Part 1: Select the most appropriate answer: (1 mark for each question) A ‘The most potent drug in reducing the H Cl secretion in the stomach is: Antacids H2 receptors antagonists Sucralfate Proton pump inhibiters Prostaglandins paoge In inflammatory bowel disease Pain is more evident in Crohn's disease than in ulcerative colitis Bloody diarthea is uncommon in ulcerative colitis Weight loss is common in ulcerative colitis nal symptoms are common in ulcerative col rare in Crohn’s disease3. A 25-year-old woman with known mitral valve prolapse develops a low-grade fever, malaise and night sweats within a couple of weeks of a major dental procedure. Examination reveals a pulse rate of 110/minute, which is regular, tender vasculitic lesions on the finger pulps and microscopic hematuria. Which investigation is most likely to provide a definitive diagnosis? a. Full blood count b. ECG c. Autoantibody screen d. Blood culture e Coronary angiography4. The following conditions are required for liver Biopsy excey Cooperative Patient. Prothrombin Time prolong more than 18 seconds (N 10-13sec). Platelets count more than 80;000/ml Exclusion bile duct obstruction No Ascites peaoge 5. In hemolytic anemia. It causes deep colored Jaundice. Positive bile pigments in the Pruritus. Positive urobilinogen in urine. NO splenomegaly paoge7. In hepatitis C infection: a b. « 4, e. 8. The following drugs cause acute hepati a b. e d. e. ‘Acute symptomatic hepatitis is common Vaccination gives 90%protection 80%of patients exposed to hepatitis C virus becomes chronic hepatitis. Itis DNA virus Vertical transmission is common. except: Isoniazid B-halothane Paracetamol Estrogen Rifampicin 9. All the followings cause chronic liver disease except: Hepatitis A Wilson disease Auto immune hepatitis Hemochromatosis Non-Alcoholic fatty liver disease10. In hepatitis B viral infection all following true except Chronic hepatitis B infection represented 90% of the cases. Chronicity more common by vertical transmi Vaccination protection in 90% Anti-hepatitis core anti bodies IgM is Diagnostic RNA virus. 11. A 56-year-old woman admits to a 60-pack-year smoking history. She complains ¢ fatigue and dyspnea with minimal exertion, and a cough that is productive each morning. Which of the following is the most likely finding in this patient? Higher diffusing capacity of lung for carbon monoxide (DLCO) Decreased residual volume Normal to slightly increased FEV1 Decreased FEV1/ FVC Decreased FVC12. A 38-year-old man is worried after noticing that his urine and contact lenses hae been colored red. Two weeks ago, he was started on combination therapy for tuberculosis. Which drug is most likely to cause these side effects? a. Isoni b. Metronidazole . Pyrazinamide 4. Rifampicin fe. Ethambutol13. A 60-year-old man presents with a history of cough and weight loss. He has srdaio \is skin and cigarettes a day since he was 17 years old. He describes recent darkening of the chest X-ray reveals a mass (suspicious for lung ara) at the left hilum. What is the most likely histology? a. Adenocarcinoma b. Large-cell carcinoma, Mesothelioma d. Small-cell carcinoma fe. Squamous-cell carcinoma 14, A 24-year-old patient presents with anorexia, fever and hot flushes. The chestX- fay shows a large (4-cm), left upper-lobe cavity. Active tuberculosis is suspected. Which of the following is most likely to lead to a definitive diagnosis? Blood cultures ‘Computed tomographic scanning Mantoux test ‘Serum inflammatory markers ‘Sputum sample paese15 .chest pain is an important feature of ischemic heart disease, but myocardial infarction could less (silent) in some patient who are Hypertensive Female . Old age l. Athlete Smoker 16 .Middle age male presented with chest pain, which of the following investigation is more specific in diagnosis of myocardial infarction? Blood hemoglobin level Serum cholesterol ‘Myoglobulin level Serum troponin level Crreactive protein level sacge17 Regarding aortic aneurysm, surgical repei icated in al the following EXCEPT ‘a. Asymptomatic abdominal aortic aneurysm has reached more than 5.5 cm in diameter. b. ic abdominal aortic aneurysm. © _ Distal embolization. d. Hypertension, . Ruptured abdominal aortic aneurysm. 18 .Which of the following is NOT a feature of cardiac tamponade? a. Dyspnea. . Collapse . & Tachycar d. Hypertension. fe. Elevated JVP (jugular Venus pressure).19 . Which of the following is a common cause of right heart failure? 220 e0 Chronic lung disease. Aortic valve regurgitation. Hypertension. Stable angina. Diabetes mellitus. 20 .Symptoms and signs of Acute limb ischemia include the following EXCEPT eacge Pallor. Pulseless. Pain, Peripheral edema. Paralysis.21. A 28-year-old man has noticed that the tissue around his breasts has become increasingly swollen. They are non-tender. He has recently started chemotherapy for testicular cancer. Which is the single most likely biochemical cause for this change? a. Androgen b. L Dopamine 1 Growth hormone d. 4 Estrogen/androgen ratio e. Prolactin 22. A 33-year-old woman has not had @ period for the last 3 months. She has also noticed frequent ischarge from her breasts. She is currently being treated for type 1 diabetes, depression, benign positional vertigo, and back pain. Serum B -human chorionic gonadotropin (B -hCG): negative. ‘Which single drug is most likely to have caused these new symptoms? .Codeine phosphate b.Gabapentin Insulin .Prochlorperazine e.Venlafaxine23, A33-year-old female is referred to endocrinology with thyrotoxicosis. Following a discussion of management options, she elects to have radioiodine therapy. Which one of the following is the most likely adverse effect? ‘Hypothyroidism b.Thyroid malignancy .Agranulocytosis d.Qesophagitis e-Precipitation of thyroid eye disease 24, A33-year-old woman presents with weight loss and excessive sweating. Her partner reports that she is 'on edge' all the time and during the consultation you notice a fine tremor. Her pulse rate is 96/min. A large, non-tender goiter is noted. Examination of her eyes is unremarkable with no evidence of exophthalmos. Free T4 26 pmol/l (N 11.5-22.7) Free T3 12.2 pmol/l (N3-7.5) TSH < 0.05 mu/l(NO.5-5) ‘What is the most likely diagnosis? ‘a. Toxic multinodular goiter b.Hashimoto's thyroiditis c.T3-secreting adenoma De Quervain's thyroiitis 7 e.Graves' disease25. A.30-year-old female is started on carbimazole 20mg bd following a diagnosis of Grave's disease. What is the best biochemical marker to assess her response to treatment? a.Total T4 b.TSH cree Ta d.ESR e.FreeT326. A.49-year-old woman has felt tired over the last few months and her thyroid function tests are returned as follows: Thyroid-stimulating hormone (TSH) 11 mU/L (N 0.35-5.5), free thyroxine (FT4) 19pmol/L (N 11.5-22.7). She has no detectable goiter. Which is the single most likely explanation for the blood results? Sick euthyroidism a b. « d imoto’s thyroiditis fe. Unknown use of levothyroxine 27. A45-year-old woman is investigated for weight gain. She had had been unwell for around four months and described a combination of symptoms including depression, facial male-pattern hair growth and reduced libido. During the work-up she was found to be hypertensive with a blood pressure of 170/100 mmHg, Which one of the following tests is most likely to be diagnostic? ‘a, Renin/ aldosterone levels b. High-dose dexamethasone suppression test . Pelvic ultrasound d. Overnight dexamethasone suppression test €. 24 hr urinary free cortisol28. A 24-year-old female with a history of type 1 diabetes mellitus presents to the Emergency Department with vomiting and abdominal pain. Finger-prick testing estimates the blood sugar to be 25 mmol/l (N 4-5.4). Arterial blood gases record a pH of 7.22 (N 7.34-7.45) .On examination the patient is dehydrated and weighs 80 kg. An intravenous line is sited and bloods are sent. One liter of 0.9% saline is infused and an intravenous insulin pump is set-up. ‘What rate should insulin be initially given? a.10 unit / hour b.1 unit / hour 2 unit / hour 4.6 unit / hour e.8 unit / hour 29, A'56-year-old man is reviewed in the Cardiology outpatient clinic following a myocardial infarction ‘one year previously. During his admission he was found to be hypertensive and diabetic. He complains that he has put on 5 kg in weight in the past 6 months. Which of his medications may be contributing to his weight gain? a.Metformin b.Losartan Clopidogrel .Gliclazide e.Sinwestatin30. 58-year-old woman presents to the emergency department with confusion. She is found to have a raised temperature, tachycardia and is hypotensive. After further investigation, she is found to be ina thyrotoxic storm. Given her presentation what is the best first line treatment? a. Adrenaline and hydrocortisone b.Beta blockers and propylthiouracil ¢. Adrenaline, propylthiouracil and hydrocortisone .Beta blockers, propylthiouracil and hydrocortisone e.Propylthiouracil and hydrocortisone 31. A 24-year-old woman is diagnosed as having nephrotic syndrome after being investigated for proteinuria. A diagnosis of minimal change glomerulonephritis is made. What is the most appropriate initial treatment to reduce proteinuria? a. Protein restriction in diet b. No treatment shown to effective c. Angiotensin-converting-enzyme d. Diuretic e. Prednisolone32. A sample of tissue from a renal biopsy is viewed using an electron microscope. Podocyte fusion is seen. Which one of the following types of glomerulonephritis is most associated with this finding? ‘a. Membranous glomerulonep! b. IgA nephropathy . Focal segmental glomerulosclerosis . Mesangiocapillary glomerulonephritis e, Minimal change glomerulonephritis, 33, Autosomal dominant polycystic kidney disease type 1 is associated with a gene defect in: a. Chromosome 4 b. Chromosome 8 c. Chromosome 12 d. Chromosome 16 e. Chromosome 2034. A 62-year-old man with chronic kidney disease secondary to diabetes mellitus is reviewed. When assessing his estimated glomerular filtration rate (eGFR), which one of the following variables is not required by the Modification of Diet in Renal Disease (MDRD) equation? 2. Age b. Serum creatinine Ethnicity d. Gender e. Serum urea 35. Which one of the following may be useful in the prevention of calcium renal stones? a. Pyridoxine b. Allopurinol . Lithium d. Ferrous sulphate . Thiazide diuretics36. A45-year-old man is seen in the Emergency Department with nausea, pallor and lethargy. He has no past medical history of note. A cannulas inserted and bloods show the following Nas 140 mmol/L, (N 135-145) K+ 6.7 mmol/l (N3.5-5.5) Bicarbonate 14 mmol/|_(N 22-29) Urea 18.2 mmol/I(N2.5-7) Creatinine 230 umol/I (N 50-120) What is the most appropriate initial management? a. Nebulized salbutamol b. Intravenous bicarbonate c. Hemodialysis d. Insulin/dextrose infusion e. Intravenous calcium gluconate 37. A 34-year-old man presents to the Emergency Department with abdominal pain. This started earlier on in the day and is getting progressively worse. The pain is located on his left flank and radiates down into his groin. He has had not had a similar pain before and is normally fit and well. Examination reveals a man who is flushed and sweaty but is otherwise unremarkable. What is the most suitable initial management? a. Oral ciprofloxacin b. IM diclofenac 75 mg c. Immediate abdominal ultrasound d. 1M morphine 5 mg e. IM diclofenac 75 me + start Bendroflumethiazide to prevent further episodes38. A 62-year-old man is reviewed in the renal clinic. He has been referred as his creatinine level increased from 90 to 173 yumol/I(N 50-120) after the introduction of ramipril. This had been started in an attempt to control his blood pressure. An ultrasound abdomen is reported as follows: Both kidneys are small with the right measuring 5.8cm and the left 5.6cm. Normal liver, pancreas, spleen and bladder outti What is the most appropriate next line investigation? a. Albumin creatinine rati b. 24-hour urinary protein collection c. Renal artery Doppler flow studies d.eGFR e. MR angiography39. Zahraa is 30 years old with pallor and progressive chronic renal failure, she typically develops: 2. Hemolytic anemia . Aplastic anemia . Normochromic normocytic anemia d. Macrocytic anemia €. Micoangiopathic aner 40. A 65-year-old man with a history of hypertension is reviewed. As part of routine blood tests to monitor his renal function whilst taking ramipril the following blood tests are received: Nat 140 mmol/l_(N 135-145) K+ 4.8 mmol/I (3.5-5.5) Urea 6.2 mmol/I(N2.5-7) Creatinine 102 mol/l (N 50-120) (GFR 68 ml/min urine dipstick is subsequently performed which is normal and a renal ultrasound sound shows normal sized kidneys with no abnormality detected. What stage of chronic kidney disease does this patient have? ‘a. No chronic kidney disease b. chronic kidney disease stage 4 . chronic kidney disease stage 3 d. chronic kidney disease stage 2 e. chronic kidney disease stage 1mitral stenosis ventricular septal defect mitral regurgitation aortic stenosis, tricuspid regurgitation pangs For the following sets of signs, give the most likely cause for the heart murmur. Each option may be used only once. List B: 41. Tapping apex beat, loud $1, mid-diastolic murmur loudest at the apex in expiration lying on the left side. 42. Heaving undisplaced apex beat, absent A2 with ejection systolic murmur radiating to the carotids. 43, Pansystolic murmur heard best at lower left sternal edge during inspiration in a patient with pulsatile hepatomegaly. 44. Displaced, volume-overloaded apex. Soft $1, pansystolic murmur at apex radiating to axilla, 45. Left parasternal thrill and harsh pansystolic murmur at lower left sternal edge that is also audible at apex.2: Chose the most appropriate next investigation for each of the patients below: List A: List B: epoge 46. 47. Ultrasound of the abdomen Chest X ray oGD Abdominal X ray erect position Intravenous urogram Obese 40-year-old women complains of right hypochondrial pain after eating fatty meal. 30-year-old man with history of chronic dyspepsia presented to the emergency department with sudden onset of severe abdominal pain radiating to the tip of right shoulder.List B: 46. Obese 40-year-old women complains of right hypochondrial pain after eating fatty meal. 47. 30-year-old man with history of chronic dyspepsia presented to the emergency department with sudden onset of severe abdominal pain radiating to the tip of right shoulder. 48. 65-year-old man presented to the surgical assessment unit with a 2-day history of abdominal pain and absolute constipation. 49. 21-year-old student presented with sudden onset left loin pain radiating to the groin. She is rolling in the bed with agony. She has never had the pain before. 50. 64-year-old man presented to the emergency department with epigastric pain. While he is in the department, he developed vomiting. The nurse commented the vomitus is coffee ground in color.Part 3: Short essay questions. (4 marks for each question) Q1. Give short account on treatment of acute exacerbation of COPD. Q2. Give 3 presentations of congenital heart for each. 3. Outline how would you treat diabetic ketoacidosis. ase in adolescents & adults with 1 example Q4, Enumerate 5 differences between Hepatitis B and Hepatitis C viral infection? QS. What are the indications for the dialysis?Part 4: Modified Essay questions. (7.5 marks for each question) Q1. A 50-year-old nurse presented complaining of menstrual irregularities, lethargy, and mood changes. She had also cold intolerance and constipation. She was a known hypertensive, currently on amlodipine and doxazosin therapy, but was not diabetic. On examination, her visual fields were normal on confrontation testing. 1. Whats the most likely diagnosis? 2. How would you investigate this lady? 3. How would you treat? Q2. Middle aged female patient had arrhythmia on chronic use of amiodarone, presented with asymptomatic abnormal liver function test, on examination she had hepatomegaly without jaundice &negative viral screen. 1. What is the diagnosis? 2. What is the histopathology? 3. How would you manage this patient?Q3. A Thirty-four years old male with negative past medical history, presented with chest pain aggravated by left upper limb movement and associated with local tenderness. He is smoker (1pak per day fOr 15 years). His father had cardiac attack when he was 70 years old. 1. What are the urgent investigations he should do? 2. Ifthe investigation was normal what is the most likely diagnosis? 3. What advice will you give him as a primary prevention from ischemic heart disease?Q4. A 19-year-old previously healthy girl visits her doctor with loin pain and episodes of urgency over the last few days then she develops a fever with rigors and accompanied by nausea, emesis, worsening flank pain and decreased urine output. Physical examination reveals a temperature of 38.9C and costovertebral angle tenderness. WBC count: 13,900/mm3 Neutrophils: 74% Blood urea nitrogen (BUN): 10 mg/dl (N7-20) Serum creatini Urinalysis: 2+ protein, many WBCs, 2-5 RBCs/hpf, few bacteri 1. What is your likely diagnosis? 2. How you can confirm your diagnosis? 3. Your management plan. 1.1 mg/dl (N and WBC casts 1.2)