/p MV repair Recommendations on IE
with prosthesis, consults your clinic for medical clearance prior to prophylaxis
dental extraction under local anesthesia. Patient has a known allergy to
ibuprofen and penicillin. She is alert and oriented. What is your best
recommendation prior to dental procedure?
A. Amoxicillin: 2g P.O. 1 hour before procedure

B. Ampicillin: 2 gm IM within 1 hour before procedure
C. Azithromycin 500mg P.O. 1 hour before procedure
D. Clindamycin 600mg IM 1 hour before procedure
Answer: C (p. 932 table 123-7)

5 A 45 year-old female with metastatic breast cancer was treated with Indications for G-CSF or
palliative combination chemotherapy of cyclophosphamide and GM-CSF
doxorubicin. She developed febrile neutropenia (absolute neutrophil
count of <500/uL) after her second cycle of chemotherapy. An empiric
broad spectrum antibiotic with anti-Pseudomonal activity was started.
On her third cycle of chemotherapy, she has apprehensions regarding
recurrence of febrile neutropenia. You would:
A. Start G-CSF or GM-CSF 24 hours before chemotherapy

B. Start G-CSF or GM-CSF 24 hours after chemotherapy
C. Continue G-CSF or GM-CSF, until absolute neutrophil count becomes >
1,000/uL

D. Assure her that G-CSF or GM-CSF is not needed since she is younger than
65 years old and she has no current active infection
Answer: B (p. 500 table 69-7)

6 A 55-year old male has been having intermittent fever for the past 6 Treatment principles and
weeks. He has no co-morbid condition and is not on any medications. approach to treatment of
Obligatory work ups and imaging tests were non-specific. He is FUO
otherwise in stable condition. What therapeutic option may be
considered at this point?
A. NSAID
B. Glucocorticoid trial therapy
C. Anti-TB drugs
D. Broad spectrum antibiotics
Answer: A (p 122)
7 A 45-year-old male sought consult due to intermittent fever (highest at 39C), Recommended
dry cough and dyspnea. He was tested HIV positive. CD4 count is 180. Oral management of common
thrush is present. Lungs with bibasilar crackles. Chest X ray showed fine opportunistic diseases in
reticular interstitial changes that are perihilar in distribution. Which is the most HIV infection
appropriate next step in the treatment of this patient?
A. Azithromycin
B. Dapsone
C. Pyrimethamine
D. Trimethoprim-Sulfamethoxazole
Answer: D (p 1431 table 197-11)

8 A 36/M presents with symmetric multiple xanthoma-like nodules on his WHO treatment
extremities and torso. He also complains of blurring of vision and nasal recommendation based on
congestion. On PE, he is afebrile with stable vital signs. He is noted to form/spectrum of leprosy
have leonine facies with clawing of the 4th and 5th fingers of both hands.
Skin biopsy showed Bacterial Index (BI) >2 with 4+ AFB, no
lymphocytic infiltration with absent Langerhans giant cells and foamy
macrophages. Based on WHO, what is the recommended treatment for
this patient?
A. Dapsone 100mg/day x 5 years
B. Dapsone 100mg/day (unsupervised) + Rifampin 600mg/month
(supervised) x 6months
C. Dapsone 100mg/day + Clofazimine 50mg/day (unsupervised) and
Rifampin 600mg/month + Clofazimine 300mg/month (supervised) x 1-2
years
D. Rifampin 600mg/day x 3 years + Dapsone 100mg/day indefinitely
Answer: C (p.1260, 1264 table 174-2)

9 A 24-year-old G1P0 24 weeks AOG from Sampaloc Manila consults Chemoprophylaxis of
your clinic for advise. She and her husband had a history of wading in Leptospirosis in patients
stagnant flood waters on the way home from work 2 days ago. She with special
claims to have immediately washed her feet and legs upon arrival at considerations
home but noted an abraded skin on her left posterior ankle area probably
from ill-fitting shoes. She has no subjective complains, including fever
and myalgia. She has stable vital signs and the rest of the physical exam
is unremarkable. The foot lesion has healed. What is your advise for the
patient?
A. Start Doxycycline 200mg 1x week PO

B. Start Azithromycin 250mg 2x week PO
C. Start Amoxicilin 500mg TID PO
D. No antibiotics and do close monitoring for flu-like symptoms
Answer: B (p. 1294)

10 A healthy Canadian newlywed couple consults your clinic as advised by Indications for
their travel agent. The husband is 34 years old while the wife is 31 years chemoprophylaxis and
old. They just arrived in Manila to meet with some friends and is choice of drugs for
scheduled to travel to Palawan in 2 days for their extended honeymoon. Malaria
The travel agent advised them to consult you for “vaccinations” to
prevent infections endemic in the area of destination. Your best advise
is:
A. Start chloroquine 500mg PO now then once weekly until 4 weeks after
leaving Palawan
B. Start hydroxychloroquine 400mg PO now then once weekly until 4 weeks
after leaving Palawan
C. Start doxycycline 100mg PO now then once daily until 4 weeks after
leaving Palawan
D. Start mefloquine 250mg PO now then once daily until 4 weeks after
leaving Palawan
Answer C. (p 1589 table 219-8)

11 A 22 year-old student was admitted due to a 4-day history of high grade fever Recommended treatment of
accompanied with diarrhea, chills, headache, body malaise, and right-sided schistosomiasis based on
abdominal pain. He denies cough nor dysuria. Upon further history, he visited stage and clinical
his relatives in Leyte a month ago. On physical exam, the patient was febrile presentation
(T=38.5), no rashes noted. Abdominal examination showed soft abdomen
with tenderness over the epigastric and right upper quadrant area, hyperactive
bowel sounds, no flank tenderness. CBC showed neutrophilia with moderate
eosinophilia. Ultrasound showed moderate hepatomegaly. Urinalysis and
Chest Xray were unremarkable. Stool microscopy showed a small, round ova
with a small lateral spine.
What would be the recommended treatment for his condition?
A. Chloroquine
B. Ciprofloxacin + Metronidazole
C. Mebendazole
D. Praziquantel
Answer: D (p. 1639)

12 A 24-year old male came in to the emergency room due to severe 1. To recognize the
abdominal pain. He had 10 -day undocumented fever, anorexia, nausea clinical manifestation/s of
and vomiting and abdominal pain. Patient came in tachycardic with BP typhoid fever
90/50 febrile at 38.8C. Significant physical exam findings noted were 2. To identify
faint, salmon-colored, blanching, maculopapular rash located primarily complication/s of typhoid
on the trunk and chest and hepatosplenomegaly. The abdomen is rigid fever
with guarding. Which of the following is the most likely cause of the
severe abdominal pain?
A. Gastric perforation
B. Splenic rupture
C. Ileal perforation
D. Secondary peritonitis
Answer: C (p.1175-1176)
13 A 30 year old female consulted due to rashes. The rashes were faint, To identify appropriate
salmon-colored, blanching, maculopapular rash located on the trunk and empiric antibiotic
chest. She had high grade fever, abdominal pain, nausea and vomiting. treatment for typhoid
Pertinent physical examination include temperature was 39°C, heart rate fever
76, respiratory rate of 18, diffuse abdominal tenderness and
hepatosplenomegaly. Which is the most appropriate EMPIRIC
antibiotic regimen?
A. Ciprofloxacin 500 mg bid (IV) 5 to 7 days

B. Ceftriaxone 2 g/d (IV) 10–14 days
C. Amoxicillin 2 g q6h (IV) 14 days
D. Trimethoprim sulfamethoxazole 160/800 mg bid (PO) 7–14 days
Answer: B (p1176 table 160-1)
14 A 33-year old healthy female nulligravid was referred to you for Asymptomatic bacteriuria
evaluation, management and fit to work certification. She is
asymptomatic with stable vital signs. Rest of systemic findings are
unremarkable. There was an incidental note of moderate bacteria on
routine urinalysis. The company doctor requested for urine culture and
result showed 10,000 col/ml growth of E. coli sensitive to ciprofloxacin
and ertapenem. You would:
A. Start ciprofloxacin for 1 week then repeat urinalysis; fit for employment
once urinalysis is clear
B. advise increase oral fluid intake and perineal hygiene then repeat
urinalysis and culture after 3 days; fit for employment once no growth
C. Advise supportive measures only and issue fit to work certificate
D. Prescribe ertapenem for 3 days then issue fit to work certificate once
antibiotic completed
Answer: C (p. 972 Fig. 130-4)

15 A 50-year old male was admitted due to depressed sensorium. He is a 1. Clinical presentation and
heavy chronic alcoholic drinker but has stopped almost 2 years ago. He diagnosis of PBP
was noted to have undocumented on and off fever 1 day prior to 2. Management of PBP
admission with note of nausea and anorexia. He was received drowsy
with the ff vital signs: BP 130/70 HR 102 regular, RR 22, Temp 38C
with O2 95%. Bibasal breath sounds were decreased. Abdomen was
soft, nontender and globular with positive fluid wave. Ascitic fluid
studies revealed 500 PMNs/uL. Grams stain of ascitic fluid revealed
gram negative bacilli. Which antibiotics will you initiate?
A. Metronidazole 500 mg IV q8
B. Cefotaxime 2g IV q8
C. Levofloxacin 750mg IV q24 + Metronidazole 500 mg IV q8
D. Meropenem 1g IV q8 + Metronidazole 500 mg IV q8
Answer: B (p 953)

Part 3: Pulmonary Medicine and Critical Care (15)
Question and Answer Objectives
For Questions 1 and 2, please refer to the case:
A 60 year old woman was admitted due to pneumonia. However, on the

third day of admission, she had worsening of dyspnea and cough. Her
oxygen saturation dropped to 85% while breathing oxygen at 10 liters per
minute via non-rebreather mask. She was immediately intubated for frank
respiratory distress.
Her arterial blood gas after intubation showed the following:
pH-7.43, pCO2- 31, pO2-160, bicarbonate-14, saturations-92% at FiO2-
80% and PEEP-12.
Her chest X-ray showed diffuse bilateral alveolar infiltrates.
1 According to the Berlin Definition, what is the severity classification of 1. Pathophysiology and
her condition? clinical course of ARDS
A. Mild 2. Prognosis and
B. Moderate functional recovery of
C. Severe ARDS
D. Very Severe 3.Management principles
in ARDS
4. Therapies currently not
ANSWER: B (Moderate) proven to be useful in
ARDS
2. Which of the following intervention/s has been shown by at least one

clinical trial to increase survival in patients with severe ARDS?
A. Low tidal volume
B. Prone positioning
C. Glucocorticoids
D. A and B only
ANSWER: D (A and B only)

3. This type of shock causes reduced tissue oxygen delivery primarily due Different types of shock
to reduction in peripheral vascular resistance:
A. Hypovolemic Shock
B. Cardiogenic Shock
C. Obstructive Shock
D. Distributive Shock
ANSWER: D (Distributive Shock)

4. Which of the following is included in the goals and targets in the initial 1. Key principle in the initial
management of sepsis and septic shock? management of shock
A. Resuscitation with IV crystalloids at 30ml/kg should begin within the 2. Elements of care in sepsis
first 6 hours and septic shock
B. In patients who require vasopressors, the target systolic blood
pressure is >90 mmHg
C. Packed red blood cell transfusion is indicated for patients who have
hemoglobin values of <8.0 g/dL in the absence of acute myocardial
infarction, severe hypoxemia, or acute hemorrhage
D. Saline and balanced crystalloids are suggested for the initial
resuscitation
ANSWER: D
5 True about asthma triggers: Clinical presentation of
A. Inhaled allergens activate TH2 cells that start the downward cascade asthma
of inflammation
B. Viral upper respiratory tract infections, especially from influenza virus
infection, are the most common causes of acute severe exacerbations
of asthma
C. All beta-blockers need to be avoided and even selective beta-1
blockers may be dangerous
D. Exercise-induced asthma typically begins during exercise and tends to
persist even after the end of exercise
ANSWER: C
6 True about long-acting beta agonists: Pharmacotherapy of
A. Includes formoterol and salmeterol, both of which have the duration asthma medications
of action of over 12 hours, and need to be given twice daily
B. LABA monotherapy is shown to be more effective than SABA and is
thus recommended for more uncontrolled symptoms
C. LABA has been shown to increase the ICS dose required to control
asthma symptoms
D. All of the above statements are true
ANSWER: A
7. A 43 year-old executive came in to the emergency room due to Treatment of asthma
increased breathlessness over the past 3 days. She is a known asthmatic, exacerbations
maintained on high doses of ICS + LABA since 10 years prior to
consult. Due to the fear that she might contract COVID by going to her
doctor’s clinic, she discontinued her maintenance medications because
she “felt well”.
Over the past few days, she developed fever and cough with a greenish
sputum, and her dyspnea also worsened. She was seen tachypneic,
tachycardic, but she is oriented and can speak in phrases. Her oxygen
saturations are 92% while breathing room air.
The following interventions are indicated for her, except:
A. Systemic intravenous antibiotics
B. Inhaled SABA
C. Supplemental oxygen
D. Systemic corticosteroids
ANSWER: C (Supplemental oxygen)

For questions 8-9, please refer to the case below:
A 76 year old retired ship captain consulted at your clinic due to

progressive exertional dyspnea. He reported that over the past year, his
dyspnea progressed from dyspnea occurring during strenuous exercise,
and now he complains that he cannot catch up with his friends when
they walk together in the golf course. He was never admitted to the
hospital for any illness.
He used to smoke 2 packs of cigarettes per day when he was still active
as a seaman.
He is comfortable, can speak in short sentences and is coherent. His
resting saturation is 86% on room air, auscultation of his chest seemed
quiet with no audible wheezing, crackles or rhonchi.
Pulmonary function testing showed an FEV1/FVC value of 0.40, with
FEV1-50% predicted, and a significant bronchodilator response.
8. What is the patient’s classification according to the GOLD Refined Diagnosis and clinical
ABCD Assessment Tool: presentation of COPD
A. GOLD Grade 2, Group B

B. GOLD Grade 2, Group D
C. GOLD Grade 3, Group B
D. GOLD Grade 3, Group D
ANSWER: A (GOLD Grade 2, Group B)

9. The following intervention/s have been proven to increase survival in Management of COPD
his case:
A. Long term oxygen therapy (>8hours/day)
B. Triple therapy with ICS+LABA+LAMA
C. Dual bronchodilator therapy with LABA+LAMA
D. None of the above
ANSWER: D (None of the above)

10 True statement regarding pleural effusions: Management of Pleural
A. In patients with heart failure, thoracentesis is indicated if the pleural Effusion
effusion is unilateral
B. A serum-pleural fluid gradient of >2.1 g/dL is indicative of a
transudative effusion
C. Pleural fluid glucose >60 mg/dL and pleural fluid pH >7.20 indicates
that a procedure more invasive than a thoracentesis is warranted
D. All of the above
ANSWER: A
11 A previously healthy 34/F was diagnosed to have bacteriologically Treatment of tuberculosis
confirmed pulmonary tuberculosis after she presented with cough and
weight loss for the past 3 months. She has no known close contacts with
TB and lives alone in an apartment.

Upon diagnosis, her sputum AFB was 3+ and 2+ on the first and second
samples, respectively.
She was adherent to the prescribed regimen by DOTS and her
symptoms have dramatically improved after 1 month of intensive phase.
At the end of the second month of HRZE, her repeat AFB showed 1+
and 1+ for both specimens.
What is the next best course of action?
A. Extend HRZE for 1 more month and repeat sputum testing after 1
month
B. Shift HRZE to HR and repeat sputum testing after 1 month
C. Perform GeneXpert testing and consider MDRTB
D. Extend HRZE for 1 more month and perform TB culture
ANSWER: B
12 A 28-year old male, PLHIV came in to your clinic for clearance to Management of Latent
return to work. He has been maintained on oral antiretrovirals for 4 PTB
years, his latest CD4 is 1200/mm3. Part of his pre-employment check is
a tuberculin skin test, and his test result was read as 12mm induration.
He is asymptomatic, weighs 65kgs, with no cough or sputum
production, and his chest CT scan is normal, his Xpert MTB-Rif also
came in negative.
What is the next best course of action?
A. Perform an Interferon Release Assay Test

B. Begin treatment with Isoniazid 300mg once a day for 6 months and
clear for work
C. Begin treatment with HRZE 4 tablets once a day and clear for work
after 2 weeks of treatment
D. No treatment is needed and clear for work
ANSWER: B
13 A 54/F, diabetic was treated for bacteriologically confirmed PTB Management of Treatment
already completed 2 months of intensive phase HRZE and 3 1/2 months Interruptions
of maintenance phase HR. However due to the lockdown caused by the
COVID pandemic, she forgot to follow-up with the DOTS center and
stopped her medications. After 2 months of treatment interruption, she
returned to the clinic due to cough and fever, and sputum AFB showed
2+.
How will you proceed with the treatment?
A. Continue with the remaining months of HR

B. Restart continuation phase
C. Continue treatment with HR and prolong to compensate
D. Do sputum Xpert MTB-Rif
ANSWER: D
For items 14-15, please refer to the case below: Management of
Pneumonia
A 30/F with a history of generalized epilepsy was admitted for seizure
while she was eating peacefully at home.
Her seizure episode began suddenly and was resolved within 2 minutes.
She was then noted to have vomiting episodes after the seizure. They
initially did not seek consult but 2 days after, she developed high grade
fever accompanied by cough and greenish sputum. She was seen awake,
coherent, RR-18, sats-95% on room air.
Chest X-ray showed opaficiation of the right lower lung with air
bronchograms.
14 What is the most appropriate empiric antibiotic therapy?

A. Ceftriaxone 2gm IV OD + Clindamycin 600mg IV every 6 hours
B. Cefuroxime 1.5gm IV every 8 hours + Moxifloxacin 400mg OD
C. Ceftriaxone 2gm IV OD + Vancomycin 1g IV every 12 hours
D. Piperacillin-Tazobactam 4.5 g IV every 6 hours + Azithromycin 500mg
OD
ANSWER: B
15 In which of the following scenarios can de-escalation of antibiotic
therapy be initiated?
A. Resolution of fever >12 hours
B. Respiratory rate <25
C. White blood cell count decreased from 25,000 to 12,000
D. Isolation of gram positive cocci in blood
ANSWER: C

Part 4: Gastroenterology (12)
1 A 54 year old male consulted due to 3 week history of intermittent Approach to diagnosis of
episodes of burning epigastric pain associated with bloatedness. He also PUD
complained of disturbed sleep due to the said pain. There was no
anorexia or weight loss.
Patient had the following vital signs:

BP=120/70, HR=85, RR=18, T 36.5.
Abdominal exam revealed the following findings:

Flabby, normoactive bowel sounds, mild tenderness on deep palpation of
the epigastric area.
What is the most sensitive and specific test in the diagnosis of this case?
A. Barium study
B. Fecal H. pylori antigen test
C. Plain film of the abdomen.
D. Upper gastrointestinal endoscopy
Answer: D
2 A 49 year old female who was previously diagnosed with GERD Complications of GERD
underwent an upper gastrointestinal endoscopy.
Histologic examinations from the gastroesophageal junction revealed

metaplasia. Which intervention will prevent progression of this lesion to
adenocarcinoma?
A. Second generation proton pump inhibitors taken for at least 30

days has been shown to induce regression of metaplastic changes
in Barret’s esophagus.
B. Elimination of Helicobacter pylori with proton pump inhibitor plus
a macrolide has been shown to reduce risk of neoplastic
transformation in 55-70% of cases.
C. Roux-en-Y plus Nissen funduplication reduces the risk of
progression to malignancy, but this is only reserved for patients
who continue to be symptomatic despite extensive antisecretory
medications.
D. There is no high level evidence to support the use of anti-secretory
medications or anti reflux therapy to prevent progression to
adenocarcinoma.
Answer: D
3 A 55 year old male presented to the E.R. due to a sudden onset of Diagnosis of Acute
extreme, non-remitting abdominal pain of 3 hours duration. Mesenteric Ischemia
Abdominal pain was accompanied by nausea and vomiting characterized
as non-bilious and non-projectile. Patient also claimed that he had 1
episode of bloody stool.
Patient is known Hypertensive, Diabetic with Osteoarthritis. Patient is

non-compliant with his maintenance medications. Patient claimed that
once in a while, he will take NSAID as needed for pain.
P.E revealed a distressed patient, with the following vital signs:

BP= 150/90, HR=109, RR=22, Temperature 38.2’C.
Other pertinent findings are as follows:

irregularly irregular heart rhythm, tensed and distended abdomen with
hypoactive bowel sound.
A. Ruptured Peptic Ulcer Disease

B. Appendicitis with Peritonitis
C. Acute Mesenteric Ischemia
D. Intestinal Obstruction
Answer: C
4 A 19 year old female was brought to the E.R. due to loss of Clinical features and
consciousness. treatment of liver injury
due to Acetaminophen
She was thought to be sleeping when her parents checked on her at
6:00AM, but at 11:00AM was ultimately found to be unconscious.
Beside her was an almost empty, newly opened bottle of Acetaminophen
600mg.
Which of the following treatment principles about this case is

CORRECT?
A. Activated charcoal is still effective even if given >30 minutes after

Acetaminophen ingestion.
B. Adding sodium bicarbonate to N-Acetylcysteine within 24 hours of
Acetaminophen have shown to reduce hepatic necrosis.
C. Treatment with N-Acetylcysteine will only be partially effective if
given after 24-36 hours of Acetaminophen overdose.
D. Cholestyramine is as potent as N-Acetylcysteine when given with
Activated charcoal in the next 24 to 48 hours after Acetaminophen
overdose.
Answer: C

5 A 45 year old male who suffered from 60% second degree burns was Definition and
confined at the Burn unit of your hospital. pathogenesis of Stress-
related mucosal injury
On the 2nd day of admission, patient had Acute Respiratory Failure and
was intubated.
NGT was inserted. Enteral feeding was started. However, on the 5th day
of admission patient was referred due to bleeding per NGT.
What will be your impression:
A. Cushing’s ulcer
B. Curling’s ulcer
C. Mallory-Weiss tear
D. Boerhaave syndrome
Answer: B
6 A 35 year old male consulted for clearance before working as a seaman. Laboratory features of
Hepatitis B infection
He claimed that he was previously diagnosed with Hepatitis.
He showed you the result of his latest hepatitis profile:
HBsAg Non-Reactive
Anti-HBs Non-Reactive
Anti HBc IgG Reactive
HBe Ag Non-Reactive
Anti-HBe Reactive
What is your interpretation of his hepatitis profile?

A. False positive
B. Recovery from Hepatitis B
C. Pre-core mutant Hepatitis B
D. Low-level Hepatitis B carrier
Answer: D
7 A 48 year old male consulted due to 2 month history of on and off diarrhea with General management of
associated crampy abdominal pain, tenesmus and passage of mucus. Three days Ulcerative Colitis
prior to this consult, patient noted blood on his stool.
Pertinent P.E. findings showed tenderness in anal canal and there was blood on
rectal examination. There was also tenderness on palpation of the abdomen.
Which of the following is TRUE about the management of this disease?
A. Antibiotics are very effective in the treatment of active or quiescent

phase of the disease.
B. Sulfasalazine may be effective in inducing remission of the disease but
not on maintaining it.

C. Hydrocortisone enema may control active disease and have a proven
role in maintenance therapy.
D. Cyclosporine can be given in severe cases that is refractory to steroids
and can even be an alternative to colectomy.
Answer: D
8 A 38 year old female consulted due to 3 month history of intermittent Approach to management
episodes of crampy abdominal pain, occurring almost every day and it of Irritable Bowel
was associated with change in frequency and form of stools. Patient Syndrome
claimed that there were times she will experienced diarrhea and at times,
constipation.
Which of the following treatment options is TRUE regarding the

management of this case?
A. Cholestyramine is more potent than Loperamide in controlling
diarrhea.
B. Antidepressants may improve constipation but not diarrhea.
C. Anti-cholinergic drugs may be helpful in alleviating painful cramps
related to intestinal spasms.
D. Probiotics may improve the stool consistency and may regularize stool
frequency.
Answer: C
9 A 62 year old male was brought to E.R. due to 2 episodes of hematochezia. Etiology of Lower GI
Prior to this, patient experienced 3 day history of intermittent abdominal pain bleeding
with associated anorexia and obstipation.
Abdominal CT-Scan was done and it revealed sigmoid diverticula, 6 mm wall

thickness with inflammation within the periodic fat.
According to Hinchey Classification, if this patient present with non-

communicating perforated diverticulitis with fecal peritonitis, how will you
classify this patient?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
Answer: C
10 A 45 year old female was rushed to E.R. due to severe epigastric pain radiating Laboratory findings of
to the back with pain score of 8-9/10. Patient was in distressed. Acute Pancreatitis
Two weeks ago, she was told by her physician that her triglycerides was 1250
mg/dL. She was prescribed with medication but she did not comply.
The amylase and lipase were both elevated, 6 times than the normal values.
Aside from this findings, which of the following laboratory results is consistent
with her condition?
A. Hyperbilirubinemia

B. Hemodilution
C. Hypercalcemia
D. Hypoglycemia
Answer: A
11 A 35 year old female was referred to your service due to liver ultrasound Approach to management
findings of Fatty Liver. Her SGPT is 1.5x elevated than the normal value. of NAFLD and NASH
Her BMI is 33.5
She is non-alcoholic.
She does not have any co-morbidities.
Aside from prescribing diet and exercise, which of the following is CORRECT
about the management options of her condition?
A. Metformin may improve the SGPT level as well as the liver histology.
B. Statin may improve the SGPT level, radiographic features of steatosis
and even the histologic features of NASH.
C. Vitamin E may improve SGPT level, radiographic features of steatosis
and even histologic features of NASH.
D. Ursodeoxycholic acid showed significant improvement in SGPT level
and even radiographic features of steatosis.
Answer: C
12 A 65 year old male consulted at E.R. due to intermittent episodes of epigastric Clinical features,
pain, low grade undocumented fever and jaundice. diagnosis, risk factors of
emphysematous
He was previously diagnosed with Diabetes Mellitus and was taking his cholecystitis
maintenance medications with good compliance.
Plain abdominal X-ray was done which revealed gas within the gallbladder
lumen, dissecting within the gallbladder wall and it formed gaseous ring.
Which of the following is the most likely causative agent of this condition?
A. Clostridium welchii
B. Streptococcus pyogenes
C. Staphylococcus aureus
D. Mycobacterium tuberculosis
Answer: A

Part 5: Endocrinology (12)
1 A 40 year old previously healthy male consults the clinic for decrease in 1. Etiology, presentation
libido. He also complains of headache, loss of muscle mass and decrease of hyperprolactinemia
in libido. He denies seizures, asthenia, or any unexplained weight 2. Approach to the
changes. On PE, vital signs are stable but there is note of bilateral visual diagnosis of
field cuts on confrontation test. There is also note of milky discharge from hyperprolactinemia
both nipples upon pinching but with no tenderness or warmth. Further 3. Management of
work up shows: hyperprolactinemia
Prolactin levels: 400 ng/ml (NV <20 ng/ml)
IGF-1: 100 ng/ml (NV 48-292)
TSH: 3.2 uIU/ml (NV 0.3-4.0)
FT4: 15 pM (NV 11.5-23)
8am serum cortisol: 12 ug/dl (NV 10-20)
Cranial MRI: 3.2 cm sellar mass abutting the optic chiasm with
hypoenhancement on gadolinium contrast.
What is the next best step?

A. Recommend serial MRI and prolactin determination
B. Start bromocriptine
C. Start octreotide
D. Refer to NSS for transphenoidal excision
Answer: B (p.2676)
2 A 35 year old G1P0 with PU 33-34 weeks AOG was referred for sudden 1. Clinical presentation
onset of headache with generalized weakness, cold sweating, and easy of acquired causes of
fatigability. There was no associated loss of consciousness, seizures, hypopituitarism
visual field changes, nausea or vomiting. Past medical history reveals 2. Approach to the
chronic hypertension and a stable nonfunctioning pituitary adenoma. On workup of
PE, patient is awake oriented NID with supple neck and no neurologic hypopituitarism
lateralizing signs. BP is 80/50 mmHg HR of 109 bpm regular RR of 24
cpm and Temp of 36.9C. Spot CBG was 68 mg/dl. Which tests would be
most helpful for diagnosis and treatment?
A. ACTH + TSH
B. IGF-1 + Prolactin
C. LH FSH estrogen + Prolactin
D. 8am serum cortisol + TSH FT4
Answer D (p. 2665)

3 A 53 year old female consults for gradually enlarging anterior neck mass 1. Clinical manifestation
of 2 years duration. There is associated tiredness, unexplained weight of hypothyroidism
gain, constipation and cold intolerance. Significant past medical history 2. Approach to
reveals recurrent pregnancy losses. On PE, there is note of a firm evaluation and diagnosis
nontender diffusely enlarged anterior neck mass that moves with of causes of
deglutition. There is no bruit or lymphadenopathies noted. There is hypothyroidism
nonpitting bipedal edema with +1 DTRs. Initial test shows TSH of 28
uIU/ml (NV 0.3-4.0). What is the next best test to request?
A. FT3

B. FT4
C. Anti-TPO
D. Anti- Thyroglobulin
Answer B (p2701 fig 376-2)

4 A 35-year old female, call center agent, comes into your clinic as a Indications for treatment
referral from an obstetrician. She and her partner are planning to have of subclinical
their first baby before the latter leaves for work abroad the following hypothyroidism
month. She denied signs and symptoms pertaining to any thyroid disorder.
Both of her younger female siblings have Graves disease, on clinical
remission, as claimed. Vital signs were stable, BMI= 27 kg/m2, HR
70/min, BP 120/80 mm Hg. Unremarkable physical examination. These
are the results of her thyroid function tests:
TSH 6 mIU/L (N:0.5-5 mIU/L) FT4 15 pmol/L(N: 9-23 pmol/L) FT3 5
pmol/L (N: 2-7 pmol/L)
What is the next best step for this patient?
A. Start Levothyroxine therapy

B. Request for anti-thyroid peroxidase (anti-TPO) test and thyroid
ultrasound
C. Advise patient to repeat thyroid function tests after 2-3 months prior
conception
D. Request blood test for TSH-receptor antibody (TRAb) and thyroid
ultrasound
Answer: A (p. 2702)

5 A 27 year old male referred you for palpitations of 2 months duration 1. Causes of
associated with unexplained weight loss, shortness of breath, easy thyrotoxicosis
fatigability, heat intolerance and excessive sweating. On examination, 2. Clinical
patient is noted to be mildly anxious. HR 120s bpm regular RR 24 cpm manifestations of
BP 130/90 mmHg. There is no note of lid lag or exophthalmos. There is a thyrotoxicosis
palpable nontender anterior neck nodule on the right with no bruit. There 3. Approach to
are fine finger tremors and DTRs are ++. Initial work up shows laboratory evaluation
TSH 0.002 mIU/L (N: 0.5-4.0) and diagnosis of causes
FT4 30 pmol/L (N: 9-23). Which is the next best test to order? of thyrotoxicosis
A. FT3
B. Anti TPO and Anti Thyroglobulin
C. TRAb and TSI
D. Thyroid scan
Answer: D (p2705)
6 A 29 - year old pregnant woman came to the emergency room due to 1. Management of
vomiting and diarrhea. She is G2P1 PU @ 29-30 weeks AOG. History of thyrotoxicosis based on
previous delivery was normal with a healthy baby boy. The patient was causes, thyrotoxic
diagnosed with Graves’ disease for the past 3 years but has not taken complications, and in
medications since start of present gestation. During pregnancy, the patient the setting of pregnancy.
noted palpitations, weight loss and fatigue which she attributed to 2. Clinical features of
pregnancy hence no consults or meds taken. On PE, she appears agitated thyrotoxic crisis
with BP 130/90mmHg, HR 140 bpm, temperature 38.9C. with bilateral lid 3. Management of
lag and palpable diffuse thyroid gland with bruit. Laboratory test showed thyrotoxic crisis
TSH levels of 0.005 uIU/mL (NV 0.5-4.0) and FT4 of 75pmol/L (NV 9-
23).
What will be your initial management for the patient?
A. Immediate termination of pregnancy and administration of oxytocin

B. Give PTU 50mg/tab 3 tabs now then q12, propanolol 40 mg/tab, 1 tab
now then BID and Lugols 5 drops 1 hour after PTU then q6 hours.
Prednisone 20mg now then q12; IV fluids, O2 support and antibiotics if
infection is present.
C. Give methimazole 30 mg PO now then q 12h followed by Lugols 5 drops
after 1 hour then q6. Propanolol 40 mg tab q4-6 hrs, Hydrocortisone
300mg IV bolus then 100mg q 8,hr, IV fluids, O2 support and antibiotics
if infection is present.
D. Advise low dose RAI ablation therapy
Answer C (p 2707)
7 A 50 year old female, previously healthy cyclist complained of low back Diagnostic approach in
pains. Systemic findings are unremarkable with stable vital signs and BMI osteoporosis
of 19. Lumbosacral spine xray showed osteoporosis. Bone densitometry
DXA scan showed T-score of – 2.7 at the spine area. Other labs showed
crea 0.9 mg/dl, iCa 5.0 mg/dl (NV 4.4-5.4), Vit D 38 ng/mL (NV >30),
ALT 23. What is the next best step?
A. Request for TSH
B. Request for intact PTH
C. Request for 75g OGTT
D. Start Calcium + Vit D supplementation
Answer: A (p. 2949)
8 A 65/F with diabetes, hypertension, CKD stage 4 and breast cancer in Risk prevention and
remission was diagnosed to have osteoporosis during screening with DXA treatment of
scan. Which of the following is the most appropriate treatment to prevent osteoporosis
future fractures?
A. Alendronate
B. Calcitonin
C. Denosumab
D. Tamoxifen
Answer: C (p. 2956)
9 A 40-year old woman with PCOS, came in for a wellness check-up. She is Criteria for diagnosis of
currently asymptomatic. Latest labs showed FBS of 121mg/dl HDL DM Type 2
51mg/dl, LDL 98mg/dl, triglycerides 155mg/dl. Her regular BP is at
130/80, without medications. BMI is 26. What is the next best step?
A. Request for a 75-gram OGTT
B. Request for a repeat FBS
C. Do a point-of-care glycosylated hemoglobin
D. Start metformin therapy
Answer: A (p. 2852)
10 A 56-year-old male has end-stage renal disease secondary to poorly- Clinical features of
controlled diabetes mellitus. He has been on hemodialysis thrice weekly hypercalcemia of renal
for 10 years, however he has poor compliance with his medications and failure
often misses one session per week. He is now complaining of pruritus and Management of
bone pains, and one week ago noted development of a violaceous, painful hypercalcemia of renal
lesion on his left leg that developed into a necrotic ulcer with eschar: failure
Labs show a serum calcium of 12.5 mg/dL (NV 8.6-10.3 mg/dL),

phosphate of 7.6 mg/dL (NV 2.5-4.3 mg/dL) and intact PTH of 925
pg/mL (NV 10-65 pg/mL).
Which of the following is the best approach to the treatment of the

patient’s current condition?
A. Calcitriol 0.5 μg intravenously with hemodialysis plus sevelamer TID

B. Cinacalcet 30 mg OD with sevelamer BID
C. Parathyroidectomy
D. Regular and more intensive hemodialysis to optimize fluid and
electrolyte balance
Answer: C (p 2933)
11 A 62-year-old woman is admitted to the hospital because of disorientation and Therapeutic approach to
dehydration. She is presently managed at the Oncology clinic for stage IIIB hypercalcemia of
squamous cell carcinoma of the lung. Labs done on admission: malignancy
serum calcium level 17.9 mg/dL (NV 8.6 – 10.3mg/dL),
phosphate of 1.8 mg/dL (normal 2.5-4.3 mg/dL)
intact PTH of 0.3 pg/mL (normal 10–65 pg/mL). Parathyroid hormone–related
peptide (PTHrP) screening was positive. Over the first 24 hours, the patient
received 4 L of pNSS with furosemide diuresis. Repeat labs the following day
show a decrease of calcium to 14 mg/dl. Patient is now more oriented but is
complaining of fatigue and general weakness.

What is the next best treatment approach?
A. Continue therapy with large-volume fluid administration and forced

diuresis with furosemide.
B. Initiate therapy with hydrocortisone
C. Initiate therapy with calcitonin
D. Initiate therapy with zolendronate.
Answer: D (p2936)
12 62 year old woman with increasing darkening of the skin, dizziness and Approach to diagnosis
easy fatigability and progressive weight loss sought consult at the OPD. of adrenal insufficiency
Her baseline plasma cortisol was 3.2 mcg/dL, 6.5 mcg/dL at 30 minutes, and its causes
and 9 mcg/dL at 60 minutes of cosyntropin administration. Additional
tests that may lead you to a diagnosis of primary adrenal insufficiency are:
A. High ACTH, high renin, low aldosterone
B. Normal ACTH, low renin, low aldosterone
C. Low-normal ACTH, normal renin, normal aldosterone
D. Low ACTH, low renin, low aldosterone
Answer: A (p 2737 fig 379-16)

Part 6: Renal Diseases (12)
1 A 65 year-old female was admitted to the ICU for severe abdominal pain. Management of
She underwent emergency partial colectomy for a ruptured diverticulum Hyperkalemia
with peritonitis. On the 1st post-operative day, she was noted to have a total
urine output of less than 20mL for the past 8 hours.
On physical exam the BP 110/70 mmHg; HR 92 bpm; RR 18 cpm; Temp
38.8 C. The abdomen is distended and no bowel sounds on auscultation.
Her oral mucosa is moist and neck veins are non-distended.
Laboratory studies:
Creatinine 4.5 mg/dL from 2.0 mg/dL
Serum Na: 142 mEqs/L
Serum K: 6.7 mEqs/L
Serum Cl: 102 mEqs/L
Bicarbonate: 17 mEqs/L
Arterial pH: 7.20
ECG showed widening of the QRS complexes with non discernible p-

waves.
Which of the following is the most appropriate treatment?

A. Hydrate with 30 ml/kg lactated ringer’s solution
B. Repeat plasma potassium
C. Start calcium polystyrene sulfate STAT
D. Refer for STAT hemodialysis.
ANSWER: D
2. A 32- year- old female is brought to the ER due to a two- week- history of Causes of Hyponatremia
progressive weakness, fatigue, increased sleeping time, nausea and
headache. She was diagnosed with Papillary thyroid carcinoma a year
prior and underwent total thyroidectomy and RAI but was lost to follow-
up. Serum Na is 102mmo/L, K is 3.0mmol/L, TSH is 10.5mIU/L, and Tg
is 2.1 ng/ml. What is the most likely cause of her symptoms?
A. SIADH
B. Metastatic recurrence of thyroid carcinoma to the brain
C. Hypothyroidism
D. Pituitary adenoma
ANSWER: C
3 A 35- year- old- female with no known co- morbid condition presents at Management of
the ER with a Serum Na result of 151mEq/L. She has three week- history hypernatremia
of progressive weakness, headache, irritability, polyuria, polydipsia, and
in the past few days complained of anorexia. She is awake, coherent and
oriented with BP of 90/ 70 and HR of 98 bpm. She is not in
cardiorespiratory distress. She has dry lips and oral mucosa, and her
weight is 58Kg. How should the hypernatremia be corrected?
A. Encourage free water intake ad libitum

B. Administer 0.45% NaCl 2.5L in 24 hours for 3 days
C. Administer a thiazide diuretic
D. Give intravenous DDAVP
ANSWER: A
4 Which of the following conditions can cause euvolemic hyponatremia? Causes of Euvolemic
A. Mild hypothyroidism Hyponatremia
B. Secondary adrenal insufficiency
C. Primary adrenal insufficiency
D. Severe Hyperthyroidism
ANSWER: B
5. A 55-year old female followed up at the OPD for edema. She has type 2 Management of CKD
diabetes and hypertension for 10 years. She is maintained on Metformin
1000 mg BID, Gliclazide 60 mg tab OD, Amlodipine 10 mg OD. She
weighs 62 kg and her blood pressure is 140/90 mmHg.
She brought her latest lab results, which included
Hb: 12.3 g/dl WBC: 5.5
Hba1c: 6.5%
Crea: 110 umol/L
Urine albumin:crea ratio: 310 mg/g
How will you manage this patient’s condition?
A. Start erythropoietic-stimulating agents (ESAs)

B. Shift Gliclazide to an SGLT-2 inhibitor
C. Start an ACE inhibitor
D. Start ketoanalogues & essential amino acids
ANSWER: C
6 Which of the following is not a mechanism of anemia in CKD? Cause of anemia in
A. Diminished RBC survival CKD
B. Chronic inflammation
C. Vitamin B6 deficiency
D. Relative erythropoietin deficiency
ANSWER: C
7 Which of the following is part of the commonly accepted criteria for Indication of dialysis in
initiating maintenance dialysis in patients with chronic kidney disease: CKD
A. Bleeding diathesis
B. Hyponatremia unresponsive to conservative measures
C. Creatinine clearance 10-14 mL/min per 1.73m2
D. Hyperphosphatemia refractory to medical therapy
ANSWER: A

8 A 54 year old male patient diagnosed with small cell lung cancer Clinical presentation of
underwent induction chemotherapy with Cisplatin + Etoposide. A few different etiology of
days later, he complained of decreasing urine output, tea colored-urine AKI
and rising creatinine levels. Which of the following is true about his
condition?
A. Eosinophilia is present
B. FeNa <1%
C. Urinary myoglobin levels are elevated
D. Granular casts may be present
ANSWER: D
9 A 33 year-old male who was previously well presented with gradually Clinical manifestations
progressive edema and increasing fatigability. He also reported frothy and diagnosis of
urine, and occasional episodes of headache. nephrotic syndrome
At your clinic, he appears to be anasarcous, BP is 160/90, heart rate is 88
and saturations is 95% at room air.
Initial workup revealed:
Urinalysis: light yellow, specific gravity 1.018, protein ++++, RBC +.
Upon further questioning, he disclosed that he had multiple unprotected
sexual intercourse with commercial sex workers.
Which is the most likely renal pathology?
A. Minimal Change Disease

B. Membranous Glomerulonephritis
C. Focal Segmental Glomerulosclerosis
D. Light-chain deposition disease
ANSWER: C
10 A 54/F, diagnosed hypertensive, maintained on Amlodipine 10mg once a Clinical manifestations
day, complained of progressive dyspnea on exertion and generalized and diagnosis of
body weakness. There was also associated progressive edema starting at membranous GN
the ankles ascending up to the knee.
At the clinic, you noticed that the left leg is markedly swollen,
erythematous and tender compared to the right. Her BP is 160/100, HR-
100, RR-25, sats-92% on room air.
Her CBC showed anemia (9.5 g/dL). Urinalysis showed: amber colored,
specific gravity 1.020, protein +++, RBC 2-3/hpf, WBC 0-1/hpf.
What is the most likely underlying renal pathology?
A. Minimal Change Disease

B. Membranous Glomerulonephritis
C. Focal Segmental Glomerulosclerosis
D. Ligh-chain deposition disease
ANSWER: B

For items 11-12, please refer to the case: Diagnosis and clinical
management of
A 24 year-old man presented to the emergency room with severe right- nephrolithiasis
sided flank pain that radiates to the inguinal area. It was accompanied by
nausea, vomiting and diaphoresis. Upon arrival at the ER, he was in
distressing pain, only controlled with administration of intravenous
fentanyl. A noncontrast CT scan of the KUB revealed a 0.5cm
hyperdense calculi located at the distal 1/3 of the ureter.
After 3 days, the patient was able to pass the calculi spontaneously.
He was very concerned about recurrence of the stone, and expressed
willingness for an extensive workup.
11 Which of the following tests in a 24-hour urine collection is
recommended for his case:
A. Total protein
B. Total glucose
C. Total bilirubin
D. Total creatinine
ANSWER: D
12 Analysis of the stone revealed majority of the stone is compose of

calcium oxalate. Which of the following statements is true regarding
management?
A. Low calcium diet is recommended
B. A loop diuretic is recommended to substantially lower urine calcium
excretion
C. Reduction of sodium intake to <2.5g/day may reduce urinary
excretion of calcium
D. Sodium bicarbonate may alkalize the urine and decrease stone
formation
ANSWER: C

Part 7: Oncology (7)
1 Your patient is concerned that he might already have cancer after hearing Effective screening
the news that his friend died of lung cancer. He is 60 years old and strategies/modalities and
asymptomatic. He has been smoking 20 cigarette sticks daily x 30 years. their indications for
What is the best screening test to request? Lung cancer
A. Low-dose chest CT scan
B. Chest X-ray PA with lateral view
C. Sputum cytology
D. Advise him to quit smoking first and observe for symptoms
Answer: A (p.449 table 66-3)
2 A 55 year old male, diagnosed with non-small cell lung cancer a year 1. Clinical
ago, arrived at the ER in respiratory distress aggravated further by Manifestation of SVC
bending forward or lying down. Patient was noted to have nonproductive Syndrome
cough a month prior which was later on associated with hoarseness of 2. PE Findings
voice anddysphagia. On PE, he was seen cyanotic, with neck and facial 3. Management and
swelling and with prominent venous collaterals on the anterior chest. treatment based on
Chest radiograph showed right paratracheal mass with pleural effusion etiology
on the right. The primary treatment would include:
A. Chemotherapy
B. Diuretic with low salt diet and oxygen
C. Glucocorticoids
D. Radiation
Answer: D (p 511)
3 Which is the best treatment and prognostic consideration for a 32-year 1. Staging of breast cancer
old female with invasive ductal breast carcinoma and with no detectable 2. Definition of adjuvant,
distant metastasis? neoadjuvant and curative
therapy in breast cancer
A. Primary therapy consists of surgical treatment alone.
B. Tumor size and lymph node status are the most important prognostic
features if the patient has “Peau d’orange”, ulceration or tumor
fixation to the chest wall.
C. Adjuvant systemic therapies, such as antiestrogen, anti-HER2, or
chemotherapies, may be given to treat micrometastases.
D. Radiation alone may offer at least substantial survival prolongation.
Answer: C (p 558-559)
4 A 52 year old male smoker underwent elective esophagogastroscopy as 1. Clinical features and
part of his chosen wellness package. An incidental finding of 0.7 cm approach to diagnosis
gastric ulcer was noted and biopsy showed adenocarcinoma. There was 2. Approach to treatment
of gastric cancer

no evidence of distant spread on metastatic work-up. Which treatment 3. Understanding the role
option offers the best chance of cure? of treatments in early-
stage gastric cancers
A. Combination chemotherapy plus ramucirumab
B. Immunotherapy
C. Surgical resection of tumor and adjacent lymph nodes
D. Surgical resection of tumor and lymph nodes followed by radiation
Answer: C (pp. 569-570)
5 A 54/M with diabetes diagnosed with liver cirrhosis secondary to chronic Surveillance
Hep B infection consults your clinic. Which method of screening for recommendations of
hepatocellular carcinoma would you recommend? patients at high risk of
HCC
A. Ultrasonography every 6 months
B. Computed tomography every 3 months
C. Magnetic resonance imaging every year
D. PET scan every year
Answer: A (p. 581)
6 A 48/M alcoholic was seen at the OPD complaining of body malaise and 1. Approach to
abdominal discomfort. Ultrasound of the abdomen showed a 1.5cm evaluation of hepatic
nodule at the left lobe of the liver. What is the most appropriate next mass/nodules on
step? ultrasound
2. Imaging criteria for
A. Request for AFP diagnosis of HCC
B. Do repeat ultrasonography after 4 months
C. Do 4-phase CT scan
D. Refer for liver biopsy
Answer: C (p. 582 fig 78-3)
7 A 28 y/o female diagnosed with mediastinal Hodgkins Lymphoma Stage 1. Toxicity of Radiation
IIBX and completed 4 cycles of ABVD regimen underwent radiotherapy. Therapy
What test would you recommend to screen for radiotherapy- induced 2. Risk of secondary
secondary malignancy for long term surveillance for her? malignancies
A. Thyroid ultrasound
B. Mammography
C. CXR
D. Head and Neck CT scan
Answer: B (p. 483)

Part 8: Hematology (7)
1 A 22 year old male consulted due to recurrent epistaxis. Clinical features and
laboratory findings in
On further history, he has noticed decreased exercise tolerance, on and off easy Aplastic Anemia
fatigability, headache and shortness of breath for the past 3 months.
His laboratory tests are as follows:

Hemoglobin 55 g/L
Hematocrit 17%
RBC 2.5
WBC 1,500
Neutrophils 20%,
Lymphocytes 80%,
Platelets 5,000
Reticulocytes was decreased. Peripheral smear shows normocytic,

normochromic red cells, leukopenia and thrombocytopenia.
Bone marrow biopsy is hypocellular, 90% fat.
What is the most likely diagnosis for this patient?
A. Aplastic Anemia
B. Cooley’s Anemia
C. Hemolytic Anemia
D. Pernicious Anemia
Answer: A
2 A 23 year old male consulted due to findings of pancytopenia, portal vein Diagnosis and
thrombosis and hemolytic anemia. pathophysiology of
PNH
He has a history of intermittent hematuria. His Coombs’ Test is
NEGATIVE. Flow cytometry of the peripheral blood showed absent
CD55 and CD59.
Which of the following is TRUE regarding the patient’s condition?
A. Iron-deficiency anemia can develop from chronic iron loss through

hemoglobinuria.
B. Long-term glucocorticoids is usually indicated to ameliorate
hemolysis.
C. The pathophysiologic mechanism of the patient’s anaemia is
increased RBC destruction in the spleen.
D. The sucrose hemolysis test is a highly reliable test to diagnose this
condition.
Answer: A

3 A 70 year old male consulted due to anemia. His hemoglobin was 5.0 Laboratory findings of
g/dL but he is otherwise asymptomatic. Waldenstrom’s
Macroglobulinemia
Direct and indirect Coombs test was POSITIVE. His peripheral blood
smear shows clumping of RBCs consistent with cold agglutinin disease.
Which of the following diseases is LIKELY to be the cause of the

patient’s condition?
A. Chronic inflammatory disorders such as IBD

B. Chronic Lymphocytic Leukemia
C. Systemic Lupus Erythematosus
D. Waldenstrom’s Macroglobulinemia
Answer: D
4 A 35 year old pregnant woman presents with decrease in sensorium, fever Diagnostic approach
and renal failure. Her blood tests showed thrombocytopenia and anemia. and treatment of
Thrombocytopenic
Other laboratory findings were as follows: purpura
Increased lactate dehydrogenase
Increased indirect bilirubin
Increased reticulocyte count
Decreased haptoglobin,
Negative direct antiglobulin test
The peripheral smear showed evidence of schistocytes. What is the

treatment of choice for this condition?
A. IV Immunoglobulin
B. Plasma Exchange
C. Pulse steroid therapy
D. Platelet transfusion
Answer: B
5 A 20 year old female previously diagnosed with Glucose-6-Phosphate Treatment of

Dehydrogenase Deficiency was complaining of dysuria of 3 days abnormalities in G6PD
duration. Her urinalysis is consistent with UTI.
Which of the following antibiotics is the most appropriate for the patient?
A. Cefuroxime
B. Cotrimoxazole
C. Nalidixic acid
D. Nitrofurantoin
Answer: A
6 A 38 year old female consulted due to persistence of anemia for 6 months. Laboratory findings in
anemia of chronic
Aside from pale conjunctivae, the rest of P.E. findings were inflammation
unremarkable.
Interpretation of
Laboratory revealed: laboratory iron studies
Reticulocyte count index – 2.0
Serum iron - 30 ug/dL (50-150ug/dL) Approach to establish
Total iron binding capacity -200 ug/dL (300-360 ug/dL) diagnosis of anemia of
Serum ferritin - 100 ug/L. chronic inflammation
Blood smear demonstrates microcytic and hypochromic red cells.
What is the most likely cause of anemia in this patient?
A. Iron deficiency
B. Thalassemia
C. Sideroblastic anemia
D. Inflammation
Answer: D
7 A 35 year old female consulted due to pallor and fatigue of 6 months Interpretation of
duration. laboratory iron studies
P.E. revealed pale conjunctivae and nail beds. There was no Laboratory findings in
hepatosplenomegaly. anemia of iron-
deficiency
Laboratory showed: Hemoglobin 8.7 g/dL, Leukocytes 5 cells/uL
Platelet -300 cells/uL Approach to establish
diagnosis of IDA
Reticulocyte count index is 2.
Serum iron and total iron binding capacity are 15 ug/dL (50-150ug/dL)
and 450 (300-360 ug/dL) respectively.
Which additional diagnostic finding will help establish the diagnosis?
A. Transferrin saturation of 33%

B. Serum ferritin of 30 ug/L
C. Blood smear showing hypochromic and microcytic red cells
D. Bone marrow exam demonstrating myeloid/erythroid ratio of 1:1
Answer: C

Part 9: Rheumatology (7)
1 A 29 year-old young flight attendant sought consult due to recurrent Diagnosis of SLE and
pregnancy loss. She was diagnosed with systemic lupus erythematosus APAS
since she was 18 years old, with controlled symptoms of photosensitivity
and occasional joint pains. She is maintained on hydroxychloroquine
200mg once a day.
Which of the following autoantibodies will likely be positive?
A. Antihistone
B. Anti-Ro
C. Anticardiolipin
D. Anti-RNP
ANSWER: C
2 Which of the following is not part of the ACR/EULAR classification Diagnosis of
criteria for rheumatoid arthritis? Rheumatoid Arthritis
A. Duration of symptoms of greater or less than 8 weeks
B. Rheumatoid factor
C. Anti cyclic citrullinated peptides
D. C-reactive protein
ANSWER: A
3 A 43 year-old banker came in to your clinic for persistent and progressive Treatment of
joint pains, lasting for more than 1 year, markedly pronounced in both Rheumatoid Arthritis
wrists and hands, which impairs his daily functions. He previously self-
medicated with ibuprofen but lately, he noted that it seems not to work
anymore. He has no other comorbids and denies any vices. MRI of both
hands showed joint erosions and minimal effusion.
He is an executive in a bank and is due for promotion and is asking you if
he could have medications that will control disease progression and
alleviate symptoms. You will:
A. Start Prednisone 60mg daily in 2 divided doses for 2 weeks
B. Shift Ibuprofen to Etoricoxib 60mg once a day
C. Start Methotrexate 25 mg/ week
D. Start Allopurinol 300mg once a day
ANSWER: C
4 A 54 year old woman complains of dyspnea on exertion, associated with Diagnosis of
“dryness” of her skin and episodes of bluish discoloration in her fingernails Scleroderma and
that gradually and spontaneously return back to normal, Associated Diseases
On physical examination, she was dyspneic upon arrival at your clinic,
can speak in short sentences, and her oxygen saturations are at 99%
while breathing room air.
Which of the following tests is a sensitive test to perform to detect early
pulmonary involvement in her case?
A. Chest CT scan with Pulmonary Angiography

B. Chest Xray
C. Chest MRI
D. Pulmonary Function Test with DLCO
ANSWER: D
5 A 36 year old woman was referred to you from the local health center for Management of
increasing episodes “asthma attacks”, some of which lead to Churg-Strauss (EGP)
hospitalization and would require prolonged courses of steroids. She is
maintained on high dose of budesonide+formoterol inhalation and
Montelukast 10mg once a day.
Upon workup, CBC revealed mild anemia (Hgb-11.2 g/dL, slight
leukocytosis WBC-12.9, neutrophils-40%, lymphocytes-45%,eosinophil-
15%), pulmonary function testing revealed a reversible obstructive defect,
chest CT scan showed lung hyperinflation.
What is the most appropriate treatment?
A. Increase dose of budesonide+formoterol

B. Add on tiotropium
C. Start Omalizumab
D. Start maintenance Prednisone
ANSWER: D
6 Which of the following are the most common sites involved in Takayasu Diagnosis of Takayasu
arteritis? arteritis
A. Pulmonary artery
B. Coronary artery
C. Renal artery
D. Subclavian artery
ANSWER: D
7 A 34 year old Roman Catholic priest complained of chronic nonproductive Diagnosis and
cough associated with fatigue and night sweats. He is a previously healthy Management of
young male, no vices and is active in church service and charity work. Sarcoidosis
Workup showed mediastinal and hilar lymphadenopathies in chest CT

scan. An endobronchial ultrasound-guided biopsy of the lymph node
showed multiple non-caseating granulomas in a background of fibrosis and
inflammatory debris. Bronchial washing Xpert MTB-Rif was negative and
interferon-gamma release assay was negative. Fungal and bacterial cultures
were also negative.
What is the most appropriate next step?
A. Begin Prednisone 20mg BID and assess response

B. Start anti-TB medications
C. Refer to oncologist for possible chemotherapy
D. Start empiric antibiotics that cover for atypical bacteria
ANSWER: A

Part 10: Dermatology (6)
1 A 53 year old female consulted due to varicose veins associated with mild Clinical features and
erythema and scaling. She claimed that she experienced occasional pruritus dermatologic
noted at the medial aspect of her ankle specifically over the area of presentation of Stasis
distended vein. dermatitis
What is the most likely dermatologic diagnosis?
A. Cellulitis
B. Dermal fibrosis
C. Stasis dermatitis
D. Contact dermatitis
Answer: C
2 A 40 year old female complained of persistent facial flushing which started Dermatologic
1 month ago. The symptom worsened with alcohol intake, hot drinks and manifestations of
spicy foods. Acne rosacea
There were no other complaints.
P.E findings revealed erythema, telangiectasia, scattered papules and small

pustules that is more prominent on the cheeks and nose.
What is your impression?
A. Acne rosacea
B. Pityriasis rosea
C. Seborrheic dermatitis
D. Hypersensitivity reaction
Answer: A
3 A 35 year old female with Hepatitis C consulted due to pruritic rashes on Characteristic lesions,
her wrists, shins, and scalp. She also complained of painful oral ulcers and clinical manifestations
loss of fingernails. and body involvement
of Lichen planus
On P.E., there were multiple polygonal, flat topped, violaceous plaques
and papules over the affected skin. There were erosions and ulcerations on
the side of the tongue.
What is your impression?
A. Acne rosacea
B. Pityriasis rosea
C. Lichen planus

D. Seborrheic dermatitis
Answer: C
4 A 68 year old man from a prison had a 7-day history of tender papules and Primary lesions,
necrotic ulcers on the chest and extremities. Cutaneous findings showed infectious causes, and
crusted polymorphous papules, vesicles, and hemorrhagic ulcers on the forms of echthyma
chest and arms, and multiple eschars on the lower extremities. The ulcers
were tender with a ‘punched-out’ appearance, with well-demarcated
elevated borders.
What is the causative agent of the patient’s disease?
A. Streptococcus pyogenes
B. Clostridium perfringens
C. Pseudomonas aeruginosa
D. Arthropod bite
Answer: A
5 A 20 year old male athlete, dark skinned, complained of mild itching and Clinical presentation,
skin discoloration on the back and chest. diagnosis, and
treatment of Tinea
On P.E., there were multiple oval scaly patches with area of versicolor
hypopigmentation on the affected skin.
KOH smear done showed ‘spaghetti and meatball’ appearance under the
microscope.
What is the treatment of choice for this patient?
A. Topical corticosteroids
B. Selenium sulphide lotion
C. Topical retinoids
D. Ultraviolet light
Answer: B
6 A 34 year old female consulted at the E.R. due to pruritic rashes. Clinical presentation
of non-immunologic
Her history revealed intake of Cefuroxime 500mg/tab 1tab BID for UTI Cutaneous Drug
which she started 5 days ago. According to the patient, rashes appeared on Reactions
the trunk upon waking up this morning. Common
cutaneous reactions
She denies fever, abdominal pain, nausea, vomiting or difficulty breathing. and their causes
On P.E., vital signs were stable. Dermatologic findings include blanching

erythematous macules and papules that were symmetric and confluent on

the trunk and intertriginous areas. No mucosal involvement was noted. The
rest of the findings were unremarkable.
Which of the following drug-induced cutaneous reaction is the most likely

diagnosis in this case?
A. Anaphylactoid reaction
B. Morbiliform eruption
C. Fixed drug eruption
D. Urticaria
Answer: B

Part 11: Allergology (6)
1 A 45- year old female complains of recurrent skin lesions on the face and Definition,
upper extremities described as well-circumscribed wheals with raised predisposing factors,
serpiginous borders initially pruritic but later on becoming painful. The clinical presentations
areas around the eyes and lips become swollen. The lesions are on and off of angioedema and
and lasts 1-2 days the spontaneously resolves.
urticaria
Which is correct regarding her condition?
A. It is due to dilatation of the vascular structures in the superficial dermis

B. All patients with this condition have a history of atopy
C. Lesions are symmetric
D. It is more common in women
Answer: D (p2500-2502)
2 A 19-year old female arrives at the ER by ambulance. She was eating 1.Definition and
lanzones when she suddenly started coughing followed by shortness of clinical manifestation
breath and dyspnea until she became progressively less responsive. Her of anaphylaxis
initial blood pressure is 70/40 mmHg, HR 122 bpm regular, RR was rapid 2.Treatment and
and shallow with O2 sat of 88%. You auscultate tight wheezes bilaterally. supportive therapy of
Which is correct regarding her condition? anaphylaxis
A. Symptoms typically occur 1-2 hours after exposure to the triggering

factors.
B. In 90% of cases, symptoms will recur after an hour or longer after
resolution
C. Failure to use epinephrine within 20 minutes of symptoms is a risk
factor for poor clinical outcomes
D. Patients who suffer from this condition should be placed in a high-back
rest position to avoid fluid accumulation in the lungs
Answer: C (p 2506)
3 A 55 year old female sought consult after developing pruritic, red wheals General features
of varying sizes at the torso, and both upper and lower extremities that etiology, clinical
started last night. She also complained of body malaise and fever up to presentation, and
38.3oC which was relieved with paracetamol. She denies any allergies to classification
food and medications. However, around a week ago, she visited the local hypersensitivity
health center to get injected with tetanus toxoid after a pedicure accident. reactions
What classification of allergic reaction would most likely explain the
patient’s symptoms?
a. Type I: IgE-mediated
b. Type II: IgG mediated cytotoxicity
c. Type III: Immune-complex mediated
d. Type IV: T-lymphocytic mediated inflammation
Answer: C (p 363)

4 A 30 year old woman came in for 1 week history of cough with nasal 1. General features
catarrh. She was treated as a case of Community Acquired Pneumonia and etiology serum
Low Risk, and was started on Cefaclor 500 mg/tablet 1 tablet BID. She sickness
subsequently developed generalized pruritic rash, joint pains, and fever. 2. Difference between
She improved upon treatment with systemic steroids. Available serum sickness and
laboratories showed normal CBC, Creatinine and Complement Levels. serum sickness-like
Which one of the following diagnoses is most likely in this case? reactions
A. Serum sickness reaction to Cefaclor

B. Serum sickness-like reaction to Cefaclor
C. Delayed-type hypersensitivity reaction to Cefaclor
D. Immunoglobulin E–mediated allergy to Cefaclor
Answer: B (p. 363)
5 A 40-year old male developed fever and dusky erythema lesions with 1. General features of
large sheets of necrotic epidermis noted at the face and trunk with a total SJS and TEN
detachment of 20% body surface area noted after 7 days of taking 2. Classification
allopurinol. What is the most likely diagnosis? based on extent of
body surface area
A. Acute Generalized Exanthematous Pustulosis (AGEP) involvement
B. Stevens- Johnson Syndrome (SJS)
C. Toxic Epidermal Necrolysis (TEN)
D. Overlap of SJS and TEN
Answer: D (p 368)
6 A 56-year-old male was given meloxicam and after 2 weeks he developed 1. Classification
a fever, sore throat, conjunctivitis and acute painful dusky macules over based on extent of
the trunk, upper and lower extremities with total detachment of <10% body surface area
body surface. Which of the following is true in the management of this involvement in SJS
case? TEN
2. Management of
A. Fluid management, wound care, and infection treatment are critical SJS TEN
B. Oral antihistamines and emollients can reduce inflammation and symptoms
C. Skin biopsy can indicate drug casualty
D. Systemic glucocorticoids (1.5-2mg/kg/d prednisone equivalent) should be
started and tapered slowly over 8-12 weeks
Answer: A (p368)

Part 12: Neurology (6)
1 A 67 yr-old right-handed female was rushed to the ER because of aphasia Identify specific stroke
noted 30 minutes prior. She is a known hypertensive and diabetic with syndrome based on the
unknown control and compliance to medications. Pertinent neurologic PE clinical presentation
revealed contralateral homonymous hemianopsia, contralateral motor and and PE findings
sensory loss in the face, arm and leg. What is the stroke syndrome?
A. Middle cerebral artery

B. Anterior cerebral artery
C. Posterior cerebral artery
D. Basilar artery
ANSWER: A
2 What is not a contraindication to administration of recombinant tissue Treatment and
plasminogen activator in ischemic stroke? indications of
fibrinolysis for
A. Gastrointestinal bleeding in the past 1 month ischemic stroke
B. Active bleeding diathesis
C. Recent myocardial infarction
D. Recent intracerebral hemorrhage
ANSWER: A
3 A 27 year old medical intern came to your clinic for recurrent episodes of Treatment and
headache. She describes it as severe and throbbing, occurring mostly on management of
the retroorbital area. Before the episodes, she notices bright flashing lights migraine
and nausea, followed by the disabling headache. She is worried that the
headaches will occur during her upcoming USMLE, and she seeks your
advice regarding prevention of acute attacks.
You will prescribe:

A. Sumatriptan 50mg once a day
B. Ergotamine+Caffeine 2/100mg once a day
C. Etoricoxib 60mg once a day
D. Valproate 400 mg twice a day
ANSWER: D
4 Treatment of choice for typical absence seizures: Management of
seizures
A. Diazepam
B. Phenytoin
C. Levetiracetam
D. Lamotrigine
ANSWER: D

For items 5-6, please refer to the case: Diagnosis and
Management of Status
A 54 year old woman was rushed to the emergency room for sudden onset Epilepticus
headache and generalized tonic-clonic seizures. She was at the mall
walking her dog and onlookers noted that she suddenly stopped to rest in
the bench and then began having convulsive movements. The seizures
lasted for approximately 3 minutes. When paramedics arrived, she was
noted to be stuporous, with no eye opening and no verbal output. At the
ambulance en route to the hospital, paramedics noted 5 more seizure
episodes, which were increasingly longer in duration.
At the ER, she arrived in active seizure, her BP was 60/40, HR-100,
capillary blood glucose of 140 mg/dL,and oxygen saturations of 99% on
room air.
5 Which of the following constitute the most appropriate immediate
management of her case?
A. Start IV propofol at 25 mcg/kg/min
B. Start IV pentobarbital 5mg/kg
C. Fluid resuscitation with isotonic saline solution
D. Prompt intubation and mechanical ventilation
ANSWER: C
6 After a few hours of resuscitation and medical management, she regained
consciousness and was oriented to time and place but not to person. She
can also recall the events prior to the events. Which of the following test/s
is/are prudent to rule in possible complications of her seizure episodes?
A. High sensitivity toponin I
B. Serum creatine kinase
C. Arterial blood gas
D. All of the above
ANSWER: D

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RITE Full Exam with Answers

RITE Full Exam with Answers Page 1 of 47

What is the rhythm?

What is the initial management of this rhythm?

A. Give Atropine 0.5mg IV

What will be your immediate intervention?

What is the ECG reading?

RITE Full Exam with Answers Page 3 of 47

A. Start the patient on digoxin

A 2D Echocardiogram was done and revealed an asymmetric hypertrophy of the

What is the most likely diagnosis?

She became diaphoretic during the interview with a BP of 110/70, HR of 59

RITE Full Exam with Answers Page 4 of 47

What is your management for this patient?

RITE Full Exam with Answers Page 5 of 47

Which medication would you start to address this problem?

Vital signs were as follows: Pathologic

Chest X-ray showed Pulmonary edema and Cardiomegaly and 2D

What is the pathologic basis of this disease?

RITE Full Exam with Answers Page 6 of 47

What will be the most suitable pressure for your patient?

ECG showed low voltage complexes. 2D Echocardiography revealed thickened

What is the most likely diagnosis?

Upon auscultation, there was a note of high-pitched, blowing, decrescendo, diastolic

What is the most likely valvular heart pathology?

RITE Full Exam with Answers Page 7 of 47

Troponin-I was also done and it was 0.02ng/ml.

RITE Full Exam with Answers Page 8 of 47

Answer: B (p. 1488-89)

A. PCV 13 should be given at least 8 weeks before PPSV 23

Answer: A (p. 1432 table 197-11)

RITE Full Exam with Answers Page 9 of 47

A. Dengue without warning signs

A. Amoxicillin: 2g P.O. 1 hour before procedure

Answer: C (p. 932 table 123-7)

A. Start G-CSF or GM-CSF 24 hours before chemotherapy

RITE Full Exam with Answers Page 10 of 47

Answer: B (p. 500 table 69-7)

Answer: D (p 1431 table 197-11)

Answer: C (p.1260, 1264 table 174-2)

A. Start Doxycycline 200mg 1x week PO

Answer: B (p. 1294)

Answer C. (p 1589 table 219-8)

Answer: D (p. 1639)

RITE Full Exam with Answers Page 12 of 47

A. Ciprofloxacin 500 mg bid (IV) 5 to 7 days

Answer: B (p1176 table 160-1)

Answer: C (p. 972 Fig. 130-4)

RITE Full Exam with Answers Page 13 of 47

RITE Full Exam with Answers Page 14 of 47

A 60 year old woman was admitted due to pneumonia. However, on the

2. Which of the following intervention/s has been shown by at least one

ANSWER: D (A and B only)

ANSWER: D (Distributive Shock)

ANSWER: C (Supplemental oxygen)

RITE Full Exam with Answers Page 16 of 47

A 76 year old retired ship captain consulted at your clinic due to

A. GOLD Grade 2, Group B

ANSWER: A (GOLD Grade 2, Group B)

ANSWER: D (None of the above)

RITE Full Exam with Answers Page 17 of 47

A. Perform an Interferon Release Assay Test

A. Continue with the remaining months of HR

14 What is the most appropriate empiric antibiotic therapy?