INTERNAL MEDICINE

JANUARY 2021 END OF ROTATION EXAM

1. The following illnesses can cause peripheral neuropathy, EXCEPT:

A. Sjogren syndrome
B. Diabetes mellitus
C. Hyperthyroidism
D. Sarcoidosis

Answer: C. Hyperthyroidism
Ratio: Different causes of Acquired Neuropathies include Primary or AL Amyloidosis,
Diabetes Mellitus, HYPOthyroidism, Sjogren Syndrome, Rheumatoid Arthritis, Systemic
Lupus Erythematosus, Scleroderma, Mixed Connective Tissue Disease, Sarcoidosis,
Hypereosinophilic syndrome, Celiac Disease, Inflammatory Bowel Disease, Uremic
Neuropathy, Chronic Liver Disease, Critical Illness Polyneuropathy, Leprosy (Hansen’s
Disease), Lyme Disease, Diphtheritic Neuropathy, HIV-related, Herpes Varicella-Zoster,
Cytomegalovirus, Epstein-barr, Hepatitis

2. The following are essential in the diagnosis of Guillian-Barre Syndrome, EXCEPT:

A. Clinical characteristics
B. Spinal cord MRI
C. CSF analysis
D. Nerve conduction velocity studies

Answer: B. Spinal Cord MRI

Ratio: GBS is a descriptive entity. The diagnosis of AIDP is made by recognizing the pattern
of rapidly evolving paralysis with areflexia, absence of fever or other systemic symptoms, and
characteristic antecedent events. Table 439-3 Brighton Criteria for Diagnosis of Guillian-Barre
Syndrome (GBS) and Miller Fisher Syndrome revealed different clinical characteristics,
electrophysiologic findings, nerve conduction studies, and CSF analysis.

3. In determining the possible cause of seizure, intake of these drugs should be asked, EXCEPT:
a. Tramadol
b. Isoniazid
c. Ibuprofen
d. Gingko

Answer: C. Ibuprofen
Ratio: The following drugs and other substances causes seizures: Alkylating agents (busulfan,
chlorambucil), Antimalarials (chloroquine, mefloquine), Antimicrobials/antivirals (beta lactam
and related compounds, quinolones, acyclovir, isoniazid, ganciclovir), Anesthethics and
analgesics (meperidine, fentanyl, tramadol, local anesthetics), Dietary supplements (Ephedra
- ma huang, Gingko), Immunomodulatory drugs (Cyclosporine, OKT3 - monoclonal
antibodies to T cells, Tacrolimus, Interferons), Psychotropics (Antidepressants - bupropion,
 Antipsychotics - clozapine, Lithium), Radiographic contrast agents, Drug withdrawal (Alcohol,
Baclofen, Barbiturates - short-acting, Benzodiazepines - short-acting, Zolpidem), Drugs of
abuse (Amphetamine, Cocaine, Phencyclidine, Methylphenidate), Flumazenila

4. Which among these anti-epileptic drugs can cause weight gain?

a. Phenytoin
b. Topiramate
c. Valproic acid
d. Levetiracetam

Answer: C. Valproic Acid

Ratio: Table 418-9 Dosage and Adverse Effects of Commonly Used Antiepileptic Drugs

5. Lacunar infarction accounts for how many percent of all strokes?

a. 50%
b. 5%
c. 30%
d. 20%

Answer: D. 20%
Ratio: Lacunar strokes account for about 20% of all strokes in the United States. (Harvard
Health)

6. Which of the following genetic mutations largely contribute to the development of colonic
cancer?
a. K-ras point mutation
b. EGFR mutation
c. HER-2 amplification
d. BRCA 1 mutation

Answer: A. K-ras point mutation

Ratio: A number of molecular changes are noted in adenomatous polyps and colorectal
cancers that are thought to reflect a multistep process in the evolution of normal colonic
mucosa to life-threatening invasive carcinoma. These developmental steps toward
carcinogenesis include, but are not restricted to, point mutations in the K-ras
protooncogene; hypomethylation of DNA, leading to gene activation; loss of DNA (allelic
loss) at the site of a tumor-suppressor gene (the adenomatous polyposis coli [APC] gene) on
the long arm of chromosome 5 (5q21); allelic loss at the site of a tumor-suppressor gene
 located on chromosome 18q (the deleted in colorectal cancer [DCC] gene); and allelic loss at
chromosome 17p, associated with mutations in the p53 tumor- suppressor gene.

7. Which of the following symptoms most commonly occur in right-sided colonic tumors?
a. Fatigue
b. Hematochezia
c. Obstruction
d. Narrowing of stool calibre

Answer: A. Fatigue
Ratio: Lesions of the right colon commonly ulcerate, leading to chronic, insidious blood loss
without a change in the appearance of the stool. Consequently, patients with tumors of the
ascending colon often present with symptoms such as fatigue, palpitations, and even
angina pectoris and are found to have a hypochromic, microcytic anemia indicative of
iron deficiency. Because the cancers may bleed intermittently, a random fecal occult
blood test may be negative. As a result, the unexplained presence of iron-deficiency anemia
in any adult (with the possible exception of a premenopausal, multiparous woman) mandates
a thorough endoscopic and/or radiographic visualization of the entire large bowel.

8. Which of the following agents has been proven to reduce the risk of colon adenomas and
carcinomas?
a. Ascorbic acid
b. Beta-carotene
c. Fiber
d. Aspirin

Answer: D. Aspirin
Ratio: Several orally administered compounds have been assessed as possible inhibitors of
colon cancer. The most effective class of chemopreventive agents is aspirin and other
NSAIDs, which are thought to suppress cell proliferation by inhibiting prostaglandin synthesis.
Regular aspirin use reduces the risk of colon adenomas and carcinomas as well as
death from large-bowel cancer; such use also appears to diminish the likelihood for
developing additional premalignant adenomas following successful treatment for a prior colon
carcinoma. This effect of aspirin on colon carcinogenesis increases with the duration and
dosage of drug use.

9. Which of the following chemotherapeutic agents causes dose-dependent sensory

neuropathy?
a. 5FU
b. D2 Panitumumab
c. Oxaliplatin
d. Irinotecan

Answer: C. Oxaliplatin
 Ratio: Oxaliplatin frequently causes a dose-dependent sensory neuropathy that often but not
always resolves following the cessation of therapy.
Table 69-4 Cytotoxic Chemotherapy Agents

From Management of Oxaliplatin-induced peripheral neuropathy journal (ncbi), Neurotoxicity

is the most frequent dose-limiting toxicity of oxaliplatin. A cumulative sensory peripheral
neuropathy may develop with prolonged treatment with oxaliplatin.

10. A 43 year old male diagnosed with colon cancer stage III s/p hemicolectomy s/p adjuvant
chemotherapy x 3 cycles had a repeat CEA which was more elevated than the pre-op CEA.
What is the next appropriate diagnostic examination?
a. Fecalysis with occult blood
b. Repeat CEA
c. Request for lipid profile
d. Chest and abdominal CT scan

Answer: B. Repeat CEA *not sure*

Ratio: Following recovery from a complete resection, patients should be observed carefully
for 5 years by semiannual physical examinations and blood chemistry measurements. If a
complete colonoscopy was not performed preoperatively, it should be carried out within the
first several postoperative months. Some authorities favor measuring plasma CEA levels
at 3-month intervals because of the sensitivity of this test as a marker for otherwise
undetectable tumor recurrence. (Harrisons)

When serum CEA levels are measured over time after surgery, the serum CEA level often
increases several months before recurrence is detected on conventional imaging
studies and clinical examinations. Serum CEA levels have therefore been widely used
for postoperative surveillance in patients with colorectal cancer. However, serum CEA
levels fluctuate over time even in the same individuals. In some patients, the serum CEA level
becomes positive in the absence of recurrence. In other patients who have positive serum
CEA levels at initial surgery, the level becomes negative at the time of recurrence. Therefore,
the sensitivity and specificity of serum CEA levels for the detection of recurrence are not high.
(NCBI journal: ncbi.nlm.nih.gov/pmc/articles/PMC5452279)

11. Which of the following is a criterion for screening for diabetes in asymptomatic adults?
a. Family History of type 1 diabetes mellitus
b. Asian with a BMI >= 23 kg/m2
c. Women who delivered a baby > 7.5 lbs
d. Triglyceride level of >150 mg/dL

Ratio:
Criteria for testing Diabetes or Prediabetes in Asymptomatic Adults:
 ● Begin at age 45 years old, then every 3 years
● Screen at earlier age if they are overweight (BMI >/= 25 kg/m2 or 23 kg/m2 in Asians)
+ one additional risk factor for DM
● May use A1C, FPG or 2 hour plasma glucose after 75g OGTT for screening

Risk Factors for Diabetes Include the following:

● A1C >/= 5.7% IGT or IFG on previous testing
● First degree relative with diabetes
● High-risk ethnicity (african american, latino, native american, asian american)
● Gestational diabetes Mellitus or or delivery of a baby weighing 8 lbs or above
● Hypertension or history of CVD
● HDL <35 mg.dL and/or triglyceride >250 mg/dL
● Physical inactivity
● Polycystic ovarian syndrome
● Other conditions with insulin resistance (severe obesity, acanthosis nigricans)

12. Who of the following can definitely be diagnosed to have type 2 diabetes mellitus?
a. 14/F, non-obese with Graves’ disease and pernicious anemia with an RBS of 323 mg/dL
b. 47/M, hypertensive with an FBS of 125 mgdL
c. 29/F, with polycystic ovarian syndrome with an FBS of 90 mg/dL and a 2nd hour post 75
grams oral glucose tolerance blood glucose of 211 mg/dL
d. 63/M, post-myocardial infarction and hypertensive with an HbA1C of 6.3%

RATIO
The diagnosis of Diabetes Mellitus can be made based on the following criteria:

HbA1C >6.5%

Fasting Plasma Glucose (FBG) or >/= 126 mg/dl (7.0 mmol/L)

Fasting Serum Glucose (FBS)

2-hour plasma glucose during 75 g OGTT >/= 200 mg/dL (11.1 mmol/L)

Random Blood Sugar >/= 200 mg/dL (11.1 mmol.L) with

classic symptoms of hyperglycemia

13. A 45/F consulted due to dysuria. On history, she was diagnosed with type 2 diabetes a month
ago and was given several oral hypoglycemia agents. Which of the following medications could
be the culprit?
a. Empagliflozin
b. Pioglitazone
c. Glimepiride
d. Linagliptin
Ratio:
Empagliflozin ● Na-glucose cotransporter-2 inhibitor (SGLT2i)
● MOA: Increase urinary glucose excretion
● Common Side effects:
○ Urinary & vaginal infections
○ Dehydration

Pioglitazone ● Thiazolidinediones
● MOA: decreases insulin resistance, increases glucose
utilization
● Common side effects:
○ Edema
○ Weight gain
○ Osteoporosis
○ Anemia
○ CHF

Glimepiride ● Sulfonylureas
● MOA: Increases insulin secretion
● Common side effects:
○ Hypoglycemia
○ Weight gain

Linagliptin ● DPP-IV inhibitors (DPP4i)

● MOA: Prolongs endogenous GLP-1 action
● Common side effects:
○ Headache
○ Nasopharyngitis
○ Requires renal dose adjustment

14. Which of the following insulin should always be given before a meal?
a. Insulin detemir
b. Insulin glargine
c. Insulin degludec
d. Insulin lispro

Ratio:
Basal Insulin ● Required to regulate metabolic processes even in the
absence if meals
● Examples:
○ Glargine
○ Detemir
○ Degludec

Bolus Insulin ● Required to cover glycemic excursions following a meal

 ● Rapid-acting insulin given within 15-20 mins or immediately
before meals
● Short-acting insulin given within 30-45 mins before meals
● Examples
○ Lispro
○ Aspart
○ Glulisine

15. A 39/M was referred to for evaluation and clearance prior to employment. He has a past
history and family history of goiter. On PE, a 2.5 cm mass in the isthmus, a 3.0 mass in the right
thyroid lobe were palpated. Review of systems and PE suggest a clinically euthyroid state.
Thyrotropin was elevated. What is the most likely diagnosis?
a. Multinodular toxic goiter
b. Graves’ disease
c. Multinodular non-toxic goiter
d. Subacute painless thyroiditis with nodules

Ratio:
● Multinodular toxic goiter - similar to non-toxic goiter but with functional autonomy;
includes subclinical/mild overt hyperthyroidism.
● Graves’s disease - goiter results mainly from the TSH-R mediated effects of thyroid
stimulating immunoglobulins
● Multinodular non-toxic goiter - nodules in the thyroid of normal size;
asymptomatic and euthyroid
● Subacute painless thyroiditis with nodules - disordered growth of thyroid cells which can
be either hyperplastic or neoplastic

16. The stage of negative iron balance is characterized by:

a. Decreased hemoglobin/hematocrit
b. Decreased ferritin
c. Decreased serum iron
d. hypochromic, microcytic red cells

Ratio: If there is a negative iron balance, iron stores are depleted and serum ferritin levels
decrease

17. The diagnostic test for autoimmune hemolytic anemia:

a. Osmotic fragility
b. Direct antiglobulin test
c. Direct and indirect bilirubin test
d. Peripheral blood smear

Ratio: Autoimmune hemolytic anemia is diagnosed by coomb’s direct antiglobulin test

18. A hypochromic, microcytic form of anemia with codocytes, decreased red cell indices but
normal iron stores
a. Iron deficiency anemia
b. Sideroblastic anemia
c. Thalassemia
d. Anemia of chronic disease

Ratio:
Iron deficiency anemia
● Microcytic, hypochromic
● Low serum iron
Sideroblastic anemia
● Variable smear
● Normal to high iron
Thalassemia
● Microcytic/hypochromic with targeting or codocyte
● Normal to high serum iron
Anemia of chronic disease
● Normal/microcytic/hypochromic
● Low serum iron

19. A 58 y/o male with cirrhosis of the liver consulted because of easy fatigability associated
with pallor, ictericia, and splenomegaly. Bone marrow aspiration showed hypercellular reactive
marrow with no dysplastic changes or increase in blasts. The most likely diagnosis of this
patient is __________.
a. Myelodysplastic syndrome
b. Myelophthisic syndrome
c. Hypersplenism
d. Hereditary spherocytosis

Ratio:
Myelodysplastic syndrome - one of a group of cancers in which immature blood cells in the bone
marrow do not mature, so do not become healthy blood cells

Myelophthisic syndrome - characterized by the presence of immature erythrocytes in the

peripheral blood due to the infiltration (crowding out) of the bone marrow by abnormal tissue

Hypersplenism - characterized by a significant reduction in one or more of the cellular elements

of the blood in the presence of normocellular or hypercellular bone marrow and
splenomegaly

Hereditary spherocytosis - autosomal dominant inheritance, deficiency of spectrin and ankyrin,

increased MCHC on PBS and diagnosed by osmotic fragility test.
20. The characteristic lesion seen in type 1 hypersensitivity reaction is
a. Vasculitis
b. Angioedema
c. Vesiculobullous lesions
Ratio:

21. A twenty-one-year-old female developed joint pains, fever, rash and palpable lymph nodes
three weeks after receiving a vaccine. The adverse reaction is characteristic of:
a. Type 1 hypersensitivity reaction
b. Type 2 hypersensitivity reaction
c. Type 4 hypersensitivity reaction
d. Type 3 hypersensitivity reaction
Ratio:
Type I- “immediate reactions”; they are antibody-mediated and include anaphylactic and atopic
immune responses.
● Immediate reaction: allergic reaction within minutes of contact with the antigen
● Late-phase reaction: occurs hours after immediate reaction for a duration of 24–
72 hours
Type II- “cytotoxic reactions,” are antibody-mediated and responsible for a number of
autoimmune disorders
● Examples: Goodpasture syndrome, rheumatic fever

Type III- referred to as immune complex reactions, are antibody-mediated.

● Serum sickness
○ usually develops as a complication of antitoxin or antivenom
administration.
 ○ Clinical Features- Symptoms appear 1–2 weeks following initial exposure
(because antibodies take several days to form), and usually resolve within
a few weeks after discontinuation of the offending agent.
○ Fever
○ Rash (urticarial or purpuric)
○ Arthralgias, myalgia
○ Lymphadenopathy
○ Headache, blurred vision
○ Abdominal pain, diarrhea, nausea/vomiting
● Arthus Reaction
○ Etiology: vaccination against tetanus, diphtheria
○ Clinical features
■ Localized swelling, erythema, hemorrhage
■ Sometimes superficial skin necrosis a few hours after booster
vaccination
■ Reaction peaks
■ 12–36 hours later.

Type IV- referred to as delayed and cell-mediated.

● Examples- Allergic contact dermatitis, DRESS syndrome, TYPE IV drug
reactions, Guillain-Barré syndrome, Hashimoto thyroiditis, Multiple sclerosis,
Rheumatoid arthritis, Type 1 diabetes mellitus.

22. Serum tryptase, used as marker of anaphylaxis is a:

a. Cytokine released from activated lymphocytes
b. A neutral protease from mast cells
c. Preformed mediator from eosinophils
d. Readily formed mediator from basophils
Ratio:
Tryptase is a neutral protease selectively concentrated in the secretory granules of human
mast cells (but not basophils), and released by mast cells together with histamine and serves
as a marker of mast-cell activation. Serum tryptase is a relatively specific marker of mast cell
activation. Elevated levels indicate an increased risk of severe reactions.

23. A 25-year-old primigravid on her 24 week of gestation consults because of blood pressure
readings of 140 to 160 mmHg systolic on her pre-natal checkup. She is asymptomatic. Blood
pressure 150/100 mmHg. What is the diagnosis?
a. Chronic hypertension
b. Eclampsia
c. Hypertensive urgency
d. Pregnancy induced hypertension
Ratio:
Chronic Hypertension- BP> or = to 140/90 before pregnancy or diagnosed before 20 weeks
gestation.

Eclampsia- onset of generalized tonic-clonic convulsions in a woman with preeclampsia that

cannot be attributed to other causes; >/= 20 weeks AOG

Hypertensive urgency- BP- 180/110 or higher without damage to the body’s organs.

Pregnancy induced hypertension- systolic BP > or = 140 or diastolic BP > or = 90 mmHg

for the first time after mid-pregnancy.

24. A 24-year-old male, known hypertensive and poorly compliant with medications was brought
to ER due to syncopal attack during a drinking spree. He was unresponsive with a blood
pressure of 240/140 mmHg, heart rate 55 beats per minute. Fundoscopy showed hemorrhage
and papilledema.
a. Acute cerebral infarction???
b. Hypertension stage 2
c. Hypertensive emergency
d. Hypertensive urgency

Ratio:
Acute cerebral infarction- A synergistic effect of alcohol and hypertension has been
suggested to increase the risk for stroke. Men with a severe form of hypertension showed a 12-
fold increased risk for cardiovascular disease mortality associated with heavy binge drinking.
Binge drinking is a significant risk factor for stroke. Hypertensive patients should be warned
about the risks of alcohol and urged to avoid binge drinking because of an increased risk for all
subtypes of stroke.

Hypertension stage 2- systolic pressure of 140 mm Hg or higher or a diastolic pressure of 90

mm Hg or higher.

Hypertension emergency- High BP associated with signs of target-organ damage

Hypertensive urgency- BP- 180/110 or higher without damage to the body’s organs.

25. A 62-year-old male hypertensive, smoker, diabetic on physical examination is a risk of

developing which among the following?
a. Congenital heart disease
b. Rheumatic heart disease
c. Coronary artery disease

Ratio:
Coronary artery disease
 ● Risk factors: Male, Older group, smoking, high blood pressure, obese, high
blood cholesterol, diabetes, family history of CAD

26. A 60-year-old male smoker diagnosed to have pulmonary mass/malignancy presented with
prominent neck veins on physical examination. What is the diagnosis?
a. Long QT syndrome
b. Marfan’s syndrome
c. Superior vena cava syndrome
d. Congestive heart failure

Ratio:
Superior vena cava syndrome (SVCS) is the clinical manifestation of superior vena cava (SVC)
obstruction, with severe reduction in venous return from the head, neck, and upper extremities.
Malignant tumors,such as lung cancer, lymphoma, and metastatic tumors, are responsible
for the majority of SVCS cases. The characteristic physical findings are dilated neck veins;
an increased number of collateral veins covering the anterior chest wall; cyanosis; and edema of
the face, arms, and chest. Facial swelling and plethora are typically exacerbated when the patient
is supine. More severe cases include proptosis, glossal and laryngeal edema, and obtundation.

27. Acne is caused by which organism?

a. Streptococcus
b. Propionibacterium
c. Staphylococcus
d. Candida
Ratio:

28. A patient presents with erosions & “honey-colored” crusts at his perioral area. This
characteristic skin finding is classic for which condition?
a. Tinea corporis
b. Perioral dermatitis
c. Bullous impetigo
d. Herpes Simplex infection

Ratio:
29. A patient presents with a 4-month history of hyperpigmented plaques with active scaly
borders in his groin area. What diagnostic test can be done to help diagnose this condition?
a. KOH
b. Blood Culture
c. GS/CS
d. Tzanck smear

Ratio:
Tinea cruris or known as Jock itch is a fungal infection of the skin. The rash has a scaly raised
red border that spreads down the inner thighs from the groin or scrotum. The diagnosis of tinea
can be made from skin scrapings, nail scrapings or hair culture or direct microscopic
examination with KOH

30. 75 year old male with COPD poorly compliant with medications, was rushed to the ER due
to shallow breathing, cyanosis and decreased sensorium. ABG showed respiratory acidosis and
hypoxemia. What is the treatment for the patient?
a. Start hydration and repeat vital signs
b. Start NIPPV or non invasive positive pressure ventilation
c. Start nebulization and observe patient
d. Intubate the patient and hook to mechanical ventilator

Ratio:
31. What are the organisms frequently implicated in acute exacerbations of COPD?
a. P. aeruginosa, A. baumanii, K. pneumoniae
b. S. pneumoniae, H. influenzae, M. catarrhalis
c. E. coli, E. aerogenes, S. marcescens
d. M. kansasii, M. chelonei, M. tuberculosis

Answer: B
Ratio:
Bacteria frequently implicated in COPD exacerbations include Streptococcus
pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. In addition,
Mycoplasma pneumoniae or Chlamydia pneumoniae are found in 5-10% of
exacerbations.

32. What is the spirometry finding in patients with obstructive disease?

a. FVC > 80%
b. FEV1 > 80%
c. FEV1 / FVC > 70%
d. FEV1 / FVC < 70%

Answer: D
Ratio:
Post-bronchodilator FEV1/FVC < 0.7 confirms presence of persistent airflow limitation
33. 62 year old female hypertensive developed easy fatigability, orthopnea, leg edema, and non
productive cough. No fever and weight loss noted. Chest xray showed bilateral pleural effusion.
What is the most likely cause of pleural effusion?
a. Congestive heart failure
b. Malignant effusion
c. Tuberculous effusion
d. Parapneumonic effusion

Answer: A
Ratio:
Heart failure is the most common cause of pleural effusion. The patient also presented
with signs and symptoms of HF such as fatigue and dyspnea (cardinal symptoms),
orthopnea, cheyne-stokes respiration, peripheral edema

34. 33 year old male, factory worker consulted your clinic due to coughing with yellowish
phlegm, intermittent fever and progressive dyspnea for 2 weeks. PE revealed lagging, absent
breath sounds and dullness upon percussion on the right lung base. What is the most likely
impression?
a. Pleural thickening
b. Pulmonary mass
c. Pneumothorax
d. Pleural effusion

Answer: D
Ratio:
Parapneumonic effusions are associated with bacterial pneumonia, lung abscesses, or
bronchiectasis and is the most common exudative pleural effusion. Pneumonia
presents with fever, cough with purulent sputum, and dyspnea. The PE finding of absent
breath sounds indicate that there is air or fluid around the lungs, and the dull percussion
indicates that fluid or solid tissue replaces air-containing lung tissues.

35. Which of the following urinary indices suggest Pre-renal azotemia?

a. Urine:Plasma Creatinine (U/P Crea) 13
 b. BUN:Creatinine ratio (BCR) 10:1
c. Urine Sodium (UNa) 25 mmol/L
d. Fractional Excretion of Sodium (FENa) 0.6%

Answer: D.
Ratio:
Prerenal azotemia lab findings:
● BUN/creatinine ratio above 20
● FeNa <1%
● Hyaline casts in urine sediment
● Urine specific gravity >1.018
● Urine osmolality >500 mOsm/kg

36. 70/M with diarrhea was noted to have rising creatinine from 92 umol/L to 110 umol/L and
155 umol/L in 3 days despite hydration. What urine microscopic findings would suggest Acute
Tubular Necrosis?
a. Granular cast
b. Waxy cast
c. WBC cast
d. Hyaline cast

Answer: A
Ratio:

37. 45/M, 65 kg consulted due to right flank pain. Labs: Creatinine 170 umol/L, Urinalysis: sp.gr
= 1.025; pH = 5.0; Albumin = +1; Sugar = negative; RBC = 15-20/hpf; WBC = 5-8/hpf; Uric acid
crystals = +. What is the recommended imaging study for this patient?
a. Non-Contrast CT scan
 b. Intravenous Pyelogram (IVP)
c. Magnetic Resonance Imaging (MRI)
d. Plain abdominal radiograph

Answer: A
Ratio:
This is suggestive of a Nephrolithiasis, specifically Uric Acid Stones because of the
findings: right flank pain, increased RBC and WBC, and Uric acid in urine. The gold
standard diagnostic for nephrolithiasis is Helical CT scan without contrast

38. A 50/F, wt. 60 kg is scheduled for coronary angiogram. Her baseline Creatinine is 130
umol/L. What is the recommended IV fluid for the prevention of Contrast induced AKI?
a. Lactated Ringers
b. D5 0.3 NaCl
c. 0.9% NaCl
d. 0.45% NaCl

Answer: C
Ratio:
Contrast induced AKI is characterized as the rise of SCr beginning 24-48 hrs following
exposure, peaking within 3-5 days, and resolving within 7 days. High risk patients (i.e.
CKD) should undergo periprocedural hydration by initiating IV fluid with isotonic saline
solution (0.9% NaCl) at a rate of 1 ml/kg/hr for 6-12 hours before the procedure and
continuing after the procedure.

39. Which of the following laboratory parameter is an indication for renal replacement therapy in
AKI?
a. Bicarbonate 14 mmol/L
b. BUN 60 mg/dL
c. Potassium 6 mmol/L
d. Creatinine 4 mg/dL

Answer: A
Ratio:
Renal replacement therapy or dialysis is indicated when medical management fails to
control volume overload, severe hyperkalemia, or metabolic acidosis; in some toxic
ingestions; and severe complications of uremia. Normal bicarbonate is 22-26 mmol/L,
therefore a 14 mmol/L bicarbonate means there is acidosis.

40. A 55/M on twice weekly hemodialysis missed his dialysis for a week came to the emergency
room because of palpitation. Persistent findings on physical examination include BP = 160/90,
HR = 45, RR = 21, bibasal crackles, grade 2 bipedal edema. ECG showed sinus bradycardia,
peaked T waves on chest leads with prolonged PR interval. Which of the following should be
given first?
a. Calcium gluconate slow IV infusion
b. D5050 with regular insulin infusion
c. Nebulization with Salbutamol
d. NaHCO3 slow IV infusion

Answer: A
Ratio:
The patient’s ECG showed that there are peaked T waves, meaning that he is
undergoing hyperkalemia. ECG manifestations of hyperkalemia are considered as an
emergency. Management in order include:
● Cardioprotection - IV calcium gluconate
● Cellular redistribution - Insulin, Beta agonists, IV Bicarbonate
● Potassium excretion - Cation exchange resin, diuretics, dialysis

41. Of the medications used in the treatment of hyperkalemia, which does not cause a
transcellular shift of potassium?
a. Insulin infusion
b. Calcium gluconate
c. Albuterol nebulization
d. Bicarbonate infusion

Answer: B.
Calcium only protects from heart block or other contractility issues (membrane stabilization), but
is used together with insulin, albuterol and other drugs in conjunction for hyperkalemia
management. REFER to table and to #40 ratio.

42. Which of the following patients are uncommon to have gout?

a. Middle aged men
b. Elderly men
c. Post menopausal women
 d. Pre-menopausal women

Answer: D.

Probably pre-menopausal women. Post menopausal women lack estrogen, which contributes
to gout accumulation secondary to reduced excretion (lack of estrogen). MEN are more at risk
for gout in general. The MOST LIKELY is middle age men.

43. Which of the following drugs is generally not initiated during an acute gouty arthritis attack?
a. Colchicines
b. NSAIDS
c. Prednisone
d. Allopurinol

Answer: D.

allopurinol is for maintenance to reduce uric acid levels and thus reduce recurrence. The
other 3 choices are for acute attack symptomatic relief. Refer to image.

44. Which of the following pathologic changes is not a source of pain in osteoarthritis?
a. Synovial inflammation
b. stretching of joint capsule
c. Bone marrow edema
d. Cartilage loss

Answer: C.

All of these can cause pain (di ko sure for OA). Choices A, B, D are more associated with
osteoarthritis changes, although C can also occur in osteoarthritis, but more associated with
fractures. Refer to the picture below.
45. Which of the following is a risk factor for shortened survival in rheumatoid arthritis.
a. College graduate
b. Minimal limitation on activities of daily living
c. Chronic prednisone use
d. Middle income earner

Answer: C.
Dependence on steroids causes various range of side effects that increases morbidity of the
patient, thus shortened survival. The other risk factors are incorrect: should be, lower education
level, great limitation to daily living, and low income earner. Other prognostic criteria are seen in
the image below:

46. Viral arthritis most commonly presents with__.

a. Acute polyarthritic
b. Chronic monoarthritis
c. Acute monoarthritis
d. Recurrent monoarthritis

Answer: A.
usually presents as acute, self limiting, non-destructive symmetrical, peripheral small joints
(hands, wrists, knee and ankle).

47. Which of the following are disease modifying drugs for rheumatoid arthritis?
a. Methotrexate
b. Diclofenac
c. Aspirin
d. Allopurinol

Answer: A.

Among these choices only Methotrexate is a DMARD. The other DMARS for RA are listed in the
table below:

48. A definitive diagnosis of CPPD arthropathy is made by demonstration of which of the

following crystals under polarized microscopy?
a. Weakly positive birefringent rhomboid shaped crystals
b. Strongly birefringent bipyramidal crystals
c. Negatively birefringent needle shaped crystals
d. Positive birefringent needle shaped apative crystals

Answer: A.

Pseudogout has calcium pyrophosphate crystals, which appear as rhomboid and are only
weakly positive birefringent. In GOUT, the crystals are needle shaped and strongly
negative birefringent.

49. Which of the following dermatologic manifestations is pathognomonic of dermatomyositis?

a. Oral ulcer
b. Gottron's papules
c. Circinate balanitis
d. Discoid rash

Answer: B.
Classic sign seen in this condition. These are seen as erythematous to violaceous papules and
plaques over the extensor surfaces of the metacarpophalangeal and interphalangeal joints.
Circinate balanitis is seen in reactive arthritis/Reiter's syndrome. Discoid Rash is seen in
CLE(cutaneous lupus erythematosus).

50. A premenopausal 50 year old woman came in for consult due to polyarthritis of three
months duration temporarily relieved with intake of diclofenac. PE confirms swelling and
tenderness of both wrists and knees and left ankle. Lab workup reveals anemia,
thrombocytosis, elevated esr and normal urinalysis. Which of the following immunologic tests is
most helpful in the diagnosis of this patient?
a. Serum uric acid
b. Rheumatoid factor
c. Antinuclear antibody
d. anti-dsDNA antibody

Answer: B.

Choice B is more useful test, since there is high clinical suspicion for inflammatory arthritis
conditions like Rheumatoid arthritis . there is no definitive diagnosis for RA, but elevated ESR,
CRP, anti-CCP and RF are indicators for this condition. Choices C and D are more specific for
SLE, while choice A more on Gout.

51. A 70 year-old male sought consult due to pain and swelling involving the right knee of 3
days duration. He denies trauma, fever, dysuria and diarrhea. On PE you noted a positive bulge
sign on the right knee hence arthrocentesis was done. Synovial fluid analysis revealed an
inflammatory count of 5000 wbc/uL, rod shaped weakly birefringent crystals under polarized
microscopy and no growth on culture. What is the diagnosis for this patient?
a. Calcium apatite deposition disease
b. Acute gouty arthritis
c. Calcium oxalate deposition disease
d. Calcium pyrophosphate deposition disease

Answer: D
Ratio:
ACUTE CALCIUM PYROPHOSPHATE DEPOSITION (CPPD) DISEASE
(PSEUDOGOUT)
● Common in elderly
● Pain, redness, warmth, swelling, and joint disability
● Most common affected joint: knee
○ MTP in gout
● Other sites: wrist, shoulder, ankle, elbow, and hands
○ UE site of inflammation for a first attack should raise suspicion for
pseudogout
● How to differentiate?
 ○ Initial episodes of pseudogout may persist longer before remitting
than the one or two weeks commonly encountered in urate gout
○ !"#$%&'()*(+&,)'#'("-&-).)/0"-1'(),212/12,)&#)132)-"#$%&'()*(+&,)&-)

/'(/&+4)5"0$53$-53'12),&3",0'12

○ 6',&$70'53").)5+#/1'12)'#,8$0)(&#2'0)0',&$,2#-2),25$-&1-)9&13&#)
*&:0$/'01&('7&#$+-);$&#1)42#&-/&)$0)'01&/+('0)3"'(&#2)/'01&('72)

</3$#,0$/'(/&#$-&-=
● Definitive Dx: demonstration of typical rhomboid or rod-like crystals that
are weakly positively birefringent or nonbirefringent with polarized
light microscopy

52. A 54 yr old female suddenly collapsed inside her doctor’s clinic. Vital signs: blood pressure
undetected with generalized erythematous wheals. The first thing you should do as the doctor in
charge at the emergency room is to
a. Start dopamine infusion
b. Administer epinephrine 0.5 ml deep IM
c. Start intravenous plasma expanders
d. Administer diphenhydramine 50 mg slow IV

Answer: B
Ratio:
● Patient had anaphylactic shock with salient features of sudden collapsing, and
generalized erythematous wheals. Therapeutics of this condition is the
administration of Epinephrine 0.5 mL deep IM ASAP
○ IM injection preferred for all ages, no CI
○ Faster but safer - lower risk of cardiovascular complications like severe
HPN or arrhythmias
○ Can be repeated in 5-15 min intervals if no or inadequate response
○ Poor outcome if not given within 20 mins

53. An 8 year female with history of seizure complained of fever, painful mouth sore, yellowish
eye discharge and bullous lesions involving 7% of total body area may be suffering from
a. Drug reaction with eosinophilia and systemic symptoms (DRESS) prob secondary to
carbamazepine
b. Toxic epidermal necrolysis prob secondary to carbamazepine
c. Steven Johnson syndrome prob secondary to carbamazepine
d. Acute generalized pustulosis (AGEP) prob secondary to carbamazepine

Answer: C
Ratio:
Steven Johnson syndrome prob secondary to carbamazepine
 ● Type IV hypersensitivity reaction involving the skin and mucous
membranes. Characterized by blisters and mucosal or epidermal
detachment
History
● Symptoms:
○ Acute painful skin lesions
○ Fever >39 C
○ Sore throat
○ Conjunctivitis
○ Headache
○ Malaise
○ Arthralgia
● Burning rash starting symmetrically from the face to upper torso
● May affect GI and pulmonary systems
● CAUSATIVE DRUGS
○ Sulfonamides
○ Neviparine
○ Allopurinol
○ Lamotrigine
○ Aromatic anticonvulsants - Carbamazepine
○ NSAIDs (Oxicam)
Physical Examination
● Cutaneous lesions:
○ Macules becoming papules, vesicles, bullae, urticarial plaques,
confluent erythema
○ “Target” lesions (pathognomonic)
○ Lesion’s core may be vesicular, purpuric, or necrotic, surrounded by
macular erythema
○ Lesions may become bullous and erupt, leaving denuded skin
susceptible to infection
○ Most affected: palms, soles, dorsum of hand, extensor surfaces
● Signs of mucosal involvement:
○ Erythema
○ Edema
○ Sloughing
○ Blistering
○ Ulceration
○ Necrosis
● Ocular signs on slit-lamp exam:
○ Blepharitis
○ Meibomian gland dysfunction
○ Keratitis
○ Epithelial defect
○ Stromal ulcer
 ○ Neovascularization
● Difference between SJS and TEN:
○ SJS = <10% Skin detachment of body surface area (BSA)
○ Overlap SJS/TEN = Detachment between 10% and 30% of BSA
○ TEN = Detachment > 30% of BSA

54. A 60/ male diabetic is admitted for body weakness with serum Na = 115 mmol/L. His
physical exam shows edema suggestive of hypervolemia. His condition is most probably due to:
a. Syndrome of Inappropriate Anti-Diuretic Hormone
b. Adrenal insufficiency HYPOV
c. Acute renal failure HYPERV
d. Hypothyroidism

Answer: B
Ratio:
Patient had mild symptoms of body weakness, with edema, hyponatremia and
hypovolemia.
Hyponatremia - Hypovolemia = Renal losses (Diuretics or Adrenal
insufficiency - mineralocorticoid deficiency)
Hyponatremia - Euvolemia = SIADH, hypothyroidism, adrenal insufficiency -
glucocorticoid deficiency)
Hyponatremia - Hypervolemia = Renal failure, Heart failure, Nephrosis,
Hypoalbunemia

Mineralocorticoid deficiency
● Primary AI only
● Abdominal pain, nausea, vomiting
● Dizziness, postural hypotension
● Salt craving
● Low blood pressure
● Increased serum creatinine
● Hyponatremia - CHARACTERISTIC biochemical feature in primary AI
● Hyperkalemia
55. 78/ female known diabetic for 20 years is admitted for loss of consciousness. The capillary
blood glucose of 35 mg/dL. Review of medicines include metformin and
glibenclamide/glyburide. After giving two doses of 50 cc of 50% dextrose via IV push, her
capillary blood glucose went up to 105 mg/dL. When should you discharge the patient from the
ER?
a. Right away since her CBG is now normal
b. After 24 hours which is the expected duration of action of glibenclamide/ glyburide
c. After 8 hours which is the expected duration of action of short acting metformin
d. Check her cbg every hour for 2 hours and she may go home after 2 hours if &gt; 100
mg/dL

Answer: B
 Ratio:
Glibenclamide/glyburide can cause hypoglycemia. The patient is needed to be
observed for at least 24 hours for any recurrences.

56. 28/male admitted for fever, palpitations. PE showed BP = 100/60 HR = 120 beats per
minute, proptosis, a minimally enlarged goiter. On auscultation, his heart sounds showed rapid
regular rhythm. On further questioning he tells you he was admitted twice before in two other
hospitals in 2017 and 2018 due to muscle weakness and inability to ambulate. No other
members in his family presents with this condition. Unrecalled meds were given and no further
work-ups were advised by the doctors who attended to him. What lab tests should have been
prioritized if you were the first MD to admit him with severe muscle weakness?
a. TSH, Free T4, serum K and urine K
b. Serum K, Free T3, Free T4 levels
c. TSH, Free T4, serum aldosterone level, plasma renin activity
d. TSH, muscle biopsy, Electromyography-nerve conduction velocity (EMG-NCV)

Answer: A
Ratio:
Patient has may possibly have Thyrotoxic Periodic Paralysis, due to excess
amount of thyroxine causing hyperthyroidism and hypokalemia secondary to
thyrotoxicosis, which would manifest arrhythmia, muscle weakness and paralysis. To
confirm, TSH and Free T4 are tested to know the level of hyperthyroidism, and Serum K
and Urine K to know the level of Potassium.

57. A patient presents with multiple pustules and honey-colored crusts around the nasal area.
What diagnostic test can be done to help diagnose this condition?
a. KOH
b. GS/CS
c. Tzank Smear
d. Blood Culture

Answer: B
Ratio:
Impetigo can be diagnosed with clinical history and physical appearance;
however, gram staining and culture is done to know the causative agent and choose the
appropriate antibiotic therapy.

58. A patient presented with multiple erythematous pruritic excoriated papules on the axillae,
groin, umbilicus, and interdigital spaces. Lesions are more pruritic at night with similar lesions
within family members. What is your diagnosis?
a. Scabies
b. Arthropod Bite Hypersensitivity Reaction
c. Atopic Dermatitis
d. Intertrigo
 Answer: A
Scabies is contagious causing multiple erythematous pruritic excoriated papules
in skin folds and itching is worse at night.

59. A 60 year old female diagnosed with breast cancer 5 years ago, consulted for back pains
which were getting more severe at night. On PE, there were no significant joint deformities nor
neurological deficits. Which of the following is the BEST imaging modality?
a. Total body bone scan
b. Bone densitometry
c. X-ray of the spine and pelvis
d. MRI of the spine

Answer: D
Ratio:
● Total body bone scan - highly sensitive in the detection of osseous metastases,
provides images of the entire skeleton, and has been suggested as the first
imaging study in asymptomatic patients
● Bone densitometry - An imaging test that's used to evaluate bone fractures,
monitor bone conditions like infections, arthritis or osteoporosis, and detect
cancerous cells that have metastasized to the bone from another site.
● X-ray of the spine and pelvis - initial imaging study ordered in evaluating a patient
presenting with back pain or neurological symptoms
● MRI of the spine - gold-standard diagnostic modality in the imaging of
metastatic spinal tumors

60. What is the recommended adjuvant treatment for a premenopausal breast cancer patient
S/P MRM with ER(-) PR(-) Her2neu(+++) and positive lymph node status?
a. Aromatase inhibitors, Trastuzumab
b. Tamoxifen, Trastuzumab
c. Multi-drug chemotherapy, Trastuzumab
d. Multi-drug chemotherapy, Tamoxifen, Trastuzumab

Answer: C
Ratio:
61. A 50 year old male with non-hodgkin’s lymphoma developed new pleural effusion after his
6th cycle of chemotherapy. What is the recommended treatment?
a. Stop chemotherapy and observe
b. Continue the same chemotherapy
c. Administer new chemotherapy regimen
d. Stop chemotherapy and give natural therapy.

Answer:A

Ratio:
62. Mechanical small bowel obstruction is most likely in which of the following clinical
presentation?
a. Obstipation implies complete gut obstruction
b. Less severe crampy mid-abdominal pain in cases of higher obstruction
c. More profuse with feculent vomiting in low gut obstruction
d. Diarrhea is common in partial obstruction

Answer: A

Ratio: Complete obstruction is characterized by the failure to pass either stool or flatus with
an empty rectal vault (unless the obstruction is in the rectum). If the patient has a partial
obstruction, the patient appears obstipated but continues to pass some gas or stools. Partial
obstructions are a less urgent condition.

63. Which of the following clinical and laboratory features suggest progression of acute hepatitis
to chronic hepatitis?
● Could not see answer choices
● Alternatively, acute viral hepatitis may evolve into chronic hepatitis. HBV infection is
considered to have progressed to chronic infection when HBsAg, hepatitis B e
antigen (HBeAg), and high titers of hepatitis B viral DNA are found to persist in the
serum for longer than 6 months. Hepatitis C infection is considered to have progressed to
chronic infection when HCV RNA persists in the blood for longer than 6 months. Hepatitis A
and hepatitis E never progress to chronic hepatitis, either clinically or histologically.The
likelihood of progressing to chronic hepatitis B infection varies with the age at the time of
infection. Chronic hepatitis B infection develops in up to 90% of individuals infected as
neonates; however only 1-5% of individuals infected with HBV as adults develop chronic
hepatitis B infection.Chronic hepatitis C infection develops in 75-85% of patients infected
with hepatitis C. Individuals infected with HCV at a younger age are less likely to develop
chronic hepatitis C infection.Some patients with chronic hepatitis remain asymptomatic for
their entire lives. Other patients report fatigue (ranging from mild to severe) and dyspepsia.

64. A 25 year old ale non- smoker, nondiabetic came in for pre-employment screening with his
physical exams found to be unremarkable other than having an abnormal chest radiology. An
apicolordotic view done and show minimal hazy densities on the right apex. According to the
latest NTP MOP guidelines on TB management, what will be the initial diagnostic test to
request?
a. Request for interferon gamma release assay/ IGRA
b. Request for direct sputum smear microscopy/DSSM
c. Request for sputum GeneXpert
d. Request for Tuberculin skin test/TST

Answer: C

Ratio:
65. According to the latest 2016 Philippines CPG on management of Community Acquired
Pneumonia, how long is the duration of treatment for antibiotic coverage for the type of
etiology cause pneumonia?
a. 5 days for High Risk CAP
b. 7 days for anaerobic bacteria
c. 10 days for Legionella spp.
d. 14 days for mycoplasma

Answer: D
Ratio:
66. What is the next step if a patient with pneumonia did not improve after 3 days of empiric
antibiotic?
a. Revision of antibiotics
b. De-escalation of antibiotics
c. Treat for mycobacteria tuberculosis
d. Repeat chest radiology

Answer: A

Ratio:

67. A 55 year old known diabetic and hypertensive male was admitted at the ICU due to
severe pneumonia, according to the latest 2016 Philippines CPG on management of CAP
initial empiric antibiotic to be given should cover be
a. Ertapenem 1gm IV OD + Levofloxacin 500mg IV OD
b. Co-amoxiclav 1gm IV BID + Azithromycin 500mg PO OD
c. Cefuroxime 1.5gm IV q8hrs + Clarithromycin 500mg PO DIB
d. Ceftriaxone 1gm IV q8hrs + Azithromycin 500mg 1 tab OD

Answer: A

Ratio: this is a treatment for high risk CAP, also known as severe pneumonia
68. A 60 year old male chronic smoker was admitted due to COPD exacerbation and
pneumonia, according to latest Philippines CPG on management of CAP the empiric antibiotic
to be initiated should cover for this organism.
a. Legionella spp.
b. Pseudomonas spp.
c. Mycobacterium spp.
d. Anaerobes

Answer: A and D

Ratio: COPD is usually seen in moderate risk CAP and the antibiotic coverage should be for the
following microorganisms : Streptococcus pneumoniae, Haemophilus influenzae,
Chlamydophila pneumoniae, Mycoplasma pneumoniae, Moraxella catarrhalis, Enteric Gram-
negative bacilli, Legionella pneumophila, Anaerobes (among those with risk of aspiration) .
According to my research, patients with COPD exacerbation has a risk of aspiration due to
discoordination between breathing and swallowing. Making it hard to choose the exact
answer for this case.
69. A 28 year old non pregnant woman consulted at your clinic for a second opinion regarding
her urine culture and sensitivity yielding E.coli of more than 100,000 cfu/ml. She has no
vaginal discharge, dysuria, hematuria, frequency or flank pain. She had one episode of
terminal dysuria last year. What is your diagnosis?
a. Recurrent UTI
b. Acute uncomplicated cystitis
c. Asymptomatic bacteriuria
d. Recurrent UTI, reinfection

Answer: C

Ratio: Asymptomatic bacteriuria is the presence of bacteria in the properly collected urine of a
patient that has no signs or symptoms of a urinary tract infection. For women, two consecutive
specimens with isolation of the same bacteria species with at least 100,000 colony-forming units
(CFUs) per ml of urine.

An uncomplicated UTI is one that occurs in a healthy host in the absence of structural or
functional abnormalities of the urinary tract. Recurrent uncomplicated UTI may be defined as 3
or more uncomplicated UTIs in 12 months (Level 4 evidence, Grade C recommendation).

Recurrent UTIs occur due to bacterial reinfection or bacterial persistence. Persistence involves
the same bacteria not being eradicated in the urine 2 weeks after sensitivity-adjusted treatment. A
reinfection is a recurrence with a different organism, the same organism in more than 2 weeks, or
a sterile intervening culture (Level 4 evidence, Grade C recommendation).

Uncomplicated cystitis occurs in patients who have a normal, unobstructed genitourinary

tract; who have no history of recent instrumentation; and whose symptoms are confined to
the lower urinary tract. Uncomplicated cystitis is most common in young, sexually active
women. Patients usually present with dysuria, urinary frequency, urinary urgency, and/or
suprapubic pain.
70. Diabetic patients with intermittent chest pain complain of 2 pillow orthopnea, bipedal
edema and paroxysmal nocturnal dyspnea. Physical exams revealed a JVP at 12cmH2O
and bibasal fine rales. What is the most appropriate drug to use?
a. Furosemide
b. Metolazone
c. Hydrochlorothiazide
d. Tolvaptan
Answer: A

Ratio: This is a case of Heart Failure, presenting with cardiogenic pulmonary edema and
furosemide is the most commonly used of these drugs.

Tolvaptan (Samsca) is used to treat hyponatremia (low levels of sodium in the blood) in people
who have heart failure (a condition in which the heart cannot pump enough blood to all parts of the
body).

Metolazone is a prescription drug and is a "water pill" (diuretic) that increases the amount of urine
you make, which causes your body to get rid of excess water.

Hydrochlorothiazide can cause high blood sugar levels. If you take hydrochlorothiazide with
diabetes drugs. Patient is diabetic

71. A 45 year old female complains to you of numbness of the right side of the face with
associated weakness of the right upper and lower quadrant of her face of 3 days
duration. She complains of pain behind the pina of her right ear with associated ringing of
her ears. The first thing you will do is?
 a. Recommend admission to a hospital
b. Order blood test and brain CT scan
c. Interview her about her family background
d. Do a complete history and neurologic exams
Answer: D

Ratio: As we may all know, the best approach in the diagnosis and treatment of all clinical
cases is through a complete history and PE, in this case, family history is included in complete
history. Laboratory test and admissions are necessary if you know first what you are dealing
with. This maybe you eliciting other underlying causes through history and P.E.

72. A 32 year old male office worker after joining a company outing complains to you of low
back pain after a weekend stint of basketball. He felt a vague ache on his right low back after a
rebound landing but still continued to play. The next day, he could not get up from bed due to
left buttock pain radiating to his left posterior leg. He had not played basketball for about 6
months nor had adequate warm up. What special test would you perform first?
a. Pivot shift test
b. Ely Test
c. Schober test
d. Option D is missing in picture

Ratio:
Pivot shift test: The pivot shift is a dynamic but passive test of knee stability, carried out
by the examiner without any activity of the patient. It shows a dysregulation between
rolling and gliding in the knee joint. The purpose of this test is to detect anterolateral
rotary instability of the knee. The structures that could be compromised if this test is
positive are the ACL, LCL, posterolateral capsule, arcuate complex and ITB.

Ely Test: Ely’s test or Duncan-Ely test is used to assess rectus femoris spasticity or
tightness

Schober Test: Schober’s test is classically used to determine if there is a decrease in

lumbar spine range of motion (flexion)
The measurement of this test is useful for screening the status of ankylosing spondylitis
disease, determination of progression and therapeutic effects of ankylosing spondylitis
and other pathologic conditions associated with low back pain

73. A 55 year old cachectic teacher was diagnosed with stage 3 breast cancer S/P Double
mastectomy was referred to you for evaluation. She complains of general body malaise, has
poor appetite and is unable to move her right upper limb due to whole arm swelling. She further
complains of right upper limb pain. She is afebrile, with BP 110/70 mmHg; HR 90; RR 22. In
your examination of her right limb, you check for ____ in consideration of ___:
a. Blanching, Causalgia
b. Peripheral pulses, Neuropathy
 c. Stemmer Sign, Lymphedema
d. Tenderness, Cellulitis

Ratio:
Option B: It is related to patient underwent chemotherapy for breast cancer

Option C: Stemmer sign is a thickened skin fold at the base of the second toe or second
finger (Not for upper limb) that is a diagnostic sign for lymphedema

Option D: In cellulitis, there should be redness

74. A recently diagnosed HIV patient presented with fever and cough of 3 weeks duration. The
most likely diagnostic result to diagnose active PTB is smear ____.
a. Negative, PPD positive
b. Positive, Xpert MTB/RIF all negative, TB Culture result of non tuberculous mycobacteria
c. Negative, PPD negative, Chest X Ray apical infiltrate
d. Negative, Xpert MTB/RIF positive for MTB negative RIF, TB Culture positive
growth

Ratio:
Smear: HIV patients frequently show negative smear.

PPD: Positive PPD, it means you have been exposed to a person who has tuberculosis
and is infected with the bacteria (mycobacterium tuberculosis). But positive PPD does
not differentiate active infection vs latent infection.

Gene Xpert: It is more sensitive, accurate and faster than traditional acid-fast bacillus
smear microscopy for diagnosing pulmonary tuberculosis.

Culture: Remains the gold standard for TB diagnosis especially in ruling out non-
tuberculous mycobacteria (NTM)

75. BG, a 29 year old female diagnosed to have CML, was confined due to cough, fever and
dyspnea. He is in his 9th day of 3rd cycle of chemotherapy. Broad spectrum antibiotics were
given but he deteriorated. Bronchoalveolar lavage was done which revealed septated hyphae,
branching at 45 degrees. The patient is diagnosed to have ____.
a. Pneumocystis Pneumonia
b. Invasive Candidiasis
c. Pulmonary Cryptococcosis
d. Invasive Aspergillosis

Ratio: Aspergillus is an opportunistic fungus. It is an ascomycete and therefore is

characterized by dimorphism (yeast forms and hyphae forms), septate hyphae, sexual
spores found in an ascus and asexual spores (conidia) found on conidiophores.
 Aspergillus can be identified quickly by its septate hyphae and the 45 degree angle
branching of its hyphae.

76. A patient was diagnosed with catheter-associated urinary tract infection (CA-UTI) and the
urine culture result was: 100,000 cfu/mL of Escherichia coli
S: Piperacillin-Tazobactam, Ciprofloxacin, Amikacin, Ertapenem, Meropenem
R: Ampicillin-sulbactam, Cefuroxime, Ceftriaxone, Ceftazidime, Cefepime
The best treatment plan is to replace the IFC and start patient with _____.
a. Ciprofloxacin
b. Meropenem
c. Piperacillin-Tazobactam
d. Ertapenem

Ratio: For this case, first look at the resistance pattern of the pathogen. It is resistant to
Ampicillin-sulbactam, Cefuroxime, Ceftriaxone, Ceftazidime, and Cefepime.
Ceftriaxone, and Ceftazidime are 3rd generation Cephalosporins (another is
Cefotaxime), making E. coli an ESBL (extended spectrum beta-lactamase).

The only current proven therapeutic option for severe infections caused by extended-
spectrum beta-lactamase (ESBL)-producing organisms is the carbapenem family:
- Ertapenem
- Meropenem
- Imipenem
- Doripenem

Since this is an isolated pathogen from the urine, you don’t need a carbapenem with
antiPseudomonal coverage; therefore, Ertapenem is the best answer.

77. Which of the following concepts is TRUE of sepsis? 2044

a. There is a specific test considered gold standard to diagnose sepsis.
b. The use of two or more systemic inflammatory response syndrome criteria (SIRS) is
accurate for identifying patients with sepsis.
c. Sepsis is differentiated from infection by the presence of dysregulated host
response and organ dysfunction.
d. The clinical and biological characteristics of sepsis cannot be modified by a patient's
long-standing comorbidities.

Ratio:
Option A: There is NO specific test
Option B: The SIRS criteria is UNRELIABLE that’s why we have new criterias like the
qSOFA.
qSOFA criteria
• Respiratory rate >= 22/min
 • Altered mentation
• Systolic blood pressure <= 100 mmHg systolic
Option D: CAN BE MODIFIED

78. Which of the following patients should be given empiric broad-spectrum antibiotics while
investigating the cause of the FUO?
a. 28/F, 10-days post-chemotherapy for breast cancer
b. 75/M, retired banker, who complains of intermittent difficulty in voiding
c. 46/F, medical technologist, who reports persistent fatigue at work
d. 35/M, HIV positive who reports non-compliance with his antiretroviral therapy for 1
month

Ratio: Empirical Therapeutic Trials are probably the best reserved for those few patients
in whom all other approaches have failed, and for the occasional patient who is too ill for
the therapy to be withheld pending further observation.

Extra: FUO is now defined as follows:

>?)@2%20)ABC?BDE)<A>F>D@=)$#)'1)(2'-1)19$)$//'-&$#-

G?)H((#2--),+0'1&$#)$*)AB)922I-
3. No known immunocompromised state
4. Diagnosis that remains uncertain after a thorough history-taking, physical
examination, and the following obligatory investigations

79. Among the different types of acute coronary syndromes, the ECG characteristics
(Incomplete question seen in picture)

80. No available question

81. A 58 year old male recently underwent primary PCl for an anterior STEMI. As the laboratory
results showed normal cholesterol and LDL-C levels (4.0mmol/L and 2.5 mmol/L, respectively),
he is inquiring whether he should continue to take Atorvastatin calcium 40 mg OD which was
prescribed when he was sent home. The appropriate answer would be
a. For him to just consume his stock of Atorvastatin, after which he may stop taking it
b. Shift the medication to fish oil instead
c. For him to continue to take Atorvastatin, even if the lipid levels are within normal
limits
d. Shift the medication to Fenofibrate

Ratio: Due to prior anterior STEMI, level of risk is considered high enough to warrant a
preventive statin, even if cholesterol and LDL-C is normal.

82. A 60 year old man consults because of progressive exertional dyspnea ang bipedal edema.
On history, paroxysmal nocturnal dyspnea was also reported and on physical examination, an S3
gallop was appreciated as well as rales over the lower half of both lung fields. 2D echo revealed
eccentric LVH with global hypokinesia and an EF fraction of 38%. Which of the following
medications are most appropriate in the initial management of his condition?
a. Statin and diuretic
b. diuretics , ACE-I, mineralocorticoid receptor antagonists
c. Digitalis and beta blockers
d. Amiodarone and beta blockers

83. An 18 year old female, asymptomatic, was subjected to an SCG treadmill exercise test prior
to joining a marathon and the test was interpreted as being positive. Applying Bayes’ theorem to
the diagnostic examination, you would
a. Diagnose the patient as having coronary artery disease and start her on nitrates
b. Diagnose the patient as having ischemic heart disease and advised her against joining
the marathon
c. Advise the patient to undergo coronary angiogram as her test was positive
d. Advise the patient that both her pre-test and post-test probability of having coronary
artery disease are low and she should not worry about the test result.

84. A 35-year old female, right-handed, non-hypertensive, non-diabetic, came over to the ER due
to a 2 hour sudden onset, right-sided weakness. Patient is drowsy, unable to speak but can follow
one-step commands. She has a shallow right nasolabial fold, right hemiparesis at ⅗ on both right
upper and lower limb and Babinski sign over the right. Where is the probable location of the
lesion?
a. Left parietal lobe
b. Right parietal lobe
c. Left frontal lobe
 d. Left thalamus

Answer: C
Ratio:
Aphasia is caused by damage to one or more of the language areas of the brain. Many
times, the cause of the brain injury is a stroke.

Individuals with Broca’s aphasia are able to understand the speech of others to varying
degrees. Because of this, they are often aware of their difficulties and can become easily
frustrated by their speaking problems. Individuals with Broca’s aphasia often have right-
sided weakness or paralysis of the arm and leg because the frontal lobe is also important
for body movement.

In contrast to Broca’s aphasia, damage to the temporal lobe may result in a fluent aphasia
that is called Wernicke’s aphasia. Individuals with Wernicke’s aphasia may speak in long
sentences that have no meaning, add unnecessary words, and even create new “words.”

85. A 59 y/o female, diabetic with good compliance to meds, complains of a 6-month history of
intermittent sharp shooting pain over her left cheek aggravated by chewing and brushing her
teeth. Treatment of this condition includes the use of the following medications, EXCEPT.
a. Prednisone (corticosteroid)
b. Carbamazepine (Anti-convulsant)
c. Amitriptyline (TCA)
d. Gabapentin (Anti-convulsant)

Answer: A
Ratio:
Diabetic neuropathy is a type of nerve damage that can occur if you have diabetes. High
blood sugar (glucose) can injure nerves throughout your body. There are four main types
of diabetic neuropathy, namely: peripheral neuropathy, autonomic neuropathy, proximal
neuropathy & focal neuropathy.

Pain-relieving prescription treatments may include:

● Anti-seizure drugs - Some medications used to treat seizure disorders (epilepsy) are
also used to ease nerve pain.
● Antidepressants - Some antidepressants ease nerve pain, even if you aren't depressed.
Tricyclic antidepressants may help with mild to moderate nerve pain. Sometimes, an
antidepressant may be combined with an anti-seizure drug.

Correcting underlying causes can result in the neuropathy resolving on its own as the
nerves recover or regenerate. Prednisone is more commonly used as an
immunosuppressive drug for inflammatory and autoimmune conditions leading to
neuropathy.
86. A 23-year old male, unemployed was seen lying on the floor unconscious. He was last seen
having his lunch alone. He regained consciousness after 10 minutes with noticeable confusion,
disorientation and nor recall of what happened. Intermediate diagnostic tests needed for this
patient include the following EXCEPT:
a. Cranial MRI
b. Blood chemistry studies
c. 24 hour Holter monitoring
d. Electroencephalogram

Answer: C
Ratio:
● Cranial MRI- Almost all patients with new-onset seizures should have a brain
imaging study to determine whether there is an underlying structural abnormality
that is responsible.
● Blood chemistry studies- Routine blood studies are indicated to identify the more
common metabolic causes of seizures such as abnormalities in electrolytes,
glucose, calcium, or magnesium, and hepatic or renal disease.
● 24 hour Holter monitoring- a continuous test to record your heart's rate and rhythm
for 24 hours, to check if a cardiac problem is responsible for the patient’s syncope.
Holter monitoring is recommended for patients who experience frequent syncopal
episodes (one or more per week).
● Electroencephalogram- a test or record of brain activity produced by
electroencephalography. All patients who have a possible seizure disorder should
be evaluated with an EEG as soon as possible.

87. A 43 year old male diagnosed with colon cancer stage III s/p hemicolectomy had a post-op
CEA which was abnormally elevated than the pre-op CEA. what is the next diagnostic
examination?
a. Repeat CEA after 3 months
b. Colonoscopy and upper GI endoscopy
c. Chest and abdominal CT scan
d. Fecalysis with occult blood

Answer: A
Ratio:
After curative resection of colorectal cancer, CEA levels decrease and normalise within
4–6 weeks. Persistent elevation of CEA levels following surgery suggests incomplete
resection or occult metastasis and post treatment serial assays of CEA levels could aid in
the early detection of recurrent disease. A high postoperative CEA was associated with
increased risk of recurrence and decreased survival. TNM is currently the best predictor
of outcomes in colorectal cancer although outcomes vary widely within the same stage.
The College of American Joint Committee on Cancer suggested that CEA should be
incorporated into the TNM staging system for colorectal cancer to improve prognostic
 accuracy. In addition, 3 monthly CEA levels and yearly CT scans have been
recommended for 3 years by the “American Society of Clinical Oncology”.

88. A 54 year old male presented with slurred speech, right-sided weakness, preferential gaze
to the left and right central facial palsy with (+) Babinski sign on the right. The level of the lesion
is at the:
a. Cerebral hemispheres
b. Peripheral nerves
c. Spinal cord
d. Brainstem

Answer: A

Ratio:
Cerebral hemisphere:
● “Hemi-deficit”: hemiparesis, hemisensory, hemi-seizures (focal motor
hemianopsia/hemianopia)
● Hyperreflexia (UMNL sign) with pathologic reflexes (involvement of corticospinal
tract)
● If with cortical involvement s/sx: language and visuospatial dysfunction +/-
seizures
○ Aphasia – Broca’s aphasia, Wernicke’s aphasia, global aphasia
○ Peripheral gaze to one side
○ Seizures
○ Language impairment (Aphasias) involves the dominant hemisphere (left
hemisphere)

89. What is the most common etiologic agent of non-traumatic acute bacterial meningitis in
adults?
a. Staphylococcus aureus
b. Clostridium species
c. Streptococcus pneumoniae
d. Mycobacterium tuberculosis

Answer: C
Ratio:
90. The cancers that most often metastasize to the brain are the following, EXCEPT”
a. Lung
b. Lymphoma
c. Melanoma
d. Breast

Answer: B
Ratio:
Brain metastases can develop from any type of cancer. The types of cancer most likely to
spread to the brain are breast cancer, lung cancer, kidney cancer, and melanoma. The
symptoms of a brain tumor or brain metastases depend on where in the brain the tumor
forms, the tumor's size, and how fast the tumor spreads.

91. What change/s occur/s in the gastric lining after H. pylori infection that contribute to the
development of gastric adenocarcinoma?
a. Atrophic gastritis
b. Increased gastric acidity
c. Polypoid lesions

Answer: A
Ratio:
Long standing infection of H. pylori may progress and invade to the other parts of the
stomach like the body and fundus (hot zones) – multifocal atrophic gastritis
● Looks similar to autoimmune gastritis
● Atrophy of parietal and chief cells
● Less ulceration
● Leads to intestinal metaplasia and eventually cancer

92. What of the following examination is the best modality to diagnose gastric adenocarcinoma?
a. Upper GI series
b. Circulating tumor cells
 c. CEA and CA19-9
d. Esophagogastroscopy

Answer: D
Ratio:
Endoscopy is the best diagnostic method to diagnose gastric cancer as it visualizes the
gastric mucosa and allows biopsy for a histologic diagnosis.

93. Which among the following tests measure the biosynthetic function of the liver?
a. ALT
b. Protime
c. Ammonia
d. Direct bilirubin

Answer: B
Ration:
Several biochemical tests are useful in the evaluation and management of patients with
hepatic dysfunction. These tests can be used to (1) detect the presence of liver disease,
(2) distinguish among different types of liver disorders, (3) gauge the extent of known liver
damage, and (4) follow the response to treatment.

TESTS BASED ON DETOXIFICATION AND EXCRETORY FUNCTIONS:

● Serum bilirubin
● Urine bilirubin
● Blood ammonia
● Serum enzymes
● Enzymes that reflect damage to the hepatocyes (ALT/AST)
● Enzymes that reflect cholestasis (GGT)

TESTS THAT MEASURE BIOSYNTHETIC FUNCTION OF THE LIVER

● Serum albumin
● Serum globulin
● Prothrombin time (PT)/international normalized ratio (INR)

94. The most common etiology of acute pancreatitis is:

a. Alcohol
b. Hypertriglyceredemia
c. Gallstones disease
d. Sphincter of oddi dysfuction

Ratio:
Common etiologies of pancreatitis:
● Gallstones = most common cause of acute pancreatitis
● Alcohol = second most common cause of acute pancreatitis
● Hypertriglyceremia (usually with serum triglycerides >1000 mg/dL)
● Endoscopic retrograde cholangiopancreatography
 ● Drugs

95. The most common cause of acute intestinal obstruction is:

a. Malignancy
b. Lieus
c. Intestinal adhesions
d. Intussusceptions
Ratio:

96. The hallmark of intestinal obstruction is:

a. Abdominal distension
b. Abdominal pain
c. Vomiting
d. Absence of flatus

Answer: A
Ratio:
 The hallmark of intestinal obstruction, whether due to mechanical cause or to absence of
peristalsis, is the intraluminal accumulation of fluid.
(https://pubmed.ncbi.nlm.nih.gov/114013/)

97. “Step-ladder” pattern with air fluid levels and paucity of colonic gas are pathognomonic of:
a. Gastric outlet obstruction
b. Sigmoid volvulus
c. Large bowel obstruction
d. Small bowel obstruction

Ratio:
Stepladder sign represents the appearance of gas-fluid distended small bowel loops that
appear to be stacked on top of each other, typically observed on erect abdominal radiographs in
the setting of small bowel obstruction.

98. Cervical Degenerative Disease may present with Radicular pain that is characterized as:
a. Stiffness and pain in the cervical spine
b. Pain more severe in upright position
c. Pain on cervical motion especially hyperextension
d. Pain that follows a dermatomal distribution

Answer: D

Ratio: since the affected area is the nerve roots of the cervical spine, the pattern of the pain
(together with either sensory or motor dysfunction) follows the nerve root distribution as well.

99. The painful stage of adhesive Capsulitis is characterized by:

a. Discomfort felt at extreme range of motion
b. Pain with movement
c. Increasing stiffness and restriction of motion
d. Spontaneous recovery but frequently incomplete
Answer: B

Ratio:
Stage 1: "Prefreezing"
During stage 1 of its development, it may be difficult to identify your problem as adhesive
capsulitis. You've had symptoms for 1 to 3 months, and they're getting worse. Movement of the
shoulder causes pain. It usually aches when you're not using it, but the pain increases and
becomes "sharp" with movement. You'll begin to limit shoulder motion during this period and
protect the shoulder by using it less. The movement loss is most noticeable in "external rotation"
(this is when you rotate your arm away from your body), but you might start to lose motion when
you raise your arm or reach behind your back. Pain is the hallmark feature of this stage; you
may experience pain during the day and at night.

Stage 2: "Freezing"
By this stage, you've had symptoms for 3 to 9 months, most likely with a progressive loss of
shoulder movement and an increase in pain (especially at night). The shoulder still has some
range of movement, but it is limited by both pain and stiffness.

Stage 3: "Frozen"
Your symptoms have persisted for 9 to 14 months, and you have a greatly decreased range of
shoulder movement. During the early part of this stage, there is still a substantial amount of
pain. Toward the end of this stage, however, pain decreases, with the pain usually occurring
only when you move your shoulder as far you can move it.

Stage 4: "Thawing"
You've had symptoms for 12 to 15 months, and there is a big decrease in pain, especially at
night. You still have a limited range of movement, but your ability to complete your daily
activities involving overhead motion is improving at a rapid rate.

100. Patient with rotator cuff tendinopathy normally present with the following EXCEPT:
a. The pain is described as dull and achy and often occurs at night.
b. Pain in the posterolateral shoulder region and often, deltoid muscle pain, which is
referred from the shoulder.
c. PE findings may reveal atrophy of the trapezius and scalenes
d. Positive drop arm test

Ratio: If you have rotator cuff tendinopathy, you will notice pain in the outer part of your
upper arm and sometimes the front and top of your shoulder. This could be worse when
you raise your hands above your head or reach behind you. It could also wake you up at
night. Pain can be localized to anterior / lateral aspect of the shoulder, with referred pain
down the upper arm (lateral aspect).