Internal Medicine - 1081 ﺔﻠﺌﺳﻷا دﺪﻋ 08-04-2023 ﺔﻠﺌﺳﻷا ﺚﻳﺪﺤﺗ ﺦﻳرﺎﺗ ﻒﻴﻔﻋ ﺪﺠﻣأ .د ﻖﻴﺒﻄﺗ ﰲ ةدﻮﺟﻮﳌا ﺔﻠﺌﺳﻷا ﻊﻴﻤﺟ ﲆﻋ يﻮﺘﺤﻳ ﻊﻴﻤﺠﺘﻟا اﺬﻫ

‫ﺑﻨﻚ أﺳﺌﻠﺔ اﻟﺪﻛﺘﻮر أﻣﺠﺪ ﻋﻔﻴﻒ‬
‫‪Internal Medicine -‬‬
‫ﻋﺪد اﻷﺳﺌﻠﺔ ‪1081‬‬
‫ﺗﺎرﻳﺦ ﺗﺤﺪﻳﺚ اﻷﺳﺌﻠﺔ ‪08-04-2023‬‬
‫ﻫﺬا اﻟﺘﺠﻤﻴﻊ ﻳﺤﺘﻮي ﻋﲆ ﺟﻤﻴﻊ اﻷﺳﺌﻠﺔ اﳌﻮﺟﻮدة ﰲ ﺗﻄﺒﻴﻖ د‪ .‬أﻣﺠﺪ ﻋﻔﻴﻒ‬
‫‪Page - 1‬‬
‫ﻣﻮاﺿﻴﻊ اﻷﺳﺌﻠﺔ وأﻋﺪادﻫﺎ‬
1) Cardiology => 155 Questions

2) Endocrinology => 162 Questions
3) Gastroenterology => 106 Questions
4) Hematology => 155 Questions
5) Hepatology => 66 Questions
6) Infectious diseases => 44 Questions
7) Nephrology => 96 Questions
8) Neurology => 82 Questions
9) Pulmonology => 144 Questions
10) Rheumatology => 71 Questions
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Cardiology
Page - 3
Cardiology
1) Acute and decompensated heart failure (DHF) => 5 Questions

2) Acute coronary syndrome (ACS) => 11 Questions
3) Anaphylaxis => 9 Questions
4) Brain Natriuretic Peptide (BNP) => 3 Questions
5) Cardiac Transplant => 2 Questions
6) Cardiac tumors => 1 Questions
7) Cardiomyopathies => 11 Questions
8) Cardiopulmonary resuscitation (CPR) => 4 Questions
9) Chest Pain => 3 Questions
10) Cocaine-induced Chest Pain => 3 Questions
11) Complications of MI => 2 Questions
12) Congestive heart failure (CHF) => 19 Questions
13) Digoxin and Digoxin toxicity => 2 Questions
14) Dysrhythmias => 40 Questions
15) Infective Endocarditis (IE) => 7 Questions
16) Nitroglycerin => 2 Questions
17) Normal heart conduction and basic ECG => 5 Questions
18) Pericardial eusion and Tamponade => 3 Questions
19) Pericarditis => 4 Questions
20) Prinzmetal Angina => 1 Questions
21) Stable angina => 6 Questions
22) Syncope => 3 Questions
23) Valvular diseases and heart murmurs => 9 Questions
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Internal Medicine - Cardiology
Question 1/155
Question #1
A 55-year-old male patient presents with acute typical chest pain and is diagnosed with STEMI.
Which of the following mostly indicates a diagnosis of cardiogenic shock in this patient?
a. Acute refractory pulmonary edema

b. High CVP and hypotension
c. Low CVP and hypotension
d. Sinus bradycardia and hypotension
e. Ventricular arrhythmia and hypotension
‫اﻹﺟﺎﺑﺔ ﻋﲆ اﻟﺼﻔﺤﺔ اﻟﺘﺎﻟﻴﺔ‬
Page - 5
Internal Medicine - Cardiology - Acute and decompensated heart failure (DHF)
Question 1/155
Question #1
A 55-year-old male patient presents with acute typical chest pain and is diagnosed with STEMI.
Which of the following mostly indicates a diagnosis of cardiogenic shock in this patient?
a. Acute refractory pulmonary edema

b. High CVP and hypotension √
c. Low CVP and hypotension
d. Sinus bradycardia and hypotension
e. Ventricular arrhythmia and hypotension
Description
Cardiogenic shock is sustained hypotension with tissue hypoperfusion despite adequate le
ventricular filling pressure.
e main signs of cardiogenic shock are hypotension, oliguria, cold extremities, altered mental
status, hypotension, rapid and weak thready pulse, and jugular venous distension.
Page - 6
Question 2/155
Question #2
A 65-year-old patient with a history of CHF presents with acute shortness of breath, orthopnea, and
diaphoresis. His blood pressure is 210/120, pulse 120 bpm, and ECG and cardiac enzymes are
unremarkable. What is the most appropriate initial treatment?
a. Furosemide
b. Metoprolol
c. Enalapril
d. Morphine
e. Aldactone
Page - 7
Question 2/155
Question #2
A 65-year-old patient with a history of CHF presents with acute shortness of breath, orthopnea, and
diaphoresis. His blood pressure is 210/120, pulse 120 bpm, and ECG and cardiac enzymes are
unremarkable. What is the most appropriate initial treatment?
a. Furosemide √
b. Metoprolol
c. Enalapril
d. Morphine
e. Aldactone
Description
Elevated blood pressure here is the main trigger of pulmonary edema. is may occur due to non-
compliance with medications, a high salt diet, cardiac insult such as acute myocardial infarction, etc.
Intravenous furosemide is the first-line medication to help the kidneys remove excess fluid from the
body.
e treatment of pulmonary edema is achieved by reducing the preload and the aerload of the
heart:
Diuretics (intravenous furosemide)

Morphine (anxiolytic and reduced catecholamine production leading to reduced vascular
resistance)
Nitroprusside (reduces the preload and aerload)
Noninvasive ventilation may have a rule
Dobutamine and intra-aortic balloon pump can be used in the presence of concomitant
hypotension
Page - 8
Question 3/155
Question #3
A 66-year-old male patient has shortness of breath, diaphoresis, and tachypnea. He is a known case
of CHF and is compliant with his medications. However, physical examination reveals lower limb
edema, increased JVP, and lung crepitations; his heart rate is 115/ minute, his respiratory rate is
32/minute, and his blood pressure is 170/100 mmHg. What is the most appropriate medication to
prescribe at this time?
a. Inderal 40mg PO
b. Digoxin 500 mic intravenously
c. Intravenous mannitol
d. Intravenous morphine
e. Intravenous normal saline
Page - 9
Question 3/155
Question #3
A 66-year-old male patient has shortness of breath, diaphoresis, and tachypnea. He is a known case
of CHF and is compliant with his medications. However, physical examination reveals lower limb
edema, increased JVP, and lung crepitations; his heart rate is 115/ minute, his respiratory rate is
32/minute, and his blood pressure is 170/100 mmHg. What is the most appropriate medication to
prescribe at this time?
a. Inderal 40mg PO
b. Digoxin 500 mic intravenously
d. Intravenous morphine √
e. Intravenous normal saline
Description
is case is typical for decompensated heart failure and acute pulmonary edema.
e treatment of pulmonary edema is achieved by reducing the preload and the aerload of the
heart:
Diuretics (intravenous furosemide)

Morphine (anxiolytic and reduce catecholamine production, leading to reduced vascular
resistance)
Nitroprusside (reduces the preload and aerload)
Noninvasive ventilation may have a rule
Dobutamine and intra-aortic balloon pump can be used in the presence of concomitant
hypotension
Beta-blockers are not used in acute pulmonary edema because they can limit the heart rate. is will
lead to more reduction in cardiac output and worsen the condition.
Page - 10
Question 4/155
Question #4
A 72-year-old male patient with a history of COPD, CHF, and HTN presents with dyspnea. On
examination, reduced breath sounds and scattered wheezes are noted, but there is no Jugular
venous distention. e heart sound is distant, and lower limb edema is noted. his BNP level is
850pg/mL. Which of the following is the best initial management of this patient?
a. Intravenous heparin
b. Oral high-dose aspirin
c. Start dobutamine infusion
d. Short-acting beta-agonists
e. Furosemide intravenously
Page - 11
Question 4/155
Question #4
venous distention. e heart sound is distant, and lower limb edema is noted. his BNP level is
850pg/mL. Which of the following is the best initial management of this patient?
a. Intravenous heparin
b. Oral high-dose aspirin
c. Start dobutamine infusion
d. Short-acting beta-agonists
e. Furosemide intravenously √
Description
Given the high level of BNP, this patient is suering from acute heart failure exacerbation. e best
initial treatment in the treatment of decompensated heart failure and pulmonary edema is
furosemide
BNP (brain natriuretic peptide) is an enzyme secreted by heart muscles due to stretching or
infarction of these muscles. It acts as a diuretic to decrease blood pressure and decrease the load on
the heart. Helpful to investigate if you are not sure if shortness of breath is due to a cardiac or
respiratory cause
If the BNP level is high (> 500 pg/ml) à cardiac cause

If BNP is not elevated à non-cardiac cause
Causes of high BNP:
Heart failure
Acute MI
Mitral valve rupture
Constrictive pericarditis
Large pulmonary embolus
Page - 12
Question 5/155
Question #5
A non-compliant with his medications 60-year-old male known for CHF presents with increasing
shortness of breath, cyanosis, distress, and sweating. e patient is agitated, and his vital signs are
as follows: blood pressure is 230/130, pulse is 130 bpm (regular), and temperature is 37.8 °C. His chest
examination reveals diuse crepitations and wheezes bilaterally. All the following are appropriate
management except:
a. Brain natriuretic peptide will dierentiate the cardiac from the respiratory source of the shortness
of breath
b. Morphine is important to be given to this patient
c. Furosemide is an important symptomatic reliever for his condition
d. Beta-blockers are indicated for treating this patient at this time
e. Place the patient in a semi-setting position
Page - 13
Question 5/155
Question #5
A non-compliant with his medications 60-year-old male known for CHF presents with increasing
shortness of breath, cyanosis, distress, and sweating. e patient is agitated, and his vital signs are
as follows: blood pressure is 230/130, pulse is 130 bpm (regular), and temperature is 37.8 °C. His chest
examination reveals diuse crepitations and wheezes bilaterally. All the following are appropriate
management except:
a. Brain natriuretic peptide will dierentiate the cardiac from the respiratory source of the shortness
of breath
b. Morphine is important to be given to this patient
c. Furosemide is an important symptomatic reliever for his condition
d. Beta-blockers are indicated for treating this patient at this time √
e. Place the patient in a semi-setting position
Description
Because they can suppress the compensatory tachycardia, beta-blockers are not allowed to be given
in a patient with acute decompensated heart failure
Beta-blockers help reduce the mortality rate in congestive heart failure, but it is only used when the
patient is out of decompensation
Page - 14
Question 6/155
Question #6
A 76-year-old male patient presents with chest pain, and his ECG with back leads is shown below.
What is the most likely diagnosis?
a. Low Lateral MI
b. Inferior MI
c. Posterior MI
d. High lateral MI
e. Normal ECG
Page - 15
Internal Medicine - Cardiology - Acute coronary syndrome (ACS)
Question 6/155
Question #6
A 76-year-old male patient presents with chest pain, and his ECG with back leads is shown below.
a. Low Lateral MI
b. Inferior MI
c. Posterior MI √
d. High lateral MI
e. Normal ECG
Description
is ECG shows ST depression and prominent R wave on the anterior leads and ST elevation on V7 –
V9 (back leads).
is ECG indicates posterior MI.
Page - 16
Question 7/155
Question #7
A 66-yaar-old male patient presents with STEMI on leads II, III, aVF, and the right V4. Which of the
following arteries is most likely occluded in this patient?
a. Le circumflex artery

b. Right coronary artery
c. Le anterior descending artery
d. Post descending artery
e. Le the main artery
Page - 17
Question 7/155
Question #7
A 66-yaar-old male patient presents with STEMI on leads II, III, aVF, and the right V4. Which of the
following arteries is most likely occluded in this patient?
a. Le circumflex artery

b. Right coronary artery √
c. Le anterior descending artery
d. Post descending artery
e. Le the main artery
Description
Anatomy of the coronary artery:
e le and right coronary arteries arise from the aortic root.
e le coronary artery branches:
Le circumflex artery (provide blood supply to the le lateral wall of the heart
Anterior descending (LAD): the main blood supply to the anterior and septal walls
e right coronary artery branches:
It supplies the right side of the heart
It supplies the inferior wall of the heart.
e following figures demonstrate the anatomy of the coronary arteries and the correlation
between myocardial infarction and ECG changes in dierent leads.
Page - 18
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Question 8/155
Question #8
A 45-year-old male presents with typical chest pain and ST elevation on inferior leads. Which of the
following is shown to reduce the mortality rate in this condition?
a. Nitrates
b. Digoxin
c. iazide diuretics
d. Calcium channel blockers
e. Beta-blockers
Page - 20
Question 8/155
Question #8
A 45-year-old male presents with typical chest pain and ST elevation on inferior leads. Which of the
following is shown to reduce the mortality rate in this condition?
a. Nitrates
b. Digoxin
c. iazide diuretics
e. Beta-blockers √
Description
Beta-blockers and ACE inhibitors have been found to decrease the mortality rate in patients with
myocardial infarction
Nitrates, digoxin, thiazide diuretics, and calcium channel blockers have not been found to reduce
the mortality rate aer myocardial infarction
Page - 21
Question 9/155
Question #9
A patient is diagnosed with Anterior STEMI. His Blood pressure is 130/80. His heart rate is 69 bpm,
O2 saturation is 96%. Which of the following is the initial treatment for his condition?
a. Aspirin, Clopidogrel, Heparin, metoprolol, Oxygen, Nitrates

b. Aspirin, Clopidogrel, Heparin, metoprolol, Nitrates
c. Aspirin, Clopidogrel, metoprolol, Oxygen
d. Aspirin, metoprolol, Oxygen, Nitrates
e. Aspirin, Clopidogrel, Heparin, Oxygen, Nitrates
Page - 22
Question 9/155
Question #9
A patient is diagnosed with Anterior STEMI. His Blood pressure is 130/80. His heart rate is 69 bpm,
O2 saturation is 96%. Which of the following is the initial treatment for his condition?
a. Aspirin, Clopidogrel, Heparin, metoprolol, Oxygen, Nitrates

b. Aspirin, Clopidogrel, Heparin, metoprolol, Nitrates √
c. Aspirin, Clopidogrel, metoprolol, Oxygen
d. Aspirin, metoprolol, Oxygen, Nitrates
e. Aspirin, Clopidogrel, Heparin, Oxygen, Nitrates
Description
Oxygen is not indicated in patients with ACS whose O2 saturation is more than 94%.
Dual antiplatelet agents are indicated in all cases of ACS.
Unless contraindicated, beta-blockers are indicated to reduce the mortality rate in patients with
ACS.
Nitrates will be indicated to reduce the infarction size but never given in a patient with inferior wall
Myocardial infarction
Page - 23
Question 10/155
Question #10
A 44-year-old male presents to the ER with typical chest pain and ST elevation on leads V4 – V6.
Which of the following is the most important step in managing this patient?
a. Administration of heparin
b. Administration of nitroglycerine
c. Cardiac enzymes
d. Cardiac monitoring
e. Oxygen administration
Page - 24
Question 10/155
Question #10
A 44-year-old male presents to the ER with typical chest pain and ST elevation on leads V4 – V6.
Which of the following is the most important step in managing this patient?
a. Administration of heparin
b. Administration of nitroglycerine
c. Cardiac enzymes
d. Cardiac monitoring √
e. Oxygen administration
Description
Monitoring cardiac electrical activity is the most important step in the management because the
patient is at risk of sudden death due to arrhythmia.
If ventricular arrhythmia develops, early DC cardioversion is indicated to control the patient’s

condition
Page - 25
Question 11/155
Question #11
A patient is just diagnosed with acute coronary syndrome, which of the following would be an
indication for thrombolytic therapy?
a. A 42-year-old male with new ST-segment depression

b. A 45-year-old male with a new le bundle branch block
c. A 49-year-old with new ST elevation and brain hemorrhage
d. A 50-year-old with a new-onset first-degree AV block
e. A 39-year-old with new-onset ectopic beats
Page - 26
Question 11/155
Question #11
A patient is just diagnosed with acute coronary syndrome, which of the following would be an
indication for thrombolytic therapy?
a. A 42-year-old male with new ST-segment depression

b. A 45-year-old male with a new le bundle branch block √
c. A 49-year-old with new ST elevation and brain hemorrhage
d. A 50-year-old with a new-onset first-degree AV block
e. A 39-year-old with new-onset ectopic beats
Description
rombolytic therapy is contraindicated in patients with a brain hemorrhage
New-onset Le bundle branch block is considered ST-elevation equivalent, and thrombolytic
treatment could be given unless contraindicated
Page - 27
Question 12/155
Question #12
A 48-year-old female patient with a known panic disorder presents with le-side chest tightness
radiating to the le shoulder for the last 3 hours. In addition, she complains of shortness of breath.
Which of the following is the best next step in managing this patient?
a. Reassurance and explanation that this is a panic attack

b. Admission for further evaluation
c. Obtain CBC, chemistry profile, LFT, and ECG
d. Obtain ECG and cardiac enzymes
e. Refer for cardiac catheterization immediately
Page - 28
Question 12/155
Question #12
A 48-year-old female patient with a known panic disorder presents with le-side chest tightness
radiating to the le shoulder for the last 3 hours. In addition, she complains of shortness of breath.
Which of the following is the best next step in managing this patient?
a. Reassurance and explanation that this is a panic attack

b. Admission for further evaluation
c. Obtain CBC, chemistry profile, LFT, and ECG
d. Obtain ECG and cardiac enzymes √
e. Refer for cardiac catheterization immediately
Description
ECG and cardiac enzymes are the first steps to managing any patient with chest pain.
is patient is suering from typical chest pain. Acute coronary syndrome can’t be excluded, and
ECG should be done immediately
Page - 29
Question 13/155
Question #13
A 65-year-old male patient is a known case of DM, HTN, and old MI 2 years ago. He had exertional
angina since the myocardial infarction happened. His medications include propranolol and aspirin.
Today he presents to you with chest pain at rest for 30 hours. ECG reveals an old myocardial
infarction. What is the most appropriate treatment for this patient?
a. Admission and adjustment of the treatment

b. Admission and CABG
c. Add nitrate and discharge home
d. Exercise stress test
e. Reduce the dose of propranolol
Page - 30
Question 13/155
Question #13
A 65-year-old male patient is a known case of DM, HTN, and old MI 2 years ago. He had exertional
angina since the myocardial infarction happened. His medications include propranolol and aspirin.
Today he presents to you with chest pain at rest for 30 hours. ECG reveals an old myocardial
infarction. What is the most appropriate treatment for this patient?
a. Admission and adjustment of the treatment √

b. Admission and CABG
c. Add nitrate and discharge home
d. Exercise stress test
e. Reduce the dose of propranolol
Description
is patient has a typical presentation of unstable angina with a possible progression to myocardial
infarction. erefore, he needs to be admitted, and his treatment should be adjusted.
CABG is not indicated at this point.
Indications for CABG:
ree vessels disease

Le main artery disease
Proximal LAD occlusion with EF% less than 50%
Chronic disabling angina
Page - 31
Question 14/155
Question #14
A 65-year-old male patient has had chest pain for the last 30 minutes, and his ECG is shown in the
picture below. What is the most likely occluded artery?
a. Right coronary artery

b. Le Anterior Descending artery
c. Le main coronary artery
d. Le circumflex coronary artery
e. Posterior descending artery
Page - 32
Question 14/155
Question #14

b. Le Anterior Descending artery √
Description
e ECG shows ST elevation on V2 – V4
is indicates anterior wall myocardial infarction
e most common artery aected in this case is LAD
e locations of infarctions and their relation to ECG are shown in the following table:
Page - 33
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Question 15/155
Question #15

Page - 35
Question 15/155
Question #15
a. Right coronary artery √

Description
e ECG shows ST elevation on II, III, and aVF
is indicates Inferior wall myocardial infarction
e most common artery aected in this case is RCA
e locations of infarctions and their relation to ECG are shown in the following table:
Page - 36
Page - 37
Question 16/155
Question #16
A 48-year-old male patient has sudden shortness of breath and diaphoresis. On auscultation,
bibasilar lung crepitations are heard. ECG is shown below. What is the most likely diagnosis?
a. Acute pericarditis
b. Myocardial infarction
c. Pulmonary embolism
d. Pneumonia
e. Spontaneous pneumothorax
Page - 38
Question 16/155
Question #16
A 48-year-old male patient has sudden shortness of breath and diaphoresis. On auscultation,
bibasilar lung crepitations are heard. ECG is shown below. What is the most likely diagnosis?
a. Acute pericarditis
b. Myocardial infarction √
d. Pneumonia
e. Spontaneous pneumothorax
Description
is ECG shows elevated ST-segment on leads II, III, and aVF. It also has reciprocal changes on leads I,
aVL, and V6
ese changes, along with the history, are typical for acute myocardial infarction.
Page - 39
Question 17/155
Question #17
A 22-year-old male patient developed facial swelling, stridor, and hypotension immediately aer
eating shrimp at a restaurant. Which one of the following treatments should be initiated
immediately?
a. Hydrocortisone
b. Antihistamine
c. Epinephrine
d. Aminophylline
e. Dexamethasone
Page - 40
Internal Medicine - Cardiology - Anaphylaxis
Question 17/155
Question #17
A 22-year-old male patient developed facial swelling, stridor, and hypotension immediately aer
eating shrimp at a restaurant. Which one of the following treatments should be initiated
immediately?
a. Hydrocortisone
b. Antihistamine
c. Epinephrine √
d. Aminophylline
e. Dexamethasone
Description
is is a case of anaphylactic shock.
e treatment of choice for anaphylactic shock is adrenaline intramuscularly.
Hydrocortisone, dexamethasone, and antihistamines are used to treat anaphylactic shock but have
slower and lower eects.
Subcutaneous administration of drugs in hypotensive patients is inappropriate because of the

reduced skin perfusion that slows systemic absorption.
Anaphylaxis:
It is an IgE-mediated severe, life-threatening, generalized, or systemic hypersensitivity

reaction; the patient must be already sensitized to the antigen
Food (e.g., Nuts) - the most common cause in children
e rash is present in all types of anaphylaxis, while other symptoms like hypotension,
tachycardia, and respiratory symptoms are variable.
e first-line treatment is adrenalin 1/1,000 (best to give IM)
Page - 41
Question 18/155
Question #18
A 15-year-old boy develops anaphylactic shock due to a food allergy. You would administrate which
of the following intramuscular drugs?
a. Adrenalin 1/10
b. Adrenalin 1/100
c. Adrenalin 1/1000
d. Adrenalin 1/10000
e. Adrenalin 1/100000
Page - 42
Question 18/155
Question #18
A 15-year-old boy develops anaphylactic shock due to a food allergy. You would administrate which
of the following intramuscular drugs?
a. Adrenalin 1/10
b. Adrenalin 1/100
c. Adrenalin 1/1000 √
d. Adrenalin 1/10000
e. Adrenalin 1/100000
Description
Adrenalin 1/1000 is the most appropriate intramuscular dose for anaphylactic shock.
Treatment of anaphylaxis includes the following:
First-line treatment is adrenalin 1/1,000 → best to give IM

Hydrocortisone: (its action needs up to 4 hours)
Chlorphenamine (Allerfrin)
Nebulized Beta-2 agonist
Supportive measures (O2, IV Fluids)
Emergent airway protection if needed (intubation, cricothyroidotomy)
Page - 43
Question 19/155
Question #19
A 15-year-old male presented to you aer a bee sting while playing in the garden. e patient is tired,
his skin is flushing, his blood pressure is 80/70, and his pulse rate is 110 bpm. What is the most
appropriate initial medication to administer to this patient?
a. Hydrocortisone
b. Inhaled SABA
c. Subcutaneous adrenaline
d. Intramuscular adrenaline
e. IV normal saline
Page - 44
Question 19/155
Question #19
A 15-year-old male presented to you aer a bee sting while playing in the garden. e patient is tired,
his skin is flushing, his blood pressure is 80/70, and his pulse rate is 110 bpm. What is the most
appropriate initial medication to administer to this patient?
a. Hydrocortisone
b. Inhaled SABA
c. Subcutaneous adrenaline
d. Intramuscular adrenaline √
e. IV normal saline
Description
is is a case of anaphylactic shock.
Hydrocortisone, inhaled SABA, and normal saline are also used to treat anaphylactic shock, but they
have slower and lower eects.

Anaphylaxis:

Page - 45
Question 20/155
Question #20
e most appropriate route of administration for adrenalin in patients with anaphylaxis is:
a. Intravenous
b. Subcutaneous
c. Oral
d. Intramuscular
e. Inhalational
Page - 46
Question 20/155
Question #20
e most appropriate route of administration for adrenalin in patients with anaphylaxis is:
a. Intravenous
b. Subcutaneous
c. Oral
d. Intramuscular √
e. Inhalational
Description

Anaphylaxis:

Page - 47
Question 21/155
Question #21
A 17-year-old male patient is going to a camp next week. He has a history of anaphylactic shock
secondary to a bee sting 1 year ago. Which of the following would you recommend preventing
severe adverse reactions if exposed to a sting during camping?
a. He should never go to the camp

b. He should take antihistamine if stung
c. Self-administrated adrenalin should be with the patient
d. He should be indoors all the time
e. He should wear a beekeeping suit when he is outdoor
Page - 48
Question 21/155
Question #21
A 17-year-old male patient is going to a camp next week. He has a history of anaphylactic shock
secondary to a bee sting 1 year ago. Which of the following would you recommend preventing
severe adverse reactions if exposed to a sting during camping?
a. He should never go to the camp

b. He should take antihistamine if stung
c. Self-administrated adrenalin should be with the patient √
d. He should be indoors all the time
e. He should wear a beekeeping suit when he is outdoor
Description
Adrenalin is the treatment of choice for anaphylactic shock.
Adrenalin is the primary treatment and should be provided immediately
self-injectable epinephrine should be with patients with anaphylaxis all the time to avoid severe
anaphylactic reactions.
Self-injectable epinephrine can be delivered IM or SC immediately aer exposure to an allergen that

is usually causing anaphylaxis.
Anaphylaxis:

Page - 49
Question 22/155
Question #22
A 66-year-old has urine retention for 15 hours, and you ordered Foley catheter insertion. ree
minutes later, the patient started to have a wheezy chest, hypotension, and skin rash. What is the
most likely cause for this clinical scenario?
a. Pulmonary embolism
b. Acute myocardial infarction
c. Urinary bladder rupture
d. Latex allergy
e. Septic shock
Page - 50
Question 22/155
Question #22
A 66-year-old has urine retention for 15 hours, and you ordered Foley catheter insertion. ree
minutes later, the patient started to have a wheezy chest, hypotension, and skin rash. What is the
most likely cause for this clinical scenario?
c. Urinary bladder rupture
d. Latex allergy √
e. Septic shock
Description
e timing here is the most important; this patient has symptoms of anaphylaxis immediately aer
the insertion of the Foley catheter.
e most likely diagnosis here is anaphylaxis secondary to latex exposure.
Anaphylaxis:

Page - 51
Question 23/155
Question #23
An 18-year-old female was bitten by a scorpion 30 minutes ago. Her vital signs at the hospital are
blood pressure of 70/30 mmHg, her pulse is 145 bpm, her temperature is 37.3 °C, and her respiratory
rate is 33 per minute and labored. Which of the following would not be an option in her
management?
a. Adrenalin
b. Atropine
c. Salbutamol
d. Diphenhydramine
e. Methylprednisolone
Page - 52
Question 23/155
Question #23
An 18-year-old female was bitten by a scorpion 30 minutes ago. Her vital signs at the hospital are
blood pressure of 70/30 mmHg, her pulse is 145 bpm, her temperature is 37.3 °C, and her respiratory
rate is 33 per minute and labored. Which of the following would not be an option in her
management?
a. Adrenalin
b. Atropine √
c. Salbutamol
d. Diphenhydramine
e. Methylprednisolone
Description
Atropine here has no rule in the treatment and may exacerbate tachycardia in this patient.
Treatment of anaphylaxis includes the following:
First-line treatment is adrenalin 1/1,000 → best to give IM

Hydrocortisone: (its action needs up to 4 hours)
Chlorphenamine (Allerfrin)
Nebulized Beta-2 agonist
Supportive measures (O2, IV Fluids)
Emergent airway protection if needed (intubation, cricothyroidotomy)
Note that methylprednisolone is a steroid that may be used in this case
Note that diphenhydramine is an antihistamine that may be used in this case too
Page - 53
Question 24/155
Question #24
Shortly aer a bee sting, a 22-year-old male started to have a rash, shortness of breath, and
hypotension. is reaction is mediated by which of the following antibodies?
a. IgA antibodies
b. IgM antibodies
c. IgG antibodies
d. IgD antibodies
e. IgE antibodies
Page - 54
Question 24/155
Question #24
Shortly aer a bee sting, a 22-year-old male started to have a rash, shortness of breath, and
hypotension. is reaction is mediated by which of the following antibodies?
a. IgA antibodies
b. IgM antibodies
c. IgG antibodies
d. IgD antibodies
e. IgE antibodies √
Description
Anaphylaxis:

It is a type 1 hypersensitivity reaction
Pathogenesis:
Exposure to an antigen → immune system activation → IgE binds to mast cells → histamine,
prostaglandins, and leukotrienes release → vasodilatation → hypotension and shock.
Page - 55
Question 25/155
Question #25
A 66-year-old male patient was admitted as a case of warfarin overdose and was started on
intravenous fresh frozen plasma. Unfortunately, 30 minutes later, he began to have continuous
flushing, wheezing, pruritus, and urticaria. His blood pressure was 80/44mmHg, and his pulse was
130 bpm. Adrenalin was administrated, and the FFP transfusion was discontinued. Which of the
following is the most likely explanation for this condition?
a. Adrenal crisis
b. e patient has IgA deficiency
c. Gram-negative sepsis
d. Gram-positive sepsis
e. Internal bleeding due to warfarin overdose
Page - 56
Question 25/155
Question #25
A 66-year-old male patient was admitted as a case of warfarin overdose and was started on
intravenous fresh frozen plasma. Unfortunately, 30 minutes later, he began to have continuous
flushing, wheezing, pruritus, and urticaria. His blood pressure was 80/44mmHg, and his pulse was
130 bpm. Adrenalin was administrated, and the FFP transfusion was discontinued. Which of the
following is the most likely explanation for this condition?
a. Adrenal crisis
b. e patient has IgA deficiency √
c. Gram-negative sepsis
d. Gram-positive sepsis
e. Internal bleeding due to warfarin overdose
Description
In patients with IgA deficiency, anti-IgA autoantibodies of the IgG and IgE are oen present and are
the most likely cause of the anaphylactic reaction
In FFP transfusion, you have to use IgA-deficient plasma for the IgA-deficient recipients
Anaphylaxis:

Page - 57
Question 26/155
Question #26
venous distention. e heart sound is distant, and lower limb edema is noted. What is the next step
to dierentiate the cause of dyspnea in this patient?
a. Order a chest radiograph

b. Order brain natriuretic peptide level
c. Order Liver function test
d. Order Pulmonary function test
e. Order urea and creatinine levels
Page - 58
Internal Medicine - Cardiology - Brain Natriuretic Peptide (BNP)
Question 26/155
Question #26
venous distention. e heart sound is distant, and lower limb edema is noted. What is the next step
to dierentiate the cause of dyspnea in this patient?
a. Order a chest radiograph

b. Order brain natriuretic peptide level √
c. Order Liver function test
d. Order Pulmonary function test
e. Order urea and creatinine levels
Description
the heart; useful to investigate if you are not sure if shortness of breath is due to a cardiac or
respiratory cause

If BNP is not high à non-cardiac cause
Causes of high BNP:
Heart failure
Acute MI
Page - 59
Question 27/155
Question #27
A patient with shortness of breath was found to have a high brain natriuretic peptide level. Which of
the following is the least likely cause of his shortness of breath?
a. Heart failure
c. Massive pulmonary embolism
d. Chronic obstructive lung disease
e. Constrictive pericarditis
Page - 60
Question 27/155
Question #27
A patient with shortness of breath was found to have a high brain natriuretic peptide level. Which of
the following is the least likely cause of his shortness of breath?
a. Heart failure
c. Massive pulmonary embolism
d. Chronic obstructive lung disease √
e. Constrictive pericarditis
Description
Page - 61
Question 28/155
Question #28
A 62-year-old male patient with a history of COPD, CAD, and CKD presents with worsening shortness
of breath. His BNP level is 1200 pg/mL. Which of the following would be eective in the treatment of
this patient?
a. Inhaled SAMA
b. Hemodialysis
d. Loop diuretic
e. Nifedipine
Page - 62
Question 28/155
Question #28
A 62-year-old male patient with a history of COPD, CAD, and CKD presents with worsening shortness
of breath. His BNP level is 1200 pg/mL. Which of the following would be eective in the treatment of
this patient?
a. Inhaled SAMA
b. Hemodialysis
d. Loop diuretic √
e. Nifedipine
Description
A high BNP level is indicative of the presence of stretch on the cardiac muscles, mostly due to heart
failure
the heart; useful to investigate if you are not sure if shortness of breath is due to a cardiac or
respiratory cause

If BNP is not high à non-cardiac cause
Causes of high BNP:
Heart failure
Acute MI
Page - 63
Question 29/155
Question #29
A 65-year-old male patient with advanced heart failure had cardiac transplant surgery 10 years ago.
Which is the most common cause of late death following heart transplant surgery?
a. Coronary artery disease in the gra

b. Gra rejection
c. Infection
d. Malignancy
e. Side eects of the treatments
Page - 64
Internal Medicine - Cardiology - Cardiac Transplant
Question 29/155
Question #29
A 65-year-old male patient with advanced heart failure had cardiac transplant surgery 10 years ago.
Which is the most common cause of late death following heart transplant surgery?
a. Coronary artery disease in the gra √

b. Gra rejection
c. Infection
d. Malignancy
Description
Coronary artery disease in the gra (allogra coronary artery disease) is the most common cause of
late death aer cardiac transplant surgery
Infection is the most common cause of death within the first year aer cardiac transplant (25% of
cases), with the greatest risk in the first few months aer the surgery
Infection à 25% of cases
Rejection à 5% of cases
Malignancy à 15% of cases
Page - 65
Question 30/155
Question #30
A 65-year-old male patient with advanced heart failure had cardiac transplant surgery 9 months ago
and died today. Which is the most common cause of morbidity and mortality within the first year
following heart transplant surgery?

b. Gra rejection
c. Infection
d. Malignancy
Page - 66
Internal Medicine - Cardiology - Cardiac Transplant
Question 30/155
Question #30
A 65-year-old male patient with advanced heart failure had cardiac transplant surgery 9 months ago
and died today. Which is the most common cause of morbidity and mortality within the first year
following heart transplant surgery?

b. Gra rejection
c. Infection √
d. Malignancy
Description
Infection is the most common cause of death within the first year aer cardiac transplant (25% of
cases), with the greatest risk in the first few months aer the surgery
Coronary artery disease in the gra (allogra coronary artery disease) is the most common cause of
late death aer cardiac transplant surgery
Infection à 25% of cases
Rejection à 5% of cases
Malignancy à 15% of cases
Page - 67
Question 31/155
Question #31
A 49-year-old patient was incidentally discovered to have atrial myxoma by an echocardiogram. e

following findings may be associated with this condition except:
a. Clubbing
b. Fever
c. Mid-diastolic murmur
d. Embolization and CVA
e. Premature ventricular tachycardia
Page - 68
Internal Medicine - Cardiology - Cardiac tumors
Question 31/155
Question #31
A 49-year-old patient was incidentally discovered to have atrial myxoma by an echocardiogram. e

following findings may be associated with this condition except:
a. Clubbing
b. Fever
c. Mid-diastolic murmur
d. Embolization and CVA
e. Premature ventricular tachycardia √
Description
Atrial fibrillation (Not PVC) is associated with atrial myxoma.
It is a heart tumor that most commonly occurs in the le atrium and may be associated with
clubbing, Embolization, atrial fibrillation, fever, and mid-diastolic murmur. It is diagnosed by
echocardiogram
Page - 69
Question 32/155
Question #32
A 17-year-old male patient suddenly died while he was playing football at school. His father died at
the age of 40 years suddenly. What is the most common cause of death in this case?
a. Dilated cardiomyopathy
b. Hypertrophic obstructive cardiomyopathy
c. Myocardial infarction
d. Myocarditis
e. Arrhythmogenic right ventricular cardiomyopathy
Page - 70
Internal Medicine - Cardiology - Cardiomyopathies
Question 32/155
Question #32
A 17-year-old male patient suddenly died while he was playing football at school. His father died at
the age of 40 years suddenly. What is the most common cause of death in this case?
a. Dilated cardiomyopathy
b. Hypertrophic obstructive cardiomyopathy √
d. Myocarditis
e. Arrhythmogenic right ventricular cardiomyopathy
Description
Sudden death in a young person with a family history of sudden death will raise suspicion of HOCM
as the most common cause. Note that the second most common cause, in this case, is ARVC
(arrhythmogenic right ventricular cardiomyopathy)
HOCM is the most common cause of sudden death in athletes
Page - 71
Question 33/155
Question #33
A 17-year-old male patient complains of dizziness and recurrent syncope while playing basketball in
school. e school doctor refers the patient to you for evaluation because he suspects a cardiac
cause. However, the patient’s past medical records are unremarkable, but his father suddenly died
at the age of 39. e following findings in the echocardiogram are typical for the most likely
diagnosis except:
a. Mitral valve leaflet hypertrophy

b. A systolic anterior motion of the anterior mitral valve leaflet
c. Asymmetrical septal hypertrophy
d. A degree of diastolic heart failure
e. Mitral stenosis
Page - 72
Question 33/155
Question #33
A 17-year-old male patient complains of dizziness and recurrent syncope while playing basketball in
school. e school doctor refers the patient to you for evaluation because he suspects a cardiac
cause. However, the patient’s past medical records are unremarkable, but his father suddenly died
at the age of 39. e following findings in the echocardiogram are typical for the most likely
diagnosis except:
a. Mitral valve leaflet hypertrophy

b. A systolic anterior motion of the anterior mitral valve leaflet
c. Asymmetrical septal hypertrophy
d. A degree of diastolic heart failure
e. Mitral stenosis √
Description
e patient most likely suers from Hypertrophic Obstructive Cardiomyopathy (HOCM).
e family history of sudden paternal death and the exertional dizziness and syncope strongly
suggest the condition.
Mitral regurgitation, not stenosis, is the likely finding in this scenario.
e patient will have le ventricular outflow obstruction due to septal or mitral leaflet hypertrophy.
Any degree of heart failure (usually diastolic) may present.
e echocardiogram findings in HOCM are (MR SAM ASH):
Mitral Regurgitation (MR)

Systolic anterior motion (SAM) of the anterior mitral valve
Asymmetric septal hypertrophy (ASH) > 1.5 times the thickness of the posterior wall.
Page - 73
Question 34/155
Question #34
A patient is diagnosed with Dilated cardiomyopathy (DCM), the following are more likely to cause
this condition except:
a. Alcoholism
b. Coxsackie B virus
c. Hemochromatosis
d. Doxorubicin
e. Wilson’s disease
Page - 74
Question 34/155
Question #34
A patient is diagnosed with Dilated cardiomyopathy (DCM), the following are more likely to cause
this condition except:
a. Alcoholism
b. Coxsackie B virus
c. Hemochromatosis
d. Doxorubicin
e. Wilson’s disease √
Description
Wilson’s disease is a possible cause of DCM, but it is extremely rare. It is likely to occur in
hemochromatosis and the other mentioned choices.
Page - 75
Question 35/155
Question #35
A 35-year-old male patient with a family history of sudden cardiac death presents with recurrent
syncope and palpitation for the past 6 months. His ECG reveals T wave inversion in V1 – V3 and a
small positive deflection at the end of the QRS complex. What is the most likely diagnosis?
a. Hypertrophic obstructive cardiomyopathy

b. Arrhythmogenic right ventricular dysplasia
c. Long QT syndrome
d. Ischemic heart disease
e. Mitral valve prolapse
Page - 76
Question 35/155
Question #35
A 35-year-old male patient with a family history of sudden cardiac death presents with recurrent
syncope and palpitation for the past 6 months. His ECG reveals T wave inversion in V1 – V3 and a
small positive deflection at the end of the QRS complex. What is the most likely diagnosis?
a. Hypertrophic obstructive cardiomyopathy

b. Arrhythmogenic right ventricular dysplasia √
c. Long QT syndrome
d. Ischemic heart disease
e. Mitral valve prolapse
Description
History of sudden death, recurrent palpitations, and syncope, along with the inverted T wave in
leads V1 – V3 and epsilon wave, suggest ARVC as the most likely diagnosis.
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiovascular disease that

may result in arrhythmia and sudden death
It is the second most common cause of sudden death in athletes
Page - 77
Question 36/155
Question #36
A patient is suspected of having hypertrophic obstructive cardiomyopathy. Which of the following is

the definitive diagnostic test for this condition?
a. Electrocardiogram
b. Family history of sudden death and history of syncope
c. Chest radiograph
d. Electrophysiological study
e. Echocardiogram
Page - 78
Question 36/155
Question #36
A patient is suspected of having hypertrophic obstructive cardiomyopathy. Which of the following is

the definitive diagnostic test for this condition?
a. Electrocardiogram
b. Family history of sudden death and history of syncope
c. Chest radiograph
e. Echocardiogram √
Description
Family history of sudden death and personal history of exertional syncope Strongly suggest HOCM,
but they are not providing definitive evidence of the disease
e definitive diagnosis is made by a two-dimensional echocardiogram
Page - 79
Question 37/155
Question #37
A 17-year-old male patient presents with recurrent syncopal attacks. e last one occurred while he
was running for a bus. His father died suddenly at the age of 38-year-old. What is the most likely
cause?
a. Hysterical conversion disorder

b. Vasovagal attack
c. Epilepsy
d. Cardiogenic syncope
e. Long QT syndrome
Page - 80
Question 37/155
Question #37
A 17-year-old male patient presents with recurrent syncopal attacks. e last one occurred while he
was running for a bus. His father died suddenly at the age of 38-year-old. What is the most likely
cause?
a. Hysterical conversion disorder

b. Vasovagal attack
c. Epilepsy
d. Cardiogenic syncope √
e. Long QT syndrome
Description
In case of sudden death or unusual collapse in a young patient, you should think about HOCM as the
most common cause, especially if there is a family history of the sudden death of a first-degree
relative
Page - 81
Question 38/155
Question #38
A 22-year-old male patient with a history of syncope and palpitation was diagnosed with HOCM. His
24-hour Holter monitoring reveals non-sustained ventricular tachycardia. What is the most
appropriate for his management?
a. Start amiodarone
b. Place an ICD
c. Start Sotalol
d. Ablation of the accessory bundle
e. Observation
Page - 82
Question 38/155
Question #38
A 22-year-old male patient with a history of syncope and palpitation was diagnosed with HOCM. His
24-hour Holter monitoring reveals non-sustained ventricular tachycardia. What is the most
appropriate for his management?
a. Start amiodarone
b. Place an ICD √
c. Start Sotalol
d. Ablation of the accessory bundle
e. Observation
Description
e most eective means of preventing sudden death in high-risk patients with hypertrophic
cardiomyopathy is an implantable cardioverter-defibrillator
Page - 83
Question 39/155
Question #39
A 17-year-old male patient presents with recurrent syncopal attacks; the last occurred while running
for a bus. His father died suddenly at the age of 38-year-old. His ECG shows le ventricular
hypertrophy and widespread T-wave inversion. What is the most appropriate investigation to be
done next in managing this patient?
a. Coronary angiography
b. Transthoracic echocardiogram
c. Transesophageal echocardiogram
d. ECG exercise stress test
e. 24-hour Holter monitor
Page - 84
Question 39/155
Question #39
A 17-year-old male patient presents with recurrent syncopal attacks; the last occurred while running
for a bus. His father died suddenly at the age of 38-year-old. His ECG shows le ventricular
hypertrophy and widespread T-wave inversion. What is the most appropriate investigation to be
done next in managing this patient?
a. Coronary angiography
b. Transthoracic echocardiogram √
c. Transesophageal echocardiogram
d. ECG exercise stress test
e. 24-hour Holter monitor
Description
A transthoracic echocardiogram will be the next step in the management of HOCM. Echocardiogram
in HOCM will show the following features:
Mitral regurgitation
Systolic anterior motion of the anterior mitral valve leaflet
Asymmetrical hypertrophy
Page - 85
Question 40/155
Question #40
A 17-year-old male patient was diagnosed with asymptomatic hypertrophic cardiomyopathy. Which
of the following is the most eective in preventing sudden death in his condition?
a. Insertable cardiac monitor

b. Verapamil
c. Metoprolol
d. Implantable cardioverter defibrillator
e. Amiodaron
Page - 86
Question 40/155
Question #40
A 17-year-old male patient was diagnosed with asymptomatic hypertrophic cardiomyopathy. Which
of the following is the most eective in preventing sudden death in his condition?
a. Insertable cardiac monitor

b. Verapamil
c. Metoprolol
d. Implantable cardioverter defibrillator √
e. Amiodaron
Description
ICD is the most eective means of preventing sudden death in high-risk patients with HOCM
Medications (verapamil, beta-blockers, and diltiazem) are used for symptom management but do
not decrease the risk of sudden death.
Amiodarone may decrease the risk of sudden death because of its eects on reducing dysrhythmias,
but it is less than ICD
Note that an Insertable cardiac monitor is a diagnostic tool implanted under the skin and records
cardiac events for up to 30 years. It is used to diagnose arrhythmias but isn’t used to treat acute
arrhythmia and to prevent sudden death
Page - 87
Question 41/155
Question #41
A 17-year-old male patient was diagnosed with asymptomatic hypertrophic cardiomyopathy.

Unfortunately, he died at 28 while running for a bus. His mother came to consult you about this
condition. What is the most appropriate advice for the patient’s mother?
a. His brother can participate in a non-contact sport

b. Cardiac catheterization should be performed immediately for his brother
c. e hypertrophy, in this case, regresses with age
d. His brother should undergo echocardiography
e. ere is no familial tendency in this condition
Page - 88
Question 41/155
Question #41
A 17-year-old male patient was diagnosed with asymptomatic hypertrophic cardiomyopathy.

Unfortunately, he died at 28 while running for a bus. His mother came to consult you about this
condition. What is the most appropriate advice for the patient’s mother?
a. His brother can participate in a non-contact sport

b. Cardiac catheterization should be performed immediately for his brother
c. e hypertrophy, in this case, regresses with age
d. His brother should undergo echocardiography √
e. ere is no familial tendency in this condition
Description
is patient died due to HOCM. HOCM is an autosomal dominant condition that may lead to sudden
death, so siblings should be monitored for the disease by doing a two-dimensional echocardiogram.
Patient with suspected HOMC should avoid strenuous sports, even those considered non-contact, to
prevent sudden death until he is properly evaluated.
Cardiac catheterization should be performed in patients with HCM who have angina, syncope,
resuscitated sudden death, or a worrisome stress test.
Page - 89
Question 42/155
Question #42
A 66-year-old male has exertional dyspnea, lower limb edema, and orthopnea. His echocardiogram
demonstrates an ejection fraction of 23% and a thin-walled enlarged le ventricle. What is the most
likely diagnosis?
a. Arrhythmogenic right ventricular dysplasia

b. Dilated cardiomyopathy
c. Hypertrophic cardiomyopathy
d. Primary pulmonary HTN
e. Restrictive cardiomyopathy
Page - 90
Question 42/155
Question #42
A 66-year-old male has exertional dyspnea, lower limb edema, and orthopnea. His echocardiogram
demonstrates an ejection fraction of 23% and a thin-walled enlarged le ventricle. What is the most
likely diagnosis?
a. Arrhythmogenic right ventricular dysplasia

b. Dilated cardiomyopathy √
c. Hypertrophic cardiomyopathy
d. Primary pulmonary HTN
e. Restrictive cardiomyopathy
Description
ese are typical echocardiogram findings of dilated cardiomyopathy (DCM).
e presence of an enlarged LV chamber and thin wall are suggestive of DCM
Hypertrophic cardiomyopathy will demonstrate hypertrophied wall of the LV
Restrictive cardiomyopathy will show reduced ventricular volume, normal le ventricular wall
thickness, normal systolic function, and impaired ventricular filling.
Page - 91
Question 43/155
Question #43
A 21-year-old male patient was brought to the emergency department aer he collapsed in the
street. He is not responsive, has a dilated right pupil, and is not breathing. What is the most
appropriate step to take?
a. Brain CT scan without contrast

b. Brain MRI
c. Immediate intravenous fluid administration
d. Immediate intubation
e. Intravenous mannitol
Page - 92
Internal Medicine - Cardiology - Cardiopulmonary resuscitation (CPR)
Question 43/155
Question #43
A 21-year-old male patient was brought to the emergency department aer he collapsed in the
street. He is not responsive, has a dilated right pupil, and is not breathing. What is the most
appropriate step to take?
a. Brain CT scan without contrast

b. Brain MRI
c. Immediate intravenous fluid administration
d. Immediate intubation √
Description
If any patient is unresponsive and not breathing, you should start the BLS protocol of CAB
(compression, airway, and breathing).
Note that the order of CPR steps rearranged to become CAB instead of ABC
Intubation here is the best choice to answer
Page - 93
Question 44/155
Question #44
While performing CPR on an adult by two rescuers, the ratio of compression to respiration should
be:
a. 3:1
b. 10:3
c. 15:1
d. 30:1
e. 30:2
Page - 94
Question 44/155
Question #44
While performing CPR on an adult by two rescuers, the ratio of compression to respiration should
be:
a. 3:1
b. 10:3
c. 15:1
d. 30:1
e. 30:2 √
Description
It is reasonable for rescuers trained in CPR using chest compressions and ventilation (rescue breaths)
to provide a compression-to-ventilation ratio of 30:2 for adults in cardiac arrest
Aer placement of an advanced airway, it is reasonable for the provider to deliver 1 breath every 6
seconds (10 breaths per min) while continuous chest compressions are being performed
You should minimize interruptions in chest compressions when placing or ventilating with an
advanced airway. In addition, excessive ventilation should be avoided.
Page - 95
Question 45/155
Question #45
You are a part of a 3-persons team providing cardiopulmonary resuscitation for a 16-year-old guy,
and no advanced airway; according to the AHA recommendations, the compression-to-ventilation
ratio should be:
a. 30:2
b. 15:2
c. 15:1
d. 30:1
e. 30:15
Page - 96
Question 45/155
Question #45
You are a part of a 3-persons team providing cardiopulmonary resuscitation for a 16-year-old guy,
and no advanced airway; according to the AHA recommendations, the compression-to-ventilation
ratio should be:
a. 30:2 √
b. 15:2
c. 15:1
d. 30:1
e. 30:15
Description
According to the recent AHA recommendations for CPR in adults, if there is no advanced airway, the
compression-to-ventilation ratio should be 30:2 regardless of the number of rescuers.
Note that the scenario will be dierent in children < 12 years old.
Compression-to-ventilation ratio:
For adults:
No advanced airway: the ratio should be 30:2 regardless of the number of rescuers.
If an advanced airway is present: continuous compression with one ventilation every 5 –
6 seconds
For pediatrics (>12 years old):
No advanced airway one rescuer, the ratio should be 30:2
No advanced airway and ≥ 2 rescuers: the ratio should be 15:2
If an advanced airway is present, continuous compression with one ventilation every 2 –
3 seconds
Excessive ventilation should be avoided
Page - 97
Question 46/155
Question #46
A 5-year-old male patient is found to have pulseless electrical activity (PEA). You started CPR
immediately. Which of the following is not a cause of PEA?
a. Cardiac tamponade
b. Tension pneumothorax
c. Hyperglycemia
d. Hypothermia
e. Hyperkalemia
Page - 98
Question 46/155
Question #46
A 5-year-old male patient is found to have pulseless electrical activity (PEA). You started CPR
immediately. Which of the following is not a cause of PEA?
a. Cardiac tamponade
b. Tension pneumothorax
c. Hyperglycemia √
d. Hypothermia
e. Hyperkalemia
Description
Hypoglycemia, not hyperglycemia, is a cause of PEA
the possible causes of PEA are shown in the table below:
Page - 99
Question 47/155
Question #47
A 35-year-old female presents to your department with severe retrosternal chest pain; the pain is
aggravated by lying down and bending forward and relieved by aluminum-containing antacids,
with no dysphagia or shortness of breath. What is the most likely diagnosis?
a. Unstable angina
b. Reflux disease
c. Achalasia
d. Costochondritis
e. Pericarditis
Page - 100
Internal Medicine - Cardiology - Chest Pain
Question 47/155
Question #47
A 35-year-old female presents to your department with severe retrosternal chest pain; the pain is
aggravated by lying down and bending forward and relieved by aluminum-containing antacids,
with no dysphagia or shortness of breath. What is the most likely diagnosis?
a. Unstable angina
b. Reflux disease √
c. Achalasia
d. Costochondritis
e. Pericarditis
Description
It is unlikely to see IHD in young females. e chest pain is atypical because it changes with body
position and is relieved by antacid
e most likely diagnosis here is GERD
Features of typical chest pain:
Central, retrosternal
Heavy, dull, squeezing in character, or pressure-like.
Radiated to neck, jaw, epigastrium, shoulders, or back
Increased by exercise and relieved by rest or nitrates
Page - 101
Question 48/155
Question #48
e following mechanisms can aggravate the ischemic chest pain by increasing myocardial oxygen
demand except:
a. Increased myocardial contractility

b. Aortic valve stenosis
c. Increased the heart rate
d. Ventricular hypertrophy
e. Decreased systemic vascular resistance
Page - 102
Question 48/155
Question #48
e following mechanisms can aggravate the ischemic chest pain by increasing myocardial oxygen
demand except:
a. Increased myocardial contractility

b. Aortic valve stenosis
c. Increased the heart rate
d. Ventricular hypertrophy
e. Decreased systemic vascular resistance √
Description
Ischemic pain of the heart develops when the oxygen demand by the myocardium exceeds the
supply to it by coronary arteries either due to
coronary artery disease or blockage due to atherosclerosis or clot formation.
Increased “not decreased” systemic vascular resistance is responsible for more workload on the
heart to pump blood; thus, more oxygen is required for the process
Page - 103
Question 49/155
Question #49
A non-smoker 32-year-old female presents to you with sharp, stabbing chest pain at the le sternal
border. e pain is non-radiating and aggravated by coughing and palpation. ere is no history or
family history of DM, HTN, or IHD. Her physical examination, ECG, and chest x-ray are otherwise
normal. What is the next step in the evaluation of this patient?
a. Admission for serial ECG and cardiac enzymes

b. Exercise stress test
c. No additional testing
d. Refer to cardiac catheterization
e. Start aspirin and clopidogrel
Page - 104
Question 49/155
Question #49
A non-smoker 32-year-old female presents to you with sharp, stabbing chest pain at the le sternal
border. e pain is non-radiating and aggravated by coughing and palpation. ere is no history or
family history of DM, HTN, or IHD. Her physical examination, ECG, and chest x-ray are otherwise
normal. What is the next step in the evaluation of this patient?
a. Admission for serial ECG and cardiac enzymes

b. Exercise stress test
c. No additional testing √
d. Refer to cardiac catheterization
e. Start aspirin and clopidogrel
Description
is patient has atypical chest pain (non-cardiac). It is most likely due to a musculoskeletal problem.
No risk factors for IHD and the probability of coronary diseases is very low.
Page - 105
Question 50/155
Question #50
A 26-year-old male patient had severe chest pain, diaphoresis, and HTN for 2 hours while at a party.
His friends told you that the patient was hyper during the party. His blood pressure is 165/115 mmHg,
his pulse is 115 bpm, and his pupils are dilated bilaterally. His ECG shows diuse ST elevation. Which
of the following is contraindicated in the treatment of this patient?
a. Verapamil
b. Propranolol
c. Enalapril
d. Valsartan
e. Hydrochlorothiazide
Page - 106
Internal Medicine - Cardiology - Cocaine-induced Chest Pain
Question 50/155
Question #50
A 26-year-old male patient had severe chest pain, diaphoresis, and HTN for 2 hours while at a party.
His friends told you that the patient was hyper during the party. His blood pressure is 165/115 mmHg,
his pulse is 115 bpm, and his pupils are dilated bilaterally. His ECG shows diuse ST elevation. Which
of the following is contraindicated in the treatment of this patient?
a. Verapamil
b. Propranolol √
c. Enalapril
d. Valsartan
Description
is patient is most likely to have a cocaine overdose. e clues here are “the party, the chest pain
with ST-elevation, and feeling hyper during the party.”
Beta-blockers are contraindicated in the case of a cocaine overdose.
Cocaine inhibits the reuptake of norepinephrine, and there is a strong alpha-1-receptor activity
causing systemic and coronary vasoconstriction.
If we inhibit the vasodilatory action using propranolol, there is unopposed alpha-1 activity leading to
coronary vasoconstriction and worsening myocardial ischemia.
Page - 107
Question 51/155
Question #51
A heavy smoker 32-year-old male patient presents to the ER with 45 minutes history of pressure-like
chest pain that radiates to the le shoulder. e pain is associated with dyspnea, anxiety,
palpitations, and sweating. He admits that he used intranasal cocaine 2 hours ago. His blood
pressure is 185/114, pulse 110, and ECG shows sinus tachycardia with early repolarization. You
administered aspirin, nitrates, and oxygen. Which of the following is indicated at this point?
a. Captopril
b. Lorazepam
c. Metoprolol
d. Nifedipine
e. Tissue plasminogen activator
Page - 108
Question 51/155
Question #51
A heavy smoker 32-year-old male patient presents to the ER with 45 minutes history of pressure-like
chest pain that radiates to the le shoulder. e pain is associated with dyspnea, anxiety,
palpitations, and sweating. He admits that he used intranasal cocaine 2 hours ago. His blood
pressure is 185/114, pulse 110, and ECG shows sinus tachycardia with early repolarization. You
administered aspirin, nitrates, and oxygen. Which of the following is indicated at this point?
a. Captopril
b. Lorazepam √
c. Metoprolol
d. Nifedipine
e. Tissue plasminogen activator
Description
In cocaine-induced chest pain, Hypertension, tachycardia, and chest pain will oen respond to
intravenous benzodiazepines.
e use of beta-blockers is contraindicated in this case as they aggravate the vasospasms
Calcium channel blockers can be used in this situation if the patient is not responding to
benzodiazepines and nitrates
Page - 109
Question 52/155
Question #52
A 30-year-old male is brought to the ER with a crushing sensation in his chest, and his nasal mucous
membranes are found to be dry due to suspected cocaine use. e following choices about cocaine-
induced chest pain are false except:
a. e patient should be treated with beta-blockers

b. e main mechanism is a dopamine-dependent state resulting in vasospasm
c. ere are predicted ECG abnormalities
d. Transient ECG changes will exclude the diagnoses of cocaine toxicity
e. A high dose of cocaine is required to cause this condition
Page - 110
Question 52/155
Question #52
A 30-year-old male is brought to the ER with a crushing sensation in his chest, and his nasal mucous
membranes are found to be dry due to suspected cocaine use. e following choices about cocaine-
induced chest pain are false except:
a. e patient should be treated with beta-blockers

b. e main mechanism is a dopamine-dependent state resulting in vasospasm √
c. ere are predicted ECG abnormalities
d. Transient ECG changes will exclude the diagnoses of cocaine toxicity
e. A high dose of cocaine is required to cause this condition
Description
e main mechanism of cocaine-induced chest pain is believed to be due to a dopamine-dependent

state resulting in coronary vasospasm.
Beta-blockers are contraindicated in case of cocaine-induced chest pain because this will aggravate
the vasospasm
ECG changes are variable and may be persistent ST elevation or maybe transient changes
Page - 111
Question 53/155
Question #53
A patient presents to you with persistent ST elevation aer sustaining a myocardial infarction 2
years ago. Which of the following is the most likely diagnosis?
a. Pericarditis
b. LV aneurysm
c. Re-infarction
d. Papillary muscle rupture
e. LV free wall rupture
Page - 112
Internal Medicine - Cardiology - Complications of MI
Question 53/155
Question #53
A patient presents to you with persistent ST elevation aer sustaining a myocardial infarction 2
years ago. Which of the following is the most likely diagnosis?
a. Pericarditis
b. LV aneurysm √
c. Re-infarction
d. Papillary muscle rupture
e. LV free wall rupture
Description
Complications of MI are shown in the following table
Page - 113
Question 54/155
Question #54
12-hours aer myocardial infarction, a 45-year-old man develops shortness of breath, mued heart
sound, raised JVP, and hypotension. His ECG is shown below. Which of the following is the most
likely diagnosis?
a. Re-infarction
b. Papillary muscle rupture
c. LV free wall rupture
d. LV aneurysm
e. Dressler’s syndrome
Page - 114
Internal Medicine - Cardiology - Complications of MI
Question 54/155
Question #54
12-hours aer myocardial infarction, a 45-year-old man develops shortness of breath, mued heart
sound, raised JVP, and hypotension. His ECG is shown below. Which of the following is the most
likely diagnosis?
a. Re-infarction
b. Papillary muscle rupture
c. LV free wall rupture √
d. LV aneurysm
e. Dressler’s syndrome
Description
Complications of MI are shown in the following table
Page - 115
Page - 116
Question 55/155
Question #55
A 63-year-old male patient with a history of systolic heart failure presents for routine evaluation. He
is on Aldactone and carvedilol. However, his Enalapril was stopped 3 weeks ago because he was
diagnosed with chronic kidney disease. Which medications are allowed and have mortality and
symptomatic benefits for this patient?
a. Digoxin
b. Nitrate
c. Hydralazine/Isosorbide
d. Losartan
e. Amlodipine
Page - 117
Internal Medicine - Cardiology - Congestive heart failure (CHF)
Question 55/155
Question #55
A 63-year-old male patient with a history of systolic heart failure presents for routine evaluation. He
is on Aldactone and carvedilol. However, his Enalapril was stopped 3 weeks ago because he was
diagnosed with chronic kidney disease. Which medications are allowed and have mortality and
symptomatic benefits for this patient?
a. Digoxin
b. Nitrate
c. Hydralazine/Isosorbide √
d. Losartan
e. Amlodipine
Description
ACE inhibitors and beta-blockers are the usual treatment for heart failure. Patients who are
intolerant to ACE inhibitors due to hyperkalemia should take a combination of hydralazine and oral
nitrates
Hydralazine and oral nitrates combination has both mortality and symptomatic benefits
Digoxin and nitrates have only symptomatic benefits in heart failure.
ARBs have the same risk of Hyperkalemia as ACE inhibitors in this patient and should be avoided.
Amlodipine will increase mortality and lower limb edema in patients with systolic heart failure.
Page - 118
Question 56/155
Question #56
e ejection fraction that matches the diagnosis of diastolic heart failure should be greater than:
a. 25%
b. 35%
c. 45%
d. 55%
e. 75%
Page - 119
Question 56/155
Question #56
e ejection fraction that matches the diagnosis of diastolic heart failure should be greater than:
a. 25%
b. 35%
c. 45%
d. 55% √
e. 75%
Description
Diastolic heart failure is also known as heart failure with preserved ejection fraction. e ejection
fraction, in this case, will be normal (>55%)
Page - 120
Question 57/155
Question #57
A 66-year-old male patient has a history of HTN, CKD, and heart failure (last Ejection Fraction is
34%). He presents with shortness of breath and fatigue on exertion. His medications include
furosemide and metoprolol. He used to be on Enalapril but was stopped because of hyperkalemia.
Which drugs will have the most mortality and symptomatic benefit in this patient?
a. Digoxin
b. Hydralazine/Isosorbide
c. Nifedipine
d. Valsartan
e. Verapamil
Page - 121
Question 57/155
Question #57
A 66-year-old male patient has a history of HTN, CKD, and heart failure (last Ejection Fraction is
34%). He presents with shortness of breath and fatigue on exertion. His medications include
furosemide and metoprolol. He used to be on Enalapril but was stopped because of hyperkalemia.
Which drugs will have the most mortality and symptomatic benefit in this patient?
a. Digoxin
b. Hydralazine/Isosorbide √
c. Nifedipine
d. Valsartan
e. Verapamil
Description
ACE inhibitors and beta-blockers are the usual treatment for heart failure. Patients who are
intolerant to ACE inhibitors due to hyperkalemia should take a combination of hydralazine and oral
nitrates
Hydralazine and oral nitrates combination has both mortality and symptomatic benefits
Page - 122
Question 58/155
Question #58
A 50-year-old male patient is on captopril for his heart failure. In addition, he has dyspnea on
significant exertion. Which of the following agents should be added to improve the survival of this
patient?
a. Amiodarone
b. Beta-blockers
c. Digitalis
d. Verapamil
e. Warfarin
Page - 123
Question 58/155
Question #58
A 50-year-old male patient is on captopril for his heart failure. In addition, he has dyspnea on
significant exertion. Which of the following agents should be added to improve the survival of this
patient?
a. Amiodarone
b. Beta-blockers √
c. Digitalis
d. Verapamil
e. Warfarin
Description
Beta-blockers are recommended to reduce the mortality rate in patients with heart failure. But beta-
blockers should be avoided in case of acute decompensated heart failure because they will suppress
the compensatory tachycardia and worsen the condition of the patient
Page - 124
Question 59/155
Question #59
A 68-year-old male patient presents with palpitations and exertional dyspnea. His blood pressure is
146/89. His pulse is 110 and regular. His echocardiogram shows a high le ventricular end-diastolic
volume and high ejection fraction. What investigation would be expected to be most beneficial in
the diagnosis?
a. Cardiac enzymes
b. Kidney function test
c. yroid function test
d. Liver function test
e. Pulmonary function test
Page - 125
Question 59/155
Question #59
A 68-year-old male patient presents with palpitations and exertional dyspnea. His blood pressure is
146/89. His pulse is 110 and regular. His echocardiogram shows a high le ventricular end-diastolic
volume and high ejection fraction. What investigation would be expected to be most beneficial in
the diagnosis?
a. Cardiac enzymes
c. yroid function test √
d. Liver function test
e. Pulmonary function test
Description
e high LVEDV and high ejection fraction suggests the diagnosis of increased cardiac output heart
failure
TSH is the investigation expected to have the greatest diagnostic yield. High cardiac output heart
failure is most likely due to thyrotoxicosis in this patient
Page - 126
Question 60/155
Question #60
Which of the following agents is indicated in a patient with congestive heart failure associated with
reduced ejection fraction?
a. Valsartan
b. Hydralazine
c. Warfarin
d. Digoxin
e. Amiodarone
Page - 127
Question 60/155
Question #60
Which of the following agents is indicated in a patient with congestive heart failure associated with
reduced ejection fraction?
a. Valsartan √
b. Hydralazine
c. Warfarin
d. Digoxin
e. Amiodarone
Description
All patients with systolic CHF should receive treatment of ACE inhibitory or ARBs as they can
significantly reduce the mortality rate in such patients
Page - 128
Question 61/155
Question #61
A 66-year-old male with a history of HTN and IHD presents with exertional dyspnea and orthopnea.
On examination, he is found to have pedal edema and bibasilar rales. His chest x-ray demonstrates
cardiomegaly and lung congestion. His echocardiogram shows cardiomegaly and an ejection
fraction of 40%. Which of the following are indicated to reduce the mortality rate in this patient?
a. Digoxin
b. Frusemide
c. Amlodipine
d. Aldactone
e. iazide diuretics
Page - 129
Question 61/155
Question #61
A 66-year-old male with a history of HTN and IHD presents with exertional dyspnea and orthopnea.
On examination, he is found to have pedal edema and bibasilar rales. His chest x-ray demonstrates
cardiomegaly and lung congestion. His echocardiogram shows cardiomegaly and an ejection
fraction of 40%. Which of the following are indicated to reduce the mortality rate in this patient?
a. Digoxin
b. Frusemide
c. Amlodipine
d. Aldactone √
Description
HF treatment with mortality benefits are: ACEI/ARB, Beta-blockers, Spironolactone, Eplerenone

(hydralazine + Nitrates), ICD
Digoxin and Loop Diuretics have no mortality benefits (only symptomatic)
Page - 130
Question 62/155
Question #62
A 62-year-old male patient with a known case of CHF presents for routine follow-up. He says he has
no problems in ordinary physical activities and can perform everyday activities without limitations.
According to the NYHA classification of heart failure, which class most accurately describes the
patient’s condition?
a. Class I
b. Class II
c. Class III
d. Class IV
e. Class V
Page - 131
Question 62/155
Question #62
A 62-year-old male patient with a known case of CHF presents for routine follow-up. He says he has
no problems in ordinary physical activities and can perform everyday activities without limitations.
According to the NYHA classification of heart failure, which class most accurately describes the
a. Class I √
b. Class II
c. Class III
d. Class IV
e. Class V
Description
NYHA classification of HF:
Class I: no limitations on ordinary physical activities

Class II: slight limitation of ordinary physical activities
Class III: marked limitation of physical activity
Class IV: symptoms of CHF present at rest
ere is no class V in the NYHA classification of heart failure.
Page - 132
Question 63/155
Question #63
e following treatments of systolic le ventricular heart failure can lower the mortality rate except:
a. Aldactone
b. Digoxin
c. ACE inhibitors / ARBs
d. Beta-blockers
e. Sacubitril/Valsartan (entresto)
Page - 133
Question 63/155
Question #63
e following treatments of systolic le ventricular heart failure can lower the mortality rate except:
a. Aldactone
b. Digoxin √
c. ACE inhibitors / ARBs
d. Beta-blockers
e. Sacubitril/Valsartan (entresto)
Description
HF treatment with mortality benefits are: ACEI/ARB, Beta-blockers, Spironolactone,

Eplerenone (hydralazine + Nitrates), ICD, Sacubitril/Valsartan
CCB may increase the mortality rate and worsen edema in systolic heart failure but reduces
the mortality in isolated diastolic heart failure
Digoxin and spironolactone are not beneficial in diastolic heart failure
Page - 134
Question 64/155
Question #64
A 60-year-old male patient with chronic heart failure presents with shortness of breath, easy
fatigability, and along with pulmonary and peripheral edema. What is the pathophysiology of this
disease?
a. Concentric cardiac hypertrophy

b. High cardiac output
c. High coronary perfusion
d. Increased myocardial contractility
e. Physiologic hypertrophy or athlete’s heart
Page - 135
Question 64/155
Question #64
A 60-year-old male patient with chronic heart failure presents with shortness of breath, easy
fatigability, and along with pulmonary and peripheral edema. What is the pathophysiology of this
disease?
a. Concentric cardiac hypertrophy √

b. High cardiac output
c. High coronary perfusion
d. Increased myocardial contractility
e. Physiologic hypertrophy or athlete’s heart
Description
Increasing the workload on the heart or injury on the heart muscles will lead to a compensatory
increase in the cell size and decreased contractility à the increase in the mass of the heart muscle
will lead to a reduction in the chamber size
Physiologic hypertrophy or athlete’s heart is a normal response of healthy exercise or pregnancy

(requiring more blood pumping) à enhance the pumping ability of the heart
Key point: cardiac hypertrophy related to stress will reduce the chamber size and the ability of the
heart to pump blood, while physiologic hypertrophy will lead to better heart function
Page - 136
Question 65/155
Question #65
A 42-year-old male patient presents to you for a pre-life insurance examination. You performed a 2-
dimensional Echocardiogram. Which of the following readings are considered normal ejection
fraction for this patient?
a. 35%
b. 45%
c. 65%
d. 85%
e. 90%
Page - 137
Question 65/155
Question #65
A 42-year-old male patient presents to you for a pre-life insurance examination. You performed a 2-
dimensional Echocardiogram. Which of the following readings are considered normal ejection
fraction for this patient?
a. 35%
b. 45%
c. 65% √
d. 85%
e. 90%
Description
e severity of HF according to EF%:
Grade I (EF > 60%) (Normal)

Grade II (EF = 40-59%)
Grade III (EF = 21-39%)
Grade IV (EF ≤ 20%)
Page - 138
Question 66/155
Question #66
An asymptomatic 55-year-old male presents for a routine examination. His blood pressure is 155/98,
ECG shows sinus rhythm and le ventricular hypertrophy. An echocardiogram confirms the findings.
Which of the following is the best management of this patient at this time?
a. Reassurance
b. Start nifedipine
c. Diclofenac sodium as needed
d. Valsartan
Page - 139
Question 66/155
Question #66
An asymptomatic 55-year-old male presents for a routine examination. His blood pressure is 155/98,
ECG shows sinus rhythm and le ventricular hypertrophy. An echocardiogram confirms the findings.
Which of the following is the best management of this patient at this time?
a. Reassurance
b. Start nifedipine
c. Diclofenac sodium as needed
d. Valsartan √
Description
ACE inhibitors and ARBs will result in regression of ventricular hypertrophy.
Note that ACE inhibitors, ARBs, beta-blockers, and thiazide diuretics are the most helpful drugs in
this setting
NSAIDs should be avoided as they will cause sodium and water retention leading to worsening of
HTN and heart failure
Page - 140
Question 67/155
Question #67
An intern doctor in the hospital wants to discuss the treatment options for heart failure. You told
him that the following conditions are contraindications for beta-blocker use in heart failure except:
a. e presence of heart block

b. Concomitant use of verapamil
c. Presence of bradycardia
d. Hemodynamic instability
e. NYHA class II heart failure
Page - 141
Question 67/155
Question #67
An intern doctor in the hospital wants to discuss the treatment options for heart failure. You told
him that the following conditions are contraindications for beta-blocker use in heart failure except:
a. e presence of heart block

b. Concomitant use of verapamil
c. Presence of bradycardia
d. Hemodynamic instability
e. NYHA class II heart failure √
Description
Contraindications to beta-blocker use include:
Hemodynamic instability
Heart block
Bradycardia
Acute decompensated heart failure
Severe asthma (but can be used in Asthma and COPD patients if they are monitored closely for
possible exacerbations)
Page - 142
Question 68/155
Question #68
A patient presents to you complaining of a gradually increasing Shortness of breath, orthopnea,

recurrent syncope, and easy fatigability. What does this patient have?
a. Right-side heart failure

b. Le-side heart failure
c. Biventricular heart failure
d. Acute myocardial infarction
e. Chronic obstructive pulmonary disease
Page - 143
Question 68/155
Question #68
A patient presents to you complaining of a gradually increasing Shortness of breath, orthopnea,

recurrent syncope, and easy fatigability. What does this patient have?
a. Right-side heart failure

b. Le-side heart failure √
c. Biventricular heart failure
d. Acute myocardial infarction
e. Chronic obstructive pulmonary disease
Description
is patient has signs and symptoms of le-sided heart failure
Symptoms of HF are as the following:
Symptoms of low cardiac output – le side (hypotension, syncope, cold extremities)
Symptoms of backward congestion, as the following:
Le-side heart failure: dyspnea, orthopnea, PND, pulmonary edema, pleural eusion,
cardiomegaly, le side S3/S4 Gallop rhythm.
Right-side heart failure: peripheral and lower limb edema, liver congestion,
hepatojugular reflux, ascites, high JVP, right side S3/S4 gallop rhythm
Page - 144
Question 69/155
Question #69
A 70-year-old male patient with an echocardiogram documented systolic dysfunction presents for
evaluation. His lab investigations are normal, including kidney and liver function tests. Which of the
following is the best initial medication for this patient?
a. Digoxin
b. Furosemide
c. Isosorbide dinitrates
d. Spironolactone
e. Valsartan
Page - 145
Question 69/155
Question #69
A 70-year-old male patient with an echocardiogram documented systolic dysfunction presents for
evaluation. His lab investigations are normal, including kidney and liver function tests. Which of the
following is the best initial medication for this patient?
a. Digoxin
b. Furosemide
c. Isosorbide dinitrates
d. Spironolactone
e. Valsartan √
Description
ACE inhibitors or ARBs are indicated for all patients with systolic heart failure, regardless of the
severity. ese drugs are shown to reduce both mortality and morbidity in both symptomatic and
asymptomatic patients
Page - 146
Question 70/155
Question #70
Which of the following heart failure treatments will reduce both preload and aerload?
a. Dobutamine
b. Enalapril
c. Furosemide
d. Hydralazine
e. Isosorbide dinitrates
Page - 147
Question 70/155
Question #70
Which of the following heart failure treatments will reduce both preload and aerload?
a. Dobutamine
b. Enalapril √
c. Furosemide
d. Hydralazine
e. Isosorbide dinitrates
Description
(ACE inhibitors, ARB’s, Prazosin, Nitroprusside) ese drugs improve cardiac output by reducing total
peripheral resistance and ventricular filling pressure by facilitating venous pooling.
Page - 148
Question 71/155
Question #71
A 55-year-old male patient with a history of HTN presents with gradually increasing shortness of breath and
easy fatigability. On examination, he has bilateral basilar crepitations and lower limb edema. However, his
vital signs are within normal limits. Which is the most preferred tool for evaluating this patient’s condition?
a. ECG
b. Chest x-ray
c. 2-dimensional Echocardiogram
e. Cardiac MRI
Page - 149
Question 71/155
Question #71
A 55-year-old male patient with a history of HTN presents with gradually increasing shortness of breath and
easy fatigability. On examination, he has bilateral basilar crepitations and lower limb edema. However, his
vital signs are within normal limits. Which is the most preferred tool for evaluating this patient’s condition?
a. ECG
b. Chest x-ray
c. 2-dimensional Echocardiogram √
e. Cardiac MRI
Description
e most preferred diagnostic tool for evaluating heart failure is a 2-dimensional echocardiogram
is test can (not exclusively) demonstrate the following details:
e cause of heart failure:

Akinesia (infarction), hypokinesia (ischemia)
Structural heart disease (ASD, VSD, valvular stenosis, valvular insuciency)
e presence of heart failure:
e ejection fraction of the heart
e systolic and diastolic dysfunction
e presence of complications of heart failure:
Ventricular hypertrophy
Pericardial eusion
Page - 150
Question 72/155
Question #72
A patient with class III CHF, whose ejection fraction is 39%, asks you about using high-dose aspirin to
relieve aches and pains. What is the most appropriate advice you provide?
a. e patient should avoid NSAIDS, but high-dose aspirin is appropriate to use in heart failure
b. NSAIDs, including aspirin, are good choices as they enhance the diuretic eect
c. High dose Aspirin is preferred over other NSAIDs for this patient
d. NSAIDs, including high-dose aspirin, should be avoided in CHF patients because they can cause
fluid retention
e. Low-dose aspirin is indicated to relieve the pain and aches in a patient with CHF
Page - 151
Question 72/155
Question #72
A patient with class III CHF, whose ejection fraction is 39%, asks you about using high-dose aspirin to
relieve aches and pains. What is the most appropriate advice you provide?
a. e patient should avoid NSAIDS, but high-dose aspirin is appropriate to use in heart failure
b. NSAIDs, including aspirin, are good choices as they enhance the diuretic eect
c. High dose Aspirin is preferred over other NSAIDs for this patient
d. NSAIDs, including high-dose aspirin, should be avoided in CHF patients because they can cause
fluid retention √
e. Low-dose aspirin is indicated to relieve the pain and aches in a patient with CHF
Description
NSAIDs should be avoided if possible in case of CHF because they can aggravate sodium and water
retention and will increase systemic vascular resistance, leading to increased workload on the heart
and thus increasing the mortality and symptoms in patients with congestive heart failure
Page - 152
Question 73/155
Question #73
A 59-year-old male patient with T2DM, HTN, and dyslipidemia presents with exertional dyspnea,
orthopnea, and pedal edema. His medications are atorvastatin, metformin, Aldactone, captopril,
and bisoprolol. His ejection fraction is 25%, his blood pressure is now 159/88, and his pulse is 72 bpm.
Which of the following agents are not important in the mortality reduction in this patient’s
condition?
a. Captopril
b. Bisoprolol
c. Aldactone
d. Implantable cardiac defibrillator
e. Digoxin
Page - 153
Question 73/155
Question #73
A 59-year-old male patient with T2DM, HTN, and dyslipidemia presents with exertional dyspnea,
orthopnea, and pedal edema. His medications are atorvastatin, metformin, Aldactone, captopril,
and bisoprolol. His ejection fraction is 25%, his blood pressure is now 159/88, and his pulse is 72 bpm.
Which of the following agents are not important in the mortality reduction in this patient’s
condition?
a. Captopril
b. Bisoprolol
c. Aldactone
d. Implantable cardiac defibrillator
e. Digoxin √
Description
Digoxin can improve the symptoms and reduce the recurrence of hospitalization in patients with
heart failure, but it never prolongs survival or improve the mortality rate.
HF treatment with mortality benefits are: ACEI/ARB, Beta-blockers, Spironolactone,

Eplerenone (hydralazine + Nitrates), ICD, Sacubitril/Valsartan
CCB may increase the mortality rate and worsen edema in systolic heart failure but reduces
the mortality in isolated diastolic heart failure
Digoxin and spironolactone are not beneficial in diastolic heart failure
Page - 154
Question 74/155
Question #74
A 56-year-old male patient is on lisinopril, digoxin, Aldactone, and beta-blockers to treat heart
failure. Recently he was symptomatic, and furosemide was added. Today he presents with nausea,
vomiting, and palpitations. What is the most logical diagnosis that will jump into your mind?
a. Myocardial infarction
b. Digoxin toxicity
c. Hyperkalemia induced arrhythmia
d. Hyperthyroidism
e. Atrial fibrillation
Page - 155
Internal Medicine - Cardiology - Digoxin and Digoxin toxicity
Question 74/155
Question #74
A 56-year-old male patient is on lisinopril, digoxin, Aldactone, and beta-blockers to treat heart
failure. Recently he was symptomatic, and furosemide was added. Today he presents with nausea,
vomiting, and palpitations. What is the most logical diagnosis that will jump into your mind?
b. Digoxin toxicity √
c. Hyperkalemia induced arrhythmia
d. Hyperthyroidism
Description
Digoxin toxicity is the most likely diagnosis here. It is most likely induced by hypokalemia due to
adding furosemide to the patient’s drugs
Page - 156
Question 75/155
Question #75
A patient with heart failure and chronic kidney diseases diagnosed to have digoxin toxicity, all the
following can manifest in this disease except:
a. Orthopnea
b. Xanthopsia
c. Severe bradycardia
d. rombocytopenia
e. Nausea and vomiting
Page - 157
Internal Medicine - Cardiology - Digoxin and Digoxin toxicity
Question 75/155
Question #75
A patient with heart failure and chronic kidney diseases diagnosed to have digoxin toxicity, all the
following can manifest in this disease except:
a. Orthopnea √
b. Xanthopsia
c. Severe bradycardia
d. rombocytopenia
e. Nausea and vomiting
Description
Digoxin is used to treat orthopnea, dyspnea, wheezing, and ankle edema related to heart failure.
Digoxin has a narrow therapeutic range and can cause toxicity leading to the following features:
Anorexia
Anxiety
Atrioventricular block
Confusion
Delirium and hallucinations
Diarrhea, nausea, and vomiting
Dizziness and headache
Rash
Severe bradycardia
Tachycardia
rombocytopenia
Ventricular arrhythmias
Visual disturbance (Xanthopsia)
Page - 158
Question 76/155
Question #76
A 22-year-old male patient complains of palpitations that occur every 10 – 14 days. e palpitations
occur for about 20 seconds and resolve spontaneously. Which of the following is the most
appropriate cardiac study to order at this time?
a. Echocardiogram
b. Electrocardiogram
c. Electrophysiological study
d. Implantable loop recorder
e. Insertable Cardiac Monitor
Page - 159
Internal Medicine - Cardiology - Dysrhythmias
Question 76/155
Question #76
A 22-year-old male patient complains of palpitations that occur every 10 – 14 days. e palpitations
occur for about 20 seconds and resolve spontaneously. Which of the following is the most
appropriate cardiac study to order at this time?
a. Echocardiogram
b. Electrocardiogram √
c. Electrophysiological study
d. Implantable loop recorder
e. Insertable Cardiac Monitor
Description
ECG is the first step in this scenario. You have to assess the rhythm and screen for chamber
enlargement or previous myocardial infarctions
Common types of cardiac monitoring:
Holter monitor: portable external monitor that is used to record cardiac activity for 24 – 48
hours
Event recorder: only record the cardiac activity when the patient activates it. It is worn on the
body for up to 30 days
Mobile cardiac telemetry: it automatically detects and records the heart rhythm for up to 30
days. It transmits the recordings to a mobile device to be reviewed by the physician
Insertable cardiac monitor: it is inserted under the skin and records cardiac events up to 30
years
Page - 160
Question 77/155
Question #77
A 42-year-old female patient presents with palpitations and dizziness for 2 hours duration. Her
blood pressure is 116/66, her pulse is 162 bpm, and her ECG is below. What is the treatment of choice
for her condition?
a. Digoxin PO
b. Digoxin IV
c. Synchronized Cardioversion
d. Adenosine
e. Verapamil
Page - 161
Question 77/155
Question #77
blood pressure is 116/66, her pulse is 162 bpm, and her ECG is below. What is the treatment of choice
for her condition?
a. Digoxin PO
b. Digoxin IV
d. Adenosine √
e. Verapamil
Description
Adenosine is the treatment of choice for stable patients with SVT.
It is contraindicated in asthma patient
It has a very short half-life
If the patient is not responsive to adenosine so verapamil can be used
If the patient is unstable, synchronized cardioversion is indicated
Digoxin is used to treat atrial fibrillation and heart failure
Supraventricular Tachycardia (SVT)
SVT: regular, no P wave, narrow QRS, and heart rate > 150 bpm
Causes: (Hypokalemia, Hyperthyroidism, Excessive alcohol)
Page - 162
Treatment of SVT:
For unstable patients: synchronized cardioversion.

For stable patients:
Step 1: Vagal maneuvers: (carotid massage, ocular massage, Ice on the forehead,
Valsalva maneuver)
Step 2: Adenosine (6, 12, then 12 mg IV push)
Step 3: I.V verapamil, Diltiazem, or metoprolol.
Step 4: synchronized cardioversion (if unresponsive)
Definitive treatment: catheter ablation.
Page - 163
Question 78/155
Question #78
A 78-year-old female with atrial fibrillation presents for evaluation. Her heart rate is 130 bpm with
irregular irregularity on ECG. What would you do in the management of this patient?
a. Rate control and warfarin

b. Rate control and no anticoagulation
c. Rhythm control and warfarin
d. Rhythm control and anticoagulation
e. Synchronized cardioversion and LMWH
Page - 164
Question 78/155
Question #78
A 78-year-old female with atrial fibrillation presents for evaluation. Her heart rate is 130 bpm with
irregular irregularity on ECG. What would you do in the management of this patient?
a. Rate control and warfarin √

b. Rate control and no anticoagulation
c. Rhythm control and warfarin
d. Rhythm control and anticoagulation
e. Synchronized cardioversion and LMWH
Description
In old patients with atrial fibrillation, you do not have to control the rhythm
Rhythm control will carry no more benefit than rate control, so you pay attention to the patient’s
symptoms.
According to the CHA2DS2VAS score, this patient has 2 points for age and 1 point for her gender, so
she needs to be put on anticoagulation to reduce the risk of stroke.
e following diagram shows the approach to the treatment of atrial fibrillation
Page - 165
Page - 166
Question 79/155
Question #79
A 60-year-old male presents with a pounding sensation in his chest. His ECG is shown in the
following figure. What does this patient have?
a. Atrial fibrillation
b. Atrial flutter
c. Ventricular fibrillation
d. Normal sinus rhythm
e. Ventricular tachycardia
Page - 167
Question 79/155
Question #79
A 60-year-old male presents with a pounding sensation in his chest. His ECG is shown in the
following figure. What does this patient have?
a. Atrial fibrillation √
b. Atrial flutter
d. Normal sinus rhythm
e. Ventricular tachycardia
Description
e presence of irregular irregularity on ECG along with absent P wave is the main feature of atrial
fibrillation on ECG.
Page - 168
Question 80/155
Question #80
A 49-year-old male patient has developed dizziness and palpitations for the past 6 hours, and his
ECG is shown below. What is the most likely diagnosis?
a. Le bundle branch block

b. Right bundle branch block
c. Ventricular tachycardia
d. Extrasystoles
e. Normal sinus rhythm
Page - 169
Question 80/155
Question #80
A 49-year-old male patient has developed dizziness and palpitations for the past 6 hours, and his
ECG is shown below. What is the most likely diagnosis?
a. Le bundle branch block

b. Right bundle branch block
c. Ventricular tachycardia
d. Extrasystoles √
Description
Extrasystole, premature ventricular contractions, also called ectopic beats. ey arise from a
ventricular focus. ey have bizarre shape-wide QRS. If they present alternatively every other beat,
they called bigeminy.
Page - 170
Question 81/155
Question #81
A 43-year-old female came with recurrent palpitations and chest discomfort. However, her ECG is
shown below. Her medications include Enalapril and spironolactone for hypertension and NYHA
class 1 heart failure. What is the anticoagulation of choice for her condition?
a. No anticoagulation needed
b. Start Warfarin therapy with an INR target of 2 – 3
c. Start Apixaban or dabigatran
d. Use only aspirin for this patient
e. e data in the question are not enough to decide
Page - 171
Question 81/155
Question #81
A 43-year-old female came with recurrent palpitations and chest discomfort. However, her ECG is
shown below. Her medications include Enalapril and spironolactone for hypertension and NYHA
class 1 heart failure. What is the anticoagulation of choice for her condition?
a. No anticoagulation needed
b. Start Warfarin therapy with an INR target of 2 – 3
c. Start Apixaban or dabigatran √
d. Use only aspirin for this patient
e. e data in the question are not enough to decide
Description
is patient has a CHA2DS2-VASc score of 3 (for her gender, history of HTN, and heart failure).
e first-line anticoagulation in patients with atrial fibrillation and high CHA2DS2-VASc score are
DOACs.
For many years, warfarin was the first line, but now DOACs are recommended, and warfarin has
become the second line for those who do not tolerate DOACs.
Aspirin is not recommended for reducing stroke risk in patients with AF.
e following table demonstrates the CHA2DS2-VASc score and its calculations.
Page - 172
Page - 173
Question 82/155
Question #82
An adult presents to you for follow-up. He was diagnosed with arrhythmia 3 years ago but is not
compliant with follow-up, and no medications have been taken for 3 years. His ECG is positive for
Delta wave and short PR interval. Which of the following is contraindicated in his condition?
a. Procainamide
b. Amiodarone
c. Digoxin
d. Nifedipine
e. Cardioversion
Page - 174
Question 82/155
Question #82
An adult presents to you for follow-up. He was diagnosed with arrhythmia 3 years ago but is not
compliant with follow-up, and no medications have been taken for 3 years. His ECG is positive for
Delta wave and short PR interval. Which of the following is contraindicated in his condition?
a. Procainamide
b. Amiodarone
c. Digoxin √
d. Nifedipine
e. Cardioversion
Description
Medications that may shorten the refractory period and enhance conduction over the bypass tract
(the bundle of Kent) are contraindicated to be given in patients with WPW Syndrome. is is because
they may cause even faster tachyarrhythmias or deterioration into ventricular fibrillation.
Page - 175
Question 83/155
Question #83
A 32-year-old male patient with diarrhea developed hypokalemia. He has been on an antihistamine
for recurrent itching and erythromycin for the last 4 days. He develops a brief episode of syncope
requiring cardiopulmonary resuscitation. Which of the following is the most likely responsible for
his condition?
a. Sinus bradycardia
b. Atrial fibrillation
c. Supraventricular tachycardia
d. Torsade de points
e. Asystole
Page - 176
Question 83/155
Question #83
A 32-year-old male patient with diarrhea developed hypokalemia. He has been on an antihistamine
for recurrent itching and erythromycin for the last 4 days. He develops a brief episode of syncope
requiring cardiopulmonary resuscitation. Which of the following is the most likely responsible for
his condition?
a. Sinus bradycardia
d. Torsade de points √
e. Asystole
Description
e presence of hypokalemia, antihistamine use, and erythromycin will raise the suspicion of long
QT syndrome and Torsade de Points.
Torsade de points (TdP):
It is also known as (twisting points)

It is associated with Long QT syndrome
May result in sudden death
Treatment of TdP:
For unstable patients: cardioversion

For stable patients: IV magnesium sulfate
Always correct the underlying cause.
Page - 177
Question 84/155
Question #84
A 68-year-old male patient presents because of palpitation; he is found to have atrial fibrillation on
ECG with a heart rate of 130 bpm, his vital signs are stable, and his echocardiogram reveals mitral
valve regurgitation and dilated le atrium. What is the best treatment option for this patient’s
condition?
a. Start a geriatric dose of digoxin

b. Start Atenolol
c. Start nifedipine
d. Start Aspirin therapy
e. Amiodarone
Page - 178
Question 84/155
Question #84
A 68-year-old male patient presents because of palpitation; he is found to have atrial fibrillation on
ECG with a heart rate of 130 bpm, his vital signs are stable, and his echocardiogram reveals mitral
valve regurgitation and dilated le atrium. What is the best treatment option for this patient’s
condition?
a. Start a geriatric dose of digoxin

b. Start Atenolol √
c. Start nifedipine
e. Amiodarone
Description
is is a stable, elderly patient who needs rate control for his atrial fibrillation.
Digoxin will be the best choice if the patient has heart failure
Nifedipine will cause more tachycardia and should be avoided at this stage
Page - 179
Page - 180
Question 85/155
Question #85
A 55-year-old male patient presents to the ER with shortness of breath and palpitation. His ECG
shows irregular irregularity; the patient’s blood pressure is 85/50, and the pulse is 133 and irregular.
What would you do next in the management of this patient?
a. Amiodarone IV infusion
b. Start CPR
c. Asynchronized cardioversion
d. Synchronized cardioversion
e. Digoxin infusion
Page - 181
Question 85/155
Question #85
A 55-year-old male patient presents to the ER with shortness of breath and palpitation. His ECG
shows irregular irregularity; the patient’s blood pressure is 85/50, and the pulse is 133 and irregular.
What would you do next in the management of this patient?
a. Amiodarone IV infusion
b. Start CPR
c. Asynchronized cardioversion
d. Synchronized cardioversion √
e. Digoxin infusion
Description
Synchronized cardioversion is the treatment of choice for any patient with atrial fibrillation and
hemodynamic instability.
Page - 182
Question 86/155
Question #86
A 19-year-old male patient has palpitations and lightheadedness, which are related to exertion. In
addition, he has a family history of an autopsy-negative sudden death of his brother while playing
football, and his mother has recurrent syncope. Which of the following is the best initial test in
management?
a. Resting ECG
b. Stress ECG
c. Echocardiogram
e. no further testing
Page - 183
Question 86/155
Question #86
A 19-year-old male patient has palpitations and lightheadedness, which are related to exertion. In
addition, he has a family history of an autopsy-negative sudden death of his brother while playing
football, and his mother has recurrent syncope. Which of the following is the best initial test in
management?
a. Resting ECG √
b. Stress ECG
c. Echocardiogram
e. no further testing
Description
Family history of sudden death and recurrent syncope is highly suggestive of inherited long QT
syndrome.
HOCM will be positive in the autopsy of his brother. So, long QT syndrome is more likely.
Resting ECG showing the corrected QT of > 440 ms is the best to diagnose long QT syndrome
Long QT syndrome is a risk for sudden death in young patients, and the management includes beta-
blockers, ICD, and avoiding competitive sports
Page - 184
Question 87/155
Question #87
A 65-year-old male patient was evaluated at the emergency room for dizziness, and his ECG is
shown below. What is the most likely diagnosis?
a. Heart block 1st-degree

b. Heart block 2nd-degree type 1
c. Heart block 2nd-degree type 2
d. Complete heart block
Page - 185
Question 87/155
Question #87

b. Heart block 2nd-degree type 1 √
Description
is ECG shows regular irregularity and a dropped beat. Progressive prolongation of PR followed by a
dropped beat is typical for first-degree AV block Mobitz type 1.
Heart block:
Also known as AV block (atrioventricular block)

Decreased or absent conduction through AV node
It could be first, second, or third-degree
Maybe due to RCA-mediated ischemia
First-degree AV block: long PR interval > 200ms, asymptomatic, need no treatment
Page - 186
Second-degree AV block (Mobitz type I): progressive prolongation of the PR interval, followed
by failure of conduction of P wave, no need for a pacemaker.
Second degree AV block (Mobitz type II): prolongation of the PR interval followed by failure of
conduction of P wave, need Pacemaker
ird-degree AV block (complete AV block): P and QRS waves are not related to each other;
regular P – P intervals and R – R intervals usually come with bradycardia and need Pacemaker
Page - 187
Question 88/155
Question #88
A 42-year-old female patient presents with palpitations and dizziness for 2 hours duration. At ER, her
blood pressure is 74/66, her pulse is 162 bpm, and her ECG is shown below. What is the next step in
the management of this patient?
a. Digoxin PO
b. Digoxin IV
d. Adenosine
e. Verapamil
Page - 188
Question 88/155
Question #88
A 42-year-old female patient presents with palpitations and dizziness for 2 hours duration. At ER, her
blood pressure is 74/66, her pulse is 162 bpm, and her ECG is shown below. What is the next step in
a. Digoxin PO
b. Digoxin IV
c. Synchronized Cardioversion √
d. Adenosine
e. Verapamil
Description
Any unstable patient with SVT should be immediately treated with synchronized cardioversion. e
patient’s blood pressure indicates instability here.
Vagal maneuvers, adenosine, and verapamil are used in stable patients.
Treatment of SVT:

Valsalva maneuver)
Page - 189
Page - 190
Question 89/155
Question #89
Regarding the risk of stroke in patients with atrial fibrillation. In comparison with patients with
permanent AF, patients with paroxysmal AF have a risk of stroke that is:
a. 25% less
b. 25% more
c. 50% less
d. 50% more
e. Similar risk of stroke for both groups
Page - 191
Question 89/155
Question #89
Regarding the risk of stroke in patients with atrial fibrillation. In comparison with patients with
permanent AF, patients with paroxysmal AF have a risk of stroke that is:
a. 25% less
b. 25% more
c. 50% less
d. 50% more
e. Similar risk of stroke for both groups √
Description
Regardless of the type or frequency of atrial fibrillation paroxysms, the risk of stroke is the same. e
risk of stroke is determined by applying the CHA2DS2VAS score
Page - 192
Question 90/155
Question #90
A patient presents to the ER with chest pain. While you take a history, he suddenly becomes
unresponsive. His ECG is shown below. What is the treatment of choice for this condition?
a. Amiodaron infusion
b. DC cardioversion
c. IV dextrose
d. IV naloxone
e. IV verapamil
Page - 193
Question 90/155
Question #90
A patient presents to the ER with chest pain. While you take a history, he suddenly becomes
unresponsive. His ECG is shown below. What is the treatment of choice for this condition?
a. Amiodaron infusion
b. DC cardioversion √
c. IV dextrose
d. IV naloxone
e. IV verapamil
Description
is patient has ventricular tachycardia, and he is unstable. is condition should be immediately
treated with DC cardioversion.
Ventricular tachycardia (VT):
VT: Regular, wide QRS (> 120 millisecond), no P wave, no T wave

Rate > 100 (usually 140-200)
Associated with (AV dissociation + capture beats)
It can be monomorphic or polymorphic
Treatment of VT:
For unstable patients: DC cardioversion

For stable patients: amiodarone, Lidocaine, procainamide
Page - 194
Question 91/155
Question #91
A 76-year-old male with a case of HTN and DM presents with atrial fibrillation. His blood pressure is
130.80, his pulse is 67 bpm, and the patient is conscious, oriented, and alert with no chest pain or
shortness of breath. What is the target level of INR for his condition?
a. 1.5 – 2
b. 2 – 3
c. 2.5 – 3.5
d. 3 – 4
e. No need for anticoagulation
Page - 195
Question 91/155
Question #91
A 76-year-old male with a case of HTN and DM presents with atrial fibrillation. His blood pressure is
130.80, his pulse is 67 bpm, and the patient is conscious, oriented, and alert with no chest pain or
shortness of breath. What is the target level of INR for his condition?
a. 1.5 – 2
b. 2 – 3 √
c. 2.5 – 3.5
d. 3 – 4
e. No need for anticoagulation
Description
According to the CHA2DS2VAS score, this patient has a score of 4 and needs anticoagulation
e target INR level for patients with atrial fibrillation is 2 – 3
Studies demonstrate that low-intensity warfarin (target 2 – 3) is equivalent to higher-intensity

anticoagulation (INR > 3) and is associated with a lower risk of major bleeding events
Page - 196
Question 92/155
Question #92
A patient is diagnosed with atrial fibrillation. Which is better for controlling heart rate at rest and
exercise?
a. Digoxin
b. Beta-blockers
c. Calcium channel blockers
d. Amiodaron
e. Flecainide
Page - 197
Question 92/155
Question #92
A patient is diagnosed with atrial fibrillation. Which is better for controlling heart rate at rest and
exercise?
a. Digoxin
b. Beta-blockers √
d. Amiodaron
e. Flecainide
Description
Beta-blockers are the best to control heart rate in both rest and exercise
Calcium channel blockers are used for the same purpose as well, but they are less eective than
beta-blockers
Digoxin primarily controls heart rate at rest only
Amiodaron and flecainide are used for rhythm control, not rate control
Page - 198
Question 93/155
Question #93
An asthmatic 42-year-old female patient presents with palpitations and dizziness for 2 hours; her
blood pressure is 116/66, her pulse is 162 bpm, and her ECG is shown below. What is the most likely
diagnosis?
b. Atrial flutter
d. Multifocal atrial tachycardia
e. Sinus tachycardia
Page - 199
Question 93/155
Question #93
blood pressure is 116/66, her pulse is 162 bpm, and her ECG is shown below. What is the most likely
diagnosis?
b. Atrial flutter
c. Supraventricular tachycardia √
d. Multifocal atrial tachycardia
Description
SVT (supraventricular tachycardia) on ECG demonstrated as an absent P wave, narrow QRS complex,
high heart rate, and regular rhythm.
Treatment of SVT:

Valsalva maneuver)
Page - 200
Page - 201
Question 94/155
Question #94
A 34-year-old male patient presents with intermittent palpitations. His ECG is shown below. What is
the most likely diagnosis?
a. Normal ECG
b. Le ventricular hypertrophy
c. WPW syndrome
d. LBBB
e. RBBB
Page - 202
Question 94/155
Question #94
A 34-year-old male patient presents with intermittent palpitations. His ECG is shown below. What is
a. Normal ECG
b. Le ventricular hypertrophy
c. WPW syndrome √
d. LBBB
e. RBBB
Description
is ECG shows Delta wave and short PR interval, which is typical for WPW syndrome
It is a congenital defect characterized by the presence of an accessory bundle between the

atrium and ventricle,
is bundle is called the “bundle of Kent.”
Type A (Le Side) or type B (Right Side)
Short PR interval and early ventricular depolarization (Delta wave)
Page - 203
Question 95/155
Question #95
blood pressure is 116/66, her pulse is 162 bpm, and her ECG is below. e carotid massage was tried,
and adenosine 6, 12, then 12 mg VI push was given, but no improvement. What is the next step in the
treatment of this patient?
a. Repeat 12 mg adenosine IV push

b. Give 24 mg adenosine IV push
c. Start IV verapamil
e. Amiodarone infusion
Page - 204
Question 95/155
Question #95
blood pressure is 116/66, her pulse is 162 bpm, and her ECG is below. e carotid massage was tried,
and adenosine 6, 12, then 12 mg VI push was given, but no improvement. What is the next step in the
treatment of this patient?
a. Repeat 12 mg adenosine IV push

b. Give 24 mg adenosine IV push
c. Start IV verapamil √
e. Amiodarone infusion
Description
is patient has SVT but no improvement on vagal maneuvers and adenosine. erefore, verapamil
is the next step in the management of this patient.
e recommended dose of adenosine is 6mg, 12mg, then 12mg IV push
Only 3 doses are used. If the patient improves at any time, further doses should not be needed.
Treatment of SVT:

Page - 205
Valsalva maneuver)
Page - 206
Question 96/155
Question #96
A 33-year-old male patient has had chest discomfort and palpitation for 30 minutes; his ECG is
b. Ventricular tachycardia
c. Sinus tachycardia
d. Atrial flutter
e. Sick sinus syndrome
Page - 207
Question 96/155
Question #96
a. Atrial fibrillation √
d. Atrial flutter
Description
is ECG shows irregular irregularity in the rhythm. ere is no P wave.
Fibrillatory waves (f waves) are present, and the QRS complexes are narrow.
is represents a case of atrial fibrillation.
Page - 208
Question 97/155
Question #97
A patient was admitted for major surgery. Which of the following is considered a risk factor for
postoperative ventricular arrhythmia?
a. Age of more than 60 years

b. History of hypothyroidism
c. History of SVT
d. Presence of congestive heart failure
e. Presence of PACs
Page - 209
Question 97/155
Question #97
A patient was admitted for major surgery. Which of the following is considered a risk factor for
postoperative ventricular arrhythmia?
a. Age of more than 60 years

b. History of hypothyroidism
c. History of SVT
d. Presence of congestive heart failure √
e. Presence of PACs
Description
Intraoperative and postoperative ventricular arrhythmias are expected in patients with the
following risk factors:
Preoperative ventricular ectopic beats

History of CHF
History of smoking
Page - 210
Question 98/155
Question #98
blood pressure is 116/66, her pulse is 162 bpm, and her ECG is shown below. What is the treatment of
choice for her condition?
a. Digoxin PO
b. Digoxin IV
d. Adenosine
e. Verapamil
Page - 211
Question 98/155
Question #98
blood pressure is 116/66, her pulse is 162 bpm, and her ECG is shown below. What is the treatment of
choice for her condition?
a. Digoxin PO
b. Digoxin IV
d. Adenosine
e. Verapamil √
Description
is patient has SVT; the first treatment of SVT in stable patients is adenosine, but this patient is
asthmatic, and adenosine is contraindicated with asthma.
Verapamil is the treatment of choice for stable patients with SVT and asthma.
Note that digoxin is used to treat AF and heart failure
Synchronized cardioversion is indicated if the patient is unstable.
Treatment of SVT:

Page - 212
Valsalva maneuver)
Page - 213
Question 99/155
Question #99
A 32-year-old female patient has had palpitations for 2 hours, and her ECG is shown below. What is
a. Atrial fibrillation with rapid ventricular response

b. Supraventricular tachycardia
d. Ventricular tachycardia
e. Normal ECG
Page - 214
Question 99/155
Question #99
A 32-year-old female patient has had palpitations for 2 hours, and her ECG is shown below. What is
a. Atrial fibrillation with rapid ventricular response

b. Supraventricular tachycardia √
d. Ventricular tachycardia
e. Normal ECG
Description
Regular, no P wave, narrow QRS, and heart rate > 150 bpm. ese features on ECG indicate SVT.
Treatment of SVT:

Page - 215
Valsalva maneuver)
Page - 216
Question 100/155
Question #100
Intravenous magnesium sulfate is used in treating which of the following arrhythmias?
a. Second-degree AV block
b. 3rd degree AV block
c. Junctional tachycardia
e. Ventricular fibrillation
Page - 217
Question 100/155
Question #100
Intravenous magnesium sulfate is used in treating which of the following arrhythmias?
a. Second-degree AV block
b. 3rd degree AV block
c. Junctional tachycardia
e. Ventricular fibrillation
Description
Torsade de points or twisting points usually result from long QT syndrome and is treated with
intravenous magnesium sulfate

Treatment of TdP:

Page - 218
Question 101/155
Question #101
e following ECG was recorded on a 45-year-old male patient. He has no symptoms at all. What is
b. Normal sinus rhythm
c. Heart block 1st degree
d. Complete Heart block
e. Junctional rhythm
Page - 219
Question 101/155
Question #101
e following ECG was recorded on a 45-year-old male patient. He has no symptoms at all. What is
c. Heart block 1st degree √
d. Complete Heart block
e. Junctional rhythm
Description
is ECG shows regular beats at a rate of 60 per minute
e axis deviation is normal, and the QRS complexes are narrow
e most important here is to note that the PR interval is more than 200 ms (1 large square). is is
typical for 1st-degree AV block.
Heart block:

Second degree AV block (Mobitz type II): prolongation of the PR interval followed by failurePage
of - 220
Page - 221
Question 102/155
Question #102
e following figure is an ECG of a 32-year-old male with hypokalemia. What is the most likely
diagnosis?
a. Ventricular fibrillation
c. Extrasystoles
e. Monomorphic ventricular tachycardia
Page - 222
Question 102/155
Question #102
e following figure is an ECG of a 32-year-old male with hypokalemia. What is the most likely
diagnosis?
c. Extrasystoles
e. Monomorphic ventricular tachycardia
Description
Long QT (mostly here due to hypokalemia) and twisted QRS complexes are typical of torsade de
points. is patient should receive magnesium sulfate intravenously, and the hypokalemia should
be corrected.

Page - 223
Treatment of TdP:

Page - 224
Question 103/155
Question #103
A 17-year-old male patient presents with recurrent palpitation. He is found to have a long QT on ECG.
All the following can be a cause except:
a. Hyperkalemia
b. Hypomagnesemia
c. Hypocalcemia
d. Romano ward syndrome
e. Erythromycin use
Page - 225
Question 103/155
Question #103
A 17-year-old male patient presents with recurrent palpitation. He is found to have a long QT on ECG.
All the following can be a cause except:
a. Hyperkalemia √
b. Hypomagnesemia
c. Hypocalcemia
d. Romano ward syndrome
e. Erythromycin use
Description
e following table shows the possible causes of torsade de points and long QT syndrome.

Treatment of TdP:

Page - 226
Question 104/155
Question #104
d. Atrial flutter
Page - 227
Question 104/155
Question #104
d. Atrial flutter √
Description
is ECG shows a saw-tooth appearance of the P wave; this represents a case of atrial flutter
Atrial flutter:
Large re-entry circuit in Right Atrium

Atrial rate: 300 BPM
Ventricular rate: 300 bpm (1:1), 150 bpm (2:1), or 100 bpm (3:1)
Rhythm: regular or maybe irregular
P waves: saw-tooth appearance, best seen in leads II, III or AVF
QRS: normal (less than 120 ms)
Page - 228
Question 105/155
Question #105
e definitive treatment of WPW syndrome is ablation in which of the following sites?
a. e pulmonary vein bifurcation

b. e right ventricle
c. e AV node
d. e bundle of HIS
e. e bundle of Kent
Page - 229
Question 105/155
Question #105
e definitive treatment of WPW syndrome is ablation in which of the following sites?
a. e pulmonary vein bifurcation

b. e right ventricle
c. e AV node
d. e bundle of HIS
e. e bundle of Kent √
Description
e bundle of Kent is an accessory bundle bypassing the AV node in case of WPW syndrome
Page - 230
Question 106/155
Question #106
A 42-year-old male patient was diagnosed with SVT, and now the heart rate is controlled on
verapamil. He presents to you for follow-up. What is the definitive treatment of this patient?
a. Adenosine
b. Verapamil
c. Cardioversion
d. Cardiac ablation
e. Amiodarone
Page - 231
Question 106/155
Question #106
A 42-year-old male patient was diagnosed with SVT, and now the heart rate is controlled on
verapamil. He presents to you for follow-up. What is the definitive treatment of this patient?
a. Adenosine
b. Verapamil
c. Cardioversion
d. Cardiac ablation √
e. Amiodarone
Description
Cardiac ablation is considered the definitive treatment of SVT.
An electrophysiological study of the heart is done, and ablation of the abnormal focus is done by a
catheter aer it is determined.
Treatment of SVT:

Valsalva maneuver)
Page - 232
Question 107/155
Question #107
Which of the following options carries the most significant risk of stroke in a patient with atrial
fibrillation?
a. Age of 74-year-old
b. History of stroke
c. Female sex
d. Heart failure
e. Diabetes mellitus
Page - 233
Question 107/155
Question #107
Which of the following options carries the most significant risk of stroke in a patient with atrial
fibrillation?
a. Age of 74-year-old
b. History of stroke √
c. Female sex
d. Heart failure
Description
According to the CHA2DS2VAS score system, the age of more than 75 and the presence of Stroke or
TIA has the highest risk (score 2 points).
e rest of mentioned choices has a score of 1 point on the CHA2DS2VAS score, so we consider them
of lower risk for stroke
Page - 234
Question 108/155
Question #108
A 32-year-old male patient was diagnosed with WPW syndrome. e episodic symptomatic
supraventricular tachycardia or atrial fibrillation benefits most from which of the following?
a. Beta-blockers
b. Digoxin
c. Amiodarone
d. Flecainide
e. Radiofrequency catheter ablation of bypass tracts
Page - 235
Question 108/155
Question #108
A 32-year-old male patient was diagnosed with WPW syndrome. e episodic symptomatic
supraventricular tachycardia or atrial fibrillation benefits most from which of the following?
a. Beta-blockers
b. Digoxin
c. Amiodarone
d. Flecainide
e. Radiofrequency catheter ablation of bypass tracts √
Description
Radiofrequency catheter ablation of the Kent bundle is safer and more cost eective than surgery,
with a similar success rate.
Beta-blockers and digoxin are contraindicated in WPW syndrome as they can shorten the refractory
period of the accessory pathway and increase the ventricular rate.
Page - 236
Question 109/155
Question #109
An asthmatic 23-year-old female patient presents to you with palpitations, and her ECG
demonstrates regular narrow complex tachycardia with an absent P wave. Her blood pressure is
130/80, her pulse is 180 bpm, and she is conscious. However, she returns to her sinus rhythm aer
carotid massage and vagal maneuvers. What is the definitive treatment for her condition?
a. Adenosine 6, 12, 12 mg intravenously

b. Verapamil administration
c. Catheter ablation
d. Digoxin administration
e. Levothyroxine therapy
Page - 237
Question 109/155
Question #109
An asthmatic 23-year-old female patient presents to you with palpitations, and her ECG
demonstrates regular narrow complex tachycardia with an absent P wave. Her blood pressure is
130/80, her pulse is 180 bpm, and she is conscious. However, she returns to her sinus rhythm aer
carotid massage and vagal maneuvers. What is the definitive treatment for her condition?
a. Adenosine 6, 12, 12 mg intravenously

b. Verapamil administration
c. Catheter ablation √
d. Digoxin administration
e. Levothyroxine therapy
Description
is is a case of supraventricular tachycardia, which was improved aer noninvasive treatment.
Note that the question is about the definitive treatment of SVT, so that the answer will be catheter
ablation.
Adenosine is contraindicated in asthmatic patients, and it is not a definitive treatment but rather a
symptomatic reliever of the SVT attack
Verapamil is useful for her condition, but again it is not a definitive treatment but can control
symptoms and reduce the recurrence of the attacks.
Page - 238
Question 110/155
Question #110
A 69-year-old patient is found to have premature ventricular contractions on routine examination.

What is the treatment for this condition according to the recent guidelines?
a. Amiodarone oral tablet

b. Flecainide oral tablet
c. Verapamil oral tablet
d. Metoprolol oral tablet
e. Reassurance and no drug therapy
Page - 239
Question 110/155
Question #110
A 69-year-old patient is found to have premature ventricular contractions on routine examination.

What is the treatment for this condition according to the recent guidelines?
a. Amiodarone oral tablet

b. Flecainide oral tablet
c. Verapamil oral tablet
d. Metoprolol oral tablet
e. Reassurance and no drug therapy √
Description
e use of beta-blockers in patients with PVCs is reserved for symptomatic cases only;
asymptomatic patients with PVCs are not indicated to receive any drug therapy according to the
recent guidelines.
Page - 240
Question 111/155
Question #111
A 32-year-old patient presented with palpitation and was diagnosed with SVT, which is now
controlled by adenosine. e ECG is demonstrated below. Which of the following is the most likely
diagnosis?
b. Premature ventricular contractions
c. Heart block
d. Sinus bradycardia
e. WPW syndrome
Page - 241
Question 111/155
Question #111
A 32-year-old patient presented with palpitation and was diagnosed with SVT, which is now
controlled by adenosine. e ECG is demonstrated below. Which of the following is the most likely
diagnosis?
b. Premature ventricular contractions
c. Heart block
e. WPW syndrome √
Description
e presence of delta wave and short PR interval indicate WPW syndrome
is patient will primarily benefit from the ablation of the Kent bundle
Page - 242
Question 112/155
Question #112
What does this ECG show?
a. Torsade de points
d. Atrial fibrillation
e. Atrial flutter
Page - 243
Question 112/155
Question #112
What does this ECG show?
a. Torsade de points
b. Ventricular tachycardia √
d. Atrial fibrillation
e. Atrial flutter
Description
Ventricular Tachycardia (VT): Regular, wide QRS (> 120 millisecond), no P wave, no T wave, and the
rate is > 100 (usually 140 – 200 bpm).
Ventricular tachycardia (VT):
VT: Regular, wide QRS (> 120 millisecond), no P wave, no T wave

Rate > 100 (usually 140-200)
Associated with (AV dissociation + capture beats)
It can be monomorphic or polymorphic
Page - 244
Treatment of VT:
For unstable patients: DC cardioversion

For stable patients: amiodarone, Lidocaine, procainamide
Page - 245
Question 113/155
Question #113

Page - 246
Question 113/155
Question #113

d. Complete heart block √
Description
Bradycardia, AV dissociation, and wide QRS complex are present in this ECG. Note that AV
dissociation is typical for a complete AV block.
Heart block:

Page - 247
Second degree AV block (Mobitz type II): prolongation of the PR interval followed by failure of
Page - 248
Question 114/155
Question #114
blood pressure is 116/66, her pulse is 162 bpm, and her ECG is below. What is the first-line treatment
for her condition?
a. Vagal maneuvers
b. Adenosine
c. Verapamil
e. Amiodarone
Page - 249
Question 114/155
Question #114
blood pressure is 116/66, her pulse is 162 bpm, and her ECG is below. What is the first-line treatment
for her condition?
a. Vagal maneuvers √
b. Adenosine
c. Verapamil
e. Amiodarone
Description
In stable patients with SVT, vagal maneuvers are the first-line treatment.
If not improved, start adenosine unless contraindicated.
Use verapamil in stable patients who don’t improve on adenosine or when adenosine is
contraindicated.
Treatment of SVT:

Page - 250
Valsalva maneuver)
Page - 251
Question 115/155
Question #115
A patient presents with palpitation, and his ECG is shown below. Which of the following is the
treatment of choice for his condition?
a. Amiodarone infusion
b. Intravenous Magnesium sulfate
c. Intravenous calcium gluconate
e. Intravenous Adenosine
Page - 252
Question 115/155
Question #115
A patient presents with palpitation, and his ECG is shown below. Which of the following is the
treatment of choice for his condition?
a. Amiodarone infusion
b. Intravenous Magnesium sulfate √
e. Intravenous Adenosine
Description
is ECG is showing Torsade de points. e best treatment for this condition is magnesium sulfate
intravenously.

Treatment of TdP:

Page - 253
Question 116/155
Question #116
A 59-year-old male patient with fever and weight loss is diagnosed with infective endocarditis. His
blood culture shows streptococcus bovis twice. He should be evaluated for which of the following
conditions?
a. Colorectal cancer
b. Lung cancer
c. Prostate cancer
d. B-cell lymphoma
e. T-cell lymphoma
Page - 254
Internal Medicine - Cardiology - Infective Endocarditis (IE)
Question 116/155
Question #116
A 59-year-old male patient with fever and weight loss is diagnosed with infective endocarditis. His
blood culture shows streptococcus bovis twice. He should be evaluated for which of the following
conditions?
a. Colorectal cancer √
b. Lung cancer
c. Prostate cancer
d. B-cell lymphoma
e. T-cell lymphoma
Description
Streptococcus bovis bacteremia or endocarditis is associated with colorectal cancer and upper
gastrointestinal malignancies as well.
In this patient, endoscopy is indicated to rule out colorectal cancer
Page - 255
Question 117/155
Question #117
A 66-year-old male patient has a fever and new-onset murmur and is diagnosed with infective
endocarditis. His blood culture is positive for Streptococcus bovis. What is the most appropriate
screening test to do at this point?
a. Chest x-ray
b. Colonoscopy
c. Repeat the blood culture
d. Perform prostate-specific antigen (PSA)
e. Bone marrow aspiration
Page - 256
Question 117/155
Question #117
A 66-year-old male patient has a fever and new-onset murmur and is diagnosed with infective
endocarditis. His blood culture is positive for Streptococcus bovis. What is the most appropriate
screening test to do at this point?
a. Chest x-ray
b. Colonoscopy √
c. Repeat the blood culture
d. Perform prostate-specific antigen (PSA)
e. Bone marrow aspiration
Description
Streptococcus bovis bacteremia or endocarditis is associated with colorectal cancer and upper
gastrointestinal malignancies as well.
In this patient, endoscopy is indicated to rule out colorectal cancer
Page - 257
Question 118/155
Question #118
According to culture results, A 32-year-old male patient is treated with amoxicillin and low-dose
gentamycin for infective endocarditis. He is still febrile and has shortness of breath. His ECG shows a
Prolonged PR interval. What is the most appropriate at this time?
a. Continue treatment with antibiotics

b. Repeat blood culture and switch to dierent antibiotics
c. Start diuretics and beta-blockers
d. Refer to cardiac surgery
e. Add rifampicin to his antibiotic regimen
Page - 258
Question 118/155
Question #118
According to culture results, A 32-year-old male patient is treated with amoxicillin and low-dose
gentamycin for infective endocarditis. He is still febrile and has shortness of breath. His ECG shows a
Prolonged PR interval. What is the most appropriate at this time?
a. Continue treatment with antibiotics

b. Repeat blood culture and switch to dierent antibiotics
c. Start diuretics and beta-blockers
d. Refer to cardiac surgery √
e. Add rifampicin to his antibiotic regimen
Description
is patient has infective endocarditis, and the ECG findings suggest an aortic root abscess. is
patient is a candidate for surgery and should have Valve debridement, valve repair, or replacement
Rifampicin is beneficial in infective endocarditis in a prosthetic heart valve.
Beta-blockers will aggravate the prolongation of PR on ECG and may result in a higher degree of AV
block
Indications for surgery in IE:
Severe valvular incompetence

An aortic abscess (oen indicated by a lengthening PR interval)
Infections resistant to antibiotics/fungal infections
Cardiac failure refractory to standard medical treatment
Recurrent emboli aer antibiotic therapy
Page - 259
Question 119/155
Question #119
A 65-year-old male patient presents with fever, chills, and weight loss for a 1-month duration. His
temperature is 39°C, his pulse is 105 bpm, and his chest examination reveals bibasilar crepitations
and pan-systolic murmur. His hand examination reveals a splinter hemorrhage. His WBC is
13,000/mm3, and his urinalysis is normal. What is the most likely diagnosis?
a. Infective endocarditis
b. Urinary tract infection
c. Bacterial pneumonia
d. Lymphoma
e. Diverticulitis
Page - 260
Question 119/155
Question #119
A 65-year-old male patient presents with fever, chills, and weight loss for a 1-month duration. His
temperature is 39°C, his pulse is 105 bpm, and his chest examination reveals bibasilar crepitations
and pan-systolic murmur. His hand examination reveals a splinter hemorrhage. His WBC is
13,000/mm3, and his urinalysis is normal. What is the most likely diagnosis?
a. Infective endocarditis √
c. Bacterial pneumonia
d. Lymphoma
e. Diverticulitis
Description
Page - 261
Question 120/155
Question #120
A 32-year-old male patient known as an IV drug user presents with fever, chills, and heart murmur.
What is the most appropriate test to do for this patient?
a. ECG
b. Blood culture
c. Urine culture
d. Chest x-ray
e. CBC
Page - 262
Question 120/155
Question #120
A 32-year-old male patient known as an IV drug user presents with fever, chills, and heart murmur.
What is the most appropriate test to do for this patient?
a. ECG
b. Blood culture √
c. Urine culture
d. Chest x-ray
e. CBC
Description
is patient is suspected of having infective endocarditis. Blood culture and echocardiogram are the
most appropriate for diagnosis at this time
Page - 263
Question 121/155
Question #121
A 39-year-old intravenous drug user has a fever and a new-onset murmur. Which of the following
statements is true?
a. e prevalence of endocarditis in this patient is equal to the average population

b. e most common site is the mitral valve
c. Streptococcus pneumonia is the most common cause
d. It is typically found in the tricuspid valve
e. e treatment of choice is NSAIDs and bed rest
Page - 264
Question 121/155
Question #121
A 39-year-old intravenous drug user has a fever and a new-onset murmur. Which of the following
statements is true?
a. e prevalence of endocarditis in this patient is equal to the average population

b. e most common site is the mitral valve
c. Streptococcus pneumonia is the most common cause
d. It is typically found in the tricuspid valve √
e. e treatment of choice is NSAIDs and bed rest
Description
Infective endocarditis (IE) is more prevalent in intravenous drug users, the most common cause of IE
in IV drug users is staphylococcus aureus, and it most commonly aects the tricuspid valve
e most common valve aected is the mitral valve, but the tricuspid is more likely to be involved in
IV drug users.
e treatment of choice for IE is intravenous antibiotics, not mere NSAIDs and bed rest
Page - 265
Question 122/155
Question #122
A 23-year-old female is an intravenous drug user who presents with fever, systolic murmur, and
general weakness. She is suspected of having infective endocarditis. What is the most common
valve to be aected in this patient?
a. Aortic valve
b. Mitral valve
c. Tricuspid valve
d. Pulmonary valve
e. ey are equally aected
Page - 266
Question 122/155
Question #122
A 23-year-old female is an intravenous drug user who presents with fever, systolic murmur, and
general weakness. She is suspected of having infective endocarditis. What is the most common
valve to be aected in this patient?
a. Aortic valve
b. Mitral valve
c. Tricuspid valve √
d. Pulmonary valve
e. ey are equally aected
Description
Infective endocarditis in IV drug users most commonly involves the tricuspid valve
In cases of infective endocarditis in non-IV drug users patients, the Mitral valve is the most
commonly aected.
Page - 267
Question 123/155
Question #123
A patient is taking Isosorbide mononitrate for his stable angina. All the following about this drug are
true except:
a. It has excellent bioavailability when administrated orally

b. e elimination half-life is 4 – 5 hours
c. Mononitrate has a longer half-life than Isosorbide dinitrate
d. It is better to be taken sublingually.
e. 2% of isosorbide mononitrate is excreted unchanged in the urine
Page - 268
Internal Medicine - Cardiology - Nitroglycerin
Question 123/155
Question #123
A patient is taking Isosorbide mononitrate for his stable angina. All the following about this drug are
true except:
a. It has excellent bioavailability when administrated orally

b. e elimination half-life is 4 – 5 hours
c. Mononitrate has a longer half-life than Isosorbide dinitrate
d. It is better to be taken sublingually. √
e. 2% of isosorbide mononitrate is excreted unchanged in the urine
Description
Isosorbide mononitrate does not undergo significant first-pass hepatic metabolism, so it has
excellent bioavailability when given orally.
Sublingual preparations are not available for mononitrates (not needed)
Mononitrates have a longer half-life and slower elimination than dinitrates. It is formulated as a
plain tablet and as a sustained-release preparation.
Sublingual isosorbide dinitrate produces maximal plasma concentrations of the drug by 6 minutes,
and the fall in concentration is rapid (half-life of approximately 45 minutes).
Glyceryl nitrate is an alternative term for nitroglycerine. In humans, peak concentrations of

nitroglycerin are found in plasma within 4 minutes of sublingual administration
Page - 269
Question 124/155
Question #124
e following are known mechanisms in which nitrates relieve the myocardial ischemic pain except:
a. Vasodilatation of the coronary artery

b. Reduce the systemic vascular resistance
c. Reduce the ventricular volume
d. Increase the oxygen demand
e. Reduce the preload and aerload
Page - 270
Internal Medicine - Cardiology - Nitroglycerin
Question 124/155
Question #124
e following are known mechanisms in which nitrates relieve the myocardial ischemic pain except:
a. Vasodilatation of the coronary artery

b. Reduce the systemic vascular resistance
c. Reduce the ventricular volume
d. Increase the oxygen demand √
e. Reduce the preload and aerload
Description
Nitrates dilate the veins, arteries, and arterioles (including the coronary artery). is will lead to a
reduction in systemic vascular resistance and a reduction of the cardiac workload, and thus a
reduction of the oxygen demands.
Nitrates reduce the preload and aerload.
It is indicated in the case of acute MI (to reduce the infarction size), heart failure and acute
pulmonary edema, and recurrent chronic anginal pain.
Page - 271
Question 125/155
Question #125
A 54-year-old female has had chest pain for the last 2 hours, and she was diagnosed with pulmonary
embolism. Her ECG is shown below. All the following features of PE are seen in her ECG except:
a. Right bundle branch block

b. Extreme axis deviation
c. S1Q3T3
d. Inverted T wave in V1 – V4
Page - 272
Internal Medicine - Cardiology - Normal heart conduction and basic ECG
Question 125/155
Question #125
A 54-year-old female has had chest pain for the last 2 hours, and she was diagnosed with pulmonary
embolism. Her ECG is shown below. All the following features of PE are seen in her ECG except:
a. Right bundle branch block

b. Extreme axis deviation
c. S1Q3T3
d. Inverted T wave in V1 – V4
e. Sinus tachycardia √
Description
Sinus tachycardia is the most common ECG finding in pulmonary embolism, but here it is not
present in the ECG of this patient.
e other mentioned choices are present in pulmonary embolism and are clearly shown in the ECG
above.
Page - 273
Question 126/155
Question #126
Which of the following is considered the normal pacemaker of the heart?
a. Atrioventricular node
b. Sinoatrial node
c. e interstitial cell of Cajal
d. Kent bundle
e. HIS bundle
Page - 274
Question 126/155
Question #126
Which of the following is considered the normal pacemaker of the heart?
a. Atrioventricular node
b. Sinoatrial node √
c. e interstitial cell of Cajal
d. Kent bundle
e. HIS bundle
Description
e normal pacemaker of the heart is the Sinoatrial (SA) node.
Typically, it generates impulses at a rate of 60 – 100 per minute
e normal conduction system of the heart is as the following:
SA node generates impulse → spread through atria → delayed at the AV node → spread down through
the HIS bundle → spread to Right and Le Bundle branches → Purkinje fibers
Note that the interstitial cell of Cajal is the normal pacemaker of the GI system, not the heart
Page - 275
Question 127/155
Question #127
About ECG interpretation, which of the following statements is true?
a. e P wave represents atrial depolarization

b. e QRS complex represents ventricular depolarization
c. e T wave represents ventricular repolarization
d. e heart rate “if regular” is calculated by dividing 300 by the RR interval
e. All of the above
Page - 276
Question 127/155
Question #127
About ECG interpretation, which of the following statements is true?
a. e P wave represents atrial depolarization

b. e QRS complex represents ventricular depolarization
c. e T wave represents ventricular repolarization
d. e heart rate “if regular” is calculated by dividing 300 by the RR interval
e. All of the above √
Description
Normally on ECG:
P wave: represents atrial depolarization (contraction)

QRS waves: represents ventricular depolarization (contraction)
T wave: represents ventricular repolarization (relaxation)
Rate assessment:
Normal heart rate is 60 – 100 bpm

A rate of more than 100 bpm is called tachycardia
A rate less than 60 bpm is called bradycardia
Calculate the rate by dividing 300/the number of large squares between each QRS complex
Page - 277
Question 128/155
Question #128
A 66-year-old male patient has had COPD for a long time, and his ECG is shown below. What is the
name of this condition?
a. Electrical alternans
b. P mitrale
c. P Pulmonale
e. Normal ECG morphology
Page - 278
Question 128/155
Question #128
A 66-year-old male patient has had COPD for a long time, and his ECG is shown below. What is the
name of this condition?
a. Electrical alternans
b. P mitrale
c. P Pulmonale √
e. Normal ECG morphology
Description
e presence of high P wave amplitude here indicates right atrial hypertrophy. is condition is
called P Pulmonale
e high amplitude P wave and COPD indicate elevated pulmonary pressure, leading to right-side
heart failure and right-side hypertrophy of the heart.
Page - 279
Question 129/155
Question #129
e following figure shows an ECG of a 62-year-old male patient. What is the most likely diagnosis?
a. Diuse ST elevation (pericarditis)

c. Right bundle branch block
d. Le bundle branch block
e. Atrioventricular block
Page - 280
Question 129/155
Question #129
e following figure shows an ECG of a 62-year-old male patient. What is the most likely diagnosis?
a. Diuse ST elevation (pericarditis)

c. Right bundle branch block
d. Le bundle branch block √
e. Atrioventricular block
Description
is ECG is irregularly irregular.
e heart rate is approximately 62 bpm
No P waves
f waves are present
QRS complexes are wide with a morphology of bundle branch block
Positive R in V6 indicates LBBB
Page - 281
is ECG shows atrial fibrillation and LBBB
Page - 282
Question 130/155
Question #130
A 67-year-old male patient with a history of lymphoma is diagnosed with cardiac tamponade. Which
of the following findings is inconsistent with this condition?
a. Hypotension
b. High JVP
c. Pulsus paradoxus
d. Quiet heart sound
e. Pericardial friction rub
Page - 283
Internal Medicine - Cardiology - Pericardial eusion and Tamponade
Question 130/155
Question #130
A 67-year-old male patient with a history of lymphoma is diagnosed with cardiac tamponade. Which
of the following findings is inconsistent with this condition?
a. Hypotension
b. High JVP
c. Pulsus paradoxus
d. Quiet heart sound
e. Pericardial friction rub √
Description
Pericardial friction rub presents in the case of pericarditis, not cardiac tamponade.
e friction rub results from the friction between the parietal and visceral layers of the pericardium,
which are not in contact with each other in the case of tamponade
Cardiac tamponade:
Cardiac tamponade is a rapid or massive accumulation of pericardial eusion or blood

collection in the pericardial space
It causes decreased venous return, filling, and stroke volume.
It presents with Beck’s tirade (hypotension, increased JVP, and mued heart sounds)
Other symptoms include dyspnea, pulsus paradoxus, shock, and peripheral edema
Pulsus paradoxus (inspiratory fall in systolic BP > 10 mmHg during quiet breathing)
Electrical alternans (high and low voltage of QRSs on ECG alternatively)
e best treatment of cardiac tamponade is urgent pericardiocentesis (it is diagnostic and

therapeutic)
Page - 284
Question 131/155
Question #131
Which of the following is considered a diagnostic and therapeutic procedure for pericardial
eusion?
a. Transthoracic echocardiogram
b. Transesophageal echocardiogram
c. Pericardiocentesis
d. oracentesis
e. Beck’s triad
Page - 285
Question 131/155
Question #131
Which of the following is considered a diagnostic and therapeutic procedure for pericardial
eusion?
a. Transthoracic echocardiogram
b. Transesophageal echocardiogram
c. Pericardiocentesis √
d. oracentesis
e. Beck’s triad
Description
Pericardial eusion is defined as a fluid collection within the pericardium
Pericardiocentesis is the most appropriate diagnostic and therapeutic procedure for pericardial
eusion (it determines exudates vs. transudate)
It can be transudate due to (CHF, hypothyroidism, or hypoalbuminemia) or exudate due to (the

same causes of pericarditis).
Symptoms depend on the amount of fluid and may be asymptomatic, dyspnea, cough, signs of
pericarditis, elevated JVP and Ewart’s sign, or mued heart sounds
Echocardiograms are diagnostic only. While becks triad is diagnostic for cardiac tamponade.
oracentesis is used for pleural eusion, not pericardial one.
Page - 286
Question 132/155
Question #132
A patient was exposed to chest trauma during a road trac accident; his ECG is shown below. What
does this patient most likely have?
c. Normal ECG
d. Cardiac tamponade
e. Cardiac muscle contusion
Page - 287
Question 132/155
Question #132
A patient was exposed to chest trauma during a road trac accident; his ECG is shown below. What
does this patient most likely have?
c. Normal ECG
d. Cardiac tamponade √
e. Cardiac muscle contusion
Description
is ECG shows dierent QRS complexes amplitude alternatively.
e condition here is called electrical alternans, which is characteristic in the case of cardiac
tamponade
Cardiac tamponade:
Cardiac tamponade is a rapid or massive accumulation of pericardial eusion or blood

collection in the pericardial space
It causes decreased venous return, filling, and stroke volume.
Page - 288
It presents with Beck’s tirade (hypotension, increased JVP, and mued heart sounds)
Other symptoms include dyspnea, pulsus paradoxus, shock, and peripheral edema
Pulsus paradoxus (inspiratory fall in systolic BP > 10 mmHg during quiet breathing)
Electrical alternans (high and low voltage of QRSs on ECG alternatively)
e best treatment of cardiac tamponade is urgent pericardiocentesis (it is diagnostic and

therapeutic)
Page - 289
Question 133/155
Question #133
A 22-year-old male patient has a mild fever and chest pain relieved by leaning forward. His ECG is
a. Acute myocardial infarction

b. Pericarditis
c. Myocarditis
d. Pneumonia
e. Muscular spasms
Page - 290
Internal Medicine - Cardiology - Pericarditis
Question 133/155
Question #133
A 22-year-old male patient has a mild fever and chest pain relieved by leaning forward. His ECG is

b. Pericarditis √
c. Myocarditis
d. Pneumonia
e. Muscular spasms
Description
Diuse saddle shape ST-elevation on ECG and the presence of positional chest pain are suggestive of
pericarditis.
Pericarditis:
Pericarditis is an inflammation of the pericardium

Most commonly – idiopathic, but the most common cause is coxsackie B virus infection
A friction rub is the earliest sign of pericarditis
Atypical chest pain (positional; increased by lying back and decreased by bending forward)
e most specific ECG change is depressed PR interval (elevated on AVR)
Page - 291
Other ECG changes: ST elevation in all leads (diuse ST elevation) (Depression on AVR)
Page - 292
Question 134/155
Question #134
A 30-year-old male patient has positional chest pain and is diagnosed with acute pericarditis. Which
of the following drugs is most commonly used to treat this condition?
a. Paracetamol
b. Prednisolone
c. Heparin
d. Ibuprofen
e. Cefuroxime
Page - 293
Question 134/155
Question #134
A 30-year-old male patient has positional chest pain and is diagnosed with acute pericarditis. Which
of the following drugs is most commonly used to treat this condition?
a. Paracetamol
b. Prednisolone
c. Heparin
d. Ibuprofen √
e. Cefuroxime
Description
Pericarditis:

Treatment of acute pericarditis includes:
Bed-rest, NSAIDs
Colchicine decreased recurrence
Steroids for severe or recurrent cases
Treatment of the underlying disease
NSAIDs are the first-line treatment, e.g., ibuprofen for 3 weeks.
Other NSAIDs can be used, but steroids are better avoided because they can cause the steroid-
dependent syndrome.
A combination of ibuprofen and colchicine may be ideal
Anticoagulants are not used in pericarditis; they increase the risk of cardiac tamponade
Page - 294
Page - 295
Question 135/155
Question #135
A 40-year-old male patient presents with acute pleuritic chest pain relieved by leaning forward, and
a physical examination reveals a pericardial friction rub. Pericarditis is suspected. Which of the
following ECG findings is the most specific for pericarditis?
a. Widespread ST elevation
b. PR depression
c. T inversion
d. Pathological Q wave
e. Short PR interval
Page - 296
Question 135/155
Question #135
a physical examination reveals a pericardial friction rub. Pericarditis is suspected. Which of the
following ECG findings is the most specific for pericarditis?
a. Widespread ST elevation
b. PR depression √
c. T inversion
d. Pathological Q wave
e. Short PR interval
Description
e most specific ECG change is depressed PR interval (elevated on AVR).
Pericarditis:

Page - 297
Question 136/155
Question #136
a physical examination reveals a pericardial friction rub. What is the most appropriate
management?
a. Antibiotics
b. Antivirals
c. Anti-inflammatory agents
d. Bronchodilators
e. Beta-blockers
Page - 298
Question 136/155
Question #136
a physical examination reveals a pericardial friction rub. What is the most appropriate
management?
a. Antibiotics
b. Antivirals
c. Anti-inflammatory agents √
d. Bronchodilators
e. Beta-blockers
Description
is is a typical condition of pericarditis; its treatment depends on the cause. In this case, viral
infection is the most likely. e treatment contains analgesics, anti-inflammatory agents (NSAIDs),
and sometimes surgery.
Pericarditis:

Page - 299
Question 137/155
Question #137
A previously healthy 23-year-old presented to the ER with typical chest pain at rest and ST elevation
on ECG and was admitted to the CCU for treatment. e second ECG 15 minutes later shows normal
sinus rhythm with no ST/T changes, and his cardiac enzymes are flat. Which of the following is the
most likely diagnosis?
a. Stable angina
b. Unstable angina
c. Prinzmetal angina
d. Non-ST elevation MI
e. ST-elevation MI
Page - 300
Internal Medicine - Cardiology - Prinzmetal Angina
Question 137/155
Question #137
A previously healthy 23-year-old presented to the ER with typical chest pain at rest and ST elevation
on ECG and was admitted to the CCU for treatment. e second ECG 15 minutes later shows normal
sinus rhythm with no ST/T changes, and his cardiac enzymes are flat. Which of the following is the
a. Stable angina
b. Unstable angina
c. Prinzmetal angina √
d. Non-ST elevation MI
e. ST-elevation MI
Description
A young, previously healthy patient with transient chest pain and ST elevation is suggestive of
Prinzmetal angina (coronary vasospasm)
Stable angina is unlikely in a young patient with chest pain not related to exertion
Unstable angina usually presents with non-specific ST/T changes, and chest pain at rest in elderly
patients or patients with a risk factor for IHD
Unlike this case, STEMI and NSTEMI will always manifest with high cardiac enzymes
Page - 301
Question 138/155
Question #138
All the following are primary prevention of coronary heart disease, except:
a. Regular exercise
b. Blood pressure control
c. Blood sugar control
d. Not to smoke
e. ACE inhibitors use
Page - 302
Internal Medicine - Cardiology - Stable angina
Question 138/155
Question #138
All the following are primary prevention of coronary heart disease, except:
a. Regular exercise
b. Blood pressure control
c. Blood sugar control
d. Not to smoke
e. ACE inhibitors use √
Description
Primary prevention means preventing the disease from developing
Secondary prevention means preventing the disease from getting worse aer it already occurs
Tertiary prevention means improving the quality of life and reducing the symptoms of the disease
aer it appears.
Regular exercise, stopping smoking, and controlling DM and HTN will prevent IHD and are
considered primary prevention measures.
e use of ACE inhibitors is considered a secondary prevention measure (not primary)
Page - 303
Question 139/155
Question #139
An obese 63-year-old male with a history of HTN and DM presents with a squeezing, pressure-like
sensation in his chest radiating to the jaw, shoulders, and neck. e pain sustains for several
minutes and then subsides. e patient has normal blood pressure, heart rate, and ECG. What is the
b. Angina pectoris
c. Transient ischemic attack
d. GERD
e. Bradyarrhythmia
Page - 304
Question 139/155
Question #139
An obese 63-year-old male with a history of HTN and DM presents with a squeezing, pressure-like
sensation in his chest radiating to the jaw, shoulders, and neck. e pain sustains for several
minutes and then subsides. e patient has normal blood pressure, heart rate, and ECG. What is the
b. Angina pectoris √
d. GERD
e. Bradyarrhythmia
Description
is patient has typical chest pain and is most likely suering from stable angina.
Page - 305
Question 140/155
Question #140
A 52-year-old male patient presents with episodic, recurrent chest pain related to exercise. e pain
radiates to both shoulders and back. It is usually subsided within 5 minutes of rest. His lab
investigations, including lipid profile, liver function test, kidney function test, ECG, and chest x-ray,
are normal. What is the next step in the management of this patient?
a. Cardiac enzyme measurement

b. ECG stress test
c. Echocardiogram
d. Coronary angiography
e. Chest CT scan
Page - 306
Question 140/155
Question #140
A 52-year-old male patient presents with episodic, recurrent chest pain related to exercise. e pain
radiates to both shoulders and back. It is usually subsided within 5 minutes of rest. His lab
investigations, including lipid profile, liver function test, kidney function test, ECG, and chest x-ray,
are normal. What is the next step in the management of this patient?
a. Cardiac enzyme measurement

b. ECG stress test √
c. Echocardiogram
e. Chest CT scan
Description
e patient is complaining of typical chest pain and is suspected of having chronic stable angina.
erefore, the best next step in his condition is to do an exercise ECG stress test.
Coronary angiography is accurate, but it is not the next step. Echocardiogram will be needed in
conditions when a structural heart disease or cardiac dysfunction is suspected.
Page - 307
Question 141/155
Question #141
In which of the following patients is coronary angiography indicated?
a. A 55-year-old female with sharp chest pain and late systolic murmur with mid-systolic click
b. A 66-year-old male with pleuritic chest pain at rest
c. A 75-year-old female with HTN, dyslipidemia, asymptomatic PVCs, and Reflux disease pain
d. A 42-year-old male with intermittent angina pain and a negative exercise stress test
e. An asymptomatic 39-year-old male with a family history of heart disease
Page - 308
Question 141/155
Question #141
In which of the following patients is coronary angiography indicated?
a. A 55-year-old female with sharp chest pain and late systolic murmur with mid-systolic click
b. A 66-year-old male with pleuritic chest pain at rest
c. A 75-year-old female with HTN, dyslipidemia, asymptomatic PVCs, and Reflux disease pain
d. A 42-year-old male with intermittent angina pain and a negative exercise stress test √
e. An asymptomatic 39-year-old male with a family history of heart disease
Description
Coronary angiography is the most accurate test in the case of coronary artery disease, but it is not
indicated to be done routinely.
e typical clinical presentation, ECG findings, Cardiac enzyme levels, and the ECG stress test should
be used appropriately in ischemic heart diseases to reach the diagnosis.
If the patient has recurrent anginal pain and no alternative diagnosis is suspected, coronary
angiography can be used to establish the diagnosis.
Page - 309
Question 142/155
Question #142
A 66-year-old male patient complains of angina chest pain unrelated to exertion. It occurs
intermittently and usually while he is lying on the couch or bed. Which type of angina does the
patient experience?
a. Stable angina
b. Unstable angina
c. Angina decubitus
d. Prinzmetal angina
e. Angina equivalent
Page - 310
Question 142/155
Question #142
A 66-year-old male patient complains of angina chest pain unrelated to exertion. It occurs
intermittently and usually while he is lying on the couch or bed. Which type of angina does the
patient experience?
a. Stable angina
b. Unstable angina
c. Angina decubitus √
d. Prinzmetal angina
e. Angina equivalent
Description
Angina decubitus is angina on changing position. Angina decubitus occurs because gravity
redistributes fluids in the body. is redistribution makes the heart work harder
Page - 311
Question 143/155
Question #143
A 55-year-old male patient has recurrent, central, crushing chest pain that manifests aer significant
exertion and is relieved by rest. In addition, he mentioned that his pain radiates to the jaw and both
shoulders. Physical examination is unremarkable except for obvious central obesity and acanthosis
nigricans. However, his ECG and cardiac enzymes are unremarkable. What is the first-line treatment
for his condition?
a. Beta-blockers
b. Calcium channel blockers
c. Sublingual nitrates on demand
d. Salbutamol inhaler on demand
e. Refer for Percutaneous coronary intervention (PCI)
Page - 312
Question 143/155
Question #143
A 55-year-old male patient has recurrent, central, crushing chest pain that manifests aer significant
exertion and is relieved by rest. In addition, he mentioned that his pain radiates to the jaw and both
shoulders. Physical examination is unremarkable except for obvious central obesity and acanthosis
nigricans. However, his ECG and cardiac enzymes are unremarkable. What is the first-line treatment
for his condition?
a. Beta-blockers √
c. Sublingual nitrates on demand
d. Salbutamol inhaler on demand
e. Refer for Percutaneous coronary intervention (PCI)
Description
is patient suers from stable angina, and he has strong indications of insulin resistance.
e first-line treatment of stable angina is beta-blockers.
Calcium channel blockers are the second-line treatment in this case
Nitrates alone will not reduce the mortality but only symptoms.
In the stable angina, PCI is found not to reduce the mortality rate more than the drug therapy alone,
so it is not indicated unless the patient has a poor quality of life and worsening symptoms despite
medical treatment.
Salbutamol inhaler is a short-acting beta agonist used to treat asthma; our patient is not asthmatic
and is aware that SABA will increase the heart rate, the oxygen demands and thus worsening his
symptoms.
Page - 313
Question 144/155
Question #144
A 77-year-old male patient has passed out 5 times in the last 6 months. All 5 attacks occurred while
the patient was walking upstairs. According to his history alone, which of the following is the most
likely cause?
a. Vasovagal syncope
b. Transient ischemic attacks (TIA)
c. Hypotension
d. Aortic stenosis
e. Hypoglycemia
Page - 314
Internal Medicine - Cardiology - Syncope
Question 144/155
Question #144
A 77-year-old male patient has passed out 5 times in the last 6 months. All 5 attacks occurred while
the patient was walking upstairs. According to his history alone, which of the following is the most
likely cause?
b. Transient ischemic attacks (TIA)
c. Hypotension
d. Aortic stenosis √
e. Hypoglycemia
Description
Patients who present with syncope with exercise should be evaluated for organic structural heart
diseases.
About 50% of patients with severe aortic stenosis have reported syncope on exertion.
Vasovagal attacks are associated with unpleasant stimuli which are not present here.
TIA usually presents with a neurological deficit and is not related to the
Exertion.
ere is no evidence of hypotension or hypoglycemia in this patient.
Page - 315
Question 145/155
Question #145
Which of the following is the most common cause of syncope?
a. Cardiac dysrhythmia
b. Medications eects
c. Orthostatic hypotension
d. Psychiatric disorders
e. Vasovagal syncope
Page - 316
Question 145/155
Question #145
Which of the following is the most common cause of syncope?
a. Cardiac dysrhythmia
b. Medications eects
c. Orthostatic hypotension
d. Psychiatric disorders
e. Vasovagal syncope √
Description
Neurocardiogenic is also known as vasovagal syncope.
It is the largest group of disorders causing syncope.
ese disorders result from reflex-mediated changes in vascular tone or heart rate.
Page - 317
Question 146/155
Question #146
e tilt table test is used to assess which of the following conditions?
b. Coronary artery disease
d. Elevated jugular venous pressure
e. Complete AV block
Page - 318
Question 146/155
Question #146
e tilt table test is used to assess which of the following conditions?
a. Vasovagal syncope √
b. Coronary artery disease
d. Elevated jugular venous pressure
e. Complete AV block
Description
e tilt table test is used to record blood pressure, heart rhythm, and heart rate on a beat-by-beat
basis as the table is tilted to dierent angles; the table always stays head-up.
e table will be tilted to 30 degrees for 2 to 3 minutes, 45 degrees for 2 to 3 minutes, and 70 degrees
for up to 45 minutes.
is test is used to evaluate patients with syncope.
Page - 319
Question 147/155
Question #147
A 17-year-old male presents due to recurrent loss of consciousness while playing sports. On
examination, a systolic ejection murmur is present at the right second intercostal space and
radiated to the neck. What is the most common cause of this patient’s condition?
a. Mitral valve prolapse

b. Calcific aortic valve stenosis
c. Tricuspid valve stenosis
d. Bicuspid aortic valve
e. Aortic regurgitation
Page - 320
Internal Medicine - Cardiology - Valvular diseases and heart murmurs
Question 147/155
Question #147
A 17-year-old male presents due to recurrent loss of consciousness while playing sports. On
examination, a systolic ejection murmur is present at the right second intercostal space and
radiated to the neck. What is the most common cause of this patient’s condition?
a. Mitral valve prolapse

b. Calcific aortic valve stenosis
c. Tricuspid valve stenosis
d. Bicuspid aortic valve √
Description
Exercise-induced syncope is usually due to fixed cardiac output, which is not rising during exercise
and high demand. is presentation is most likely to be due to aortic stenosis
e presence of a systolic ejection murmur supports this diagnosis as well.
Calcific aortic stenosis is more common in old age, but the bicuspid aortic valve is more common in
young age patients
Page - 321
Question 148/155
Question #148
A 69-yar-old male patient presents with lightheadedness, typical chest pain, and systolic ejection
murmur at the right second intercostal space radiating to the neck. Echocardiogram shows le
ventricular hypertrophy. What is the most likely diagnosis?
a. Mitral stenosis
b. Aortic stenosis
c. Aortic insuciency
d. Mitral regurgitation
e. Infective endocarditis
Page - 322
Question 148/155
Question #148
A 69-yar-old male patient presents with lightheadedness, typical chest pain, and systolic ejection
murmur at the right second intercostal space radiating to the neck. Echocardiogram shows le
ventricular hypertrophy. What is the most likely diagnosis?
a. Mitral stenosis
b. Aortic stenosis √
c. Aortic insuciency
d. Mitral regurgitation
e. Infective endocarditis
Description
Angina pectoris, syncope, and le ventricular hypertrophy and failure are the classic presentation of
aortic stenosis.
Systolic ejection murmur is one more piece of evidence of the presence of aortic stenosis
Page - 323
Question 149/155
Question #149
A 71-year-old male patient with a known case of HTN presents with exertional shortness of breath
for 3 months. On examination, a decrescendo diastolic murmur is heard at the le 3rd intercostal
space. Of the following, what is the most likely associated with this patient’s condition?
a. Narrow pulse pressure

b. Bisferiens pulse
c. Pulsus alternans
d. Wide pulse pressure
e. Pulsus paradoxus
Page - 324
Question 149/155
Question #149
space. Of the following, what is the most likely associated with this patient’s condition?
a. Narrow pulse pressure

b. Bisferiens pulse
c. Pulsus alternans
d. Wide pulse pressure √
e. Pulsus paradoxus
Description
e diastolic murmur best heard when the patient is leaning forward at Erb’s point, located at the
3rd intercostal space on the le, is most likely to be aortic regurgitation.
Wide pulse pressure is a sign that is usually seen in aortic regurgitation. It may be seen in
hyperthyroidism as well
Page - 325
Question 150/155
Question #150
A 29-year-old male patient complained of recurrent intermittent short-lasting palpitations. His

physical examination reveals normal S1 and S2, displaced apex beat 1 cm laterally, and systolic
ejection murmur at the le lower sternal border with no radiation. e murmur is aggravated by the
Valsalva maneuver and reduced by hand grip. What is the most likely diagnosis?
a. Aortic stenosis
b. Hypertrophic obstructive cardiomyopathy (HOCM)
c. Ventricular septal defect
d. Pulmonary HTN
Page - 326
Question 150/155
Question #150
A 29-year-old male patient complained of recurrent intermittent short-lasting palpitations. His

physical examination reveals normal S1 and S2, displaced apex beat 1 cm laterally, and systolic
ejection murmur at the le lower sternal border with no radiation. e murmur is aggravated by the
Valsalva maneuver and reduced by hand grip. What is the most likely diagnosis?
a. Aortic stenosis
b. Hypertrophic obstructive cardiomyopathy (HOCM) √
c. Ventricular septal defect
d. Pulmonary HTN
Description
Of the choices mentioned above, a systolic ejection murmur is present in aortic stenosis and HOCM.
e age of the patient, along with the eect of the Valsalva maneuvre and hand grip on the murmur,
is suggestive of HOCM
Ventricular septal defect presents with a pan-systolic murmur, while Aortic regurgitation presents
with a decrescendo diastolic murmur (early diastolic murmur)
Page - 327
Question 151/155
Question #151
Based on the echocardiogram, an elderly patient is diagnosed with aortic regurgitation. Which of
the following murmurs are expected to be present in this patient?
a. Systolic ejection murmur radiated to the neck

b. Early diastolic decrescendo murmur at the le sternal border
c. Pan-systolic murmur at the 5th intercostal space radiated to the axilla
d. Continuous machine-like murmur at le infraclavicular area
e. Late systolic murmur with mid-systolic click
Page - 328
Question 151/155
Question #151
Based on the echocardiogram, an elderly patient is diagnosed with aortic regurgitation. Which of
the following murmurs are expected to be present in this patient?
a. Systolic ejection murmur radiated to the neck

b. Early diastolic decrescendo murmur at the le sternal border √
c. Pan-systolic murmur at the 5th intercostal space radiated to the axilla
d. Continuous machine-like murmur at le infraclavicular area
e. Late systolic murmur with mid-systolic click
Description
Early diastolic decrescendo murmur at the le sternal border is the characteristic murmur in aortic
regurgitations
Page - 329
Question 152/155
Question #152
A patient was found to have a systolic ejection murmur at the le 2nd intercostal space. e second
heart sound is split widely during expiration as it is during inspiration. e rest of the physical
examination is normal. What is the most likely diagnosis?
a. Patent ductus arteriosus

b. Aortic stenosis
c. Aortic regurgitation
d. Atrial septal defect
e. Hypertrophic Obstructive Cardiomyopathy (HOCM)
Page - 330
Question 152/155
Question #152
A patient was found to have a systolic ejection murmur at the le 2nd intercostal space. e second
heart sound is split widely during expiration as it is during inspiration. e rest of the physical
examination is normal. What is the most likely diagnosis?
a. Patent ductus arteriosus

b. Aortic stenosis
c. Aortic regurgitation
d. Atrial septal defect √
e. Hypertrophic Obstructive Cardiomyopathy (HOCM)
Description
Systolic ejection murmur and fixed splitting are features of Atrial septal defect.
Fixed splitting: the splitting in S2 is equal in both expiration and inspiration
Note that splitting during inspiration is normal
Page - 331
Question 153/155
Question #153
A 69-year-old male patient with recurrent exertional syncope and chest pain has systolic thrill and
systolic ejection murmur radiated to both carotids. e patient is afebrile, and his vital signs and lab
investigations are normal. What is the next step in the management of this patient?
a. Cardiac enzymes
b. Chest x-ray
c. ECG stress tests
d. Echocardiogram
e. Refer to cardiac catheterization
Page - 332
Question 153/155
Question #153
A 69-year-old male patient with recurrent exertional syncope and chest pain has systolic thrill and
systolic ejection murmur radiated to both carotids. e patient is afebrile, and his vital signs and lab
investigations are normal. What is the next step in the management of this patient?
a. Cardiac enzymes
b. Chest x-ray
c. ECG stress tests
d. Echocardiogram √
e. Refer to cardiac catheterization
Description
is patient is suspected of having aortic stenosis. e presence of exertional syncope, angina, and
systolic ejection murmur that is radiated to the neck is a classic presentation of aortic stenosis.
Echocardiogram is the best next step in the management
Page - 333
Question 154/155
Question #154
space. What is the most likely diagnosis?
a. Aortic stenosis
b. Mitral regurgitation
c. Tricuspid regurgitation
d. Mitral prolapse
Page - 334
Question 154/155
Question #154
space. What is the most likely diagnosis?
a. Aortic stenosis
b. Mitral regurgitation
c. Tricuspid regurgitation
d. Mitral prolapse
e. Aortic regurgitation √
Description
e diastolic murmur best heard when the patient is leaning forward at Erb’s point, located at the
3rd intercostal space on the le, is most likely to be aortic regurgitation
Page - 335
Question 155/155
Question #155
A 73-year-old female presents for evaluation because she has had syncope 3 times in the last 2
months. All are related to exertion. What is the most likely cause of her syncope?
a. Vasovagal attack
b. Transient ischemic attack
c. Aortic stenosis
d. Non-sustained arrhythmia
e. Atrial myxoma
Page - 336
Question 155/155
Question #155
A 73-year-old female presents for evaluation because she has had syncope 3 times in the last 2
months. All are related to exertion. What is the most likely cause of her syncope?
a. Vasovagal attack
b. Transient ischemic attack
c. Aortic stenosis √
d. Non-sustained arrhythmia
e. Atrial myxoma
Description
Exercise-induced syncope is usually due to fixed cardiac output, which is not rising during exercise
and high demand. is presentation is most likely to be due to aortic stenosis
Page - 337
Endocrinology
Page - 338
Endocrinology
1) Acromegaly => 3 Questions

2) Adrenal insuciency and crisis => 9 Questions
3) Counterregulatory hormones => 1 Questions
4) Cushing’s syndrome => 6 Questions
5) Diabetes Mellitus and its complications => 39 Questions
6) Disorders of ADH => 13 Questions
7) Dyslipidemia => 3 Questions
8) Familial hypocalciuric hypercalcemia (FHH) => 1 Questions
9) Hypercalcemia => 16 Questions
10) Hyperprolactinemia => 5 Questions
11) Hyperthyroidism => 16 Questions
12) Hypocalcemia => 2 Questions
13) Hypothyroidism => 14 Questions
14) Incidentaloma => 1 Questions
15) Multiple Endocrine Neoplasias (MEN) => 2 Questions
16) Non-thyroidal illness => 2 Questions
17) Parathyroid gland => 1 Questions
18) Pheochromocytoma => 6 Questions
19) Pituitary Adenoma => 3 Questions
20) Primary hyperaldosteronism => 6 Questions
21) Subacute yroiditis => 4 Questions
22) yroid storm => 1 Questions
23) Vitamin D deficiency => 1 Questions
24) Hypoglycemia => 7 Questions
Page - 339
Internal Medicine - Endocrinology
Question 1/162
Question #1
A 49-year-old male patient complains of general weakness, bad body smells, and snoring at night. In
addition, he noted that his shoe size had become larger than previously. On examination, the
patient has a deep voice, large protruded mandible, maxilla, and orbital ridges. In addition,
acanthosis nigricans is noted on his neck and axilla, overweight. What is the most likely diagnosis?
a. Pituitary adenoma
b. Hypothyroidism
c. Adrenal gland adenoma
d. Exogenous steroid use
e. Type 2 diabetes mellitus
Page - 340
Internal Medicine - Endocrinology - Acromegaly
Question 1/162
Question #1
A 49-year-old male patient complains of general weakness, bad body smells, and snoring at night. In
addition, he noted that his shoe size had become larger than previously. On examination, the
patient has a deep voice, large protruded mandible, maxilla, and orbital ridges. In addition,
acanthosis nigricans is noted on his neck and axilla, overweight. What is the most likely diagnosis?
a. Pituitary adenoma √
b. Hypothyroidism
c. Adrenal gland adenoma
d. Exogenous steroid use
e. Type 2 diabetes mellitus
Description
ese are typical features of acromegaly.
Acromegaly is a Disease of adult life, characterized by the growth of bulk but not in the height of
bone due to over-secretion of GH aer puberty.
Pituitary adenoma is the most common cause - usually macroadenoma.
Acromegaly is associated with increased body dimensions, compression eects of the adenoma, and
metabolic eects of the growth hormone (including glucose intolerance, weight gain, DM, and
HTN).
According to the case, treatment is achieved by Dopamine agonists, surgery, or radiotherapy.
Page - 341
Question 2/162
Question #2
Which is the most common cause of death in a patient with acromegaly?
a. Renal failure
b. Cardiovascular complications
c. Colorectal cancer
d. Diabetes mellitus
e. Osteoarthritis
Page - 342
Question 2/162
Question #2
Which is the most common cause of death in a patient with acromegaly?
a. Renal failure
b. Cardiovascular complications √
d. Diabetes mellitus
e. Osteoarthritis
Description
Acromegaly can cause several complications, including arthritis, amenorrhea in women,

cardiomegaly, hypertension, carpal tunnel syndrome, colonic polyps,
kidney failure, and diabetes. However, cardiovascular diseases are the most common cause of death
in patients with acromegaly.
Acromegaly is a Disease of adult life, characterized by the growth of bulk but not in the height of
bone due to over-secretion of GH aer puberty.
Pituitary adenoma is the most common cause - usually macroadenoma.
Acromegaly is associated with increased body dimensions, compression eects of the adenoma, and
metabolic eects of the growth hormone (including glucose intolerance, weight gain, DM, and
HTN).
According to the case, treatment is achieved by Dopamine agonists, surgery, or radiotherapy.
Page - 343
Question 3/162
Question #3
A 40-year-old male patient presents with hand swelling, enlargement of his nose, and deepening of
his voice. Physical examination demonstrates above-average body dimensions and bitemporal
hemianopia. What is the most likely confirmatory test for his condition?
a. Spot serum growth hormone level

b. Serum prolactin level
c. Oral glucose tolerance with serial growth hormone measurements
d. Insulin-like growth factor level
e. Pituitary MRI
Page - 344
Question 3/162
Question #3
A 40-year-old male patient presents with hand swelling, enlargement of his nose, and deepening of
his voice. Physical examination demonstrates above-average body dimensions and bitemporal
hemianopia. What is the most likely confirmatory test for his condition?
a. Spot serum growth hormone level

b. Serum prolactin level
c. Oral glucose tolerance with serial growth hormone measurements √
d. Insulin-like growth factor level
e. Pituitary MRI
Description
is is a case of pituitary adenoma resulting in acromegaly.
e presence of increased body dimensions and bitemporal hemianopia strongly suggests the
condition.
If elevated, the insulin-like growth factor level is the most appropriate to screen for this condition.
75g OGTT with GH measurements with serial GH measurements is most appropriate for confirming
the diagnosis.
Pituitary MRI will show the macroadenoma, but it is not the most accurate test but is used to
localize the pathology only.
Growth hormone secretion is pulsatile, so spot level is not indicated to diagnose any condition but
rather a suppression test.
Page - 345
Question 4/162
Question #4
A 30-year-old male patient complains of abdominal pain, vomiting, and dizziness for 2 days. Her past
medical history is significant for rheumatoid arthritis, for which she has received steroids for the last
4 months. What is the most likely explanation for her symptoms?
a. Steroids side eects

b. Cerebrovascular accident
c. Cushing’s syndrome
d. Adrenal insuciency
e. Hyperaldosteronism
Page - 346
Internal Medicine - Endocrinology - Adrenal insuciency and crisis
Question 4/162
Question #4
A 30-year-old male patient complains of abdominal pain, vomiting, and dizziness for 2 days. Her past
medical history is significant for rheumatoid arthritis, for which she has received steroids for the last
4 months. What is the most likely explanation for her symptoms?
a. Steroids side eects

c. Cushing’s syndrome
d. Adrenal insuciency √
Description
is clinical scenario suggests steroid cessation and adrenal insuciency.
Patients using steroids for an extended period will develop adrenal atrophy and under-secretion of
endogenous steroids. If steroids are stopped suddenly, there will be cortisol deficiency manifesting
as hypotension, hypoglycemia, hyponatremia, hyperkalemia, and a non-anion gap metabolic
acidosis.
Page - 347
Question 5/162
Question #5
A 35-year-old male patient presented to the emergency department aer being found unconscious
in the street. e initial workup shows severe dehydration, hypotension, a temperature of 40 °C,
serum sodium of 122 mEq/L, serum potassium of 5.9 mEq/L, serum glucose of 45 mg/dL, and normal
ECG. What is the most appropriate initial treatment for his condition?
a. Dextrose 10% water

b. 3% hypertonic saline
d. Hydrocortisone 100 mg IV
e. Intravenous antibiotics
Page - 348
Question 5/162
Question #5
A 35-year-old male patient presented to the emergency department aer being found unconscious
in the street. e initial workup shows severe dehydration, hypotension, a temperature of 40 °C,
serum sodium of 122 mEq/L, serum potassium of 5.9 mEq/L, serum glucose of 45 mg/dL, and normal
ECG. What is the most appropriate initial treatment for his condition?
a. Dextrose 10% water

b. 3% hypertonic saline
d. Hydrocortisone 100 mg IV √
e. Intravenous antibiotics
Description
is patient is suering from an adrenal crisis.
Hydrocortisone is the first-line treatment.
Calcium gluconate is the first line in hyperkalemia, but it is indicated if the serum potassium is more
than 6.5 mEq/L or if there are ECG changes.
Adrenal crisis is a medical emergency caused by sudden and marked insuciency of adrenocortical
hormones
e precipitating factors are stress (trauma, infection, bleeding, surgery, hypotension) or sudden
chronic high-dose steroid therapy withdrawal.
Clinical features:
Dehydration, headache, confusion, coma

Hypotension (shock)
Hypoglycemia
Nausea, vomiting, diarrhea, abdominal pain
Hyponatremia, hyperkalemia
Page - 349
High urea
Treatment:
Hydrocortisone injection (first step)

IV fluids
Treatment of hypoglycemia
Antibiotics
Shock management
Page - 350
Question 6/162
Question #6
A 60-year-old male patient complains of abdominal pain and dizziness. Your evaluation
demonstrates orthostatic hypotension, hyperkalemia, and hyponatremia. Which is the best initial
test to rule out adrenal insuciency?
a. Morning serum cortisol

b. Cosyntropin stimulation test
c. Adrenal MRI
d. Growth hormone suppression test
e. Glucose tolerance test
Page - 351
Question 6/162
Question #6
A 60-year-old male patient complains of abdominal pain and dizziness. Your evaluation
demonstrates orthostatic hypotension, hyperkalemia, and hyponatremia. Which is the best initial
test to rule out adrenal insuciency?
a. Morning serum cortisol √

c. Adrenal MRI
d. Growth hormone suppression test
e. Glucose tolerance test
Description
A single morning cortisone level of more than 13 g/dL is a reliable and sensitive finding to rule out
adrenal insuciency.
A Cosyntropin stimulation test is used to confirm the diagnosis if the serum morning cortisol level is
reduced.
Page - 352
Question 7/162
Question #7
A 40-year-old male patient presents to the ER with nausea, vomiting, poor appetite, fatigue, and
dizziness. Physical examination demonstrates blood pressure of 139/82 mmHg supine and 105/63
mmHg standing. His serum electrolytes show serum sodium of 122 mEq/L, potassium of 5.9 mEq/L,
urea of 8 mmol/L, and creatinine of 90 mmol/L. What is the most common pathology of his
condition?
a. Infection
b. Infarction
c. Autoimmune
d. Protein infiltration
e. Metastasis
Page - 353
Question 7/162
Question #7
A 40-year-old male patient presents to the ER with nausea, vomiting, poor appetite, fatigue, and
dizziness. Physical examination demonstrates blood pressure of 139/82 mmHg supine and 105/63
mmHg standing. His serum electrolytes show serum sodium of 122 mEq/L, potassium of 5.9 mEq/L,
urea of 8 mmol/L, and creatinine of 90 mmol/L. What is the most common pathology of his
condition?
a. Infection
b. Infarction
c. Autoimmune √
d. Protein infiltration
e. Metastasis
Description
Hypoadrenalism, Addison’s disease, or chronic primary adrenal insuciency, is characterized by

reduced cortisol, resulting in specific metabolic features.
In 80% of cases, it is caused by an autoimmune process leading to adrenal gland destruction and
malfunction.
Clinical features include the following:
Weakness, weight loss, fatigue, vomiting, fever, constipation, abdominal pain, impotence,
syncope, postural hypotension, loss of axillary hair
Hyperpigmentation of skin (due to increased MSH), Not present in secondary adrenal
insuciency
Hypotension
Vitiligo (autoimmune process) is associated with this condition; autoimmune conditions are
associated with each other.
e main metabolic problems are:
Hyperuricemia, hyperkalemia, hypercalcemia

Hyponatremia, hypoglycemia
Page - 354
Investigations:
CT abdomen to assess the adrenal glands

Serum cortisol is the best initial test (sensitive test)
Cosyntropin stimulation test (Cosyntropin is a synthetic analog of ACTH) → (most specific test)
Anti-adrenal antibodies in 50% of cases
Low serum aldosterone
Treatment: steroid hormone replacement
Page - 355
Question 8/162
Question #8
A 33-year-old male patient was admitted yesterday to the surgical department for observation aer
sustaining a road trac accident. Today the patient develops blood pressure of 90/40 mmHg and a
heart rate of 140 bpm, but no source of bleeding is detected. His lab investigations demonstrate
hemoglobin of 15.0 g/dL (within baseline), serum sodium of 121 mEq/L, and serum potassium of 7
mEq/L. What is the most appropriate treatment at this time?
a. Intravenous ringer lactate

b. Start blood transfusion
c. Order abdominal CT scan
d. Start intravenous beta-blockers
e. Give hydrocortisone 100 mg intravenously
Page - 356
Question 8/162
Question #8
A 33-year-old male patient was admitted yesterday to the surgical department for observation aer
sustaining a road trac accident. Today the patient develops blood pressure of 90/40 mmHg and a
heart rate of 140 bpm, but no source of bleeding is detected. His lab investigations demonstrate
hemoglobin of 15.0 g/dL (within baseline), serum sodium of 121 mEq/L, and serum potassium of 7
mEq/L. What is the most appropriate treatment at this time?
a. Intravenous ringer lactate

b. Start blood transfusion
c. Order abdominal CT scan
d. Start intravenous beta-blockers
e. Give hydrocortisone 100 mg intravenously √
Description
is patient is suering from an adrenal crisis. erefore, hydrocortisone is the first-line treatment.
Adrenal crisis is a medical emergency caused by sudden and marked insuciency of adrenocortical
hormones
e precipitating factors are stress (trauma, infection, bleeding, surgery, hypotension) or sudden
chronic high-dose steroid therapy withdrawal.
Clinical features:
Dehydration, headache, confusion, coma

Hypotension (shock)
Hypoglycemia
Nausea, vomiting, diarrhea, abdominal pain
Hyponatremia, hyperkalemia
High urea
Treatment:
Hydrocortisone injection (first step)

IV fluids
Page - 357
Treatment of hypoglycemia
Antibiotics
Shock management
Page - 358
Question 9/162
Question #9
A 55-year-old male patient complains of dizziness. Aer an appropriate workup, you diagnose him
with adrenal insuciency. Which of the following are the most likely expected abnormalities in this
patient?
a. Hyperkalemia, hypernatremia
b. Hypokalemia, hypernatremia
c. Hypokalemia, hyponatremia
d. Normal potassium, hyponatremia
e. Hyperkalemia, hyponatremia
Page - 359
Question 9/162
Question #9
A 55-year-old male patient complains of dizziness. Aer an appropriate workup, you diagnose him
with adrenal insuciency. Which of the following are the most likely expected abnormalities in this
patient?
a. Hyperkalemia, hypernatremia
b. Hypokalemia, hypernatremia
c. Hypokalemia, hyponatremia
d. Normal potassium, hyponatremia
e. Hyperkalemia, hyponatremia √
Description
Adrenal insuciency is defined as a reduced cortisol serum level. It may be caused by a primary
pathology in the adrenal gland, sudden steroid withdrawal, or reduced ACTH secretion (secondary
adrenal insuciency).
Adrenal insuciency presents with hyperkalemia, hyponatremia, hypoglycemia, hypotension, and

non-anion gap metabolic acidosis
Page - 360
Question 10/162
Question #10
A 40-year-old female patient presents with abdominal pain and diarrhea. Her physical examination
shows a blood pressure of 80/49 mmHg, pulse rate of 80 bpm, and temperature of 36.8 °C. in
addition, you noted hyperpigmented skin at the palmar creases and the buccal mucosa. What is the
a. Addison’s disease
b. Cushing’s syndrome
c. Pheochromocytoma
d. Hypothyroidism
e. Hypoparathyroidism
Page - 361
Question 10/162
Question #10
A 40-year-old female patient presents with abdominal pain and diarrhea. Her physical examination
shows a blood pressure of 80/49 mmHg, pulse rate of 80 bpm, and temperature of 36.8 °C. in
addition, you noted hyperpigmented skin at the palmar creases and the buccal mucosa. What is the
a. Addison’s disease √
c. Pheochromocytoma
d. Hypothyroidism
Description

malfunction.
insuciency
Hypotension

Investigations:
Page - 362
Page - 363
Question 11/162
Question #11
A 60-year-old male patient is a known chronic steroid user due to COPD asthma overlap syndrome.
He presents to you with a 3 days history of dizziness. His physical examination and lab
investigations show hypotension, hyperkalemia, and hyponatremia. What is the most likely
diagnosis?
a. Steroid side eect

c. Hyperaldosteronism
d. Adrenal insuciency
e. Hypoxic brain injury
Page - 364
Question 11/162
Question #11
A 60-year-old male patient is a known chronic steroid user due to COPD asthma overlap syndrome.
He presents to you with a 3 days history of dizziness. His physical examination and lab
investigations show hypotension, hyperkalemia, and hyponatremia. What is the most likely
diagnosis?
a. Steroid side eect

c. Hyperaldosteronism
d. Adrenal insuciency √
e. Hypoxic brain injury
Description
is clinical scenario suggests steroid cessation and adrenal insuciency.
Patients using steroids for an extended period will develop adrenal atrophy and under-secretion of
endogenous steroids. If steroids are stopped suddenly, there will be cortisol deficiency manifesting
as hypotension, hypoglycemia, hyponatremia, hyperkalemia, and a non-anion gap metabolic
acidosis.
Page - 365
Question 12/162
Question #12
A 36-year-old female patient presents to the emergency department with severe distress. However,
his history is only significant for chronic fatigue for 6 months. Physical exam demonstrates
orthostatic hypotension and hyperpigmentation of the knuckles, palmar creases, and abdominal
scar. Laboratory investigations show hyponatremia and hyperkalemia. What is the most appropriate
test to confirm the diagnosis?
a. Serum cortisol level

b. Cosyntropin Stimulation test
c. 17-hydroxyprogesterone
d. Metanephrine level in 24-hour urine collection.
e. Low-dose dexamethasone suppression test
Page - 366
Question 12/162
Question #12
A 36-year-old female patient presents to the emergency department with severe distress. However,
his history is only significant for chronic fatigue for 6 months. Physical exam demonstrates
orthostatic hypotension and hyperpigmentation of the knuckles, palmar creases, and abdominal
scar. Laboratory investigations show hyponatremia and hyperkalemia. What is the most appropriate
test to confirm the diagnosis?
a. Serum cortisol level

b. Cosyntropin Stimulation test √
c. 17-hydroxyprogesterone
d. Metanephrine level in 24-hour urine collection.
e. Low-dose dexamethasone suppression test
Description

malfunction.
insuciency
Hypotension

Page - 367
Investigations:

Low dose dexamethasone suppression test is used in Cushing’s syndrome workup
17-hydroxyprogesterone is used in adrenal hyperplasia workup
Metanephrine level is an indicator of pheochromocytoma
Page - 368
Question 13/162
Question #13
e following are considered stress hormones that participate in glucose Counterregulation except:
a. Growth hormone (GH)

b. Glucagon
c. Cortisol
d. Epinephrine and norepinephrine
e. yroid-stimulating hormone (TSH)
Page - 369
Internal Medicine - Endocrinology - Counterregulatory hormones
Question 13/162
Question #13
e following are considered stress hormones that participate in glucose Counterregulation except:
a. Growth hormone (GH)

b. Glucagon
c. Cortisol
d. Epinephrine and norepinephrine
e. yroid-stimulating hormone (TSH) √
Description
Description:
TSH is not a stress hormone and does not aect blood sugar.
e action of insulin is counter-regulated by
Glucagon
Epinephrine (adrenaline)
Norepinephrine (noradrenaline)
Cortisol
Growth hormone
ese counterregulatory hormones raise the level of glucose in the blood by promoting
glycogenolysis, gluconeogenesis, ketogenesis, and other catabolic processes.
Page - 370
Question 14/162
Question #14
A 50-year-old female is diagnosed with HTN, hirsutism, and acne. She is referred to you by her family
physician to evaluate her laboratory findings. Her lab investigations demonstrate elevated serum
cortisol, normal ACTH, and aldosterone. What is the most likely diagnosis?
a. Cushing’s syndrome
b. Bartter’s syndrome
c. Conn’s syndrome
d. Liddle’s syndrome
e. Addison’s disease
Page - 371
Internal Medicine - Endocrinology - Cushing’s syndrome
Question 14/162
Question #14
A 50-year-old female is diagnosed with HTN, hirsutism, and acne. She is referred to you by her family
physician to evaluate her laboratory findings. Her lab investigations demonstrate elevated serum
cortisol, normal ACTH, and aldosterone. What is the most likely diagnosis?
a. Cushing’s syndrome √
b. Bartter’s syndrome
c. Conn’s syndrome
d. Liddle’s syndrome
e. Addison’s disease
Description
Cushing’s syndrome results from increased secretion of cortisone by adrenal glands
Clinical features of Cushing’s syndrome:
Hypertension, hyperglycemia, hypokalemia

Fat redistribution: Moon face, weight gain / central obesity, bualo hump, thin extremities
Skin: inning of skin, abdominal striae, decreased wound healing, easy bruising, hirsutism,
acne, skin pigmentation
Muscle weakness (proximal muscle)
Sexual disturbances, edema, amenorrhea
Psychiatric symptoms (e.g., depression)
Page - 372
Question 15/162
Question #15
A 30-year-old male patient complains of hirsutism, truncal obesity, easy bruising, and
hyperglycemia. His blood pressure is found to be 151/89 mmHg. What is the most helpful test in
localizing the cause of Cushing’s syndrome?
a. Urinary cortisol level

b. Serum cortisol level
c. Low-dose dexamethasone suppression test
d. High-dose dexamethasone suppression test
e. Plasma ACTH level
Page - 373
Question 15/162
Question #15
A 30-year-old male patient complains of hirsutism, truncal obesity, easy bruising, and
hyperglycemia. His blood pressure is found to be 151/89 mmHg. What is the most helpful test in
localizing the cause of Cushing’s syndrome?
a. Urinary cortisol level

b. Serum cortisol level
c. Low-dose dexamethasone suppression test
d. High-dose dexamethasone suppression test √
e. Plasma ACTH level
Description
A high-dose dexamethasone suppression test to dierentiate between a pituitary adenoma and an

ectopic source that is producing ACTH
Diagnosis of Cushing’s syndrome
Low dose (1 mg) dexamethasone suppression test

ACTH levels
High dose (8 mg) dexamethasone suppression test
CT or MRI to localize the pathology
Petrosal sinus sampling to confirm Cushing’s disease when microadenoma does not show in
imaging
Other labs: hyperglycemia, hyperlipidemia, hypokalemia, metabolic alkalosis
Page - 374
Page - 375
Question 16/162
Question #16
A 49-year-old male patient complains of proximal muscle weakness and tiredness over the past 6
months. she was recently diagnosed with HTN and is suspected of having Cushing’s disease. Which
of the following is not found in Cushing’s disease?
a. Failure to suppress morning cortisol with low-dose dexamethasone

b. High serum ACTH level
c. Skin pigmentation
d. Bilateral adrenal hypertrophy
e. Failure to suppress ACTH by high dose dexamethasone
Page - 376
Question 16/162
Question #16
A 49-year-old male patient complains of proximal muscle weakness and tiredness over the past 6
months. she was recently diagnosed with HTN and is suspected of having Cushing’s disease. Which
of the following is not found in Cushing’s disease?
a. Failure to suppress morning cortisol with low-dose dexamethasone

b. High serum ACTH level
c. Skin pigmentation
d. Bilateral adrenal hypertrophy
e. Failure to suppress ACTH by high dose dexamethasone √
Description
Cushing’s disease diers from Cushing’s syndrome
Cushing’s disease is a disease caused by ACTH-secreting pituitary adenoma
is will lead to a high cortisol level that fails to suppress with a low dose dexamethasone
suppression test and heavy adrenal workload leading to hypertrophy of both adrenal glands.
High-dose dexamethasone suppression test will fail to suppress ACTH in ectopic ACTH secretion.
e following diagram describes the approach to the diagnosis of Cushing’s syndrome:
Page - 377
Page - 378
Question 17/162
Question #17
A 25-year-old female patient presents with secondary amenorrhea for 10 months, feeling weak and
lethargic. On examination, dark skin pigmentation is noted, and her BMI is 36 kg/m2. Lab
investigations demonstrate hyperglycemia and hypokalemia. What is the most likely diagnosis?
a. Hypothyroidism
c. Hemochromatosis
d. Polycystic ovarian syndrome
Page - 379
Question 17/162
Question #17
A 25-year-old female patient presents with secondary amenorrhea for 10 months, feeling weak and
lethargic. On examination, dark skin pigmentation is noted, and her BMI is 36 kg/m2. Lab
investigations demonstrate hyperglycemia and hypokalemia. What is the most likely diagnosis?
a. Hypothyroidism
b. Cushing’s syndrome √
c. Hemochromatosis
d. Polycystic ovarian syndrome
Description
e clinical scenario fits with the diagnosis of Cushing’s syndrome.
Hypercortisolism (Cushing’s syndrome) results from increased secretion of cortisone by adrenal

glands
Cushing’s disease is a term used for pituitary overproduction of the ACTH hormone

Page - 380
Question 18/162
Question #18
A 33-year-old female is suspected of having Cushing’s syndrome. Which of the following is the least
likely to present in this patient?
a. Truncal obesity
b. Abdominal striation
c. Proximal muscle weakness
d. Hyperkalemia
e. Depression
Page - 381
Question 18/162
Question #18
A 33-year-old female is suspected of having Cushing’s syndrome. Which of the following is the least
likely to present in this patient?
a. Truncal obesity
b. Abdominal striation
c. Proximal muscle weakness
d. Hyperkalemia √
e. Depression
Description
Description:
Cushing’s syndrome is associated with hypokalemia, not hyperkalemia
Cushing’s syndrome results from increased secretion of cortisone by adrenal glands

Page - 382
Question 19/162
Question #19
A patient is suspected of having Cushing’s syndrome. Which of the following is the test of choice to
confirm the diagnosis?
a. Abdominal CT scan
b. Adrenal MRI
c. Dexamethasone suppression test
d. Urinary cortisol level
e. Serum cortisol level
Page - 383
Question 19/162
Question #19
A patient is suspected of having Cushing’s syndrome. Which of the following is the test of choice to
confirm the diagnosis?
b. Adrenal MRI
c. Dexamethasone suppression test √
d. Urinary cortisol level
e. Serum cortisol level
Description
e dexamethasone suppression test confirms the diagnosis by administering 1 mg of

dexamethasone around 11 pm and measuring plasma cortisol at 8 am the next morning.
Diagnosis of Cushing’s syndrome
Low dose (1 mg) dexamethasone suppression test

ACTH levels
High dose (8 mg) dexamethasone suppression test
CT or MRI to localize the pathology
Petrosal sinus sampling to confirm Cushing’s disease when microadenoma does not show in
imaging
Other labs: hyperglycemia, hyperlipidemia, hypokalemia, metabolic alkalosis
Page - 384
Page - 385
Question 20/162
Question #20
A patient was admitted to the ICU with a case of sepsis, and he was critically ill. Which of the
following is the most appropriate blood glucose target to achieve?
a. 70 – 90 mg/dL
b. 90 – 126 mg/dL
c. 120 – 140 mg/dL
d. 140 – 180 mg/dL
e. 180 – 220 mg/dL
Page - 386
Internal Medicine - Endocrinology - Diabetes Mellitus and its complications
Question 20/162
Question #20
A patient was admitted to the ICU with a case of sepsis, and he was critically ill. Which of the
following is the most appropriate blood glucose target to achieve?
a. 70 – 90 mg/dL
b. 90 – 126 mg/dL
c. 120 – 140 mg/dL
d. 140 – 180 mg/dL √
e. 180 – 220 mg/dL
Description
In critically ill patients, to avoid marked hyperglycemia and minimize the risk of hypoglycemia, it is
recommended to achieve the blood glucose target of 140 – 180 mg/dL
Page - 387
Question 21/162
Question #21
A 50-year-old male patient was admitted to the hospital with upper GI bleeding. He was NPO for 12
hours aer admission, and then investigations demonstrated the following: upper endoscopy
showed gastritis, lab investigations showed a glucose level of 170 mg/dL, and hemoglobin level of 14
g/dL. en, 6 weeks later, he presents for follow-up and is found to have a fasting glucose level of 88
mg/dL and normal oral GTT. What is the most common cause of his hyperglycemia while admitted
to the hospital?
a. Type 1 DM
b. Type 2 Dm
c. Stress hyperglycemia
d. Impaired glucose tolerance
e. Impaired fasting glucose
Page - 388
Question 21/162
Question #21
A 50-year-old male patient was admitted to the hospital with upper GI bleeding. He was NPO for 12
hours aer admission, and then investigations demonstrated the following: upper endoscopy
showed gastritis, lab investigations showed a glucose level of 170 mg/dL, and hemoglobin level of 14
g/dL. en, 6 weeks later, he presents for follow-up and is found to have a fasting glucose level of 88
mg/dL and normal oral GTT. What is the most common cause of his hyperglycemia while admitted
to the hospital?
a. Type 1 DM
b. Type 2 Dm
c. Stress hyperglycemia √
d. Impaired glucose tolerance
e. Impaired fasting glucose
Description
Remember that not any hyperglycemia is a DM.
Stress hyperglycemia is a transient elevation of blood sugar due to stress. is condition
spontaneously resolved within several hours.
e pathogenesis is related to glucose counterregulation and the elevation of the stress hormones
during stress or acute illnesses.
Patients with pneumonia, myocardial infarction, stroke, burns, or even postoperative state are at
risk of stress hyperglycemia.
Stress hyperglycemia needs no treatment; you should treat the main illness.
Page - 389
Question 22/162
Question #22
A 50-year-old male patient complains of feeling tired and frequent urination for the past month. On
examination, a deep painless ulcer is noted on his right heel. In addition, the patient complains of
unexplained weight loss during the past month. What is the most appropriate initial investigation?
a. Lower limb arteriography

b. Lower limb venography
c. Fasting blood sugar
d. Biopsy from the base of the ulcer
e. Swap culture from the ulcer base
Page - 390
Question 22/162
Question #22
A 50-year-old male patient complains of feeling tired and frequent urination for the past month. On
examination, a deep painless ulcer is noted on his right heel. In addition, the patient complains of
unexplained weight loss during the past month. What is the most appropriate initial investigation?
a. Lower limb arteriography

b. Lower limb venography
c. Fasting blood sugar √
d. Biopsy from the base of the ulcer
e. Swap culture from the ulcer base
Description
is clinical scenario strongly suggests type 2 diabetes.
Polyuria, chronic fatigue, and lower limb ulcer are characteristic
the best initial investigation will be a fasting blood glucose level which, if elevated on two separate
occasions, is diagnostic of DM
Page - 391
Question 23/162
Question #23
A 55-year-old male patient presents to the ER aer sustaining burns on his right leg while taking a
bath. He stated that he could not tell whether the water was hot enough and had recently started to
suer from pins and needles in his hands. His past history is significant for type 2 DM for the past 10
years. His physical examination demonstrates decreased touch sensation bilaterally, the power is
intact, but the tendon reflexes are reduced bilaterally. What is the most likely cause of his
symptoms?
a. Ischemic stroke
b. Multiple sclerosis
c. Spinal cord compression
d. Guillain-Barre syndrome
e. Diabetic neuropathy
Page - 392
Question 23/162
Question #23
A 55-year-old male patient presents to the ER aer sustaining burns on his right leg while taking a
bath. He stated that he could not tell whether the water was hot enough and had recently started to
suer from pins and needles in his hands. His past history is significant for type 2 DM for the past 10
years. His physical examination demonstrates decreased touch sensation bilaterally, the power is
intact, but the tendon reflexes are reduced bilaterally. What is the most likely cause of his
symptoms?
a. Ischemic stroke
c. Spinal cord compression
d. Guillain-Barre syndrome
e. Diabetic neuropathy √
Description
is patient has physical findings of lower motor neuron damage due to diabetes.
Ischemic CVA will demonstrate unilateral symptoms with hyperreflexia
Guillain-Barre Syndrome is characterized by ascending paralysis and paresthesia, which is not the
case here.
Multiple sclerosis is diagnosed in the presence of neurological deficits that are disseminated in time
and place. Furthermore, it is not common in old age.
Page - 393
Question 24/162
Question #24
An 18-year-old lady complains of dizziness, deep breathing, and abdominal pain. Her medical history
is significant for type 1 DM, for which she receives insulin. What is the best next step in the
management of this patient?
a. Serum urea and creatinine

b. Blood culture and sensitivity
c. Abdominal ultrasound
d. HbA1c
e. Blood sugar and arterial blood gas
Page - 394
Question 24/162
Question #24
An 18-year-old lady complains of dizziness, deep breathing, and abdominal pain. Her medical history
is significant for type 1 DM, for which she receives insulin. What is the best next step in the
a. Serum urea and creatinine

b. Blood culture and sensitivity
d. HbA1c
e. Blood sugar and arterial blood gas √
Description
Page - 395
Question 25/162
Question #25
A 40-year-old male patient presented to your oce for a review of his lab investigations done
yesterday. His fasting glucose is 109 mg/dL and his 2h 75 g OGTT is 130 mg/dL. What is the most
likely diagnosis?
a. Impaired fasting glucose

b. Impaired glucose tolerance
c. Clinical Diabetes
d. Maturity onset diabetes of youth
e. Normal readings
Page - 396
Question 25/162
Question #25
A 40-year-old male patient presented to your oce for a review of his lab investigations done
yesterday. His fasting glucose is 109 mg/dL and his 2h 75 g OGTT is 130 mg/dL. What is the most
likely diagnosis?
a. Impaired fasting glucose √

b. Impaired glucose tolerance
c. Clinical Diabetes
d. Maturity onset diabetes of youth
e. Normal readings
Description
- Impaired fasting glucose (IFG): FBS 90-125 mg/dl
- Impaired glucose tolerance (IGT): 2h 75 g OGTT140-199 mg/dl
Both impaired fasting glucose and impaired glucose tolerance are considered prediabetes. However,
they are not a disease but rather a risk category.
Clinical diabetes is diagnosed by the following criteria:
Diagnosis of DM: any one of the following is diagnostic:
Symptoms of DM + RBS ≥ 200 mg/dl or,

One of the following On at least two separate occasions:
a. FBS ≥ 126 mg/dl
b. 2h 75 g OGTT ≥ 200 mg/dl
c. RBS ≥ 200 mg/dl
d. HbA1c ≥ 6.5%
Page - 397
Question 26/162
Question #26
A 32-year-old female patient is found to have a fasting blood glucose of 155 mg/dL during her
routine examination. e patient is asymptomatic, previously healthy, and takes no medications.
What is the most appropriate next step in the management of this patient?
a. Start insulin therapy

b. Start oral hypoglycemic agents
c. Only lifestyle modification
d. Repeat the fasting blood glucose
e. Test for diabetic complications
Page - 398
Question 26/162
Question #26
A 32-year-old female patient is found to have a fasting blood glucose of 155 mg/dL during her
routine examination. e patient is asymptomatic, previously healthy, and takes no medications.
a. Start insulin therapy

b. Start oral hypoglycemic agents
c. Only lifestyle modification
d. Repeat the fasting blood glucose √
e. Test for diabetic complications
Description
FBS ≥ 126 mg/dl

2h 75 g OGTT ≥ 200 mg/dl
RBS ≥ 200 mg/dl
HbA1c ≥ 6.5%
Note that asymptomatic patients with one fasting blood glucose reading need another reading to
confirm DM.
Page - 399
Question 27/162
Question #27
A diabetic 66-year-old male patient has pain and pins and needle sensation in his hands and feet.
You diagnose him with diabetic nephropathy. Besides proper diabetic control, which drugs can be
used to treat his symptoms?
a. Metformin
b. Metoclopramide
c. Pregabalin
d. Folic acid and B12
e. Statin
Page - 400
Question 27/162
Question #27
A diabetic 66-year-old male patient has pain and pins and needle sensation in his hands and feet.
You diagnose him with diabetic nephropathy. Besides proper diabetic control, which drugs can be
used to treat his symptoms?
a. Metformin
b. Metoclopramide
c. Pregabalin √
d. Folic acid and B12
e. Statin
Description
Diabetic neuropathy is present in at least 50% of diabetes patients. While its primary symptoms are
unpleasant, secondary complications such as falls, foot ulcers, arrhythmias, and ileus are even more
serious.
e best option to reduce neuropathic pain in this situation is pregabalin.
Page - 401
Question 28/162
Question #28
A 66-year-old male patient has a body mass index of 33 kg/m2 and has been diagnosed with type 2
DM. Unfortunately, diet and lifestyle modifications fail to achieve his proper A1C target. Considering
normal lab tests and physical examinations other than DM findings, what is the most appropriate
next step?
a. Start biguanides
b. Start insulin therapy
c. Start a sulfonylurea drug
d. Continue lifestyle modifications and exercise
e. Start regular acarbose
Page - 402
Question 28/162
Question #28
A 66-year-old male patient has a body mass index of 33 kg/m2 and has been diagnosed with type 2
DM. Unfortunately, diet and lifestyle modifications fail to achieve his proper A1C target. Considering
normal lab tests and physical examinations other than DM findings, what is the most appropriate
next step?
a. Start biguanides √
b. Start insulin therapy
c. Start a sulfonylurea drug
d. Continue lifestyle modifications and exercise
e. Start regular acarbose
Description
Biguanides (Metformin) is the first line in the treatment of T2DM
It works by blocking gluconeogenesis and increasing insulin sensitivity but does not cause
hypoglycemia.
It is contraindicated if > 80 years old or GFR less than 30 ml/min (Risk of lactic acidosis)
It is considered the best for the treatment of DM in obese patients (Metformin help reduce weight)
e most common side eect is Gastrointestinal Upset (diarrhea, vomiting, nausea) and, rarely,
Lactic acidosis
Page - 403
Question 29/162
Question #29
Which of the following insulins does the onset of action at 13 minutes and the peak at 1 – 3 hours?
a. Aspart
b. Premixed insulin
c. NPH
d. Detemir
e. Glargine
Page - 404
Question 29/162
Question #29
Which of the following insulins does the onset of action at 13 minutes and the peak at 1 – 3 hours?
a. Aspart √
b. Premixed insulin
c. NPH
d. Detemir
e. Glargine
Description
Insulin Aspart starts its action 5 – 20 minutes aer administration and peaks at 0.5 to 3 hours.
Insulin can be rapid-acting, short-acting, intermediate-acting, or long-acting
Premixed insulin composed of rapid or short-acting combined with intermediated-acting
insulin
e type of insulin that can be given IV is called regular insulin
Page - 405
Question 30/162
Question #30
A 29-year-old male patient is noted to have acanthosis nigricans and an HbA1c level of 8%. Which of
the following is the most likely type of DM he has?
a. Type 1 DM
b. Type 2 DM
c. Latent autoimmune DM of adults (LADA)
d. DM secondary to hemochromatosis
e. Maturity onset DM of youth (MODY)
Page - 406
Question 30/162
Question #30
A 29-year-old male patient is noted to have acanthosis nigricans and an HbA1c level of 8%. Which of
the following is the most likely type of DM he has?
a. Type 1 DM
b. Type 2 DM √
c. Latent autoimmune DM of adults (LADA)
d. DM secondary to hemochromatosis
e. Maturity onset DM of youth (MODY)
Description
Acanthosis nigricans is a skin condition that results from hyperinsulinemia.
High insulin level stimulates epidermal keratocytes and dermal fibroblast proliferation leading to a
darkening of the skin in particular areas of the body.
Acanthosis nigricans is strong evidence of insulin resistance which points to the diagnosis of Type 2
DM.
Despite the young age of this patient, the presence of acanthosis nigricans is strongly suggestive of
Type 2 DM
Page - 407
Page - 408
Question 31/162
Question #31
A 72-year-old male patient complains of morbid obesity and type 2 DM. His medications include
metformin and insulin, and his A1C level is 6.6%. e additional routine investigations demonstrate
persistent albuminuria and a high cholesterol level. Which of the following are the most appropriate
medications to be added to his regimen?
a. Atorvastatin and Valsartan

b. Atorvastatin and nitrates
c. Valsartan and niacin
d. B complex and folic acid
e. Sulfonylurea and enalapril
Page - 409
Question 31/162
Question #31
A 72-year-old male patient complains of morbid obesity and type 2 DM. His medications include
metformin and insulin, and his A1C level is 6.6%. e additional routine investigations demonstrate
persistent albuminuria and a high cholesterol level. Which of the following are the most appropriate
medications to be added to his regimen?
a. Atorvastatin and Valsartan √

b. Atorvastatin and nitrates
c. Valsartan and niacin
d. B complex and folic acid
e. Sulfonylurea and enalapril
Description
e presence of persistent albuminuria suggests diabetic nephropathy.
Both diabetic nephropathy and high cholesterol level should be treated to reduce the risk of
complications in DM patients.
ACE inhibitors or ARBs are the best options to delay nephropathy as they reduce the pressure inside
the nephrons and delay the progression of the damage.
Statin is the first-line treatment of dyslipidemia in a patient with DM as it reduces the mortality and
the risk of complications in this patient.
Page - 410
Question 32/162
Question #32
A 66-year-old male patient complains of being thirsty and urinating more than usual. His body mass
index is 35 kg/m2, and his urine dipstick is positive for glucose. What is the most appropriate next
step in the management of this patient?
a. Renal biopsy
b. KFT and electrolytes
c. Blood sugar measurement
d. Urinalysis for microscopy
e. Vasopressin serum level
Page - 411
Question 32/162
Question #32
A 66-year-old male patient complains of being thirsty and urinating more than usual. His body mass
index is 35 kg/m2, and his urine dipstick is positive for glucose. What is the most appropriate next
a. Renal biopsy
b. KFT and electrolytes
c. Blood sugar measurement √
d. Urinalysis for microscopy
e. Vasopressin serum level
Description
is is a classic scenario of type 2 DM in which the symptoms of DM (polyuria and polydipsia) are
present, and the glucose is detected to be high in the urine.
Serum glucose measurement is the most appropriate at this point because it is more sensitive and
specific than urinary glucose level in diagnosing DM.
Page - 412
Question 33/162
Question #33
A 23-year-old male patient with type 1 Dm presents with abdominal pain and rapid breathing.
Physical examination demonstrates deep, rapid breathing, dehydration, drowsiness, and fruity-
smelling breath. His plasma glucose is elevated, and the urine is positive for ketonuria. What is the
most appropriate initial treatment?
a. Normal saline followed by insulin infusion and KCL

b. Dextrose saline followed by an insulin
c. Normal saline and potassium infusion
d. Normal saline and subcutaneous insulin
e. Normal saline and sodium bicarbonate infusion
Page - 413
Question 33/162
Question #33
A 23-year-old male patient with type 1 Dm presents with abdominal pain and rapid breathing.
Physical examination demonstrates deep, rapid breathing, dehydration, drowsiness, and fruity-
smelling breath. His plasma glucose is elevated, and the urine is positive for ketonuria. What is the
most appropriate initial treatment?
a. Normal saline followed by insulin infusion and KCL √

b. Dextrose saline followed by an insulin
c. Normal saline and potassium infusion
d. Normal saline and subcutaneous insulin
e. Normal saline and sodium bicarbonate infusion
Description
Description:
is patient suers from DKA.
e main treatments for DKA patients include normal saline, insulin infusion, and KCL.
Insulin and KCL should be initiated aer the first 1 liter of normal saline and until the serum
potassium results are known.
Page - 414
Question 34/162
Question #34
A 22-year-old male patient was admitted to the hospital due to a road trac accident. However, his
investigations demonstrate glucosuria. Which of the following is the most appropriate investigation
for following up on his glucose level aer successfully treating his injury?
a. Random blood glucose

b. Fasting blood glucose
c. Repeat urinary dipstick for glucose
d. 24 hours urinary collection for glucose
e. Glycated hemoglobin (A1C)
Page - 415
Question 34/162
Question #34
A 22-year-old male patient was admitted to the hospital due to a road trac accident. However, his
investigations demonstrate glucosuria. Which of the following is the most appropriate investigation
for following up on his glucose level aer successfully treating his injury?
a. Random blood glucose

b. Fasting blood glucose √
c. Repeat urinary dipstick for glucose
d. 24 hours urinary collection for glucose
e. Glycated hemoglobin (A1C)
Description
Urinary glucose level is not a reliable indicator for DM. However; it increases due to a decreased
urinary threshold (e.g., stress, pregnancy, and young people)
If an acutely ill or injured patient has glucosuria, you better perform fasting blood glucose
concentration to follow up and exclude DM.
Fasting blood sugar is more accurate than random blood sugar
HbA1C is a reliable screening and follow-up test used in the diagnosis, but it is more beneficial in
following up the treatment of known DM cases.
Page - 416
Question 35/162
Question #35
An obese patient is diagnosed with type 2 DM. What is the first-line treatment if no
contraindications are present?
a. Pioglitazone
b. Sulfonylurea
c. Insulin
d. Metformin
e. Acarbose
Page - 417
Question 35/162
Question #35
An obese patient is diagnosed with type 2 DM. What is the first-line treatment if no
contraindications are present?
a. Pioglitazone
b. Sulfonylurea
c. Insulin
d. Metformin √
e. Acarbose
Description
hypoglycemia.
It is considered the best for the treatment of DM in obese patients (Metformin helps decrease
weight)
Lactic acidosis
Page - 418
Question 36/162
Question #36
Regarding diabetic ketoacidosis, which of the following statements is true?
c. e fluid of choice used in the treatment is Ringer lactate

d. e target treatment is to reduce the serum glucose to normal.
e. e lower the HCO3 reading, the more severe the disease
a. Insulin bolus of 0.1 unit per kg should be used
b. Ketogenesis results from suppressed lipolysis
Page - 419
Question 36/162
Question #36

e. e lower the HCO3 reading, the more severe the disease √
Description
e lower HCO3 readings indicate more severe DKA (it correlates with the severity)
DKA usually occurs in T1DM, characterized by insulin deficiency with increasing
counterregulatory hormones (GH, Cortisone, Adrenalin, Glucagon)
Ketogenesis in this situation results from lipolysis which is activated by the low insulin levels.
Insulin boluses are not used in the treatment of DKA, but insulin infusion is the correct
treatment
e fluid of choice is normal saline; switch to dextrose containing fluid if the serum glucose is
less than 250 mg/dL
e target of the DKA treatment is to treat acidosis, HCO3 should be more than 15 and the
anion gap returns to normal. Aer that, the blood glucose should be controlled and then the
patient should be weaned from the DKA protocol
Page - 420
Question 37/162
Question #37
Which of the following conditions is treated with metformin other than DM?
a. Diabetes insipidus
b. Hyperthyroidism
c. Hypothyroidism
d. Polycystic kidney disease
e. Polycystic ovarian syndrome
Page - 421
Question 37/162
Question #37
Which of the following conditions is treated with metformin other than DM?
b. Hyperthyroidism
c. Hypothyroidism
d. Polycystic kidney disease
e. Polycystic ovarian syndrome √
Description
Besides diabetes, metformin is used to treat polycystic ovarian syndrome (PCOS)
hypoglycemia.
weight)
Lactic acidosis
Page - 422
Question 38/162
Question #38
A 50-year-old male patient was recently diagnosed with type 2 DM. Which laboratory test should be
ordered before starting him on metformin?
a. Serum potassium and sodium

b. Serum creatinine
c. Complete blood count
d. Lipid profile
e. ECG stress test
Page - 423
Question 38/162
Question #38
A 50-year-old male patient was recently diagnosed with type 2 DM. Which laboratory test should be
ordered before starting him on metformin?
a. Serum potassium and sodium

b. Serum creatinine √
d. Lipid profile
e. ECG stress test
Description
hypoglycemia.
weight)
Lactic acidosis
Page - 424
Question 39/162
Question #39
In patients with DKA, which of the following is true about the potassium levels in the body?
a. It remains unaected
b. It can be normal despite low total body potassium
c. It can be normal despite high total body potassium
d. It will naturally correct when insulin administrated
e. Hyperkalemia is always present
Page - 425
Question 39/162
Question #39
In patients with DKA, which of the following is true about the potassium levels in the body?
a. It remains unaected
b. It can be normal despite low total body potassium √
c. It can be normal despite high total body potassium
d. It will naturally correct when insulin administrated
e. Hyperkalemia is always present
Description
Description:
In DKA patients, the total body potassium is deficient, but normal serum potassium is due to shiing
to extracellular fluids.
e insulin administration will shi the serum potassium intracellularly, causing hypokalemia, so
KCL should be provided even if the serum potassium is normal during the treatment of DKA.
Page - 426
Question 40/162
Question #40
A 40-year-old male patient is found to have a fasting blood glucose level of 130 mg/dL during the
routine examination. However, on further evaluation, he has a second reading of 140 mg/dL aer 72
hours. What is the most appropriate at this time?
a. e patient has type 1 DM and should be treated with insulin

b. e patient has type 2 DM and should be started on lifestyle modification and exercise
c. A glucose tolerance test should be ordered at this time
d. is patient has prediabetes and should change his lifestyle
e. Fasting blood sugar should be repeated aer 1 month to ensure the diagnosis
Page - 427
Question 40/162
Question #40
A 40-year-old male patient is found to have a fasting blood glucose level of 130 mg/dL during the
routine examination. However, on further evaluation, he has a second reading of 140 mg/dL aer 72
hours. What is the most appropriate at this time?
a. e patient has type 1 DM and should be treated with insulin

b. e patient has type 2 DM and should be started on lifestyle modification and exercise √
c. A glucose tolerance test should be ordered at this time
d. is patient has prediabetes and should change his lifestyle
e. Fasting blood sugar should be repeated aer 1 month to ensure the diagnosis
Description
Even in asymptomatic patients, two readings of fasting blood sugar of more than 126 are diagnostic
for DM.
Note that type 1 DM presents at a younger age and is not diagnosed during the routine examination
but presents with DKA.
Prediabetes is diagnosed when the fasting blood sugar is 90 – 125 mg/dL
A glucose tolerance test will not add value to the diagnosis at this stage; two elevated fasting
glucose readings are enough for the diagnosis.
Page - 428
Question 41/162
Question #41
A 40-year-old male patient was diagnosed to have impaired glucose tolerance. Which of the
following lab test is most consistent with this diagnosis?
a. Fasting blood glucose of 105 mg/dL

b. Fasting blood glucose of 250 mg/dL
c. Random blood glucose of 130 mg/dL
d. 2h-75g-OGTT of 180 mg/dL
e. 2h-75g-OGTT of 280 mg/dL
Page - 429
Question 41/162
Question #41
A 40-year-old male patient was diagnosed to have impaired glucose tolerance. Which of the
following lab test is most consistent with this diagnosis?
a. Fasting blood glucose of 105 mg/dL

b. Fasting blood glucose of 250 mg/dL
d. 2h-75g-OGTT of 180 mg/dL √
e. 2h-75g-OGTT of 280 mg/dL
Description
Impaired glucose tolerance and impaired fasting glucose are not a disease but rather risk categories.
ey are called prediabetes (at risk of having DM in the future)
Fasting blood glucose of 105 mg/dL is called impaired fasting glucose
Fasting blood glucose of 250 mg/dL suggests DM
2h-75g-OGTT of 280 mg/dL suggests DM (not pre-DM)

FBS ≥ 126 mg/dl
RBS ≥ 200 mg/dl
HbA1c ≥ 6.5%
Diagnosis of Prediabetes:
Impaired fasting glucose (IFG): FBS 90-125 mg/dl

Impaired glucose tolerance (IGT): 2h 75 g OGTT 140-199 mg/dl
Page - 430
Page - 431
Question 42/162
Question #42
One of the following lab tests is diagnostic for type 2 DM:
e. 2-hour postprandial 75g OGTT of 160 mg/dL

a. Symptoms of DM and random blood sugar of 180 mg/dl
b. Fasting plasma glucose of 126 mg/dL on two separate occasions
d. HbA1C of 6% on 2 dierent occasions
Page - 432
Question 42/162
Question #42
One of the following lab tests is diagnostic for type 2 DM:
e. 2-hour postprandial 75g OGTT of 160 mg/dL

a. Symptoms of DM and random blood sugar of 180 mg/dl
b. Fasting plasma glucose of 126 mg/dL on two separate occasions √
d. HbA1C of 6% on 2 dierent occasions
Description
FBS ≥ 126 mg/dl

RBS ≥ 200 mg/dl
HbA1c ≥ 6.5%
e choices d and e are considered prediabetes, while one RBS reading of 200 without symptoms of
DM is not diagnostic.
Page - 433
Question 43/162
Question #43
Glycated hemoglobin (HbA1C) is an appropriate screening test to assess the adequacy of the
treatment of DM patients. In which of the following patients does the HbA1C assay is inaccurate?
a. A 62-year-old male with Type 2 DM and dyslipidemia

b. A 52-year-old male with Type 2 DM and HTN
c. A 40-year-old with type 1 DM and Hypothyroidism
d. A 39-year-old male with Type 2 DM and morbid obesity
e. A 20-year-old male with Type 1 DM and sickle cell anemia
Page - 434
Question 43/162
Question #43
Glycated hemoglobin (HbA1C) is an appropriate screening test to assess the adequacy of the
treatment of DM patients. In which of the following patients does the HbA1C assay is inaccurate?
a. A 62-year-old male with Type 2 DM and dyslipidemia

b. A 52-year-old male with Type 2 DM and HTN
c. A 40-year-old with type 1 DM and Hypothyroidism
d. A 39-year-old male with Type 2 DM and morbid obesity
e. A 20-year-old male with Type 1 DM and sickle cell anemia √
Description
e short RBC lifespan makes the HbA1C level show false low values.
e glycosylated hemoglobin assay is inaccurate by conditions aecting red blood cell survival, such
as sickle cell disease or the presence of hemoglobin C.
Page - 435
Question 44/162
Question #44
In diabetic ketoacidosis, the formation of ketone bodies results from which of the following?
a. Reduced urinary ketone excretion

b. Destruction of the free fatty acids
c. Reduced cortisol level
d. High glucose level
e. High insulin level
Page - 436
Question 44/162
Question #44
In diabetic ketoacidosis, the formation of ketone bodies results from which of the following?
a. Reduced urinary ketone excretion

b. Destruction of the free fatty acids √
c. Reduced cortisol level
d. High glucose level
e. High insulin level
Description
Description:
In the case of DKA, the lack of insulin is the main cause of lipolysis that leads to ketone bodies
formation and metabolic acidosis
DKA usually occurs in T1DM, characterized by insulin deficiency with increasing counterregulatory
hormones (GH, Cortisone, Adrenalin, Glucagon). It can present in T2DM, but that is very rare.
Page - 437
Question 45/162
Question #45
A 49-year-old male patient complains of excessive thirst and urination. However, his vital signs are
normal, and his serum glucose level is 370 mg/dL. What is the most appropriate treatment?
a. Oral hypoglycemic agent

b. Long-acting insulin
c. Short-acting insulin
d. Intravenous regular insulin
e. Get an additional blood sugar reading
Page - 438
Question 45/162
Question #45
A 49-year-old male patient complains of excessive thirst and urination. However, his vital signs are
normal, and his serum glucose level is 370 mg/dL. What is the most appropriate treatment?
a. Oral hypoglycemic agent √

b. Long-acting insulin
c. Short-acting insulin
d. Intravenous regular insulin
e. Get an additional blood sugar reading
Description
e presence of random blood glucose (RBS) of ≥ 200 mg/dL and the classic DM symptoms are
diagnostic of DM without the need for additional RBS reading.
Lifestyle modifications are the first-line treatment in this situation. However, it is not listed in the
choices, so starting an oral hypoglycemic agent is the first line in this scenario.
Page - 439
Question 46/162
Question #46
A 70-year-old male patient was diagnosed recently with type 2 DM. His past history is significant for
CKD, and his baseline GFR is 25 ml/min. His body mass index is 37 kg/m2. What is the drug of choice
to control his DM?
a. Biguanides
b. Sulfonylurea
c. Pioglitazone
d. SGLT2 inhibitors
e. Insulin
Page - 440
Question 46/162
Question #46
A 70-year-old male patient was diagnosed recently with type 2 DM. His past history is significant for
CKD, and his baseline GFR is 25 ml/min. His body mass index is 37 kg/m2. What is the drug of choice
to control his DM?
a. Biguanides
b. Sulfonylurea
c. Pioglitazone
d. SGLT2 inhibitors
e. Insulin √
Description
Biguanides, sulfonylurea, and sodium-glucose cotransporter 2 inhibitors are contraindicated

because of poor renal function.
Pioglitazone causes weight gain, so it is better to be avoided in this situation
Insulin is the most appropriate drug for this patient.
Page - 441
Question 47/162
Question #47
A 49-year-old male patient complains of polyuria, polyphagia, and polydipsia for 4 months. His
physical examination demonstrates acanthosis nigricans and high BMI. His lab investigations show
a random blood sugar of 292 mg/dL. What is the best next step in the management of this patient?
a. Repeat random blood sugar

b. Perform fasting blood sugar
c. Urinary cortisol level
d. CBC, KFT, LFT, Electrolytes, A1C, and start DM treatment
e. Start insulin therapy
Page - 442
Question 47/162
Question #47
A 49-year-old male patient complains of polyuria, polyphagia, and polydipsia for 4 months. His
physical examination demonstrates acanthosis nigricans and high BMI. His lab investigations show
a random blood sugar of 292 mg/dL. What is the best next step in the management of this patient?
a. Repeat random blood sugar

b. Perform fasting blood sugar
c. Urinary cortisol level
d. CBC, KFT, LFT, Electrolytes, A1C, and start DM treatment √
e. Start insulin therapy
Description
is patient has diabetes, and he needs to be treated.
e appropriate workup is to take baseline lab readings and start DM treatment.
FBS ≥ 126 mg/dl

RBS ≥ 200 mg/dl
HbA1c ≥ 6.5%
Symptomatic patients with elevated random blood sugar do not need additional readings to
confirm DM.
Insulin therapy is not indicated at this stage of type 2 DM; you better start on lifestyle modifications
and oral agents, and then insulin will be a choice.
Page - 443
Question 48/162
Question #48
A diabetic 60-year-old male patient has complained of diarrhea for the past 4 months. His past
history is significant for type 2 DM treated with insulin alone. His lab tests show glycated
hemoglobin of 12%. What is the most likely cause of his diarrhea?
a. Gastroenteritis
b. Autonomic neuropathy
c. Inflammatory bowel disease
d. Irritable bowel syndrome
e. Giardiasis
Page - 444
Question 48/162
Question #48
A diabetic 60-year-old male patient has complained of diarrhea for the past 4 months. His past
history is significant for type 2 DM treated with insulin alone. His lab tests show glycated
hemoglobin of 12%. What is the most likely cause of his diarrhea?
a. Gastroenteritis
b. Autonomic neuropathy √
e. Giardiasis
Description
Autonomic neuropathy is a well-known consequence of diabetes mellitus.
It aects both the sympathetic and parasympathetic branches of the autonomic nervous system.
Natural aging and alcoholism are other possible causes of neuropathy.
e damage to the sympathetic nervous system in the GI tract will lead to diarrhea, while the
damage to the parasympathetic typically results in constipation.
Page - 445
Question 49/162
Question #49
e risk of diabetic complications is best reduced by which of the following measures?
a. Tight diabetic control

b. e usage of statin
c. e usage of ACE inhibitors
d. e usage of Aspirin
e. Lifestyle modification
Page - 446
Question 49/162
Question #49
e risk of diabetic complications is best reduced by which of the following measures?
a. Tight diabetic control √

b. e usage of statin
c. e usage of ACE inhibitors
d. e usage of Aspirin
e. Lifestyle modification
Description
Tight glycemic control is the most important and eective method in reducing both microvascular
and macrovascular complications of diabetes mellitus.
ACE inhibitors can reduce the progression of diabetic nephropathy
Aspirin and statins can reduce the mortality rate and the cardiovascular events resulting from DM.
Page - 447
Question 50/162
Question #50

e. e lower the HCO3 reading, the more severe the disease
Page - 448
Question 50/162
Question #50

e. e lower the HCO3 reading, the more severe the disease √
Description
e lower HCO3 readings indicate more severe DKA (it correlates with the severity)
DKA usually occurs in T1DM, characterized by insulin deficiency with increasing
counterregulatory hormones (GH, Cortisone, Adrenalin, Glucagon)
Ketogenesis in this situation results from lipolysis which is activated by the low insulin levels.
Insulin boluses are not used in the treatment of DKA, but insulin infusion is the correct
treatment
e fluid of choice is normal saline; switch to dextrose containing fluid if the serum glucose is
less than 250 mg/dL
e target of the DKA treatment is to treat acidosis, HCO3 should be more than 15 and the
anion gap returns to normal. Aer that, the blood glucose should be controlled and then the
patient should be weaned from the DKA protocol
Page - 449
Question 51/162
Question #51
A 22-yer-old female patient presents to the emergency department with abdominal pain. Her
physical examination demonstrates fruity-smelling breath and tachypnea. In addition, her lab
investigations show a blood sugar of 380 mg/dL, urinary ketones +++, and arterial blood PH of 7.3.
what is the most appropriate initial management?
a. Intravenous normal saline

b. Intravenous KCL infusion
c. Intravenous insulin infusion
d. Intravenous antibiotics
e. Intravenous bicarbonates
Page - 450
Question 51/162
Question #51
A 22-yer-old female patient presents to the emergency department with abdominal pain. Her
physical examination demonstrates fruity-smelling breath and tachypnea. In addition, her lab
investigations show a blood sugar of 380 mg/dL, urinary ketones +++, and arterial blood PH of 7.3.
what is the most appropriate initial management?
a. Intravenous normal saline √

b. Intravenous KCL infusion
c. Intravenous insulin infusion
d. Intravenous antibiotics
e. Intravenous bicarbonates
Description
Normal saline is the first-line treatment for any patient suering from DKA.
Insulin infusion and KCL infusion should be started aer the initiation of normal saline or until the
serum potassium status is known.
All the mentioned choices are used in DKA treatment, but intravenous normal saline should be
started early before other treatments.
Page - 451
Question 52/162
Question #52
A diabetic patient was prescribed metformin as a part of his management. All of the following are
true except:
a. It carries a risk of hypoglycemia

b. It is contraindicated if the GFR < 30 ml/min
c. Gastrointestinal ax are the most common side eects
d. It can help losing weight
e. It Works by blocking gluconeogenesis and increasing insulin sensitivity
Page - 452
Question 52/162
Question #52
A diabetic patient was prescribed metformin as a part of his management. All of the following are
true except:
a. It carries a risk of hypoglycemia √

b. It is contraindicated if the GFR < 30 ml/min
c. Gastrointestinal ax are the most common side eects
d. It can help losing weight
e. It Works by blocking gluconeogenesis and increasing insulin sensitivity
Description
Metformin does not carry the risk of hypoglycemia.
hypoglycemia.
weight)
Lactic acidosis
Page - 453
Question 53/162
Question #53
A 62-year-old male patient with a history of Type 2 DM requires urgent major abdominal surgery.
Which of the following drugs should be withheld until the normal KFT is documented 48 hours
postoperatively?
a. Acarbose
b. Sulfonylurea
c. Biguanides
d. Insulin
e. Pioglitazone
Page - 454
Question 53/162
Question #53
A 62-year-old male patient with a history of Type 2 DM requires urgent major abdominal surgery.
Which of the following drugs should be withheld until the normal KFT is documented 48 hours
postoperatively?
a. Acarbose
b. Sulfonylurea
c. Biguanides √
d. Insulin
e. Pioglitazone
Description
e administration of general anesthesia may result in hypotension, which leads to kidney and
peripheral hypoperfusion, with subsequent lactate buildup. As a result, if radiocontrast material is
administered or urgent surgery is required, metformin should be delayed, and hydration should be
maintained until intact kidney function is confirmed at 24 and 48 hours following the intervention.
Page - 455
Question 54/162
Question #54
A 43-year-old male patient is a known history of type 1 DM. He was presented by his wife to the
emergency department aer falling downstairs and becoming unconscious. What is the most
appropriate initial investigation?
a. Brain CT scan
b. Random blood sugar
c. Arterial blood gas
d. Brain MRI
e. ECG
Page - 456
Question 54/162
Question #54
A 43-year-old male patient is a known history of type 1 DM. He was presented by his wife to the
emergency department aer falling downstairs and becoming unconscious. What is the most
appropriate initial investigation?
a. Brain CT scan
b. Random blood sugar √
c. Arterial blood gas
d. Brain MRI
e. ECG
Description
It is not uncommon to encounter hypoglycemia in diabetic patients because of high insulin doses or
taking insulin without adequate food intake.
Random blood sugar is the first rational investigation to be done in this situation to exclude
hypoglycemia.
Hypoglycemia is a priority and should be treated rapidly to avoid prolonged hypoglycemia and brain
damage.
Page - 457
Question 55/162
Question #55
A 50-year-old female patient is a known case of type 2 DM. She presented for routine investigations
and was found to have a blood pressure of 142/91 mmHg and persistent albuminuria. What is the
most appropriate drug management?
a. ACE inhibitors
c. Beta-blockers
d. Statins
e. Aspirin
Page - 458
Question 55/162
Question #55
A 50-year-old female patient is a known case of type 2 DM. She presented for routine investigations
and was found to have a blood pressure of 142/91 mmHg and persistent albuminuria. What is the
most appropriate drug management?
a. ACE inhibitors √
c. Beta-blockers
d. Statins
e. Aspirin
Description
Persistent albuminuria (previously called microalbuminuria) is an early sign of diabetic

nephropathy. ACE inhibitors and ARBs are the drugs of choice for this situation because they are
nephroprotective.
ACE inhibitors and ARBs delay the progression of diabetic nephropathy by reducing the pressure
inside the nephrons and reducing the damage.
Page - 459
Question 56/162
Question #56
A 22-year-old male patient complains of central obesity and acanthosis nigricans. His family history
is significant for type 2 DM in his father and mother, and his lab tests show a fasting glucose level of
110 mg/dL. What is the most likely diagnosis?
a. Type 1 DM
b. Type 2 Dm
c. Prediabetes
d. Maturity onset diabetes of youth (MODY)
e. Latent autoimmune diabetes in adults (LADA)
Page - 460
Question 56/162
Question #56
A 22-year-old male patient complains of central obesity and acanthosis nigricans. His family history
is significant for type 2 DM in his father and mother, and his lab tests show a fasting glucose level of
110 mg/dL. What is the most likely diagnosis?
a. Type 1 DM
b. Type 2 Dm
c. Prediabetes √
d. Maturity onset diabetes of youth (MODY)
e. Latent autoimmune diabetes in adults (LADA)
Description
is patient is at risk of having DM in the future.
His family history of DM, the presence of acanthosis nigricans, and the blood glucose reading of 90 –
125 mg/dL strongly suggest prediabetes
Diagnosis of Prediabetes:
Impaired fasting glucose (IFG): FBS 90-125 mg/dl

Impaired glucose tolerance (IGT): 2h 75 g OGTT140-199 mg/dl
Page - 461
Question 57/162
Question #57
A 40-year-old male patient with DM comes for a follow-up. He recently has increased appetite and
weight loss. He takes insulin in divided doses but takes no other medications. His serum glucose
concentrations were tested at home for the last 3 weeks, ranging from 300 – 350 mg/dL. What is the
most appropriate next step in the management of his condition?
a. Add metformin
b. Change to another insulin type
c. Increase his insulin dose
d. Reduce his insulin dose
e. Provide his daily insulin as a single dose
Page - 462
Question 57/162
Question #57
A 40-year-old male patient with DM comes for a follow-up. He recently has increased appetite and
weight loss. He takes insulin in divided doses but takes no other medications. His serum glucose
concentrations were tested at home for the last 3 weeks, ranging from 300 – 350 mg/dL. What is the
most appropriate next step in the management of his condition?
a. Add metformin
b. Change to another insulin type
c. Increase his insulin dose √
d. Reduce his insulin dose
e. Provide his daily insulin as a single dose
Description
is patient has inadequate blood glucose control and needs more insulin.
Reducing insulin dose will result in more elevated blood sugar
Adding metformin is not appropriate because it will be of a little benefit
Single-dose insulin carries a risk of hypoglycemia and will not help reduce blood sugar control in this
situation.
Page - 463
Question 58/162
Question #58
In a patient with diabetes, which of the following is the most appropriate test for long-term follow-
up of his blood sugar control state?
a. Glycated hemoglobin
c. Random blood glucose
d. C-Peptide
e. GAD antibodies titer
Page - 464
Question 58/162
Question #58
In a patient with diabetes, which of the following is the most appropriate test for long-term follow-
up of his blood sugar control state?
a. Glycated hemoglobin √
c. Random blood glucose
d. C-Peptide
e. GAD antibodies titer
Description
Glucose can bind irreversibly to hemoglobin via a process known as glycation. erefore, the
hemoglobin with glucose attached is known as glycated hemoglobin, oen abbreviated to HbA1C.
HbA1C gives an Idea about the last 2 – 3 months of glycemic control, and it is an appropriate test to
assess the adequacy of DM treatment.
Another method is the frequent measurements of blood glucose, but this is a short-term method
and results in multiple punctures and pain in the skin.
Page - 465
Question 59/162
Question #59
A 40-year-old male patient complains of feeling thirsty despite drinking plenty of water. Which of
the following is the most likely laboratory finding associated with central diabetes insipidus?
a. Increased urine osmolality with the administration of vasopressin

b. Decreased urine osmolality with the administration of vasopressin
c. Increased urine osmolality with water restriction
d. Decreased urine osmolality with water restriction
e. Increased urine osmolality with intravenous fluid administration
Page - 466
Internal Medicine - Endocrinology - Disorders of ADH
Question 59/162
Question #59
A 40-year-old male patient complains of feeling thirsty despite drinking plenty of water. Which of
the following is the most likely laboratory finding associated with central diabetes insipidus?
a. Increased urine osmolality with the administration of vasopressin √

b. Decreased urine osmolality with the administration of vasopressin
c. Increased urine osmolality with water restriction
d. Decreased urine osmolality with water restriction
e. Increased urine osmolality with intravenous fluid administration
Description
Positive water deprivation test is present in both types of DI, while vasopressin challenge test is
positive in central DI, not nephrogenic DI
Increased urine osmolality with water restriction is a normal finding that indicates no DI.
Diabetes insipidus manifests as low urinary sodium, urine osmolality, and specific gravity. In
addition, serum sodium and serum osmolality are elevated.
Diabetes insipidus (DI) results in insucient (central) or ineective (nephrogenic) ADH → high
volume water loss in urine
ere are two types of the disease:
Central DI: Any CNS disorder (stroke, tumor, trauma, hypoxia, infection, histiocytosis) that
impairs the production of ADH in the hypothalamus or storage in the posterior pituitary gland.
Nephrogenic DI: less common, characterized by loss of ADH eect on collecting ducts, caused
by (lithium, demeclocycline, CKD, Hypokalemia, hypercalcemia, pyelonephritis, renal
amyloidosis, Sjögren’s syndrome)
Page - 467
Question 60/162
Question #60
A 33-year-old male patient develops polyuria aer his pituitary surgery. Physical examination
demonstrates dehydration despite receiving 5 liters of fluid in the past 24 hours. What is the most
appropriate management?
a. Provide vasopressin
b. Provide more intravenous fluid
c. Provide tap water orally in addition to the intravenous fluid
d. Provide thiazide diuretics
e. Start demeclocycline
Page - 468
Question 60/162
Question #60
A 33-year-old male patient develops polyuria aer his pituitary surgery. Physical examination
demonstrates dehydration despite receiving 5 liters of fluid in the past 24 hours. What is the most
a. Provide vasopressin √
b. Provide more intravenous fluid
c. Provide tap water orally in addition to the intravenous fluid
d. Provide thiazide diuretics
e. Start demeclocycline
Description
Persistent polyuria, despite appropriate fluid therapy in a patient with pituitary gland surgery,
suggests diabetes insipidus.
Central type DI is treated by vasopressin (DDAVP), while nephrogenic DI is treated by the correction
of the cause and stopping the oending agent
Page - 469
Question 61/162
Question #61
A 65-year-old male patient complains of confusion. His lab investigations demonstrate serum
sodium of 116 mEq/L, serum osmolality of 248 mOsm/Kg H2O, and urine osmolality of 286
mOsm/Kg H2O. However, his liver, kidney, cardiac, and hepatic functions are normal. What is the
most appropriate treatment at this time?
a. Hypertonic 3% saline
b. Normal saline 0.9%
c. Water restriction only
d. Demeclocycline
e. Vasopressin
Page - 470
Question 61/162
Question #61
A 65-year-old male patient complains of confusion. His lab investigations demonstrate serum
sodium of 116 mEq/L, serum osmolality of 248 mOsm/Kg H2O, and urine osmolality of 286
mOsm/Kg H2O. However, his liver, kidney, cardiac, and hepatic functions are normal. What is the
most appropriate treatment at this time?
a. Hypertonic 3% saline
b. Normal saline 0.9%
c. Water restriction only
d. Demeclocycline √
e. Vasopressin
Description
In the presence of hyponatremia, kidneys are expected to dilute urine maximally to less than 100
mOsm/kg water.
is patient has reduced serum sodium and serum osmolality and a urine osmolality of more than
100 mOsm/Kg water (not maximally diluted urine). is is typical for SIADH.
Syndrome of inappropriate anti-diuretic hormone (SIADH) is a syndrome in which there is over-

secretion of ADH leading to water retention, hyponatremia, hypoosmolality, high urine sodium, and
high urine osmolality.
Page - 471
Question 62/162
Question #62
A patient complains of confusion secondary to hyponatremia. Which of the following fits with the
diagnosis of SIADH?
a. Elevated serum glucose

b. Elevated serum osmolality
c. Reduced urine osmolality
d. Elevated urine osmolality
e. Low plasma arginine vasopressin
Page - 472
Question 62/162
Question #62
A patient complains of confusion secondary to hyponatremia. Which of the following fits with the
diagnosis of SIADH?
a. Elevated serum glucose

b. Elevated serum osmolality
c. Reduced urine osmolality
d. Elevated urine osmolality √
e. Low plasma arginine vasopressin
Description
In the presence of hyponatremia, kidneys are expected to dilute urine maximally to less than 100
mOsm/kg water.

Page - 473
Question 63/162
Question #63
A 66-year-old male patient complains of confusion for a one-day duration. His lab investigations
demonstrate serum sodium of 116 mEq/L, random blood sugar of 130 mg/dL, and serum osmolality
of 248 mOsm/kg H2O. Which of the following is the most likely diagnosis?
b. Inappropriate ADH secretion
c. Hyperosmolar hyperglycemic state
d. Pseudohyponatremia
e. Congestive heart failure
Page - 474
Question 63/162
Question #63
A 66-year-old male patient complains of confusion for a one-day duration. His lab investigations
demonstrate serum sodium of 116 mEq/L, random blood sugar of 130 mg/dL, and serum osmolality
of 248 mOsm/kg H2O. Which of the following is the most likely diagnosis?
b. Inappropriate ADH secretion √
c. Hyperosmolar hyperglycemic state
d. Pseudohyponatremia
e. Congestive heart failure
Description
Hyponatremia and hypoosmolality suggest SIADH as the most likely diagnosis.

Page - 475
Question 64/162
Question #64
A 32-year-old female is known to have bipolar disorder. She receives her treatment regularly. She
presents with polyuria, hypernatremia, and features of dehydration. Her water deprivation test fails
to raise urine osmolality. What is the most likely diagnosis?
a. Central diabetes insipidus

b. Nephrogenic diabetes insipidus
c. Inappropriate ADH secretion
d. Renal impairment
e. Heart failure
Page - 476
Question 64/162
Question #64
A 32-year-old female is known to have bipolar disorder. She receives her treatment regularly. She
presents with polyuria, hypernatremia, and features of dehydration. Her water deprivation test fails
to raise urine osmolality. What is the most likely diagnosis?
a. Central diabetes insipidus

b. Nephrogenic diabetes insipidus √
c. Inappropriate ADH secretion
d. Renal impairment
e. Heart failure
Description
e use of lithium (a mood stabilizer used in bipolar disorder) is associated with nephrogenic DI
Page - 477
Question 65/162
Question #65
In a 22-year-old female, the diagnosis of diabetes insipidus is suspected. What is the most likely
laboratory pattern to manifest in this patient?
a. High plasma osmolality, low urine osmolality, high serum sodium

b. High plasma osmolality, low urine osmolality, low serum sodium
c. High plasma osmolality, high urine osmolality, high serum sodium
d. Low plasma osmolality, low urine osmolality, high serum sodium
e. Low plasma osmolality, high urine osmolality, high serum sodium
Page - 478
Question 65/162
Question #65
In a 22-year-old female, the diagnosis of diabetes insipidus is suspected. What is the most likely
laboratory pattern to manifest in this patient?
a. High plasma osmolality, low urine osmolality, high serum sodium √

b. High plasma osmolality, low urine osmolality, low serum sodium
c. High plasma osmolality, high urine osmolality, high serum sodium
d. Low plasma osmolality, low urine osmolality, high serum sodium
e. Low plasma osmolality, high urine osmolality, high serum sodium
Description
Diabetes insipidus manifests as low urinary sodium, urine osmolality, and specific gravity. In
addition, serum sodium and serum osmolality are elevated.
Page - 479
Question 66/162
Question #66
A 20-year-old male patient is treated for meningitis. On the third day aer admission, the patient
becomes confused and develops convulsions that fail to respond to anticonvulsant therapy. Which
is the most likely cause of refractory seizure in meningitis patients?
a. Brain tissue ischemia

b. Brain abscess
c. Elevated intracranial pressure
d. Hyponatremia from SIADH
e. Subdural empyema
Page - 480
Question 66/162
Question #66
A 20-year-old male patient is treated for meningitis. On the third day aer admission, the patient
becomes confused and develops convulsions that fail to respond to anticonvulsant therapy. Which
is the most likely cause of refractory seizure in meningitis patients?
a. Brain tissue ischemia

b. Brain abscess
c. Elevated intracranial pressure
d. Hyponatremia from SIADH √
e. Subdural empyema
Description
Hyponatremia from the syndrome of inappropriate secretion of ADH (SIADH) is a common

complication of bacterial meningitis.
Hyponatremia may cause refractory seizures that should be treated with an appropriate hypertonic
saline solution.

Page - 481
Question 67/162
Question #67
A 50-year-old male patient with a history of lung cancer presents with confusion. His lab
investigations demonstrate serum sodium of 119 mEq/L and normal blood sugar. In addition, his
urine Osmolality is high. What is the most likely diagnosis?
a. Renal impairment
b. Hyperaldosteronism
c. Diabetes insipidus
d. Inappropriate ADH secretion
e. Pseudohyponatremia
Page - 482
Question 67/162
Question #67
A 50-year-old male patient with a history of lung cancer presents with confusion. His lab
investigations demonstrate serum sodium of 119 mEq/L and normal blood sugar. In addition, his
urine Osmolality is high. What is the most likely diagnosis?
a. Renal impairment
b. Hyperaldosteronism
d. Inappropriate ADH secretion √
e. Pseudohyponatremia
Description

secretion of ADH leading to water retention, hyponatremia, hypo-osmolality, high urine sodium,
and high urine osmolality.
In this patient, the ADH source is mostly from lung cancer (as a paraneoplastic feature).
Page - 483
Question 68/162
Question #68
A 33-year-old man with Sjögren’s syndrome came to your clinic with polyuria and polydipsia for the
past week. His lab investigations demonstrate a serum fasting glucose of 70 mg/dL, serum calcium
of 9.1 mg/dL, serum sodium of 152 mEq/L, serum creatinine of 0.8 mg/dL and serum urea of 15
mmol/L. what is the best initial test to do for this patient?
a. Desmopressin challenge test

b. Water deprivation test
c. Brain CT scan
d. Sweat chloride test
e. Schirmer’s test
Page - 484
Question 68/162
Question #68
A 33-year-old man with Sjögren’s syndrome came to your clinic with polyuria and polydipsia for the
past week. His lab investigations demonstrate a serum fasting glucose of 70 mg/dL, serum calcium
of 9.1 mg/dL, serum sodium of 152 mEq/L, serum creatinine of 0.8 mg/dL and serum urea of 15
mmol/L. what is the best initial test to do for this patient?
a. Desmopressin challenge test

b. Water deprivation test √
c. Brain CT scan
d. Sweat chloride test
e. Schirmer’s test
Description
e history of Sjögren’s syndrome, polyurea, hypernatremia, hyperosmolality, and normal glucose

and calcium strongly suggest diabetes insipidus (DI).
e best initial test in this situation is water deprivation test.
e most accurate to dierentiate central vs. peripheral DI is desmopressin challenge test.
Note that sweat chloride test is used for cystic fibrosis while Schirmer’s test is used for the diagnosis
of Sjögren’s syndrome which is already diagnosed here.
Page - 485
Question 69/162
Question #69
A 45-year-old male patient complains of polyuria of about 5 liters per day. His urinalysis shows a
urine specific gravity of 1.001, absent RBC, absent WBC, normal glucose, and absent albumin. His
serum sodium is 146 mEq/L, and his serum potassium is 4 mEq/L. e water deprivation test results
in a urine specific gravity of 1.001 and serum sodium of 150 mEq/L. What is the most likely diagnosis?
a. Primary polydipsia
b. Diabetes insipidus
c. Syndrome of inappropriate ADH secretion
d. Chronic renal failure
Page - 486
Question 69/162
Question #69
serum sodium is 146 mEq/L, and his serum potassium is 4 mEq/L. e water deprivation test results
in a urine specific gravity of 1.001 and serum sodium of 150 mEq/L. What is the most likely diagnosis?
b. Diabetes insipidus √
Description
Polyuria, hyponatremia, and diluted urine that fails to concentrate aer the water deprivation test
strongly suggest diabetes insipidus.
Page - 487
Question 70/162
Question #70
serum sodium is 140 mEq/L, and his serum potassium is 4 mEq/L. Water deprivation test results in a
urine specific gravity of 1.025 and serum sodium of 142 mEq/L. What is the most likely diagnosis?
Page - 488
Question 70/162
Question #70
serum sodium is 140 mEq/L, and his serum potassium is 4 mEq/L. Water deprivation test results in a
urine specific gravity of 1.025 and serum sodium of 142 mEq/L. What is the most likely diagnosis?
a. Primary polydipsia √
Description
e elevation of specific gravity with water restriction indicates that there is no diabetes insipidus.
Primary polydipsia (psychogenic polydipsia) is the presence of high fluid intake leading to polyuria
and diluted urine that will concentrate with a water deprivation test.
Page - 489
Question 71/162
Question #71
A previously healthy 33-year-old male patient complains of polyuria and polydipsia for several days.
On examination, the patient is euvolemic and has no significant findings. His lab investigations
show serum calcium, potassium, glucose, and kidney function of normal limits. However, urinalysis
demonstrates low specific gravity and low urine osmolality. Which of the following is the most likely
deficient hormone in this patient?
a. Renin
b. Cortisol
c. Insulin
d. Arginine vasopressin
e. Growth hormone
Page - 490
Question 71/162
Question #71
A previously healthy 33-year-old male patient complains of polyuria and polydipsia for several days.
On examination, the patient is euvolemic and has no significant findings. His lab investigations
show serum calcium, potassium, glucose, and kidney function of normal limits. However, urinalysis
demonstrates low specific gravity and low urine osmolality. Which of the following is the most likely
deficient hormone in this patient?
a. Renin
b. Cortisol
c. Insulin
d. Arginine vasopressin √
e. Growth hormone
Description
Polyuria, low specific gravity, and low urine osmolality suggest diabetes insipidus
Page - 491
Question 72/162
Question #72
e following lipid-lowering agents are matched with the correct statement except:
a. Statin → the best to treat high LDL

b. Niacin → the best to rise HDL
c. Fibrates → the best to reduce Triglycerides
d. Cholestyramine → bile acid sequestrant
e. Ezetimibe → high mortality benefit
Page - 492
Internal Medicine - Endocrinology - Dyslipidemia
Question 72/162
Question #72
e following lipid-lowering agents are matched with the correct statement except:
a. Statin → the best to treat high LDL

b. Niacin → the best to rise HDL
c. Fibrates → the best to reduce Triglycerides
d. Cholestyramine → bile acid sequestrant
e. Ezetimibe → high mortality benefit √
Description
Ezetimibe (Cholesterol absorption inhibitor) Lowers LDL but with no mortality benefit
e drugs used in dyslipidemia are as the following:
Statins (HMG CO-A inhibitors)

e best treatment for a high LDL level
e lipid-lowering agent with the strongest mortality benefit
ey have an antioxidant eect on the endothelial lining
E.g., Atorvastatin, Simvastatin, Lovastatin, Rosuvastatin
Side eects: Myositis, hepatotoxicity, warfarin potentiation
Niacin:
Excellent drug to add the statin
Niacin is stronger than statin, exercise, and smoking cessation in raising HDL
Associated with Glucose intolerance, the elevation of uric acid, and itching
Fibrates (lipoprotein lipase stimulators)
E.g., Gemfibrozil, fenofibrate
Lower TG level more than statin
e combination with a statin increases the risk of Myositis
Cholestyramine:
Bile acid Sequestrant
Has significant interaction with other medications in the gut (decrease their absorption)
Side eects include constipation and Flatus.
Ezetimibe (Cholesterol absorption inhibitor)
Page - 493
Lowers LDL but with no benefit
Not better than placebo in the clinical endpoint
Protein Convertase Subtilisin Kexin type 9 (PCSK9) inhibitors
E.g., Evolocumab, Alirocumab
Injectable medication that can decrease LDL strongly
Used if the patient is not responsive or can’t tolerate statin
Page - 494
Question 73/162
Question #73
Which of the following is the most atherogenic?
a. High-density lipoprotein (HDL)

b. Very Low-density lipoprotein (VLDL)
c. Chylomicrons
d. Low-density lipoprotein (LDL)
e. Triglycerides
Page - 495
Question 73/162
Question #73
Which of the following is the most atherogenic?
a. High-density lipoprotein (HDL)

b. Very Low-density lipoprotein (VLDL)
c. Chylomicrons
d. Low-density lipoprotein (LDL) √
e. Triglycerides
Description
LDL is the leading cause of atherosclerosis

HDL is good lipoprotein and does not cause atherosclerosis
Page - 496
Question 74/162
Question #74
Regarding dyslipidemia, all of the following are true except:
a. LDL is the most atherogenic

b. HMG CO-A inhibitors are the best for the treatment of High LDL levels and have a mortality
benefit in CAD-equivalent patients
c. Niacin is more vital than statins, exercise, and smoking cessation to raise HDL
d. Fibrates are used in combination with statin and are better for lowering Triglycerides level
e. Eruptive xanthoma is a specific skin lesion for familial hypercholesterolemia.
Page - 497
Question 74/162
Question #74
Regarding dyslipidemia, all of the following are true except:
a. LDL is the most atherogenic

b. HMG CO-A inhibitors are the best for the treatment of High LDL levels and have a mortality
benefit in CAD-equivalent patients
c. Niacin is more vital than statins, exercise, and smoking cessation to raise HDL
d. Fibrates are used in combination with statin and are better for lowering Triglycerides level
e. Eruptive xanthoma is a specific skin lesion for familial hypercholesterolemia. √
Description
Eruptive xanthoma is a specific skin lesion for hypertriglyceridemia, not familial

hypercholesterolemia. In contrast, Tendinous xanthoma is typical for familial hypercholesterolemia.
Page - 498
Question 75/162
Question #75
A patient was found to have the following laboratory tests:
Serum calcium: 11.8 mg/dL
Serum PTH: 97 ng/L
Urine Ca:creatinine rato is low
a. Primary hyperparathyroidism
b. Secondary hyperparathyroidism
c. Familial hypocalciuric hypercalcemia (FHH)
d. Vitamin D excess
e. Pseudohypoparathyroidism
Page - 499
Internal Medicine - Endocrinology - Familial hypocalciuric hypercalcemia (FHH)
Question 75/162
Question #75
A patient was found to have the following laboratory tests:
Serum calcium: 11.8 mg/dL
Serum PTH: 97 ng/L
Urine Ca:creatinine rato is low
a. Primary hyperparathyroidism
b. Secondary hyperparathyroidism
c. Familial hypocalciuric hypercalcemia (FHH) √
d. Vitamin D excess
e. Pseudohypoparathyroidism
Description
High serum sodium, low urine sodium, and high parathyroid hormone are typical for two conditions:
FHH and primary hyperparathyroidism.
e main dierence between these two conditions is the urinary calcium:creatinine ratio which is
low in FHH and high in primary hyperparathyroidism.
e following table demonstrates the dierent lab investigations in the disorders of parathyroid
gland and calcium:
Page - 500
Page - 501
Question 76/162
Question #76
A patient is found to have elevated both calcium and parathyroid levels. However, he was previously
healthy and had no significant medical history of note. Which of the following is an indication of
parathyroid surgery?
a. Patients age of 60-year-old

b. Presence of renal stones
c. Serum calcium of 10.8 mg/dL
d. Increased bone density
e. Visible adenoma on neck CT scan
Page - 502
Internal Medicine - Endocrinology - Hypercalcemia
Question 76/162
Question #76
A patient is found to have elevated both calcium and parathyroid levels. However, he was previously
healthy and had no significant medical history of note. Which of the following is an indication of
parathyroid surgery?
a. Patients age of 60-year-old

b. Presence of renal stones √
c. Serum calcium of 10.8 mg/dL
d. Increased bone density
e. Visible adenoma on neck CT scan
Description
e indications for parathyroid surgery in primary hyperparathyroidism are:
e presence of kidney stones

Age less than 50-year-old
Serum calcium of 1 mg/dL (0.25 mmol/L) above the normal upper limit
Reduced bone density
Page - 503
Question 77/162
Question #77
A 40-year-old female patient is treated for metastatic lung cancer with chemotherapy.
Unfortunately, she develops polyuria and confusion and is found to have hypercalcemia. What is the
first-line treatment in this clinical scenario?
a. Start bisphosphonates
b. Change the chemotherapy regimen
c. Normal saline and diuretics
d. Normal saline alone
e. Dextrose 5% in water solution
Page - 504
Question 77/162
Question #77
A 40-year-old female patient is treated for metastatic lung cancer with chemotherapy.
Unfortunately, she develops polyuria and confusion and is found to have hypercalcemia. What is the
first-line treatment in this clinical scenario?
a. Start bisphosphonates
b. Change the chemotherapy regimen
c. Normal saline and diuretics
d. Normal saline alone √
e. Dextrose 5% in water solution
Description
Patients with hypercalcemia should initially receive normal saline intravenously, but you should be
aware not to exacerbate dehydration with diuretics.
Furosemide may be used in this case, but you should postpone its use until the patient is euvolemic
and out of dehydration
Treatment of hypercalcemia is as the following:
IV normal saline (first line)

Furosemide (Lasix) – use with caution because it may exacerbate dehydration
Calcitonin has a faster eect than Bisphosphonates
Bisphosphonates (inhibit bone resorption)
Surgical removal of the adenoma
Mithramycin (used to treatment of hypercalcemia in malignancy)
Steroids (treat hypercalcemia in sarcoidosis)
Page - 505
Question 78/162
Question #78
A 40-year-old female patient was referred to you because of hypercalcemia. Her medical history is
significant for chronic kidney disease. However, further investigations demonstrate a calcium level
of 2.8 mmol/L, PTH level of 79 ng/mL, Vitamin D of 70 nmol/L, and elevated urea and creatinine.
a. Multiple myeloma
b. Familial hypocalciuric hypercalcemia
c. Secondary hyperparathyroidism
d. Tertiary hyperparathyroidism
e. Hypervitaminosis D
Page - 506
Question 78/162
Question #78
A 40-year-old female patient was referred to you because of hypercalcemia. Her medical history is
significant for chronic kidney disease. However, further investigations demonstrate a calcium level
of 2.8 mmol/L, PTH level of 79 ng/mL, Vitamin D of 70 nmol/L, and elevated urea and creatinine.
a. Multiple myeloma
d. Tertiary hyperparathyroidism √
Description
Tertiary hyperparathyroidism develops in patients who have had secondary hyperparathyroidism

for a long time (typically due to CKD)
Page - 507
Question 79/162
Question #79
e main mechanism of hypercalcemia development in sarcoidosis patients is:
a. Reduced renal calcium excretion

b. Parathormone-related peptide secretion (PTHrP)
c. Osteoclastic activation
d. Vitamin D activation
e. Parathyroid hormone release
Page - 508
Question 79/162
Question #79
e main mechanism of hypercalcemia development in sarcoidosis patients is:
a. Reduced renal calcium excretion

b. Parathormone-related peptide secretion (PTHrP)
c. Osteoclastic activation
d. Vitamin D activation √
e. Parathyroid hormone release
Description
In sarcoidosis, the pathological granuloma contains macrophages that are responsible for
converting 25(OH)D3 to 1.25(OH)D3 (the active form), leading to hypercalcemia.
Page - 509
Question 80/162
Question #80
A 40-year-old female patient was referred to you because she was incidentally found to have
hypercalcemia. Her further investigations demonstrate a calcium level of 2.8 mmol/L, PTH level of 79
ng/mL, Vitamin D of 70 nmol/L, and normal urea and creatinine. What is the most likely diagnosis?
a. Multiple myeloma
Page - 510
Question 80/162
Question #80
A 40-year-old female patient was referred to you because she was incidentally found to have
hypercalcemia. Her further investigations demonstrate a calcium level of 2.8 mmol/L, PTH level of 79
ng/mL, Vitamin D of 70 nmol/L, and normal urea and creatinine. What is the most likely diagnosis?
a. Multiple myeloma
b. Familial hypocalciuric hypercalcemia √
Description
e correct answer is familial hypocalciuric hypercalcemia (FHH). e patient suers from

hypercalcemia and has a high PTH level. erefore, possible dierentials are primary
hyperparathyroidism, tertiary hyperparathyroidism, and familial hypocalciuric hypercalcemia.
Tertiary hyperparathyroidism develops in patients with secondary hyperparathyroidism for a long

time (typically due to CKD, which is absent here).
Primary hyperparathyroidism is not listed in the options above, so FHH is the most likely diagnosis.
Page - 511
Question 81/162
Question #81
A 60-year-old female with a history of breast cancer and bone metastasis complains of excessive
thirst, polyuria, nausea, vomiting, and confusion. Which of the following is the most likely
explanation?
a. Brain metastasis
b. Hypercalcemia
c. Hypocalcemia
d. Hypernatremia
e. SIADH
Page - 512
Question 81/162
Question #81
A 60-year-old female with a history of breast cancer and bone metastasis complains of excessive
thirst, polyuria, nausea, vomiting, and confusion. Which of the following is the most likely
explanation?
a. Brain metastasis
b. Hypercalcemia √
c. Hypocalcemia
d. Hypernatremia
e. SIADH
Description
Hypercalcemia is the most prevalent cancer-related paraneoplastic condition. Hypercalcemia

manifestations may develop when total blood calcium is more than 12 mg/dL (> 3 mmol/L).
Anorexia, GI regurgitation, vomiting, lethargy, convulsions, restlessness, hypertension, constipation,
dehydration, and feeding intolerance are known features of hypercalcemia
Page - 513
Question 82/162
Question #82
You consulted regarding a 46-year-old male patient admitted to the ICU for confusion and lethargy.
His lab investigations demonstrate a serum creatinine of 1.1 mg/dL, serum protein of 7.3 g/dL, serum
calcium of 3.2 mmol/L, and serum albumin of 4.2 g/L. What is the most appropriate treatment at
this time?

b. Furosemide intravenously
c. Bisphosphonates
d. Mithramycin
e. Steroids
Page - 514
Question 82/162
Question #82
You consulted regarding a 46-year-old male patient admitted to the ICU for confusion and lethargy.
His lab investigations demonstrate a serum creatinine of 1.1 mg/dL, serum protein of 7.3 g/dL, serum
calcium of 3.2 mmol/L, and serum albumin of 4.2 g/L. What is the most appropriate treatment at
this time?
a. Intravenous normal saline √

b. Furosemide intravenously
c. Bisphosphonates
d. Mithramycin
e. Steroids
Description

Page - 515
Question 83/162
Question #83
A 55-year-old male patient was found to have hypercalcemia on routine investigations. Additional
tests demonstrate elevated alkaline phosphatase and hypophosphatemia. Which of the following is
a. Hypervitaminosis D
b. Parathyroid adenoma
c. Excessive calcium intake
d. Multiple myeloma
e. Sarcoidosis
Page - 516
Question 83/162
Question #83
A 55-year-old male patient was found to have hypercalcemia on routine investigations. Additional
tests demonstrate elevated alkaline phosphatase and hypophosphatemia. Which of the following is
a. Hypervitaminosis D
b. Parathyroid adenoma √
c. Excessive calcium intake
d. Multiple myeloma
e. Sarcoidosis
Description
is is most likely due to primary hyperparathyroidism.
e high PTH level will cause high bone turnover leading to hypercalcemia and elevated alkaline
phosphatase levels. However, hypophosphatemia may present.
Parathyroid hormone (PTH) causes phosphate loss through the kidneys.
Vitamin D promotes calcium and phosphorus absorption in the gastrointestinal tract; hence high
levels are linked to raised calcium and phosphorus levels
Sarcoidosis enhances calcium absorption by activating vitamin D, so the same situation as vitamin D
excess will result.
Multiple myeloma is associated with normal alkaline phosphatase levels.
Page - 517
Question 84/162
Question #84
A 70-year-old male patient with lung cancer presents with excessive urination and lower back pain.
His ECG demonstrates a short QT interval. What is the best next step in management?
a. Spinal MRI
b. PET scan
c. DEXA scan
d. Alkaline phosphatase level
e. Serum calcium level
Page - 518
Question 84/162
Question #84
A 70-year-old male patient with lung cancer presents with excessive urination and lower back pain.
His ECG demonstrates a short QT interval. What is the best next step in management?
a. Spinal MRI
b. PET scan
c. DEXA scan
d. Alkaline phosphatase level
e. Serum calcium level √
Description
e presence of polyuria and short QT interval in a cancer patient strongly suggests hypercalcemia
Serum calcium level is the best initial investigation.
Page - 519
Question 85/162
Question #85
A patient complains of primary hyperparathyroidism. Which of the following is the most common
case?
a. Lithium therapy
b. Parathyroid hyperplasia
c. MEN type 1
d. Parathyroid adenoma
e. Pituitary adenoma
Page - 520
Question 85/162
Question #85
A patient complains of primary hyperparathyroidism. Which of the following is the most common
case?
a. Lithium therapy
b. Parathyroid hyperplasia
c. MEN type 1
d. Parathyroid adenoma √
e. Pituitary adenoma
Description
In 85 % of instances, a solitary parathyroid gland adenoma is the cause of primary

hyperparathyroidism. Multiple adenomas and enlargement of all four glands are also common
causes. Multiple endocrine neoplasia and cancer are uncommon. Hyperparathyroidism can be
caused by lithium medication; however, this is not considered primary hyperparathyroidism.
Pituitary adenoma has no relation to hyperparathyroidism.
Page - 521
Question 86/162
Question #86
A 55-year-old female presents with flank pain, and her ultrasound demonstrates a 4 mm ureteral
stone. In addition, she has a serum calcium level of 3.1 mmol/L. e patient is not taking any
medication and has a free medical history. What is the most appropriate investigation at this time?
a. Urinary calcium level

b. Repeat serum calcium in 4 weeks
c. Serum vitamin D level
d. Serum calcitonin level
e. Serum PTH level
Page - 522
Question 86/162
Question #86
A 55-year-old female presents with flank pain, and her ultrasound demonstrates a 4 mm ureteral
stone. In addition, she has a serum calcium level of 3.1 mmol/L. e patient is not taking any
medication and has a free medical history. What is the most appropriate investigation at this time?
a. Urinary calcium level

b. Repeat serum calcium in 4 weeks
c. Serum vitamin D level
d. Serum calcitonin level
e. Serum PTH level √
Description
Primary hyperparathyroidism and malignancy account for 90% of the cases of hypercalcemia.
e best initial step here is to check for PTH level
Elevated PTH level indicates primary hyperparathyroidism.
Vitamin D is necessary if the serum PTH is low
Serum calcitonin level is not indicated in this scenario
Repeating serum calcium in 4 weeks without action is inappropriate because the patient has
symptomatic severe hypercalcemia.
Page - 523
Question 87/162
Question #87
A patient develops hypercalcemia, and you suspect a medication side eect. Which of the following
is the most likely cause?
d. Amlodipine
e. Valsartan
a. Furosemide
b. Allopurinol
c. Hydrochlorothiazide
Page - 524
Question 87/162
Question #87
A patient develops hypercalcemia, and you suspect a medication side eect. Which of the following
is the most likely cause?
d. Amlodipine
e. Valsartan
a. Furosemide
b. Allopurinol
c. Hydrochlorothiazide √
Description
iazides reduce calcium clearance in the kidneys by increasing calcium reabsorption in the distal
tubule.
Furosemide is a diuretic that lowers blood calcium levels and is used to treat hypercalcemia.
Page - 525
Question 88/162
Question #88
A 50-year-old male patient complains of thirst and polyuria. His lab investigations demonstrate
hypercalcemia. However, his medical records are significant for recurrent calcium oxalate stones.
What is the most appropriate at this time?
a. Repeat serum calcium in 1 month

b. Skeletal survey
c. Brain CT scan
d. Parathyroid hormone level
e. yroid function test
Page - 526
Question 88/162
Question #88
A 50-year-old male patient complains of thirst and polyuria. His lab investigations demonstrate
hypercalcemia. However, his medical records are significant for recurrent calcium oxalate stones.
What is the most appropriate at this time?
a. Repeat serum calcium in 1 month

b. Skeletal survey
c. Brain CT scan
d. Parathyroid hormone level √
e. yroid function test
Description
Primary hyperparathyroidism and malignancy account for 90% of the cases of hypercalcemia.
e best initial step here is to check for PTH level
Elevated PTH level indicates primary hyperparathyroidism.
Repeating serum calcium in 1 month without action is inappropriate because the patient has
symptomatic hypercalcemia.
Page - 527
Question 89/162
Question #89
A 60-year-old male patient who takes multiple medications presents to your oce for a routine
check-up. His lab investigations were unremarkable except for serum calcium of 2.8 mmol/L and
PTH level of 82 pg/mL. What is the most likely cause of his condition?
a. Lithium use
b. Furosemide use
c. Calcium carbonate use
d. Vitamin D excess
Page - 528
Question 89/162
Question #89
A 60-year-old male patient who takes multiple medications presents to your oce for a routine
check-up. His lab investigations were unremarkable except for serum calcium of 2.8 mmol/L and
PTH level of 82 pg/mL. What is the most likely cause of his condition?
a. Lithium use √
b. Furosemide use
c. Calcium carbonate use
d. Vitamin D excess
Description
is patient complains of high PTH and calcium levels which is most likely due to Lithium usage
Lithium increases serum calcium by enhancing PTH secretion.
Furosemide is known to cause hypocalcemia and is used to treat hypercalcemia
Calcium carbonate, vitamin D, and thiazides increase the serum calcium leading to secondary
hypoparathyroidism (high calcium has negative feedback and reduces the PTH)
Page - 529
Question 90/162
Question #90
e initial treatment of hypercalcemia in malignancy should be which of the following?
a. Calcium gluconate
b. Magnesium sulfate
c. Mithramycin
d. Aggressive hydration
e. Furosemide
Page - 530
Question 90/162
Question #90
e initial treatment of hypercalcemia in malignancy should be which of the following?
b. Magnesium sulfate
c. Mithramycin
d. Aggressive hydration √
e. Furosemide
Description

Page - 531
Question 91/162
Question #91
A 55-year-old male patient is known to have multiple myeloma. He presents with confusion and
polyuria. What is the most likely electrolyte abnormality in his condition?
a. Hypocalcemia
b. Hypercalcemia
c. Hyperkalemia
d. Hypernatremia
e. Hyponatremia
Page - 532
Question 91/162
Question #91
A 55-year-old male patient is known to have multiple myeloma. He presents with confusion and
polyuria. What is the most likely electrolyte abnormality in his condition?
a. Hypocalcemia
c. Hyperkalemia
d. Hypernatremia
e. Hyponatremia
Description
Osteoclastic activation is the main mechanism of hypercalcemia in multiple myeloma patients.
is patient complains of polyuria and confusion mostly secondary to hypercalcemia, and he should
receive normal saline initially
Page - 533
Question 92/162
Question #92
A 40-year-old female complains of unexplained milk expression in her nipples. Her last menstrual
period was 9 months ago, and she complains of reduced sexual drive. What is the most likely
diagnosis?
a. Hyperaldosteronism
b. Pheochromocytoma
c. Hypercortisolism
d. Hyperprolactinemia
Page - 534
Internal Medicine - Endocrinology - Hyperprolactinemia
Question 92/162
Question #92
A 40-year-old female complains of unexplained milk expression in her nipples. Her last menstrual
period was 9 months ago, and she complains of reduced sexual drive. What is the most likely
diagnosis?
a. Hyperaldosteronism
b. Pheochromocytoma
c. Hypercortisolism
d. Hyperprolactinemia √
Description
Hyperprolactinemia is an Increased level of PRL hormone.
Prolactin’s function is to stimulate the production of milk by breasts.
Prolactin is physiologically stimulated by stress, lactation, and nipple stimulation and suppressed by
dopamine and dopamine agonists.
Infertility, galactorrhea, amenorrhea, or sometimes heavy menstruation are typical features of this
condition.
Pregnancy should be ruled out if any female patient presents with amenorrhea, galactorrhea, or
both.
Plasma PRL level is the best initial test to perform if hyperprolactinemia is suspected
TFT, KFT, and LFT are used to estimate the cause, while pituitary imaging is only used to localize
pituitary adenoma if diagnosed.
Page - 535
e majority of patients are treated medically with dopamine agonists (cabergoline, bromocriptine)
Transsphenoidal surgical adenoma removal should be done for those who cannot tolerate or failed
medical treatment.
Page - 536
Question 93/162
Question #93
A 20-year-old female develops secondary amenorrhea and milky nipple discharge. Her pregnancy
test is negative. What is the best initial investigation at this time?
a. Serum ADH level

b. Serum ACTH level
c. Growth hormone suppression test
d. Serum prolactin level
e. Pituitary MRI
Page - 537
Question 93/162
Question #93
A 20-year-old female develops secondary amenorrhea and milky nipple discharge. Her pregnancy
test is negative. What is the best initial investigation at this time?
a. Serum ADH level

b. Serum ACTH level
c. Growth hormone suppression test
d. Serum prolactin level √
e. Pituitary MRI
Description
condition.
both.
medical treatment.
Page - 538
Question 94/162
Question #94
A 32-year-old female patient complains of infertility, galactorrhea, and visual field defect. Her
medical history is significant for ESRD, hepatitis C, and hypothyroidism. However, her lab
investigations demonstrate high levels of prolactin hormone. Which of the following is the most
likely diagnosis?
a. Primary hypothyroidism
b. Pituitary adenoma
c. Renal impairment
d. Liver disease
e. Oral contraceptive pills use
Page - 539
Question 94/162
Question #94
A 32-year-old female patient complains of infertility, galactorrhea, and visual field defect. Her
medical history is significant for ESRD, hepatitis C, and hypothyroidism. However, her lab
investigations demonstrate high levels of prolactin hormone. Which of the following is the most
likely diagnosis?
a. Primary hypothyroidism
b. Pituitary adenoma √
c. Renal impairment
d. Liver disease
e. Oral contraceptive pills use
Description
e most common cause is adenoma (called prolactinoma)
Other causes include:
Primary hypothyroidism (high TRH will stimulate PRL secretion)

Pregnancy (high level but opposed by estrogen)
Chronic renal failure, liver cirrhosis
PCOS
Drugs (OCP, estrogen, TCA, Haldol, metoclopramide, dopamine antagonists, verapamil)
While other choices are still possible, the presence of a visual field defect in this patient suggests
prolactinoma as the most likely diagnosis.
Page - 540
condition.
both.
medical treatment.
Page - 541
Question 95/162
Question #95
A 40-year-old female was treated with cabergoline for prolactinoma for the past year, but she still
has no response. Recently she developed a visual field defect and complained of reduced libido.
What is the most appropriate treatment at this time?
a. Bromocriptine
b. Transsphenoidal surgical resection
c. Radiotherapy
d. Chemotherapy
e. Continue cabergoline
Page - 542
Question 95/162
Question #95
A 40-year-old female was treated with cabergoline for prolactinoma for the past year, but she still
has no response. Recently she developed a visual field defect and complained of reduced libido.
What is the most appropriate treatment at this time?
a. Bromocriptine
b. Transsphenoidal surgical resection √
c. Radiotherapy
d. Chemotherapy
e. Continue cabergoline
Description
medical treatment.
condition.
both.
Page - 543
Page - 544
Question 96/162
Question #96
A 30-year-old female presents with amenorrhea and galactorrhea. Her pituitary MRI shows a 1 cm
mass. What is the most appropriate management?
a. Cabergoline
c. Chemotherapy
d. Radiotherapy
e. Reassurance
Page - 545
Question 96/162
Question #96
A 30-year-old female presents with amenorrhea and galactorrhea. Her pituitary MRI shows a 1 cm
mass. What is the most appropriate management?
a. Cabergoline √
c. Chemotherapy
d. Radiotherapy
e. Reassurance
Description
condition.
both.
medical treatment.
Page - 546
Question 97/162
Question #97
A lady with Grave’s disease is seeking treatment for her condition. Which of the following has been
found to aggravate ophthalmopathy?
a. Propylthiouracil
b. Methimazole
c. Radioactive iodine ablation
d. yroidectomy
e. Propranolol
Page - 547
Internal Medicine - Endocrinology - Hyperthyroidism
Question 97/162
Question #97
A lady with Grave’s disease is seeking treatment for her condition. Which of the following has been
found to aggravate ophthalmopathy?
a. Propylthiouracil
b. Methimazole
c. Radioactive iodine ablation √
d. yroidectomy
e. Propranolol
Description
When treated with radioactive iodine, Graves’ disease ophthalmopathy may flare up and worsen
initially.
Other mentioned treatments are not associated with this problem.
Page - 548
Question 98/162
Question #98
A young lady has high T4, suppressed TSH, and positive thyroid-stimulating antibodies. What is the
a. Toxic multinodular goiter

b. Hashimoto’s thyroiditis
c. Grave’s disease
d. Subacute thyroiditis
e. yroid cancer
Page - 549
Question 98/162
Question #98
A young lady has high T4, suppressed TSH, and positive thyroid-stimulating antibodies. What is the
a. Toxic multinodular goiter

b. Hashimoto’s thyroiditis
c. Grave’s disease √
e. yroid cancer
Description
Grave’s disease is an autoimmune condition resulting from thyroid-stimulating antibodies.
ese antibodies will stimulate the thyroid gland via the TSH receptors leading to increased
thyroxine production and thyrotoxicosis with eye signs and pretibial myxedema.
e thyroid gland may diusely be enlarged, and there is a diuse increased radioactive iodine
uptake.
Lab investigations will show suppressed TSH, high T3 and T4, and positive thyroid-stimulating
antibodies.
Page - 550
Question 99/162
Question #99
A patient with thyrotoxicosis has her radioactive iodine uptake results, and it was reduced. Which of
the following is the most likely diagnosis?
a. Grave’s disease
b. Multinodular goiter
c. Solitary toxic thyroid nodule
e. None of the above
Page - 551
Question 99/162
Question #99
A patient with thyrotoxicosis has her radioactive iodine uptake results, and it was reduced. Which of
the following is the most likely diagnosis?
b. Multinodular goiter
c. Solitary toxic thyroid nodule
d. Subacute thyroiditis √
Description
Radioactive iodine uptake is elevated in Graves’ disease, multinodular goiter, and autonomously
functioning solitary thyroid nodule. In addition, it will be low in subacute thyroiditis, silent
thyroiditis, and exogenous thyroxine use.
e destructed cells in subacute thyroiditis will not be able to uptake iodine.
Subacute thyroiditis is mostly due to viral infection of the thyroid gland leading to cell destruction
and release of the preformed thyroxine and features of thyrotoxicosis initially, which will be later
transformed into hypothyroidism.
Page - 552
Question 100/162
Question #100
A 33-year-old female patient presents with double vision when looking upward and painful eye
movement. On examination, the patient has lid lag, a noticeable welling of her eyelids, and
tachycardia. What are the most appropriate investigations to perform?
a. yroid function test

b. Liver function test
c. Brain MRI
d. Fundoscopic examination
e. Autoantibodies test
Page - 553
Question 100/162
Question #100
A 33-year-old female patient presents with double vision when looking upward and painful eye
movement. On examination, the patient has lid lag, a noticeable welling of her eyelids, and
tachycardia. What are the most appropriate investigations to perform?
a. yroid function test √

b. Liver function test
c. Brain MRI
d. Fundoscopic examination
e. Autoantibodies test
Description
is patient is most likely suering from Graves disease.
yroid function test showing suppressed TSH and high T3 and T4 is characteristic
e presence of thyroid-stimulating antibodies is specific for this condition.
Page - 554
Question 101/162
Question #101
A 25-year-old female patient presents with chronic diarrhea and palpitation. Her lab investigations
demonstrate high T4 and very low TSH. What is the most eective treatment for relieving
symptoms?
a. Propranolol
b. Verapamil
c. Diltiazem
d. Terazosin
e. yroxin
Page - 555
Question 101/162
Question #101
A 25-year-old female patient presents with chronic diarrhea and palpitation. Her lab investigations
demonstrate high T4 and very low TSH. What is the most eective treatment for relieving
symptoms?
a. Propranolol √
b. Verapamil
c. Diltiazem
d. Terazosin
e. yroxin
Description
is patient suers from thyrotoxicosis (high T4 and low TSH)
Propranolol is important in preventing cardiovascular complications of hypothyroidism.
Propranolol will act as an antiarrhythmic agent to prevent the conversion of T4 to the active T3; it
will prevent tachycardia and has a role in treating thyroid storm.
Page - 556
Question 102/162
Question #102
A 32-year-old female complains of palpitations, tachycardia, restlessness, tremor, and weight loss.
Her physical examination is remarkable for lid lag and pretibial myxedema. In addition, her
investigations demonstrate undetectable TSH and increased radioactive iodine uptake. What is the
a. Hashimoto’s thyroiditis
b. Grave’s disease
c. Multinodular goiter
e. Pheochromocytoma
Page - 557
Question 102/162
Question #102
investigations demonstrate undetectable TSH and increased radioactive iodine uptake. What is the
b. Grave’s disease √
c. Multinodular goiter
e. Pheochromocytoma
Description
e typical clinical features of thyrotoxicosis and the presence of eye signs and pretibial myxedema
strongly suggest Grave’s disease
Undetectable TSH indicates negative feedback from the very high thyroxine level.
Diusely increased iodine uptake is typical for Grave’s disease as well.
Page - 558
Question 103/162
Question #103
investigations demonstrate undetectable TSH and increased radioactive iodine uptake. e most
specific test to make the expected diagnosis is:
a. Free T3 level.
b. Free T4 level.
c. Serum TSH level.
d. Serum yroid Stimulating Immunoglobulin.
e. Serum Total T4 level.
Page - 559
Question 103/162
Question #103
investigations demonstrate undetectable TSH and increased radioactive iodine uptake. e most
specific test to make the expected diagnosis is:
a. Free T3 level.
b. Free T4 level.
c. Serum TSH level.
d. Serum yroid Stimulating Immunoglobulin. √
e. Serum Total T4 level.
Description
Grave’s disease is the most likely diagnosis because of the clinical features of thyrotoxicosis,
undetectable TSH, and eye signs.
yroid-stimulating antibodies are the most specific in this scenario.
Page - 560
Question 104/162
Question #104
A 29-year-old female patient complains of heat intolerance, tachycardia, tremor, and nervousness.
Despite a good appetite, she loses weight. What are the most likely lab results to present in her
condition?
a. Reduced TSH and high T4

b. Reduced TSH and normal T4
c. High TSH and normal T4
d. High TSH and low T4
e. Normal TSH and normal T4
Page - 561
Question 104/162
Question #104
A 29-year-old female patient complains of heat intolerance, tachycardia, tremor, and nervousness.
Despite a good appetite, she loses weight. What are the most likely lab results to present in her
condition?
a. Reduced TSH and high T4 √

b. Reduced TSH and normal T4
d. High TSH and low T4
e. Normal TSH and normal T4
Description
Description:
is patient is most likely suering from thyrotoxicosis, mostly primary hyperthyroidism.
Primary hyperthyroidism manifested as high T4 and suppressed TSH.
e following table demonstrates the lab findings of dierent thyroid diseases:
Page - 562
Question 105/162
Question #105
A 35-year-old female presents with a neck mass, weight loss, increased appetite, tachycardia, and
chronic diarrhea. Physical examination demonstrates exophthalmos, lid retraction, lid lag, and
pretibial myxedema. What is the most likely finding in the neck ultrasound of this patient?
a. yroid cyst
b. yroid mass
c. Diuse thyroid enlargement
d. Lymph node enlargement
e. Normal thyroid gland
Page - 563
Question 105/162
Question #105
A 35-year-old female presents with a neck mass, weight loss, increased appetite, tachycardia, and
chronic diarrhea. Physical examination demonstrates exophthalmos, lid retraction, lid lag, and
pretibial myxedema. What is the most likely finding in the neck ultrasound of this patient?
a. yroid cyst
b. yroid mass
c. Diuse thyroid enlargement √
d. Lymph node enlargement
e. Normal thyroid gland
Description
is is a case of Grave’s disease, and It is associated with diuse homogenous thyroid enlargement
Grave’s disease is an autoimmune condition resulting from thyroid-stimulating antibodies.
ese antibodies will stimulate the thyroid gland via the TSH receptors leading to increased
thyroxine production and thyrotoxicosis with eye signs and pretibial myxedema.
e thyroid gland may diusely be enlarged, and there is a diuse increased radioactive iodine
uptake.
Lab investigations will show suppressed TSH, high T3 and T4, and positive thyroid-stimulating
antibodies.
Page - 564
Question 106/162
Question #106
A 30-year-old lady presents with palpitation and atrial fibrillation. Her medical history is
unremarkable, but she has complained of heat intolerance and weight loss for the past month. Her
lab investigations demonstrate high free T4, suppressed TSH, and low thyroglobulin levels. What is
a. Primary hyperthyroidism
b. Hypothyroidism
c. Secondary hyperthyroidism
d. Factitious disorder
e. Subacute thyroiditis
Page - 565
Question 106/162
Question #106
A 30-year-old lady presents with palpitation and atrial fibrillation. Her medical history is
unremarkable, but she has complained of heat intolerance and weight loss for the past month. Her
lab investigations demonstrate high free T4, suppressed TSH, and low thyroglobulin levels. What is
b. Hypothyroidism
c. Secondary hyperthyroidism
d. Factitious disorder √
e. Subacute thyroiditis
Description
e laboratory values in this patient show hyperthyroidism, but the presence of low thyroglobulin
strongly suggests that the patient is taking a high dose of exogenous thyroxine.
A low yroglobulin level is useful in patients with thyrotoxicosis caused by the surreptitious use of
thyroid hormone.
Page - 566
Question 107/162
Question #107
A 30-year-old female complains of tremors, tachycardia, weight loss, increased appetite, and heat
intolerance. Which of the following is the main mechanism of these symptoms?
a. Reduced thyroid hormone level

b. Increased calcitonin level
c. Increased metabolic rate
d. Increased insulin resistance
e. Reduced caloric intake
Page - 567
Question 107/162
Question #107
A 30-year-old female complains of tremors, tachycardia, weight loss, increased appetite, and heat
intolerance. Which of the following is the main mechanism of these symptoms?
a. Reduced thyroid hormone level

b. Increased calcitonin level
c. Increased metabolic rate √
d. Increased insulin resistance
e. Reduced caloric intake
Description
is patient complains of features of thyrotoxicosis.
Hyperthyroidism is an increased thyroid gland activity, leading to excessive thyroid hormone,

resulting in a high metabolic rate.
A high metabolic rate is the main mechanism of action to cause these symptoms.
Page - 568
Question 108/162
Question #108
A 33-year-old female patient is receiving methimazole for Graves disease treatment. She started on
this drug 1 month ago and presents now for a follow-up. Which of the following is the most
appropriate indicator of her response to treatment?
a. TSH level
b. Free T4 level
c. Free T3 level
d. Total T4 level
e. Total T3 level
Page - 569
Question 108/162
Question #108
A 33-year-old female patient is receiving methimazole for Graves disease treatment. She started on
this drug 1 month ago and presents now for a follow-up. Which of the following is the most
appropriate indicator of her response to treatment?
a. TSH level
b. Free T4 level √
c. Free T3 level
d. Total T4 level
e. Total T3 level
Description
Free T4 has the highest sensitivity to the activity of the thyroid gland.
It is the best indicator and the test of choice for titration doses of anti-thyroid medications.
TSH is an insensitive index of treatment response because it remains suppressed by thyroid

hormones for several months.
Note that TSH is the most sensitive in diagnosing hyperthyroidism but not the most sensitive in
following up the anti-thyroid doses.
Page - 570
Question 109/162
Question #109
A 30-year-old female patient presents to the endocrine clinic with a history of thyrotoxicosis. Her
last menstrual period was 4 weeks ago, and her pregnancy test was discovered to be positive
yesterday. Which of the following is the most appropriate treatment option for her condition at this
time?
a. Carbimazole alone
b. Propylthiouracil alone
d. yroidectomy
e. Propranolol alone
Page - 571
Question 109/162
Question #109
A 30-year-old female patient presents to the endocrine clinic with a history of thyrotoxicosis. Her
last menstrual period was 4 weeks ago, and her pregnancy test was discovered to be positive
yesterday. Which of the following is the most appropriate treatment option for her condition at this
time?
a. Carbimazole alone
b. Propylthiouracil alone √
d. yroidectomy
e. Propranolol alone
Description
Because of its lower teratogenic profile, propylthiouracil (PTU) is the drug of choice in thyrotoxicosis
in women in their first trimester. In addition, because of its ecacy, it is the drug of choice in thyroid
storm.
Carbimazole is used in pregnancy aer the first trimester and in non-pregnant women because it is
eective and less hepatotoxic than PTU.
Propranolol alone will control symptoms, but it should not be used without anti-thyroid therapy.
yroidectomy is rarely performed in pregnancy, it is reserved for patients not responding to anti-
thyroid medication, but if necessary, it is preferable in the second trimester
Page - 572
Question 110/162
Question #110
A patient complains of hyperthyroidism, and you suspect a drug-induced etiology. Which of the
following is the most likely cause?
a. Propranolol
b. Verapamil
c. Propylthiouracil
d. Amiodarone
e. Methimazole
Page - 573
Question 110/162
Question #110
A patient complains of hyperthyroidism, and you suspect a drug-induced etiology. Which of the
following is the most likely cause?
a. Propranolol
b. Verapamil
c. Propylthiouracil
d. Amiodarone √
e. Methimazole
Description
Amiodarone is a drug used in treating and preventing arrhythmias. Amiodarone is 37% iodine; it is
known to cause either hypothyroidism or hyperthyroidism
Around 1 in 6 patients taking amiodarone to develop thyroid dysfunction
Propranolol, PTU, and methimazole are used to treat hyperthyroidism
Page - 574
Question 111/162
Question #111
A 33-year-old female patient was diagnosed with Grave’s disease and is at your oce today to
discuss radioactive iodine therapy. is therapy increases the risk of which of the following?
a. Hyperthyroidism
b. Hypothyroidism
c. yroid cancer
e. Bleeding
Page - 575
Question 111/162
Question #111
A 33-year-old female patient was diagnosed with Grave’s disease and is at your oce today to
discuss radioactive iodine therapy. is therapy increases the risk of which of the following?
a. Hyperthyroidism
b. Hypothyroidism √
c. yroid cancer
e. Bleeding
Description
Radioactive iodine ablation is a method to treat hyperthyroidism without exposing the patient to
surgical complications. However, hypothyroidism is the main complication of this therapy; it aects
up to 70% of patients in 10 years.
Patients may need thyroxine replacement aer radioactive iodine ablation.
Page - 576
Question 112/162
Question #112
A 33-year-old female patient complains of hyperactivity, irritability, insomnia, heat intolerance,

sweating, and palpitations. In addition, she has a neck mass that is mobile with swallowing. Which
of the following is the most likely diagnosis?
a. Lymphoma
b. yroglossal cyst
c. yroid cyst
d. Toxic nodular goiter
e. yroid cancer
Page - 577
Question 112/162
Question #112
A 33-year-old female patient complains of hyperactivity, irritability, insomnia, heat intolerance,

sweating, and palpitations. In addition, she has a neck mass that is mobile with swallowing. Which
a. Lymphoma
b. yroglossal cyst
c. yroid cyst
d. Toxic nodular goiter √
e. yroid cancer
Description
is patient complains of thyrotoxicosis symptoms, and she has a thyroid mass.
is mass is likely a goiter rather than a cancer or cyst because it is functioning and has no features
suggestive of malignancy.
Page - 578
Question 113/162
Question #113
A 38-year-old female patient underwent thyroidectomy for thyroid cancer a week ago. She presents
with spasms, numbness, and paresthesia. What is the most likely diagnosis?
a. yroid storm
b. Hyperparathyroidism
c. Hypothyroidism
d. Hypocalcemia
e. Hypokalemia
Page - 579
Internal Medicine - Endocrinology - Hypocalcemia
Question 113/162
Question #113
A 38-year-old female patient underwent thyroidectomy for thyroid cancer a week ago. She presents
with spasms, numbness, and paresthesia. What is the most likely diagnosis?
a. yroid storm
b. Hyperparathyroidism
c. Hypothyroidism
d. Hypocalcemia √
e. Hypokalemia
Description
Primary hypothyroidism and hypocalcemia are among the most common complications of thyroid
gland surgeries.
Disruption or removal of parathyroid glands will reduce PTH production and primary
hypoparathyroidism.
Page - 580
Question 114/162
Question #114
A 55-year-old male patient with a long history of T2DM presents with a tingling sensation around his
mouth and a muscle twitching. His symptoms have been worsening recently. What is the most likely
biochemical finding in this patient?
a. Hyponatremia
b. Hypernatremia
c. Hypercalcemia
d. Hypocalcemia
e. Hypokalemia
Page - 581
Internal Medicine - Endocrinology - Hypocalcemia
Question 114/162
Question #114
A 55-year-old male patient with a long history of T2DM presents with a tingling sensation around his
mouth and a muscle twitching. His symptoms have been worsening recently. What is the most likely
biochemical finding in this patient?
a. Hyponatremia
b. Hypernatremia
c. Hypercalcemia
d. Hypocalcemia √
e. Hypokalemia
Description
Tingling sensation around the mouth (perioral paresthesia) and muscle twitching are typical
straightforward indicators of hypocalcemia.
e history of DM is also related to hypocalcemia; it is mostly associated with a degree of renal

impairment that leads to hypocalcemia.
Page - 582
Question 115/162
Question #115
A previously healthy 55-year-old female has her lab tests for a routine check-up. Her TSH level is 12
μU/mL, and her T4 was normal. What is the most likely diagnosis?
a. Normal readings
b. Primary Hypothyroidism
c. Primary Hyperthyroidism
d. Subclinical hypothyroidism
e. Central hyperthyroidism
Page - 583
Internal Medicine - Endocrinology - Hypothyroidism
Question 115/162
Question #115
A previously healthy 55-year-old female has her lab tests for a routine check-up. Her TSH level is 12
μU/mL, and her T4 was normal. What is the most likely diagnosis?
a. Normal readings
b. Primary Hypothyroidism
c. Primary Hyperthyroidism
d. Subclinical hypothyroidism √
e. Central hyperthyroidism
Description
In a patient not known to have hypothyroidism and not treated with thyroxine, high TSH and
normal T4 indicate subclinical hypothyroidism. In this condition, there are no symptoms of
hypothyroidism.
Page - 584
Question 116/162
Question #116
A 27-year-old female with bipolar disorder presents with cold intolerance, general weakness, and
decreased appetite. What is the most appropriate investigation at this time?
a. Complete blood count

b. C-Reactive protein
c. Free T3 level
d. Lithium level
e. Serum TSH level
Page - 585
Question 116/162
Question #116
A 27-year-old female with bipolar disorder presents with cold intolerance, general weakness, and
decreased appetite. What is the most appropriate investigation at this time?

b. C-Reactive protein
c. Free T3 level
d. Lithium level
e. Serum TSH level √
Description
Lithium is a mood stabilizer used to treat bipolar disorder and is known to cause hypothyroidism.
e patient complains of typical features of hypothyroidism, so you better start with serum TSH
level.
TSH level is the most appropriate, accurate, and cost-eective screening test for thyroid diseases.
Page - 586
Question 117/162
Question #117
A 55-year-old female presents for routine investigations. Which of the following is the most
appropriate screening test for thyroid diseases?
a. Free T3
b. Free T4
c. Serum TSH level
d. Serum TRH level
e. yroglobulin level
Page - 587
Question 117/162
Question #117
A 55-year-old female presents for routine investigations. Which of the following is the most
appropriate screening test for thyroid diseases?
a. Free T3
b. Free T4
c. Serum TSH level √
d. Serum TRH level
e. yroglobulin level
Description
Periodic screening for thyroid diseases by performing TSH level is indicated in all female patients
who are 50-year-old or older.
TSH level is the most appropriate, accurate, and cost-eective screening test for thyroid diseases.
Page - 588
Question 118/162
Question #118
A 50-year-old female with a history of Sheehan’s syndrome is on levothyroxine replacement therapy

due to secondary hypothyroidism. She was at a GP clinic, and the doctor referred her to you because
he found her TSH level of 0.05 mIU/mL. What is the most appropriate action at this time?
a. Reduce the dose of thyroxine

b. Increase the dose of thyroxine
c. Repeat TSH aer 6 weeks
d. Order free T4 level
e. Order thyroglobulin level
Page - 589
Question 118/162
Question #118
A 50-year-old female with a history of Sheehan’s syndrome is on levothyroxine replacement therapy

due to secondary hypothyroidism. She was at a GP clinic, and the doctor referred her to you because
he found her TSH level of 0.05 mIU/mL. What is the most appropriate action at this time?
a. Reduce the dose of thyroxine

b. Increase the dose of thyroxine
c. Repeat TSH aer 6 weeks
d. Order free T4 level √
e. Order thyroglobulin level
Description
In this scenario, the TSH level will not be a reliable indicator for hypothyroidism because of the
pituitary gland infarction; TSH will be low even if the thyroxine therapy is adequate, insucient, or
more than required.
e best indicator in this scenario is the free T4 level.
Page - 590
Question 119/162
Question #119
A 52-year-old female patient complains of general weakness and low energy for the past 3 months.
On examination, delayed tendon reflexes, bradycardia, and cold, dry extremities are noted. Her labs
show high TSH and low free T4. What is the most likely agent to cause her symptoms?
a. Estrogen replacement therapy

b. Lithium
c. Valsartan
d. Metformin
e. Erythromycin
Page - 591
Question 119/162
Question #119
A 52-year-old female patient complains of general weakness and low energy for the past 3 months.
On examination, delayed tendon reflexes, bradycardia, and cold, dry extremities are noted. Her labs
show high TSH and low free T4. What is the most likely agent to cause her symptoms?
a. Estrogen replacement therapy

b. Lithium √
c. Valsartan
d. Metformin
e. Erythromycin
Description
High TSH, low free T4, and the clinical scenario in this patient are secondary to hypothyroidism.
Lithium is a mode stabilizer used in Bipolar disorder; it is well known to cause hypothyroidism.
erefore, thyroid function tests should be followed closely with patients taking lithium.
Page - 592
Question 120/162
Question #120
A 32-year-old female patient complains of chronic fatigue, cold sensitivity, anorexia, weight gain,
and reduced appetite. Her TSH is elevated, and her T4 is low. What is the most appropriate
treatment?
a. Propranolol
b. Radioactive iodine ablation
c. yroxine
d. Methimazole
e. Propylthiouracil
Page - 593
Question 120/162
Question #120
A 32-year-old female patient complains of chronic fatigue, cold sensitivity, anorexia, weight gain,
and reduced appetite. Her TSH is elevated, and her T4 is low. What is the most appropriate
treatment?
a. Propranolol
b. Radioactive iodine ablation
c. yroxine √
d. Methimazole
e. Propylthiouracil
Description
High TSH, low T4, and the mentioned clinical manifestations are typical for hypothyroidism.
Hypothyroidism is an inability of the thyroid gland to maintain the body’s requirement of thyroxin
hormone.
yroxine replacement is the treatment of choice for this condition.
Page - 594
Question 121/162
Question #121
A 30-year-old female complains of weight gain, low energy, and constipation. Which of the
following lab findings fit with the diagnosis of primary hypothyroidism?
a. High TSH and high T4

b. High TSH and low T4
d. Low TSH and high T4
e. Low TSH and low T4
Page - 595
Question 121/162
Question #121
A 30-year-old female complains of weight gain, low energy, and constipation. Which of the
following lab findings fit with the diagnosis of primary hypothyroidism?
a. High TSH and high T4

b. High TSH and low T4 √
d. Low TSH and high T4
e. Low TSH and low T4
Description
High TSH, low T4, and the mentioned clinical manifestations are typical for hypothyroidism.
Hypothyroidism is an inability of the thyroid gland to maintain the body’s requirement of thyroxin
hormone.
Page - 596
Question 122/162
Question #122
A 55-year-old female patient complains of constipation for 6 months. on further questioning, she
complains of fatigue, feels tired, has significant weight gain, and cannot tolerate cold weather.
Which of the following is relevant to this patient’s condition?
a. Elevated TRH
b. Elevated thyroglobulin level
c. Elevated TSH level
d. Elevated TSH receptor-stimulating antibodies
e. Hypercalcemia
Page - 597
Question 122/162
Question #122
A 55-year-old female patient complains of constipation for 6 months. on further questioning, she
complains of fatigue, feels tired, has significant weight gain, and cannot tolerate cold weather.
Which of the following is relevant to this patient’s condition?
a. Elevated TRH
b. Elevated thyroglobulin level
c. Elevated TSH level √
d. Elevated TSH receptor-stimulating antibodies
e. Hypercalcemia
Description
Description:
is patient mostly suers from primary hypothyroidism.
TSH level is the most appropriate, accurate, and cost-eective in the screening for thyroid diseases;
in primary hypothyroidism, it should be elevated.
yroglobulin levels are reduced in hypothyroidism.
TSH receptor stimulating antibodies are associated with Grave’s disease (hyperthyroidism)
Hypercalcemia and bone resorption results from hyperthyroidism, not hypothyroidism
Page - 598
Question 123/162
Question #123
What is the most common cause of hypothyroidism?
a. Endemic iodine deficiency

b. Graves disease
c. Hashimoto thyroiditis
d. yroid agenesis/dysgenesis
e. Drug induced
Page - 599
Question 123/162
Question #123
What is the most common cause of hypothyroidism?
a. Endemic iodine deficiency

b. Graves disease
c. Hashimoto thyroiditis √
d. yroid agenesis/dysgenesis
e. Drug induced
Description
Hashimoto thyroiditis is the most common cause of hypothyroidism. It is an autoimmune disease in

which anti-TPO antibodies attacks the thyroid gland leading to subclinical hypothyroidism and then
clinical hypothyroidism.
Endemic iodine deficiency was the most common in the past but today the iodine was added to salt
and the condition became less common.
Graves disease is the most common cause of hyperthyroidism, not hypothyroidism.
yroid agenesis/dysgenesis are the most common cause of cretinism (congenital hypothyroidism).
Page - 600
Question 124/162
Question #124
A 29-year-old female patient is treated with daily 100 mcg of levothyroxine for primary
hypothyroidism. She presented to you with amenorrhea for 2 days, and you ordered a pregnancy
test that returned positive. Her TSH level is 2.1 μU/mL. What would you do regarding her
levothyroxine dose?
a. Increase the dose to 150 mic/day

b. Reduce the dose to 50 mic/day
c. Keep the same dose, and no changes are indicated
d. Hold levothyroxine during the first trimester
e. Hold levothyroxine and resume aer delivery
Page - 601
Question 124/162
Question #124
A 29-year-old female patient is treated with daily 100 mcg of levothyroxine for primary
hypothyroidism. She presented to you with amenorrhea for 2 days, and you ordered a pregnancy
test that returned positive. Her TSH level is 2.1 μU/mL. What would you do regarding her
levothyroxine dose?
a. Increase the dose to 150 mic/day √

b. Reduce the dose to 50 mic/day
c. Keep the same dose, and no changes are indicated
d. Hold levothyroxine during the first trimester
e. Hold levothyroxine and resume aer delivery
Description
yroxine requirements increase by 30 – 50% during pregnancy. So, you should increase the dose of
thyroxine in this patient.
Levothyroxine is not teratogenic and should never be stopped during pregnancy because this will
aect fetal physical and brain development.
Page - 602
Question 125/162
Question #125
A 40-year-old female patient complains of amenorrhea and galactorrhea. On further questioning,

she told you that she has chronic constipation, felt fatigued, and has been gaining weight for the
past 6 months. In addition, physical examination demonstrates dry skin, bradycardia, and loss of the
outer one-third of her eyebrows. Lab tests show hyperprolactinemia and a negative pregnancy test.
Which of the following is the most likely cause of her hyperprolactinemia?
a. Hypothyroidism
b. Pregnancy
c. Oral contraceptive use
d. Stress
e. Prolactinoma
Page - 603
Question 125/162
Question #125
A 40-year-old female patient complains of amenorrhea and galactorrhea. On further questioning,

she told you that she has chronic constipation, felt fatigued, and has been gaining weight for the
past 6 months. In addition, physical examination demonstrates dry skin, bradycardia, and loss of the
outer one-third of her eyebrows. Lab tests show hyperprolactinemia and a negative pregnancy test.
Which of the following is the most likely cause of her hyperprolactinemia?
a. Hypothyroidism √
b. Pregnancy
c. Oral contraceptive use
d. Stress
e. Prolactinoma
Description
Hypothyroidism is a well-known cause of hyperprolactinemia because of the high TRH level that
stimulates prolactin hormone secretion.
Dry skin, bradycardia, chronic constipation, fatigue, and weight gain are typical hypothyroidism
features that are the most likely in this scenario.
In the absence of hypothyroidism symptoms, choose pituitary adenoma (prolactinoma) as the most
likely cause of hyperprolactinemia.
Page - 604
Question 126/162
Question #126
A postmenopausal woman has been treated for hypothyroidism for years but has not been
investigated for many years. Her lab investigations today demonstrate suppressed TSH. Which
complications may result from chronic excess thyroid hormone replacement in this patient?
a. Diuse toxic goiter

b. Osteoarthritis
c. Osteoporosis
e. Hyperparathyroidism
Page - 605
Question 126/162
Question #126
A postmenopausal woman has been treated for hypothyroidism for years but has not been
investigated for many years. Her lab investigations today demonstrate suppressed TSH. Which
complications may result from chronic excess thyroid hormone replacement in this patient?
a. Diuse toxic goiter

b. Osteoarthritis
c. Osteoporosis √
e. Hyperparathyroidism
Description
Bone resorption can result from even mild chronic excessive thyroxine replacement in
postmenopausal women. erefore, elevated serum calcium is expected in this clinical scenario.
Page - 606
Question 127/162
Question #127
A 40-year-old female patient complains of weight gain, constipation, cold intolerance, and
bradycardia of 50 beats per minute. What is the most likely underlying mechanism?
a. Infarction
b. Adenoma
c. Autoimmune process
d. Infection
e. Nutritional condition
Page - 607
Question 127/162
Question #127
A 40-year-old female patient complains of weight gain, constipation, cold intolerance, and
bradycardia of 50 beats per minute. What is the most likely underlying mechanism?
a. Infarction
b. Adenoma
c. Autoimmune process √
d. Infection
e. Nutritional condition
Description
is is a typical clinical scenario of hypothyroidism.
e most common cause of hypothyroidism in Jordan is Hashimoto’s thyroiditis.
Note that iodine deficiency was the most common in the past, but now the salt fortified with iodine
makes it less prevalent, and Hashimoto’s has become the most common.
Hashimoto’s thyroiditis is an autoimmune process against the thyroid tissue. It results from Anti-
TPO antibodies.
Pituitary infection, infarction, or adenoma are other possible causes of central (secondary)
hypothyroidism.
yroid infection (e.g., subacute thyroiditis is another possible cause.
Nutritional iodine deficiency is a possible cause, but Hashimoto’s thyroiditis is still the most
common and most likely in this case.
Page - 608
Question 128/162
Question #128
A 34-year-old female complains of chronic fatigue and weight gain. Her physical examination shows
delayed deep tendon reflexes, and her lab investigations show elevated thyroid-stimulating
hormone. What is the most likely diagnosis?
b. Secondary hyperthyroidism
c. Hypothyroidism
e. Chronic fatigue syndrome
Page - 609
Question 128/162
Question #128
A 34-year-old female complains of chronic fatigue and weight gain. Her physical examination shows
delayed deep tendon reflexes, and her lab investigations show elevated thyroid-stimulating
hormone. What is the most likely diagnosis?
b. Secondary hyperthyroidism
c. Hypothyroidism √
e. Chronic fatigue syndrome
Description
Delayed deep tendon reflex is the most important bedside test in hypothyroidism.
e presence of fatigue, weight gain, and high TSH level strongly suggests the diagnosis of primary
hypothyroidism.
Page - 610
Question 129/162
Question #129
In a 52-year-old female patient, A 3-cm adrenal gland mass was accidentally discovered in a CT scan
performed to evaluate suspected renal stones and hematuria. e patient has no medical history
except for her flank pain and hematuria for the past 2 weeks. Her physical examinations are
unremarkable, and her lab investigations show normal urea, electrolytes, and kidney function. What
is the most appropriate at this time?
a. 1 mg dexamethasone suppression test and 24 hours urinary metanephrine

b. Repeat the abdominal CT scan aer 6 – 12 months
c. Fine needle aspiration of the mass
d. Surgical removal
e. Reassurance and discharge home
Page - 611
Internal Medicine - Endocrinology - Incidentaloma
Question 129/162
Question #129
In a 52-year-old female patient, A 3-cm adrenal gland mass was accidentally discovered in a CT scan
performed to evaluate suspected renal stones and hematuria. e patient has no medical history
except for her flank pain and hematuria for the past 2 weeks. Her physical examinations are
unremarkable, and her lab investigations show normal urea, electrolytes, and kidney function. What
is the most appropriate at this time?
a. 1 mg dexamethasone suppression test and 24 hours urinary metanephrine √

b. Repeat the abdominal CT scan aer 6 – 12 months
c. Fine needle aspiration of the mass
d. Surgical removal
e. Reassurance and discharge home
Description
Description:
In patients with adrenal incidentaloma, you should perform a 1 mg dexamethasone suppression test
and 24 hours urinary Metanephrine levels for all patients.
Surgical removal should be done if the gland is > 4 cm in diameter (because of the risk of
malignancy)
If the gland is less than 4 cm in diameter and non-functioning, you should repeat the abdominal CT
scan aer 6 – 12 months (only once).
For the pituitary incidentaloma, you should test for PRL level, IGF-1 level, and cortisol excess.
Page - 612
Question 130/162
Question #130
A 36-year-old male patient complains of recurrent extensive peptic ulcer disease. His lab tests
demonstrate elevated gastrin and hypercalcemia. Which of the following is the most appropriate
test to establish the diagnosis of Multiple endocrine neoplasia?
b. Head MRI
c. Upper GI endoscopy
d. Urinary metanephrines
e. Serum thyroid function test
Page - 613
Internal Medicine - Endocrinology - Multiple Endocrine Neoplasias (MEN)
Question 130/162
Question #130
A 36-year-old male patient complains of recurrent extensive peptic ulcer disease. His lab tests
demonstrate elevated gastrin and hypercalcemia. Which of the following is the most appropriate
test to establish the diagnosis of Multiple endocrine neoplasia?
b. Head MRI √
c. Upper GI endoscopy
d. Urinary metanephrines
e. Serum thyroid function test
Description
e presence of pancreatic tumor (Gastrinoma) and the parathyroid adenoma that leads to
hypercalcemia is characteristic of MEN type 1
e missing piece of the MEN type 1 is the pituitary gland tumor which is better investigated by
pituitary MRI. erefore, a head MRI is the most appropriate answer.
Page - 614
Page - 615
Question 131/162
Question #131
e presence of primary hyperparathyroidism, pheochromocytoma, and medullary thyroid cancer is

characteristic of which of the following diagnoses?
a. Multiple endocrine neoplasia type I

b. Multiple endocrine neoplasia type IIa
c. Multiple endocrine neoplasia type IIb
d. Multiple myeloma
e. Sarcoidosis
Page - 616
Internal Medicine - Endocrinology - Multiple Endocrine Neoplasias (MEN)
Question 131/162
Question #131
e presence of primary hyperparathyroidism, pheochromocytoma, and medullary thyroid cancer is

characteristic of which of the following diagnoses?
a. Multiple endocrine neoplasia type I

b. Multiple endocrine neoplasia type IIa √
c. Multiple endocrine neoplasia type IIb
d. Multiple myeloma
e. Sarcoidosis
Description
Multiple Endocrine Neoplasia (MEN) is an inherited (Autosomal dominant) rare syndrome in which
multiple endocrine glands get neoplasia.
e following are the types of MEN:
Page - 617
Question 132/162
Question #132
A 30-year-old female sustained a motor vehicle accident and was admitted to the ICU. His lab
investigations are normal except for low serum T3. However, his TSH and T4 levels are normal. What
is the most appropriate management?
a. Start intravenous T3
b. Prescribe oral T4
c. Radioactive iodine uptake thyroid scan
d. yroglobulin level
e. Observation and monitoring
Page - 618
Internal Medicine - Endocrinology - Non-thyroidal illness
Question 132/162
Question #132
A 30-year-old female sustained a motor vehicle accident and was admitted to the ICU. His lab
investigations are normal except for low serum T3. However, his TSH and T4 levels are normal. What
is the most appropriate management?
a. Start intravenous T3
b. Prescribe oral T4
c. Radioactive iodine uptake thyroid scan
d. yroglobulin level
e. Observation and monitoring √
Description
Sick euthyroid syndrome (also known as Non-thyroidal illness):
Any acute, severe illness can aect the circulating TSH and thyroid hormones in the absence of
any thyroid disease
Unless a thyroid disorder is strongly suspected, routine thyroid function testing should be
avoided in acutely ill patients.
Lab investigations:
Low T3 syndrome: Low free T3 with normal T4 and TSH (the most common pattern)
Low T4 syndrome: reduced T3 and T4 due to accelerated consumption.
TSH may be reduced, normal or increased
Treatment:
Changes are reversible upon recovery from the systemic illness; hence, no treatment is usually
needed.
Page - 619
Question 133/162
Question #133
A 60-year-old male patient is admitted to the medical ICU for sepsis. His history is significant for
HTN and T2DM. his lab investigations demonstrate a TSH level of 0.19 microunits/mL, free T4 of 0.3
ng/dL. what is the most likely explanation?
a. Secondary hypothyroidism
b. Hyperthyroidism
c. Sick euthyroid syndrome
e. Grave’s disease
Page - 620
Internal Medicine - Endocrinology - Non-thyroidal illness
Question 133/162
Question #133
A 60-year-old male patient is admitted to the medical ICU for sepsis. His history is significant for
HTN and T2DM. his lab investigations demonstrate a TSH level of 0.19 microunits/mL, free T4 of 0.3
ng/dL. what is the most likely explanation?
a. Secondary hypothyroidism
b. Hyperthyroidism
c. Sick euthyroid syndrome √
e. Grave’s disease
Description
Sick euthyroid syndrome (also known as Non-thyroidal illness):
Any acute, severe illness can aect the circulating TSH and thyroid hormones in the absence of
any thyroid disease
Unless a thyroid disorder is strongly suspected, routine thyroid function testing should be
avoided in acutely ill patients.
Lab investigations:
Low T3 syndrome: Low free T3 with normal T4 and TSH (the most common pattern)
Low T4 syndrome: reduced T3 and T4 due to accelerated consumption.
TSH may be reduced, normal or increased
Treatment:
Changes are reversible upon recovery from the systemic illness; hence, no treatment is usually
needed.
Page - 621
Question 134/162
Question #134
A patient is suspected to have primary hyperparathyroidism, which of the following suggests the
disease?
a. High serum alkaline phosphatase

b. Serum calcium level above 11 mg/dL
c. Parathyroid hormone less than 10 pg/mL
d. High urinary calcium level
e. Low urine Ca:creatinine ratio
Page - 622
Internal Medicine - Endocrinology - Parathyroid gland
Question 134/162
Question #134
A patient is suspected to have primary hyperparathyroidism, which of the following suggests the
disease?
a. High serum alkaline phosphatase

b. Serum calcium level above 11 mg/dL √
c. Parathyroid hormone less than 10 pg/mL
d. High urinary calcium level
e. Low urine Ca:creatinine ratio
Description
Hyperparathyroidism:
It can be primary, secondary

Primary: adenoma, hyperplasia, or carcinoma of the parathyroid gland
Secondary: high PTH in response to low serum calcium (CRF, malabsorption, rickets…)
Primary hyperparathyroidism:
Features of hypercalcemia
Bone pain and pathological fractures
Secondary hyperparathyroidism:
Features of hypocalcemia
e following table demonstrates the dierential diagnosis of parathyroid disorders
Page - 623
Page - 624
Question 135/162
Question #135
A 60-year-old female presents with paroxysmal hypertension associated with headaches, sweating,
and tremors. His blood pressure is 160/97 mmHg, and his pulse rate is 103 bpm. He told you that he
has a strong family history of thyroid cancer. What is the most appropriate investigation?
a. 24 hours urinary collection for metanephrines

b. Adrenal gland CT scan
c. Brian CT scan
d. Pituitary CT scan
e. Serum vanillylmandelic acid
Page - 625
Internal Medicine - Endocrinology - Pheochromocytoma
Question 135/162
Question #135
A 60-year-old female presents with paroxysmal hypertension associated with headaches, sweating,
and tremors. His blood pressure is 160/97 mmHg, and his pulse rate is 103 bpm. He told you that he
has a strong family history of thyroid cancer. What is the most appropriate investigation?
a. 24 hours urinary collection for metanephrines √

c. Brian CT scan
d. Pituitary CT scan
e. Serum vanillylmandelic acid
Description
is is a typical scenario of pheochromocytoma as a part of MEN type 2.
24-hour urine collection for Metanephrine is the most specific test for pheochromocytoma.
Vanillylmandelic acid is the least specific degradation product of epinephrine and norepinephrine.
Pheochromocytoma is a tumor of the medulla of the adrenal gland that secretes epinephrine and
norepinephrine,
It can be associated with other conditions like (MEN IIB, neurofibromatosis, and Von Hippel Lindau
syndrome)
Pheochromocytoma is 10% malignant, 10% bilateral, 10% familial, and 10% extra-adrenal tumor
Clinical features include HTN (paroxysmal or persistent), sweating, tachycardia, weight loss, tremor,
hyperglycemia, hypercalcemia, and erythrocytosis.
Free metanephrine level in plasma is the best initial test, while 24 hours urinary metanephrine is the
most accurate test.
Treatment of HTN in pheochromocytoma is achieved by alpha-blockers. However, beta-blockers and

calcium channel blockers may be used aerward.
Surgical removal of the adrenal adenoma is the most accurate test.

Page - 626
Question 136/162
Question #136
A 39-year-old male patient complains of episodic headache, sweating, tremor, and palpitations. He
lost 7 kilograms in the past 2 months. His examination demonstrates HTN, tachycardia, and tremor.
In addition, his lab investigations show hyperglycemia and hypercalcemia. What is the most likely
diagnosis?
a. Pheochromocytoma
b. Hyperthyroidism
c. Essential tremor
d. Renal artery stenosis
Page - 627
Question 136/162
Question #136
In addition, his lab investigations show hyperglycemia and hypercalcemia. What is the most likely
diagnosis?
a. Pheochromocytoma √
b. Hyperthyroidism
c. Essential tremor
Description
is is a typical scenario of pheochromocytoma.
norepinephrine,
syndrome)
most accurate test.

Page - 628
Page - 629
Question 137/162
Question #137
A 33-year-old male patient is suspected of having pheochromocytoma because of paroxysmal HTN,

headaches, and sweatings. Which of the following will most likely be present during the episode of
these symptoms?
a. Hypoglycemia
b. Hypercalcemia
c. Anemia
d. Reduced catecholamines in urine
e. Bradycardia
Page - 630
Question 137/162
Question #137
A 33-year-old male patient is suspected of having pheochromocytoma because of paroxysmal HTN,

headaches, and sweatings. Which of the following will most likely be present during the episode of
these symptoms?
a. Hypoglycemia
c. Anemia
d. Reduced catecholamines in urine
e. Bradycardia
Description
Laboratory tests in pheochromocytoma may demonstrate hyperglycemia, hypercalcemia, and

erythrocytosis.
norepinephrine,
syndrome)
most accurate test.

Page - 631
Question 138/162
Question #138
Pheochromocytoma is known to be associated with all the following except:
a. Hypercalcemia
b. Multiple endocrine neoplasia type 2
c. Neurofibromatosis
d. Hypoglycemia
e. Tremor and tachycardia
Page - 632
Question 138/162
Question #138
Pheochromocytoma is known to be associated with all the following except:
a. Hypercalcemia
b. Multiple endocrine neoplasia type 2
d. Hypoglycemia √
e. Tremor and tachycardia
Description
Hyperglycemia, not hypoglycemia, is a manifestation of pheochromocytoma.
norepinephrine,
syndrome)
most accurate test.

Page - 633
Question 139/162
Question #139
A 33-year-old male patient complains of tremors, palpitation, headache, and sweating. His physical
examination demonstrates elevated blood pressure, and you suspect pheochromocytoma. What is
the most appropriate agent to control blood pressure in this patient?
a. Alpha-blockers
b. Beta-blockers
c. Diuretics
e. Angiotensin receptor blockers
Page - 634
Question 139/162
Question #139
A 33-year-old male patient complains of tremors, palpitation, headache, and sweating. His physical
examination demonstrates elevated blood pressure, and you suspect pheochromocytoma. What is
the most appropriate agent to control blood pressure in this patient?
a. Alpha-blockers √
b. Beta-blockers
c. Diuretics
e. Angiotensin receptor blockers
Description
Alpha-blockers are the drugs of choice to control blood pressure in pheochromocytoma patients.
Beta-blockers and calcium channel blockers can be used later on aer the use of alpha-blockers
Diuretics should be avoided in pheochromocytoma patients because these patients are volume-
depleted, and diuretics may exacerbate this depletion.
Page - 635
Question 140/162
Question #140
In addition, his lab investigations show hyperglycemia and hypercalcemia. Which of the following is
the most appropriate diagnostic test?
a. Brain CT scan
c. 24-hour Metanephrine level
d. yroid function test
e. Aldosteron to renin ratio
Page - 636
Question 140/162
Question #140
In addition, his lab investigations show hyperglycemia and hypercalcemia. Which of the following is
the most appropriate diagnostic test?
a. Brain CT scan
c. 24-hour Metanephrine level √
e. Aldosteron to renin ratio
Description
is is a typical scenario of pheochromocytoma.
norepinephrine,
syndrome)
most accurate test.

Page - 637
Question 141/162
Question #141
A 40-year-old female patient complains of amenorrhea, infertility, and galactorrhea. On further

questioning, the patient complains of a recurrent, progressive headache. Which of the following
visual abnormalities is most likely present in this patient?
a. Homonymous hemianopia
b. Homonymous upper quadrantanopia
c. Homonymous lower quadrantanopia
d. Bitemporal hemianopia
e. Cortical blindness
Page - 638
Internal Medicine - Endocrinology - Pituitary Adenoma
Question 141/162
Question #141
A 40-year-old female patient complains of amenorrhea, infertility, and galactorrhea. On further

questioning, the patient complains of a recurrent, progressive headache. Which of the following
visual abnormalities is most likely present in this patient?
a. Homonymous hemianopia
b. Homonymous upper quadrantanopia
c. Homonymous lower quadrantanopia
d. Bitemporal hemianopia √
e. Cortical blindness
Description
is patient most likely suers from hyperprolactinemia, most commonly caused by prolactinoma.
Prolactinoma is a pituitary gland adenoma that secrets prolactin and may cause compression.
Clinical features of pituitary adenoma are:
e compression eect of the tumor:

Visual field defect: (bitemporal hemianopia or upper temporal quadrantanopia): due to
compression on the optic chiasma
Lateral extension to cavernous sinus → Cranial nerves 3, 4 & 6 dysfunction
Compression of normal tissue of pituitary gland → Hyposecretion of the gland hormones
(Panhypopituitarism)
Hypersecretion conditions:
Gigantism or acromegaly (excessive GH secretion)
Cushing’s disease (with high ACTH)
Hyperprolactinemia
Some adenomas are called non-functioning adenomas (no excessive hormone secretion but
can cause compression eect)
Page - 639
Question 142/162
Question #142
A 29-year-old female patient complains of recurrent headaches and bitemporal hemianopia. In

addition, she has had amenorrhea for the last 4 months. What is the most likely explanation?
a. Dilatation of the third ventricle

b. Berry aneurysm of the circle of Willis
c. Pituitary adenoma
d. Pregnancy
Page - 640
Question 142/162
Question #142
A 29-year-old female patient complains of recurrent headaches and bitemporal hemianopia. In

addition, she has had amenorrhea for the last 4 months. What is the most likely explanation?
a. Dilatation of the third ventricle

b. Berry aneurysm of the circle of Willis
c. Pituitary adenoma √
d. Pregnancy
Description
e presence of headache, bitemporal hemianopia, and the failure of the HPO axis strongly suggest
compression due to pituitary adenoma.
Clinical features of pituitary tumors:
e compression eect of the tumor:

Visual field defect: (bitemporal hemianopia or upper temporal quadrantanopia): due to
compression on the optic chiasma
Lateral extension to cavernous sinus → Cranial nerves 3, 4 & 6 dysfunction
Compression of normal tissue of pituitary gland → Hyposecretion of the gland hormones
(Panhypopituitarism)
Hypersecretion conditions:
Gigantism or acromegaly (excessive GH secretion)
Cushing’s disease (with high ACTH)
Hyperprolactinemia
Some adenomas are called non-functioning adenomas (no excessive hormone secretion but
can cause compression eect)
Page - 641
Question 143/162
Question #143
A 35-year-old female presents with 2 months history of nervousness, tachycardia, heat intolerance,
and tremor. Her lab investigations demonstrate a TSH level of 15.4 μU/mL, and her free T4 level is 25
ng/dL. What is the most likely diagnosis?
b. Subacute thyroiditis
c. TSH secreting pituitary adenoma
d. Factitious hyperthyroidism
e. Hashimoto’s thyroiditis
Page - 642
Question 143/162
Question #143
A 35-year-old female presents with 2 months history of nervousness, tachycardia, heat intolerance,
and tremor. Her lab investigations demonstrate a TSH level of 15.4 μU/mL, and her free T4 level is 25
ng/dL. What is the most likely diagnosis?
b. Subacute thyroiditis
c. TSH secreting pituitary adenoma √
d. Factitious hyperthyroidism
Description
e clinical features and the elevated T4 level suggest the diagnosis of hyperthyroidism.
TSH level will be suppressed in the case of primary hyperthyroidism but elevated in the case of
secondary hyperthyroidism.
is is secondary hyperthyroidism mostly due to pituitary over-secretion of TSH, leading to elevated
thyroxine levels.
Page - 643
Question 144/162
Question #144
A 40-year-old male patient is suspected of having primary hyperaldosteronism. e following are

characteristics of this condition except:
a. Hypertension
b. Reduced urinary sodium
c. Normal to elevated urinary potassium
d. High aldosterone to renin ratio
e. All of the above
Page - 644
Internal Medicine - Endocrinology - Primary hyperaldosteronism
Question 144/162
Question #144
A 40-year-old male patient is suspected of having primary hyperaldosteronism. e following are

characteristics of this condition except:
a. Hypertension
b. Reduced urinary sodium
c. Normal to elevated urinary potassium √
d. High aldosterone to renin ratio
e. All of the above
Description
Aldosterone:renin ratio of > 20 indicates primary hyperaldosteronism.
It is the best test to dierentiate primary from secondary hyperaldosteronism.
Aldosterone, a hormone produced and secreted by the adrenal glands, signals the kidneys to excrete
less sodium and more potassium.
Primary hyperaldosteronism is the hypersecretion of aldosterone despite low renin and

hypertension.
Adrenal adenoma (Conn’s syndrome), adrenal hyperplasia, or rarely adrenal malignancy are possible
causes.
You should suspect this condition if HTN, Hypokalemia, and metabolic alkalosis are present.
e best initial test is to measure the aldosterone/renin ratio (levels of > 20 are suggestive of the
disease)
24-hour urinary collection for aldosterone should be done next.
CT or MRI are the best to localize the pathology/
Treatment is either surgery for tumors or spironolactone for hyperplasia.
Page - 645
Question 145/162
Question #145
A 35-year-old guy has felt weak, lethargic, and suering from headaches. He has a blood pressure
of 190/103 mmHg. He is not taking any medication. His blood test results indicate hypokalemia but
are otherwise normal. What is the most likely diagnosis?
a. Pheochromocytoma
b. Primary hyperaldosteronism
c. Hyperthyroidism
d. Chronic kidney disease
e. Renal artery stenosis
Page - 646
Question 145/162
Question #145
A 35-year-old guy has felt weak, lethargic, and suering from headaches. He has a blood pressure
of 190/103 mmHg. He is not taking any medication. His blood test results indicate hypokalemia but
are otherwise normal. What is the most likely diagnosis?
a. Pheochromocytoma
b. Primary hyperaldosteronism √
c. Hyperthyroidism
d. Chronic kidney disease
e. Renal artery stenosis
Description
is is a typical scenario of primary hyperaldosteronism.

hypertension.
causes.
disease)
Page - 647
Question 146/162
Question #146
A 39-year-old lady has been tired and sluggish. Despite taking enalapril, she has a blood pressure of
159/99 mmHg. Her blood test results are as follows: Hemoglobin 13.2 g/dL, Serum sodium 142
mEq/L, Serum potassium 3.2 mEq/L. What is the most likely diagnosis?
b. Pheochromocytoma
c. Chronic kidney disease
d. Primary hyperaldosteronism
e. Hypoadrenalism
Page - 648
Question 146/162
Question #146
159/99 mmHg. Her blood test results are as follows: Hemoglobin 13.2 g/dL, Serum sodium 142
mEq/L, Serum potassium 3.2 mEq/L. What is the most likely diagnosis?
b. Pheochromocytoma
c. Chronic kidney disease
d. Primary hyperaldosteronism √
e. Hypoadrenalism
Description

hypertension.
causes.
disease)
Page - 649
Question 147/162
Question #147
A 35-year-old male patient complains of HTN and headache. His recent blood tests show serum
potassium of 2.6 mEq/L. What is the most appropriate test at this time?
a. Cortisol level
b. yroxine level
c. Aldosterone level
d. Testosterone level
e. yrotropin level
Page - 650
Question 147/162
Question #147
A 35-year-old male patient complains of HTN and headache. His recent blood tests show serum
potassium of 2.6 mEq/L. What is the most appropriate test at this time?
a. Cortisol level
b. yroxine level
c. Aldosterone level √
d. Testosterone level
e. yrotropin level
Description
Hypokalemia and HTN strongly suggest primary hyperaldosteronism as the most likely diagnosis.
24-hour urinary collection for aldosterone is the most appropriate initial hormone test.

hypertension.
causes.
disease)
Page - 651
Page - 652
Question 148/162
Question #148
159/99 mmHg. Her blood test results are as follows: Hb 13.2 g/dL, Serum sodium 142 mEq/L, Serum
potassium 3.2 mEq/L. Which of the following is the most likely explanation for her hypokalemia?
a. Urinary potassium loss

b. Reduced potassium intake
c. Potassium loss in stool
d. Potassium shiing to the intracellular space
e. Metabolic alkalosis
Page - 653
Question 148/162
Question #148
159/99 mmHg. Her blood test results are as follows: Hb 13.2 g/dL, Serum sodium 142 mEq/L, Serum
potassium 3.2 mEq/L. Which of the following is the most likely explanation for her hypokalemia?
a. Urinary potassium loss √

b. Reduced potassium intake
c. Potassium loss in stool
d. Potassium shiing to the intracellular space
e. Metabolic alkalosis
Description
is is a typical scenario of primary hyperaldosteronism.

hypertension.
causes.
disease)
Page - 654
Question 149/162
Question #149
A 40-year-old male patient complains of hypertension and hypokalemia. Which of the following is
the most sensitive means of dierentiating primary from secondary hyperaldosteronism?
a. Metanephrine urinary level

c. Aldosterone:renin ratio
d. Aldosterone level
e. Renin level
Page - 655
Question 149/162
Question #149
A 40-year-old male patient complains of hypertension and hypokalemia. Which of the following is
the most sensitive means of dierentiating primary from secondary hyperaldosteronism?
a. Metanephrine urinary level

c. Aldosterone:renin ratio √
d. Aldosterone level
e. Renin level
Description

hypertension.
causes.
disease)
Page - 656
Question 150/162
Question #150
29-year-old female patient presents with neck pain, fever, and tachycardia, and you suspect
subacute thyroiditis. Which of the following is false about this condition?
a. It results from viral infection

b. ESR is elevated
c. e patient could need a thyroxine replacement
d. Features of hyperthyroidism are initial
e. Radioactive iodine uptake is elevated
Page - 657
Internal Medicine - Endocrinology - Subacute yroiditis
Question 150/162
Question #150
29-year-old female patient presents with neck pain, fever, and tachycardia, and you suspect
subacute thyroiditis. Which of the following is false about this condition?
a. It results from viral infection

b. ESR is elevated
c. e patient could need a thyroxine replacement
d. Features of hyperthyroidism are initial
e. Radioactive iodine uptake is elevated √
Description
Radioactive iodine uptake is elevated in Graves’ disease, multinodular goiter, and autonomously
functioning solitary thyroid nodule. In addition, it will be low in subacute thyroiditis, silent
thyroiditis, and exogenous thyroxine use.
e destructed cells in subacute thyroiditis will not be able to uptake iodine.
Page - 658
Question 151/162
Question #151
A 35-year-old lady complains of neck pain and tenderness associated with low-grade fever and
tachycardia. Her lab investigations show high WBC, high Free T4, high ESR, and normal TSH. What is
a. Neck cellulitis
b. Single hot nodule
c. Subacute thyroiditis
d. Grave’s disease
Page - 659
Question 151/162
Question #151
A 35-year-old lady complains of neck pain and tenderness associated with low-grade fever and
tachycardia. Her lab investigations show high WBC, high Free T4, high ESR, and normal TSH. What is
a. Neck cellulitis
b. Single hot nodule
c. Subacute thyroiditis √
d. Grave’s disease
Description
Subacute thyroiditis is characterized by elevated ESR, neck pain, and tenderness associated with
features of hyperthyroidism followed by hypothyroidism.
Page - 660
Question 152/162
Question #152
A 40-year-old female has recovered from a one-week illness of upper respiratory infection. Today,
she presents to your oce with a racing heart, neck pain, and feeling hot. Physical examination
demonstrates tachycardia and a tender neck. Her lab investigations show high T4, T3, WBC, and ESR,
and negative thyroid antibodies. What is the most likely diagnosis?
c. Subacute thyroiditis
e. yroid fibrosis
Page - 661
Question 152/162
Question #152
A 40-year-old female has recovered from a one-week illness of upper respiratory infection. Today,
she presents to your oce with a racing heart, neck pain, and feeling hot. Physical examination
demonstrates tachycardia and a tender neck. Her lab investigations show high T4, T3, WBC, and ESR,
and negative thyroid antibodies. What is the most likely diagnosis?
c. Subacute thyroiditis √
e. yroid fibrosis
Description
Description:
Page - 662
Question 153/162
Question #153
A 35-year-old female complains of neck pain, fever, and palpitations. Her physical examination
demonstrates neck tenderness and tachycardia. In addition, her lab investigations show
hyperthyroidism and reduced radioactive iodine uptake. What is the most helpful treatment at this
time?
a. Levothyroxine and NSAIDs

b. Prednisolone
c. Propylthiouracil
d. Carbimazole
e. yroidectomy
Page - 663
Question 153/162
Question #153
A 35-year-old female complains of neck pain, fever, and palpitations. Her physical examination
demonstrates neck tenderness and tachycardia. In addition, her lab investigations show
hyperthyroidism and reduced radioactive iodine uptake. What is the most helpful treatment at this
time?
a. Levothyroxine and NSAIDs

b. Prednisolone √
c. Propylthiouracil
d. Carbimazole
e. yroidectomy
Description
Treatment of subacute thyroiditis is achieved by:
Steroids, NSAIDs (aspirin)

Treatment of hyperthyroidism initially
Later, the patient will remain hypothyroidism and will need thyroxin
Page - 664
Question 154/162
Question #154
A 30-year-old female presents to the hospital with palpitations and profuse perspiration for 3 days.
On examination, you found a temperature of 39 °C, and the heart rate is irregular, 155 beats per
minute. What is the most appropriate management?
a. DC cardioversion
b. Amiodarone
c. Flecainide
d. Propranolol
e. Verapamil
Page - 665
Internal Medicine - Endocrinology - yroid storm
Question 154/162
Question #154
A 30-year-old female presents to the hospital with palpitations and profuse perspiration for 3 days.
On examination, you found a temperature of 39 °C, and the heart rate is irregular, 155 beats per
minute. What is the most appropriate management?
a. DC cardioversion
b. Amiodarone
c. Flecainide
d. Propranolol √
e. Verapamil
Description
is patient is most likely suering from a thyroid storm, so beta-blockers are the first line in this
scenario.
yroid storm is a medical emergency of hyperthyroidism, Precipitated by stress, infection, trauma
Symptoms include fever, nausea, vomiting, and diarrhea. In addition, the patient may suer from
arrhythmias, tachycardia, HTN, heart failure, and even coma
Propranolol is used in the treatment because it:
Blocks the target organ eect of thyroxine

Blocks the peripheral conversion of T4 to T3
Propylthiouracil (PTU) is the drug of choice for thyroid storm.
PTU is preferred over methimazole

It blocks the thyroid hormone’s production
Steroids and radioactive iodine ablation are used in the treatment.
Page - 666
Question 155/162
Question #155
Which of the following is the most appropriate diagnostic test to evaluate the vitamin D level?
a. Serum total calcium level

b. Serum ionized calcium level
c. 1,25 (OH)D
d. 25 (OH)D
e. Urinary calcium level
Page - 667
Internal Medicine - Endocrinology - Vitamin D deficiency
Question 155/162
Question #155
Which of the following is the most appropriate diagnostic test to evaluate the vitamin D level?
a. Serum total calcium level

b. Serum ionized calcium level
c. 1,25 (OH)D
d. 25 (OH)D √
e. Urinary calcium level
Description
e best test to evaluate vitamin D deficiency is 25 (OH)D3.
Note that 1,25 (OH)D is the active form of vitamin D synthesized by the kidneys and is aected by
kidney function.
Page - 668
Question 156/162
Question #156
A 32-year-old nurse is brought to the emergency department with confusion and sweating.
However, you draw laboratory samples during the events, his serum glucose level is 25mg/dL, and
he improves aer the administration of intravenous 10% dextrose. His medical records show
recurrent episodes of the same condition for which he admitted to the hospital multiple times
without any final diagnosis. His other lab tests later show the following:
Serum insulin: high
Serum C-Peptide: high
Urinary toxicology screen for oral hypoglycemic agents: negative.
a. Insulinoma
b. Surreptitious Insulin use
c. Surreptitious Oral hypoglycemic agents use
d. Anorexia nervosa
e. Post-prandial hypoglycemia
Page - 669
Internal Medicine - Endocrinology - Hypoglycemia
Question 156/162
Question #156
A 32-year-old nurse is brought to the emergency department with confusion and sweating.
However, you draw laboratory samples during the events, his serum glucose level is 25mg/dL, and
he improves aer the administration of intravenous 10% dextrose. His medical records show
recurrent episodes of the same condition for which he admitted to the hospital multiple times
without any final diagnosis. His other lab tests later show the following:
Serum insulin: high
Serum C-Peptide: high
Urinary toxicology screen for oral hypoglycemic agents: negative.
a. Insulinoma √
b. Surreptitious Insulin use
c. Surreptitious Oral hypoglycemic agents use
d. Anorexia nervosa
e. Post-prandial hypoglycemia
Description
is patient has recurrent episodes of the same condition that fulfills the Whipple’s triad
(Hypoglycemia).
e high C-Peptide and insulin levels indicate endogenous source of the insulin.
e negative urinary screen for OHA indicates that the patient’s condition is not surreptitious.
Always ensure that the insulin and C peptide samples are drawn during the hypoglycemia event;
they will give you a false negative results if they are taken while the blood sugar is normal.
Page - 670
Question 157/162
Question #157
A 60-year-old male patient presents to the emergency department with decreased consciousness
and sweating. He is a known case of type 2 DM for which he receives metformin and sulfonylurea.
However, you found his blood sugar of 20 mg/dL. erefore, you provided him with an ampule of
D50%, and the patient recovered consciousness. What is the most appropriate management?
a. Provide another ampule of D50% and discharge

b. Provide 2 ampules of D50% and discharge
c. Admission for continuous dextrose infusion and glucose monitoring
d. Observe at the emergency department for 2 hours, then discharge home if no hypoglycemia
occurs
e. Observe at the emergency department for 6 hours, then discharged home if no hypoglycemia
occurs
Page - 671
Question 157/162
Question #157
A 60-year-old male patient presents to the emergency department with decreased consciousness
and sweating. He is a known case of type 2 DM for which he receives metformin and sulfonylurea.
However, you found his blood sugar of 20 mg/dL. erefore, you provided him with an ampule of
D50%, and the patient recovered consciousness. What is the most appropriate management?
a. Provide another ampule of D50% and discharge

b. Provide 2 ampules of D50% and discharge
c. Admission for continuous dextrose infusion and glucose monitoring √
d. Observe at the emergency department for 2 hours, then discharge home if no hypoglycemia
occurs
e. Observe at the emergency department for 6 hours, then discharged home if no hypoglycemia
occurs
Description
Whipple’s triad here is obvious and diagnostic of hypoglycemia.
In managing hypoglycemia, you should address the cause and determine the risk of recurrence.
However, in this situation, the patient is on sulfonylurea, so he has a risk of recurrence of
hypoglycemia because of the drug’s prolonged half-life.
When the risk of recurrence is high, you should admit the patient and continue intravenous
dextrose and blood sugar monitoring.
If the patient is on insulin alone, there will be no need for admission as there is no risk of recurrence
because of the half-life of insulin.
Page - 672
Question 158/162
Question #158
A 23-year-old male patient collapses while playing football. He is brought to the emergency
department and found to have normal blood pressure, pulse rate, and respiratory rate. What is the
most appropriate next step in management?
a. Brain CT scan
b. Brain MRI
c. Blood glucose measurement
d. Intravenous fluid administration
e. Perform ECG
Page - 673
Question 158/162
Question #158
A 23-year-old male patient collapses while playing football. He is brought to the emergency
department and found to have normal blood pressure, pulse rate, and respiratory rate. What is the
most appropriate next step in management?
a. Brain CT scan
b. Brain MRI
c. Blood glucose measurement √
e. Perform ECG
Description
Exercise can result in hypoglycemia, manifesting as a reduced level of consciousness. erefore,

before taking the patient for a CT scan or any other study, check his blood sugar to ensure adequate
serum glucose level.
e next step in any case scenario should be easy, accessible, informative, and make a dierence in
the management.
Page - 674
Question 159/162
Question #159
A 40-year-old female patient complains of fainting and is found to have a blood sugar of 32mg/dL.
Which of the following criteria indicates hypoglycemia?
a. Cushing’s triad
b. Whipple triad
c. Virchow’s triad
d. Charcot triad
e. Beck’s triad
Page - 675
Question 159/162
Question #159
A 40-year-old female patient complains of fainting and is found to have a blood sugar of 32mg/dL.
Which of the following criteria indicates hypoglycemia?
a. Cushing’s triad
b. Whipple triad √
c. Virchow’s triad
d. Charcot triad
e. Beck’s triad
Description
Whipple’s triad is used to diagnose hypoglycemia, and it includes:
Decreased level of consciousness

Serum glucose < 45 mg/dl
Improvement aer administration of glucose
Cushing triad presents in increased intracranial pressure
Virchow’s triad presents in patients with hypercoagulability
Charcot triad presents in patients with cholangitis
Beck’s triad presents in cardiac tamponade
Page - 676
Question 160/162
Question #160
A 22-year-old male patient is brought to the emergency department with a decreased level of
consciousness. His friends told you he was at a party drinking alcohol and then found unconscious.
His blood pressure is 120/80, and his pulse is 94 bpm; he is afebrile and semi-conscious but has no
obvious neurological deficit. What is the most appropriate next step in the management of this
patient?
a. Brain CT scan
b. Brain MRI
c. Blood glucose measurement
e. Perform ECG
Page - 677
Question 160/162
Question #160
A 22-year-old male patient is brought to the emergency department with a decreased level of
consciousness. His friends told you he was at a party drinking alcohol and then found unconscious.
His blood pressure is 120/80, and his pulse is 94 bpm; he is afebrile and semi-conscious but has no
obvious neurological deficit. What is the most appropriate next step in the management of this
patient?
a. Brain CT scan
b. Brain MRI
c. Blood glucose measurement √
e. Perform ECG
Description
Alcohol consumption can result in hypoglycemia, manifesting as a reduced level of consciousness.

erefore, before taking the patient for a CT scan or any other study, check his blood sugar to ensure
adequate serum glucose level.
e next step in any case scenario should be easy, accessible, informative, and make a dierence in
the management.
Page - 678
Question 161/162
Question #161
A 40-year-old male patient has been diagnosed with type 1 DM for the past 23 years. His blood sugar
was well controlled on insulin, but he recently started having recurrent hypoglycemia episodes.
Which of the following is the most likely cause of his recurrent hypoglycemia?
a. Ineectiveness of his insulin

b. Increased insulin sensitivity
c. Renal impairment
d. Spontaneous beta cells improvement
e. Reduced physical activity
Page - 679
Question 161/162
Question #161
A 40-year-old male patient has been diagnosed with type 1 DM for the past 23 years. His blood sugar
was well controlled on insulin, but he recently started having recurrent hypoglycemia episodes.
Which of the following is the most likely cause of his recurrent hypoglycemia?
a. Ineectiveness of his insulin

b. Increased insulin sensitivity
c. Renal impairment √
d. Spontaneous beta cells improvement
e. Reduced physical activity
Description
Diabetic renal disease is the most prevalent cause of hypoglycemia in a previously stable, well-
controlled diabetic patient who has not changed his or her diet or insulin dose. is is because the
kidney usually metabolizes exogenous insulin. However, when kidney function is impaired, the half-
life of insulin is prolonged due to reduced levels of its degradation. As a result, hypoglycemia
episodes may frequently occur in diabetic patients (treated with insulin) and moderate to severe
renal failure.
Page - 680
Question 162/162
Question #162
A 32-year-old male patient complains of sweating and drowsiness for the past 30 minutes. However,
his blood glucose level was 25mg/dL, and he responded quickly to intravenous glucose
administration. His further evaluation demonstrates a reduced C-peptide level measured during the
attack. Shat is the most likely cause?
a. Insulinoma
b. Rebound hypoglycemia from eating
c. Sulfonylurea overdose
d. Surreptitious insulin administration
e. Glucagonoma
Page - 681
Question 162/162
Question #162
A 32-year-old male patient complains of sweating and drowsiness for the past 30 minutes. However,
his blood glucose level was 25mg/dL, and he responded quickly to intravenous glucose
administration. His further evaluation demonstrates a reduced C-peptide level measured during the
attack. Shat is the most likely cause?
a. Insulinoma
b. Rebound hypoglycemia from eating
c. Sulfonylurea overdose
d. Surreptitious insulin administration √
e. Glucagonoma
Description
During the attack of hypoglycemia, if the C-peptide is high, this indicates that the insulin causing
this condition is endogenous (e.g., insulinoma, sulfonylurea overdose, or rebound hypoglycemia
from eating).
In this scenario, the low C-peptide level indicates exogenous insulin as the most likely diagnosis.
Glucagonoma is not a cause of hypoglycemia.
Page - 682
Gastroenterology
Page - 683
Gastroenterology
1) Achalasia => 11 Questions

2) Barrette's Esophagus (BE) => 3 Questions
3) Celiac Disease => 15 Questions
4) Diarrhea => 18 Questions
5) Epigastric pain and dyspepsia => 7 Questions
6) Esophageal spasm => 3 Questions
7) Esophagitis => 3 Questions
8) Gastroesophageal Reflux Disease (GERD) => 4 Questions
9) Gastroparesis => 2 Questions
10) H. pylori Infection => 6 Questions
11) Inflammatory Bowel Diseases (IBD) => 21 Questions
12) Irritable Bowel syndrome (IBS) => 4 Questions
13) Peptic ulcer disease (PUD) => 5 Questions
14) Upper Gastrointestinal bleeding (UGIB) => 3 Questions
15) Vitamin A Deficiency => 1 Questions
Page - 684
Internal Medicine - Gastroenterology
Question 1/106
Question #1
A patient was diagnosed recently with achalasia. Which of the following symptoms is not expected
to manifest in this patient?
a. Dysphagia to solid food

b. Dysphagia to liquid food
c. Regurgitation of food
d. Odynophagia
e. Night cough
Page - 685
Internal Medicine - Gastroenterology - Achalasia
Question 1/106
Question #1
A patient was diagnosed recently with achalasia. Which of the following symptoms is not expected
to manifest in this patient?

b. Dysphagia to liquid food
c. Regurgitation of food
d. Odynophagia √
e. Night cough
Description
Achalasia is the most common esophageal motility disorder
Caused by degeneration of myenteric plexus →Hypertonic LES that fails to relax during swallowing
Long-standing, painless, slowly progressive dysphagia (to liquid more than solid foods) with periods
of remission and relapse is the most common symptom
Some patients developed severe chest pain due to esophageal spasms, Non-acidic regurgitation of
undigested food, Pulmonary aspiration (night cough, aspiration pneumonia)
Page - 686
Question 2/106
Question #2
A 39-year-old woman has a productive cough and a moderate fever. She has found it challenging to
swallow both food and liquids for the last 4 months. She complains of central chest pain and
regurgitation of undigested food. A chest X-ray shows a megaesophagus. What is the most likely
diagnosis?
a. Achalasia
b. Esophageal carcinoma
c. Esophageal web
d. Barrett’s esophagus
e. Oropharyngeal dysphagia
Page - 687
Question 2/106
Question #2
A 39-year-old woman has a productive cough and a moderate fever. She has found it challenging to
swallow both food and liquids for the last 4 months. She complains of central chest pain and
regurgitation of undigested food. A chest X-ray shows a megaesophagus. What is the most likely
diagnosis?
a. Achalasia √
c. Esophageal web
Description
Achalasia is a motility disorder of the esophagus caused by degeneration of the myenteric plexus
leading to a hypertonic LES that fails to relax during swallowing.
e condition should be suspected when a patient presents with the following presentation:
Dysphagia to solid and liquid food

History of the cause, e.g., Chagas disease, systemic sclerosis, etc.
Regurgitation of undigested food
Rat tail (bird’s peak) sign on barium swallow
Esophageal manometry is the most accurate test in the diagnosis as it shows a failure of the lower
esophageal sphincter (LES) to relax.
Upper endoscopy should be done to rule out pseudoachalasia.
Treatment is achieved by either endoscopic pneumatic dilatation, endoscopic Botulinum toxin

injection, or surgical myotomy of the lower esophageal sphincter
Page - 688
Question 3/106
Question #3
For the past few months, a 27-year-old female has suered from recurrent chest infection and
dysphagia to solid and liquid. Her medical history was significant only for Chagas disease 8 years
ago. So, what is the most likely diagnosis?
a. Achalasia cardia
b. Cystic fibrosis
c. Peptic stricture
d. Esophageal cancer
e. Hypogammaglobulinemia
Page - 689
Question 3/106
Question #3
For the past few months, a 27-year-old female has suered from recurrent chest infection and
dysphagia to solid and liquid. Her medical history was significant only for Chagas disease 8 years
ago. So, what is the most likely diagnosis?
a. Achalasia cardia √
b. Cystic fibrosis
c. Peptic stricture
d. Esophageal cancer
e. Hypogammaglobulinemia
Description


Page - 690
Question 4/106
Question #4
A 43-year-old woman complains of dysphagia to solids and liquids. Her chest x-ray shows wide
mediastinum, and the barium swallow shows dilated esophagus with a tapering distal end. What is
the next step in the management of this patient?
a. Reassurance
b. Upper GI endoscopy
c. Start nifedipine
d. Start Proton Pump inhibitors
e. Test for H pylori
Page - 691
Question 4/106
Question #4
A 43-year-old woman complains of dysphagia to solids and liquids. Her chest x-ray shows wide
mediastinum, and the barium swallow shows dilated esophagus with a tapering distal end. What is
the next step in the management of this patient?
a. Reassurance
b. Upper GI endoscopy √
c. Start nifedipine
d. Start Proton Pump inhibitors
e. Test for H pylori
Description
is patient is suering from achalasia.
Endoscopy should be done for this patient to rule out pseudoachalasia and then treat with
pneumatic dilatation of the lower esophageal sphincter


Page - 692
Question 5/106
Question #5
A 35-year-old patient complains of dysphagia to liquids more than solids. Barium swallow and
manometry are done and confirm the presence of achalasia. Which of the following is the best next
step in managing this patient?
a. Barium swallow
b. Bronchoscopy
c. Chest CT scan
d. Esophageal manometry
e. Esophagogastroduodenoscopy
Page - 693
Question 5/106
Question #5
A 35-year-old patient complains of dysphagia to liquids more than solids. Barium swallow and
manometry are done and confirm the presence of achalasia. Which of the following is the best next
step in managing this patient?
a. Barium swallow
b. Bronchoscopy
c. Chest CT scan
e. Esophagogastroduodenoscopy √
Description
A barium swallow is the best initial step to diagnose achalasia
Esophageal manometry is the most accurate test in the diagnosis
Upper endoscopy is used to rule out pseudo-achalasia before starting treatment
Achalasia:

It is caused by degeneration of the myenteric plexus leading to hypertonic LES that fails to
relax during swallowing
It is a premalignant condition; it can result in squamous cell carcinoma of the esophagus.
Long-standing, painless, slowly progressive dysphagia (to liquid more than solid foods) with
periods of remission and relapse (the most common symptom)
Non-acidic regurgitation of undigested food (heartburn is usually absent)
Chest x-ray, barium swallow (the best initial), and esophageal manometry (the most accurate)
are used in the diagnosis, while upper endoscopy is used to exclude pseudoachalasia.
Page - 694
Question 6/106
Question #6
A 33-year-old male patient has had worsening dysphagia for solid and liquid food for 2 months, and
he lost 5 kg in the past 2 months. His history is only remarkable for systemic sclerosis. What is the
most accurate method to confirm the diagnosis?
a. Upper GI endoscopy
b. Chest x-ray
c. Barium swallow
e. Positive response to PPI
Page - 695
Question 6/106
Question #6
A 33-year-old male patient has had worsening dysphagia for solid and liquid food for 2 months, and
he lost 5 kg in the past 2 months. His history is only remarkable for systemic sclerosis. What is the
most accurate method to confirm the diagnosis?
a. Upper GI endoscopy
b. Chest x-ray
c. Barium swallow
d. Esophageal manometry √
e. Positive response to PPI
Description
is patient is most likely suering from achalasia. is is suggested by the history of systemic
sclerosis and the typical dysphagia for liquid and solid food.
Esophageal manometry is the most accurate test to diagnose achalasia.
Achalasia:

Page - 696
Question 7/106
Question #7
A 30-year-old male patient was diagnosed with achalasia. e following symptoms favor the
diagnosis of achalasia, except:

b. Dysphagia to liquids
c. Odynophagia
d. Regurgitation of undigested food
e. Cough and aspiration
Page - 697
Question 7/106
Question #7
A 30-year-old male patient was diagnosed with achalasia. e following symptoms favor the
diagnosis of achalasia, except:

b. Dysphagia to liquids
c. Odynophagia √
d. Regurgitation of undigested food
e. Cough and aspiration
Description
Achalasia usually does not present with odynophagia.
Achalasia:

Page - 698
Page - 699
Question 8/106
Question #8
A 35-year-old patient with a history of dysphagia to liquids more than solids is suspected of having
achalasia. Which of the following is the most accurate test for this patient?
a. Barium swallow
b. Bronchoscopy
c. Chest CT scan
Page - 700
Question 8/106
Question #8
achalasia. Which of the following is the most accurate test for this patient?
a. Barium swallow
b. Bronchoscopy
c. Chest CT scan
d. Esophageal manometry √
Description
Achalasia:

Page - 701
Question 9/106
Question #9
achalasia. Which of the following is the best initial test for this patient?
a. Barium swallow
b. Bronchoscopy
c. Chest CT scan
Page - 702
Question 9/106
Question #9
achalasia. Which of the following is the best initial test for this patient?
a. Barium swallow √
b. Bronchoscopy
c. Chest CT scan
Description
Achalasia:

Page - 703
Question 10/106
Question #10
A 39-year-old male patient has had worsening diculty swallowing for the past 6 months. He has
not experienced weight loss and complains of regurgitation of undigested food. In addition, the
patient has had a history of recurrent respiratory infections over the past 3 years. What is the most
likely diagnosis?
a. Achalasia
c. Esophageal web
Page - 704
Question 10/106
Question #10
A 39-year-old male patient has had worsening diculty swallowing for the past 6 months. He has
not experienced weight loss and complains of regurgitation of undigested food. In addition, the
patient has had a history of recurrent respiratory infections over the past 3 years. What is the most
likely diagnosis?
a. Achalasia √
c. Esophageal web
Description


Page - 705
Question 11/106
Question #11
A previously healthy 58-year-old male comes to your oce to evaluate his dysphagia to liquid and
solid food. He has had this condition for 2 years. On barium swallow, a smooth narrowing on the
lower esophagus is noted. What is the most likely diagnosis?
a. Myasthenia gravis
c. Esophageal web
d. Achalasia
e. Gastroesophageal reflux
Page - 706
Question 11/106
Question #11
A previously healthy 58-year-old male comes to your oce to evaluate his dysphagia to liquid and
solid food. He has had this condition for 2 years. On barium swallow, a smooth narrowing on the
lower esophagus is noted. What is the most likely diagnosis?
a. Myasthenia gravis
c. Esophageal web
d. Achalasia √
e. Gastroesophageal reflux
Description

Treatment is achieved by the endoscopic pneumatic dilatation, endoscopic Botulinum toxin

injection, or surgical myotomy of the lower esophageal sphincter.
Page - 707
Question 12/106
Question #12
A 54-year-old male patient has had severe GERD for 20 years. Upper endoscopy confirms the
presence of Barrett’s esophagus (BE). Which of the following statements is true regarding this
condition?
a. e severity of symptoms here is due to Barrett’s esophagus (BE)

b. BE is an inflammation of the lower esophagus due to GERD
c. e risk of esophageal adenocarcinoma is less than 1% per year
d. Clinically, the patient with BE presents with dysphagia
e. Anti-reflux surgery prevents BE from progressing to adenocarcinoma
Page - 708
Internal Medicine - Gastroenterology - Barrette's Esophagus (BE)
Question 12/106
Question #12
A 54-year-old male patient has had severe GERD for 20 years. Upper endoscopy confirms the
presence of Barrett’s esophagus (BE). Which of the following statements is true regarding this
condition?
a. e severity of symptoms here is due to Barrett’s esophagus (BE)

b. BE is an inflammation of the lower esophagus due to GERD
c. e risk of esophageal adenocarcinoma is less than 1% per year √
d. Clinically, the patient with BE presents with dysphagia
e. Anti-reflux surgery prevents BE from progressing to adenocarcinoma
Description
In Barrett’s esophagus (BE), the Squamous lining of the lower esophagus is replaced by columnar
lining due to chronic exposure to acidity due to GERD (cellular metaplasia)
Barrett’s esophagus (BE) is a pre-malignant condition “0.5%/year risk of malignant transformation”

→ can cause adenocarcinoma of the esophagus
Anti-reflux surgery does not prevent the progression of BE to Adenocarcinoma.
BE is clinically asymptomatic, and it is only discovered by upper endoscopy.
Page - 709
Question 13/106
Question #13
A patient with a long-standing history of GERD was diagnosed by upper endoscopy and biopsy to
have Barrett’s esophagus (BE). Which of the following is false about this condition?
a. e risk of developing adenocarcinoma is <1%

b. e risk of having squamous cell carcinoma is 10%
c. Patient with Barrett’s esophagus has minimal symptoms
d. Anti-reflux therapy doesn’t prevent the progression of BE to a cancer
e. Endoscopic ablation is one of the treatment options
Page - 710
Question 13/106
Question #13
A patient with a long-standing history of GERD was diagnosed by upper endoscopy and biopsy to
have Barrett’s esophagus (BE). Which of the following is false about this condition?
a. e risk of developing adenocarcinoma is <1%

b. e risk of having squamous cell carcinoma is 10% √
c. Patient with Barrett’s esophagus has minimal symptoms
d. Anti-reflux therapy doesn’t prevent the progression of BE to a cancer
e. Endoscopic ablation is one of the treatment options
Description
e Squamous lining of the lower esophagus is replaced by columnar lining due to chronic exposure
to acidity due to GERD (cellular metaplasia)
Barrett’s esophagus (BE) has the potential to progress to an adenocarcinoma
0.5%/year risk of malignant transformation to adenocarcinoma, not squamous cell carcinoma
Page - 711
Question 14/106
Question #14
Which of the following is the most appropriate pathological description of Barrett’s Esophagus (BE)?
a. Squamous epithelium is replaced by columnar epithelium

b. e columnar epithelium is replaced by squamous epithelium
c. Hyperplasia of the lower esophageal squamous cells
d. Hyperplasia of the lower esophageal muscular layer
e. Ulcerations of the lower esophagus
Page - 712
Question 14/106
Question #14
Which of the following is the most appropriate pathological description of Barrett’s Esophagus (BE)?
a. Squamous epithelium is replaced by columnar epithelium √

b. e columnar epithelium is replaced by squamous epithelium
c. Hyperplasia of the lower esophageal squamous cells
d. Hyperplasia of the lower esophageal muscular layer
e. Ulcerations of the lower esophagus
Description
In Barrett’s esophagus (BE), the Squamous lining of the lower esophagus is replaced by columnar
lining due to chronic exposure to acidity due to GERD (cellular metaplasia)
Barrett’s esophagus (BE) is a pre-malignant condition “0.5%/year risk of malignant transformation”

→ can cause adenocarcinoma of the esophagus
Anti-reflux surgery does not prevent the progression of BE to Adenocarcinoma.
BE is clinically asymptomatic, and it is only discovered by upper endoscopy
Page - 713
Question 15/106
Question #15
A 22-year-old female patient has a 6 months history of diarrhea associated with weight loss and
easy bruising. Her examination is normal except for a chronic blistering skin consistent with
dermatitis herpetiformis. Which of the following abnormalities is expected to present in this
patient?
a. A low blood glucose level

b. Elevated total serum protein level
c. Low serum ferritin level
d. High Vitamin K level
e. Hypercalcemia
Page - 714
Internal Medicine - Gastroenterology - Celiac Disease
Question 15/106
Question #15
dermatitis herpetiformis. Which of the following abnormalities is expected to present in this
patient?
a. A low blood glucose level

b. Elevated total serum protein level
c. Low serum ferritin level √
d. High Vitamin K level
e. Hypercalcemia
Description
Iron deficiency anemia secondary to malabsorption is a known feature of celiac disease.
Malabsorption in celiac disease will result in low protein levels as well as a vitamin D deficiency
leading to low levels of calcium and elevated alkaline phosphatase
Celiac disease (gluten-sensitive enteropathy):
It is an autoimmune disease due to exposure to gliadin (gliadin is a product of gluten

breakdown) associated with HLA-DQ2 (chromosome 6) found in 80-90%, HLA-DQ8
It usually starts at age 6 months when adding food other than milk (It never manifests at
birth)
e clinical features include bloating, abdominal pain, weight loss, chronic diarrhea, and
symptoms of nutritional deficiencies.
e most accurate test is intestinal biopsy showing atrophic villi
e treatment is achieved by a strict gluten-free diet and the treatment of complications.
e most dangerous complications are small bowel lymphoma and adenocarcinoma
Page - 715
Question 16/106
Question #16
A 26-year-old female has had intermittent diarrhea and bloating for 6 months. Her stool is frothy
and dicult to flush down in the toilet. Further investigations show iron deficiency anemia and
positive endomysial antibodies. What is the most likely diagnosis?
a. Ulcerative colitis
b. Crohn’s disease
c. Celiac disease
e. Microscopic colitis
Page - 716
Question 16/106
Question #16
A 26-year-old female has had intermittent diarrhea and bloating for 6 months. Her stool is frothy
and dicult to flush down in the toilet. Further investigations show iron deficiency anemia and
positive endomysial antibodies. What is the most likely diagnosis?
c. Celiac disease √
e. Microscopic colitis
Description
Anti-gliadin, anti-endomysial, and anti-tissue transglutaminase antibodies are associated with

celiac disease
e presence of frothy stool is suggestive of steatorrhea secondary to malabsorption in celiac

disease
Iron deficiency anemia is a common complication of celiac disease.

birth)
Page - 717
Question 17/106
Question #17
A 33-year-old female patient has intermittent abdominal bloating and diarrhea that is more
prominent aer eating bread. She has no weight loss or anemia. What is the most likely diagnosis?
c. Gastroenteritis
d. Pyelonephritis
e. Celiac disease
Page - 718
Question 17/106
Question #17
A 33-year-old female patient has intermittent abdominal bloating and diarrhea that is more
prominent aer eating bread. She has no weight loss or anemia. What is the most likely diagnosis?
c. Gastroenteritis
d. Pyelonephritis
e. Celiac disease √
Description
is is a classic scenario of celiac disease. It is more common in females, and it is more prominent
aer ingestion of gluten-containing food.

birth)
Page - 719
Question 18/106
Question #18
A 25-year-old female has had intermittent diarrhea and bloating for 6 months. she is a known case
of hypothyroidism and type-1-DM. Her investigations are positive for immunoglobulin A tissue
transglutaminase antibody. What is the most appropriate next step in the management of this
patient?
a. Duodenal biopsy
b. Colonoscopy
c. Sweat chloride test
d. Start gluten-free diet
e. Gastric emptying study
Page - 720
Question 18/106
Question #18
transglutaminase antibody. What is the most appropriate next step in the management of this
patient?
a. Duodenal biopsy √
b. Colonoscopy
Description
ere are many points in the question that point to celiac disease as the most likely diagnosis:
- e patient is female (it is more common in females)
- e patient has associated autoimmune diseases (T1DM and Hypothyroidism)
- e typical symptoms of bloating and intermittent diarrhea
- e presence of positive Anti-tTG antibody
is patient should start on a gluten-free diet, but you should confirm the diagnosis by doing upper
endoscopy and duodenal biopsy.
e gastric emptying study is used in diabetic patients who are suspected of having gastroparesis,
but the patient here has positive Anti-tTG, which guides us to think about celiac disease

birth)
Page - 721
Page - 722
Question 19/106
Question #19
A 22-year-old female was diagnosed with celiac disease. Of the following, which foods are allowed
to eat by this patient?
a. Corn and rice

b. Oats
c. Wheat
d. Barley
e. Ray
Page - 723
Question 19/106
Question #19
A 22-year-old female was diagnosed with celiac disease. Of the following, which foods are allowed
to eat by this patient?
a. Corn and rice √

b. Oats
c. Wheat
d. Barley
e. Ray
Description
Celiac disease is an autoimmune disease due to exposure to gliadin (gliadin is a product of gluten
breakdown)
Gluten is a protein present in Rye, Barley, Oats, Wheat
Rice and corn are gluten-free and are safe and allowed to be eaten by celiac disease patients

birth)
Page - 724
Question 20/106
Question #20
transglutaminase antibody. In addition, her duodenal biopsy confirms the suspected diagnosis.
a. Repeat duodenal biopsy in 6 months

b. Colonoscopy
Page - 725
Question 20/106
Question #20
transglutaminase antibody. In addition, her duodenal biopsy confirms the suspected diagnosis.
a. Repeat duodenal biopsy in 6 months

b. Colonoscopy
d. Start gluten-free diet √
Description
is patient should start on a gluten-free diet, but you should confirm the diagnosis by doing upper
endoscopy and duodenal biopsy.
e gastric emptying study is used in diabetic patients suspected of having gastroparesis, but the
patient here has positive Anti-tTG, which guides us to think about celiac disease.

birth)
Page - 726
Page - 727
Question 21/106
Question #21
dermatitis herpetiformis. What is the most accurate diagnostic test to confirm the diagnosis?
b. Bowel biopsy
c. Colonoscopy
d. Gluten-free diet
e. Sweat chloride test
Page - 728
Question 21/106
Question #21
dermatitis herpetiformis. What is the most accurate diagnostic test to confirm the diagnosis?
b. Bowel biopsy √
c. Colonoscopy
d. Gluten-free diet
e. Sweat chloride test
Description
e presence of weight loss, fatty diarrhea, and features suggestive of vitamin K deficiency (easy
bruising) are all indicative of malabsorption
Dermatitis herpetiformis and features of malabsorption indicate Celiac disease as the most likely
diagnosis.
Endoscopy with biopsy is the most accurate test to do for celiac disease
e biopsy will show villous atrophy if the disease is present

birth)
Page - 729
Question 22/106
Question #22
transglutaminase antibody. What is the most likely finding in the duodenal biopsy?
a. Caseating granuloma
b. Non-caseating granuloma
c. Cystic formation
d. Villous atrophy
e. Eosinophilic infiltration
Page - 730
Question 22/106
Question #22
transglutaminase antibody. What is the most likely finding in the duodenal biopsy?
a. Caseating granuloma
c. Cystic formation
d. Villous atrophy √
e. Eosinophilic infiltration
Description
In celiac disease, gluten exposure causes characteristic changes in the small intestine lining,
resulting in malabsorption. e proximal part of the small bowel is more aected than the distal
part, and the changes are reversible if a gluten-free diet is strictly adopted.

birth)
Page - 731
Page - 732
Question 23/106
Question #23
dermatitis herpetiformis. Regarding the most likely diagnosis, all are false except:
a. Males are more aected than females

b. It may be associated with type 2 DM
c. Symptoms are limited to the GI tract
d. Bowel biopsy will be falsely negative if the patient is on a gluten-free diet
e. If the patient is asymptomatic, there is no need for a gluten-free diet
Page - 733
Question 23/106
Question #23
dermatitis herpetiformis. Regarding the most likely diagnosis, all are false except:
a. Males are more aected than females

b. It may be associated with type 2 DM
c. Symptoms are limited to the GI tract
d. Bowel biopsy will be falsely negative if the patient is on a gluten-free diet √
e. If the patient is asymptomatic, there is no need for a gluten-free diet
Description
If the patient is on a Gluten-free diet, the biopsy and his serology tests for celiac disease will be
negative (normal), and the symptoms will disappear
Like other autoimmune diseases, Females are more aected than males in celiac disease (1:13 more
common in women).
Celiac disease is associated with autoimmune diseases like Type 1 DM thyroid disease and
rheumatoid arthritis.
All patients should be treated with a gluten-free diet regardless of symptoms, including those with
isolated dermatitis herpetiformis
Page - 734
Question 24/106
Question #24
A 22-year-old female patient has had diarrhea, abdominal pain, and bloating for 4 months. she has a
blistering rash on her elbow. Her upper endoscopy and biopsy demonstrate shortening of the enteric
villi. What is the most likely diagnosis?
a. Crohn’s disease
b. Amebiasis
c. Giardiasis
d. Intestinal ischemia
e. Celiac disease
Page - 735
Question 24/106
Question #24
A 22-year-old female patient has had diarrhea, abdominal pain, and bloating for 4 months. she has a
blistering rash on her elbow. Her upper endoscopy and biopsy demonstrate shortening of the enteric
villi. What is the most likely diagnosis?
b. Amebiasis
c. Giardiasis
d. Intestinal ischemia
e. Celiac disease √
Description
is patient is a young female who has symptoms of celiac disease and the associated rash
(Dermatitis herpetiformis)
e biopsy, which is the most accurate, confirms the presence of atrophic villi

birth)
Page - 736
Question 25/106
Question #25
A 22-year-old female has been on a gluten-free diet for 6 months aer being suspected of having
celiac disease. She presents to confirm her diagnosis of the disease. What is the most appropriate
a. Upper endoscopy and biopsy

b. Stop the gluten-free diet
d. Stool analysis
e. Anti-tTG antibody
Page - 737
Question 25/106
Question #25
A 22-year-old female has been on a gluten-free diet for 6 months aer being suspected of having
celiac disease. She presents to confirm her diagnosis of the disease. What is the most appropriate

b. Stop the gluten-free diet √
d. Stool analysis
e. Anti-tTG antibody
Description
e biopsy findings of celiac disease and even the serology test for antibodies will be falsely negative
if the patient is on a gluten-free diet. In addition, there will be a rapid response and reversibility if a
gluten-free diet is taken.
You should reintroduce the gluten for at least 6 weeks before testing for celiac disease.

birth)
Page - 738
Question 26/106
Question #26
A 42-year-old female has been on a gluten-free diet for 15 years aer being diagnosed with celiac
disease. She worsens the classic symptoms of celiac disease, such as abdominal pain, diarrhea, and
bloating. In addition, the patient has significant weight loss. e biopsy of her small intestine will
show which of the following?
a. Intestinal Tuberculosis
c. Cystic formation
d. Lymphoma
e. Basophilic infiltration
Page - 739
Question 26/106
Question #26
A 42-year-old female has been on a gluten-free diet for 15 years aer being diagnosed with celiac
disease. She worsens the classic symptoms of celiac disease, such as abdominal pain, diarrhea, and
bloating. In addition, the patient has significant weight loss. e biopsy of her small intestine will
show which of the following?
a. Intestinal Tuberculosis
c. Cystic formation
d. Lymphoma √
e. Basophilic infiltration
Description
Celiac disease may be complicated by enteropathy-associated T-cell lymphoma.
e biopsy may show lymphomatous infiltrates, and mixed inflammatory infiltrate

birth)
Page - 740
Question 27/106
Question #27
A 19-year-old female with a known case of T1DM presents with weight loss, abdominal bloating, and
diarrhea for 6 months. She is also complaining of malodorous flatus and gurgling sounds in her
abdomen. Her lab investigations show microcytic hypochromic anemia but otherwise
unremarkable. If the patient has a similar family history, what is the most likely diagnosis?
a. Celiac disease
b. Food poisoning
c. Irritable bowel syndrome
d. Ulcerative colitis
e. Colorectal cancer
Page - 741
Question 27/106
Question #27
A 19-year-old female with a known case of T1DM presents with weight loss, abdominal bloating, and
diarrhea for 6 months. She is also complaining of malodorous flatus and gurgling sounds in her
abdomen. Her lab investigations show microcytic hypochromic anemia but otherwise
unremarkable. If the patient has a similar family history, what is the most likely diagnosis?
a. Celiac disease √
b. Food poisoning
c. Irritable bowel syndrome
e. Colorectal cancer
Description
e presence of weight loss, bloating, diarrhea, Iron deficiency anemia, and the association with
T1DM and a positive family history point to a diagnosis of celiac disease.
Ulcerative colitis and IBS will never cause anemia or malabsorption
Colorectal cancer is unlikely in this age group
And food poisoning is acute and will not present for 6 months

birth)
Page - 742
Question 28/106
Question #28
A 32-year-old white female presents because of 6 years history of abdominal pain and smelly
diarrhea, not responding to the usual treatment. ere is no blood in the stool or weight loss. Her
physical examination, CBC, and electrolytes are normal. What is the most appropriate next step in

c. Anti-tissue transglutaminase antibody
d. Stool analysis for ova or parasites
e. Measure bond density
Page - 743
Question 28/106
Question #28
A 32-year-old white female presents because of 6 years history of abdominal pain and smelly
diarrhea, not responding to the usual treatment. ere is no blood in the stool or weight loss. Her
physical examination, CBC, and electrolytes are normal. What is the most appropriate next step in

c. Anti-tissue transglutaminase antibody √
d. Stool analysis for ova or parasites
e. Measure bond density
Description
is is a suspected case of celiac sprue. e next step in the management is to have serology testing
for celiac disease antibodies
Note that all patients with celiac disease should be measured for bone density aer confirming the
diagnosis, but now the next step is to confirm the presence of celiac disease

birth)
Page - 744
Question 29/106
Question #29
dermatitis herpetiformis. What is the most likely diagnosis?
b. Ulcerative colitis
c. Celiac disease
d. H pylori infection
e. Von Willebrand disease
Page - 745
Question 29/106
Question #29
dermatitis herpetiformis. What is the most likely diagnosis?
c. Celiac disease √
d. H pylori infection
e. Von Willebrand disease
Description
e presence of weight loss, fatty diarrhea, and features suggestive of vitamin K deficiency (easy
bruising) are all indicative of malabsorption
Dermatitis herpetiformis and features of malabsorption indicate Celiac disease as the most likely
diagnosis.

birth)
Page - 746
Question 30/106
Question #30
e most common organism associated with pseudomembranous colitis is:
a. Clostridium septicum
b. Clostridium perfringens
c. Clostridium dicile
d. Clostridium tetani
e. Clostridium sordellii
Page - 747
Internal Medicine - Gastroenterology - Diarrhea
Question 30/106
Question #30
e most common organism associated with pseudomembranous colitis is:
a. Clostridium septicum
b. Clostridium perfringens
c. Clostridium dicile √
d. Clostridium tetani
e. Clostridium sordellii
Description
Pseudomembranous colitis is diarrhea that occurs as a result of antibiotic use due to the eradication
of the normal flora in the intestine leading to excessive growth of Clostridium dicile → release of a
toxin → bloody or watery diarrhea
Clostridia species and their diseases are as the following:
C. perfringens: food intoxication, diarrhea, gangrene, puerperal sepsis

C. dicile: pseudomembranous colitis
C. septicum: intestinal myonecrosis
C. botulinum: Botulism
C. sordellii: gangrene
C. tetani: Tetanus
C. novyi: gangrene
Page - 748
Question 31/106
Question #31
A 32-year-old male patient complains of loose, watery diarrhea and bloating since returning from his
trip to Yemen. Although he lost 3 kilograms since that time, his physical examination and lab
investigations are unremarkable. What is the most likely organism causing his symptoms?
a. Campylobacter jejuni
b. Giardia lamblia
c. Salmonella
d. Shigella
e. Staphylococcus aureus
Page - 749
Question 31/106
Question #31
A 32-year-old male patient complains of loose, watery diarrhea and bloating since returning from his
trip to Yemen. Although he lost 3 kilograms since that time, his physical examination and lab
investigations are unremarkable. What is the most likely organism causing his symptoms?
b. Giardia lamblia √
c. Salmonella
d. Shigella
e. Staphylococcus aureus
Description
is case is typical for giardiasis
Giardiasis presents as traveler’s diarrhea with symptoms lasting more than 10 days
It can cause both acute or chronic diarrhea
is is chronic giardiasis (because it is associated with weight loss)
Campylobacter, Shigella, and Salmonella usually cause bloody diarrhea.
Giardiasis:
Giardiasis presents as traveler’s diarrhea with symptoms lasting more than 10 days
It can cause both acute or chronic diarrhea
Symptoms: bloating, flatulence, abdominal pain, loose stool, explosive watery diarrhea,
weight loss
Symptoms begin aer returning from a travel
Campylobacteriosis:
Campylobacter is the commonest bacterial cause of infectious intestinal disease

Clinical features:
Prodrome: headache, myalgia, and fevers (as high as 40°C)
Abdominal pain
Profuse diarrhea (oen bloody)
Page - 750
Question 32/106
Question #32
A 19-year-ola male patient presents with diarrhea. Which of the following is the least likely cause?
a. E. coli
b. Rotavirus
c. Norwalk virus
d. Giardiasis
e. Helicobacter pylori
Page - 751
Question 32/106
Question #32
A 19-year-ola male patient presents with diarrhea. Which of the following is the least likely cause?
a. E. coli
b. Rotavirus
c. Norwalk virus
d. Giardiasis
e. Helicobacter pylori √
Description
H pylori is a gastric pathogen that causes gastritis and peptic ulcer disease. It is unlikely to cause
diarrhea
Peptic ulcer disease (PUD):
It is an ulceration of the lower esophagus, stomach, or duodenum and can occur in the ileum
adjacent to Meckel’s diverticulum.
e most common site of gastric ulcer (GU) is at the lesser curvature (exactly at the Incisura
angularis)
e most common cause in developing countries is H. Pylori infection, while NSAIDs are
responsible for most cases in developed countries
All patients with peptic ulcer disease should be tested for H. pylori regardless of the use of
NSAIDs
Dyspepsia is the most common symptom, but epigastric pain, GI bleeding, and vomiting may
present.
Upper GI endoscopy is considered the most accurate test
e treatment is achieved by elimination of the cause and the use of PPIs
Page - 752
Question 33/106
Question #33
During a sigmoidoscopy, you found the morphology shown in the picture below. What is the most
likely diagnosis?
a. Melanosis coli
b. Colorectal cancer
c. Malignant lymphoma
d. Arteriovenous malformations
e. Colitis
Page - 753
Question 33/106
Question #33
During a sigmoidoscopy, you found the morphology shown in the picture below. What is the most
likely diagnosis?
a. Melanosis coli √
b. Colorectal cancer
c. Malignant lymphoma
d. Arteriovenous malformations
e. Colitis
Description
Black or brown discoloration of the mucosa of the colon is known as melanosis coli. It is caused by
laxative use.
It results from the presence of dark pigment in large mononuclear cells or macrophages in the
lamina propria of the mucosa
Page - 754
Page - 755
Question 34/106
Question #34
At a hotel, 5 guests developed nausea, vomiting, and watery diarrhea 2 hours aer eating, and the
symptoms resolved spontaneously within 48 hours. What is the most likely etiology of their
condition?
a. Rotavirus
b. Staph aureus toxin
c. C. botulinum
d. C. jejuni
e. C. Dicile
Page - 756
Question 34/106
Question #34
At a hotel, 5 guests developed nausea, vomiting, and watery diarrhea 2 hours aer eating, and the
symptoms resolved spontaneously within 48 hours. What is the most likely etiology of their
condition?
a. Rotavirus
b. Staph aureus toxin √
c. C. botulinum
d. C. jejuni
e. C. Dicile
Description
All of them have gastroenteritis secondary to food poisoning.
e dierential diagnosis includes (E. coli, Norwalk virus, Salmonella typhimurium, Salmonella
enteritidis, Campylobacter jejuni, and Yersinia enterocolitica)
Only Staph. aureus toxin would cause these symptoms in such a short time.
Staphylococcal toxins are fast-acting, sometimes causing illness in as little as 30 minutes aer
eating contaminated foods, but usually, symptoms present 1 to 6 hours aer the patient has
consumed the contaminated food
Page - 757
Question 35/106
Question #35
A 33-year-old female just returned from her trip to Europe. She develops symptoms of watery
diarrhea and cramping abdominal pain. What is the most likely organism causing her symptoms?
a. Campylobacteriosis
b. Escherichia coli
c. Giardiasis
d. Salmonella
e. Shigella
Page - 758
Question 35/106
Question #35
A 33-year-old female just returned from her trip to Europe. She develops symptoms of watery
diarrhea and cramping abdominal pain. What is the most likely organism causing her symptoms?
a. Campylobacteriosis
b. Escherichia coli √
c. Giardiasis
d. Salmonella
e. Shigella
Description
is is a case of traveler’s diarrhea.
E. coli is the most common cause

Other causes: Shigella, Salmonella, Campylobacter, Giardia lamblia
Campylobacteriosis presents with a prodrome followed by diarrhea
Giardiasis presents with watery diarrhea, flatulence, and weight loss
Salmonella and shigella present with bloody diarrhea.
Page - 759
Question 36/106
Question #36
A sigmoidoscopy in a 32-year-old female patient shows scattered areas of black discolorations. What
is the most likely description?
a. Endometriosis
b. Laxative use
c. Colitis
d. Malignant lymphoma
e. Arteriovenous malformations
Page - 760
Question 36/106
Question #36
A sigmoidoscopy in a 32-year-old female patient shows scattered areas of black discolorations. What
is the most likely description?
a. Endometriosis
b. Laxative use √
c. Colitis
d. Malignant lymphoma
e. Arteriovenous malformations
Description
Black or brown discoloration of the mucosa of the colon is known as melanosis coli. It is caused by
laxative use.
It results from the presence of dark pigment in large mononuclear cells or macrophages in the
lamina propria of the mucosa
Page - 761
Question 37/106
Question #37
A 34-year-old female complains of diarrhea for 2 days. She has been taking amoxicillin for 1 week for
pneumonia. On examination, she is well hydrated and has normal vital signs. However, her stool is
positive for occult blood, and her stool screening is positive for C. dicile toxin. What is the most
appropriate treatment at this time?
a. Oral vancomycin
b. Oral metronidazole
c. Oral TMP/SMX
d. Oral ciprofloxacin
e. Oral clindamycin
Page - 762
Question 37/106
Question #37
A 34-year-old female complains of diarrhea for 2 days. She has been taking amoxicillin for 1 week for
pneumonia. On examination, she is well hydrated and has normal vital signs. However, her stool is
positive for occult blood, and her stool screening is positive for C. dicile toxin. What is the most
appropriate treatment at this time?
a. Oral vancomycin √
b. Oral metronidazole
c. Oral TMP/SMX
d. Oral ciprofloxacin
e. Oral clindamycin
Description
Oral metronidazole used to be the first-line treatment for C. dicile antibiotic-associated colitis
(pseudomembranous colitis)
Recently, the guidelines have been changed, and the treatment of this condition is as the following:
Always stop the oending antibiotic

Oral vancomycin (the first-line treatment)
IV metronidazole and Vancomycin enema can be added if the severe disease is associated with
ileus.
If a fulminant or complicated disease is not responsive to the previous treatment, perform a
colectomy.
Fecal microbiota transplant is used for patients with multiple relapses.
Page - 763
Question 38/106
Question #38
A 23-year-old male patient presents with watery diarrhea, abdominal pain, and vomiting. A similar
history is found in his younger sister but with milder symptoms. Seven hours ago, at dinner, they ate
a cheeseburger. Which of the following is the most likely cause of his condition?
a. Rotavirus
b. Staph aureus toxin
c. C. botulinum
d. C. jejuni
e. C. Dicile
Page - 764
Question 38/106
Question #38
A 23-year-old male patient presents with watery diarrhea, abdominal pain, and vomiting. A similar
history is found in his younger sister but with milder symptoms. Seven hours ago, at dinner, they ate
a cheeseburger. Which of the following is the most likely cause of his condition?
a. Rotavirus
b. Staph aureus toxin √
c. C. botulinum
d. C. jejuni
e. C. Dicile
Description
Both of them have gastroenteritis secondary to food poisoning.
e dierential diagnosis includes (E. coli, Norwalk virus, Salmonella typhimurium, Salmonella
enteritidis, Campylobacter jejuni, and Yersinia enterocolitica)
Only Staph. aureus toxin would cause these symptoms in such a short time.
Staphylococcal toxins are fast-acting, sometimes causing illness in as little as 30 minutes aer
eating contaminated foods, but usually, symptoms present 1 to 6 hours aer the patient has
consumed the contaminated food
Page - 765
Question 39/106
Question #39
You suspect secretory diarrhea in a 22-year-old female patient. Which of the following is a feature of
this condition?
a. Small volume (<1L/day)

b. High stool osmotic gap
c. Blood or pus in stool analysis
d. It doesn’t stop with fasting
e. Foul-smelling stools
Page - 766
Question 39/106
Question #39
You suspect secretory diarrhea in a 22-year-old female patient. Which of the following is a feature of
this condition?
a. Small volume (<1L/day)

b. High stool osmotic gap
c. Blood or pus in stool analysis
d. It doesn’t stop with fasting √
e. Foul-smelling stools
Description
Osmotic diarrhea:
Stool osmotic gap > 100 mOsm

It stops on fasting and never awakes the patient from sleep
Usually not lead to dehydration
Secretory diarrhea:
Stool osmotic gap < 50 mOsm

Occurs at fasting or during sleep
Usually high volume > 1 L/day
Page - 767
Question 40/106
Question #40
A 62-year-old male patient has been on clindamycin for recent cellulitis for the last 3 days. He
presents with a 1-day history of watery diarrhea. He is afebrile and has no blood in the stool. What is
the best initial management for this patient?
a. Stop clindamycin
b. Start ciprofloxacin
c. Start vancomycin
d. Start metronidazole
e. Start loperamide
Page - 768
Question 40/106
Question #40
the best initial management for this patient?
a. Stop clindamycin √
b. Start ciprofloxacin
c. Start vancomycin
d. Start metronidazole
e. Start loperamide
Description
Stopping the oending agent is the best initial step in this case, even before starting vancomycin or
metronidazole.
Oral metronidazole was the first-line treatment for C. dicile antibiotic-associated colitis
(pseudomembranous colitis).
Recently, the guidelines have been changed, and the treatment of this condition is as the following:
Always stop the oending antibiotic

Oral vancomycin (the first-line treatment)
IV metronidazole and Vancomycin enema can be added if the severe disease is associated with
ileus.
If a fulminant or complicated disease is not responsive to the previous treatment, perform a
colectomy.
Fecal microbiota transplant is used for patients with multiple relapses.
Page - 769
Question 41/106
Question #41
A 22-year-old male patient presents to your oce for evaluation regarding his 3 days of diarrhea.
You suspect a bacterial cause. Which of the following is the most common cause of acute bacterial
diarrhea?
a. E. coli O157:H7
b. Shigella dysentariae
c. Salmonella enterica
d. Campylobacter jejuni
e. C. dicile
Page - 770
Question 41/106
Question #41
A 22-year-old male patient presents to your oce for evaluation regarding his 3 days of diarrhea.
You suspect a bacterial cause. Which of the following is the most common cause of acute bacterial
diarrhea?
a. E. coli O157:H7
b. Shigella dysentariae
c. Salmonella enterica
d. Campylobacter jejuni √
e. C. dicile
Description
Campylobacter infection:
Campylobacter is the most common bacterial cause of infectious intestinal disease

Diagnosis is made by a positive stool culture but requires special media and handling
Clinical features:
Prodrome: headache, myalgia, and fevers (as high as 40°C)

Abdominal pain
Watery oensive diarrhea for 2 – 4 days, then become bloody
Treatment:
Usually, supportive treatment is adequate

Erythromycin or azithromycin can be used when there is a risk of complications
Page - 771
Question 42/106
Question #42
A 22-year-old male patient developed bloody diarrhea, abdominal cramping, and nausea 48 hours
aer returning from a camping trip. His stool study shows shigellosis. Which of the following is the
most important initial treatment for his condition?
a. Metronidazole
b. Fluid and electrolytes replacement
c. TMP/SMX
d. Ampicillin
e. Gastric lavage
Page - 772
Question 42/106
Question #42
A 22-year-old male patient developed bloody diarrhea, abdominal cramping, and nausea 48 hours
aer returning from a camping trip. His stool study shows shigellosis. Which of the following is the
most important initial treatment for his condition?
a. Metronidazole
b. Fluid and electrolytes replacement √
c. TMP/SMX
d. Ampicillin
e. Gastric lavage
Description
Shigellosis is an acute GI infection causing diarrhea. Symptoms include diarrhea, abdominal pain,
fever, nausea, and vomiting
In any kind of diarrhea, the priority is to maintain fluid status and electrolyte balance to avoid
dehydration and unwanted eects of fluid and electrolytes imbalance
Page - 773
Question 43/106
Question #43
the best diagnostic test to be ordered for this patient?
a. Blood culture
b. C dicile cytotoxin assay in stool
c. Colonoscopy
d. Gram stain and culture of the stool
e. Clindamycin serum level
Page - 774
Question 43/106
Question #43
the best diagnostic test to be ordered for this patient?
a. Blood culture
b. C dicile cytotoxin assay in stool √
c. Colonoscopy
d. Gram stain and culture of the stool
e. Clindamycin serum level
Description
C. dicile antibiotic-associated colitis (pseudomembranous colitis) should be suspected in any

patient who develops abdominal pain, diarrhea, and elevated white count aer the administration
of antibiotics.
Cytotoxin assay of the stool is the best test to order; it is sensitive and highly specific
A colonoscopy would show the classic Pseudomembranes, but it is invasive in this patient’s case.
Page - 775
Question 44/106
Question #44
A 29-year-old female with cellulitis started a course of clindamycin in the past 3 days. Unfortunately,
she came to you with bloody diarrhea. What is the first-line treatment for her condition?
a. Stop clindamycin and start oral metronidazole

b. Stop clindamycin and start oral vancomycin
c. Stop clindamycin and start intravenous vancomycin
d. Stop clindamycin and start intravenous metronidazole
e. Perform fecal microbiota transplant
Page - 776
Question 44/106
Question #44
A 29-year-old female with cellulitis started a course of clindamycin in the past 3 days. Unfortunately,
she came to you with bloody diarrhea. What is the first-line treatment for her condition?
a. Stop clindamycin and start oral metronidazole

b. Stop clindamycin and start oral vancomycin √
c. Stop clindamycin and start intravenous vancomycin
d. Stop clindamycin and start intravenous metronidazole
e. Perform fecal microbiota transplant
Description
Oral vancomycin has become the first-line treatment of pseudomembranous colitis.
In the past, oral metronidazole was the first line.
Treatment of pseudomembranous colitis:
If this is the first episode of Clostridium dicile infection

Oral vancomycin for 10 days (the first-line treatment)
Oral fidaxomicin (the second line)
Oral vancomycin and IV metronidazole (the third line)
If the patient has recurrent episodes:
Oral vancomycin and IV metronidazole
Consider surgery
Consider fecal microbiota transplant (if ≥ 2 episodes)
If fulminant or complicated disease is not responsive to the previous treatment, perform a

colectomy.
Page - 777
Question 45/106
Question #45
the most likely causative organism of this condition?
b. Giardia lamblia
c. Clostridium dicile
d. Salmonella
e. Rotavirus
Page - 778
Question 45/106
Question #45
the most likely causative organism of this condition?
b. Giardia lamblia
c. Clostridium dicile √
d. Salmonella
e. Rotavirus
Description
Pseudomembranous colitis is diarrhea that occurs as a result of antibiotic use due to the eradication
of the normal flora in the intestine leading to excessive growth of Clostridium dicile → release of a
toxin → bloody or watery diarrhea
Campylobacteriosis presents with a prodrome followed by diarrhea
Giardiasis presents with watery diarrhea, flatulence, and weight loss
Salmonella presents with bloody diarrhea.
Page - 779
Question 46/106
Question #46
A patient is diagnosed with traveler’s diarrhea, which of the following would be most eective in
treating this patient?
a. Amoxicillin
b. Ciprofloxacin
c. Erythromycin
d. Azithromycin
e. Ceriaxone
Page - 780
Question 46/106
Question #46
A patient is diagnosed with traveler’s diarrhea, which of the following would be most eective in
treating this patient?
a. Amoxicillin
b. Ciprofloxacin √
c. Erythromycin
d. Azithromycin
e. Ceriaxone
Description
Traveler’s diarrhea is most commonly but not exclusively caused by infection with E. coli in a traveler
person. Fluoroquinolones significantly reduce the duration and severity of traveler’s diarrhea when
given for 1 - 3 days.
Traveler’s diarrhea:
Traveler’s diarrhea occurs within 2 weeks of a visit to a tropical area

Usually, mild self-limiting diarrhea for less than 72 hours
Causes:
E. coli is the most common cause

Other causes: Shigella, Salmonella, Campylobacter, Giardia lamblia
Treatment:
Fluoroquinolones significantly reduce the duration and severity of traveler’s diarrhea when
given for 1 – 3 days.
Page - 781
Question 47/106
Question #47
A patient developed chronic watery diarrhea, weight loss, nausea, anorexia, and no fecal leukocytes.
Which of the following is the most likely diagnosis?
a. Amebiasis
b. Giardiasis
c. Salmonella
d. Shigellosis
e. Campylobacter jejuni
Page - 782
Question 47/106
Question #47
A patient developed chronic watery diarrhea, weight loss, nausea, anorexia, and no fecal leukocytes.
a. Amebiasis
b. Giardiasis √
c. Salmonella
d. Shigellosis
e. Campylobacter jejuni
Description
Giardiasis is an infection with the protozoa Giardia lamblia. e infection could be asymptomatic
and may present with chronic malabsorption and watery diarrhea
e stool will show no inflammatory process, and the diagnosis is achieved by identifying the
flagellated organism in the fresh stool or duodenal contents.
Giardia antigen in stool is diagnostic as well
e treatment is with metronidazole, tinidazole or nitazoxanide
Page - 783
Question 48/106
Question #48
A 44-year-old male patient presents with epigastric pain aer eating his dinner. What is the best
next step to take for this patient?
a. Start PPI
b. Standing Chest x-ray
c. Abdominal Ultrasound
d. Electrocardiography
e. H pylori test
Page - 784
Internal Medicine - Gastroenterology - Epigastric pain and dyspepsia
Question 48/106
Question #48
A 44-year-old male patient presents with epigastric pain aer eating his dinner. What is the best
next step to take for this patient?
a. Start PPI
b. Standing Chest x-ray
c. Abdominal Ultrasound
d. Electrocardiography √
e. H pylori test
Description
Myocardial infarction is the main concern in chest pain and epigastric pain. erefore, ECG should be
done on all patients with chest or epigastric pain to rule out myocardial infarction because it is the
most serious diagnosis.
Aer ruling out MI, you can check for GI causes of epigastric pain
Page - 785
Question 49/106
Question #49
A 33-year-old male patient has had epigastric pain and dyspepsia for 3 months. His H pylori test is
negative, and he doesn’t use NSAIDs. e patient was on esomeprazole 40mg daily for the last
month, but no improvement. Abdominal examination reveals mild epigastric tenderness. What is
the best next step in the management of this patient?
a. Repeat H pylori test again

b. Increase esomeprazole to twice daily
c. Change to another PPI
d. Perform an upper endoscopy
e. Start triple therapy
Page - 786
Question 49/106
Question #49
negative, and he doesn’t use NSAIDs. e patient was on esomeprazole 40mg daily for the last
month, but no improvement. Abdominal examination reveals mild epigastric tenderness. What is
the best next step in the management of this patient?

b. Increase esomeprazole to twice daily √
Description
is is a patient who is suering from dyspepsia. e patient is less than 55-year-old and has no red
flags
In a patient with dyspepsia, less than 55-year-old and no red flags:
Try lifestyle changes and antacids

If there is no improvement and a negative H pylori test, start PPI for 4 weeks
If there is no improvement and a positive H pylori test, start PPI and H pylori eradication
If there is no improvement aer 4 weeks of PPI, start twice-daily PPI for additional 4 weeks
If there is no improvement, do an upper endoscopy
Page - 787
Question 50/106
Question #50
A 30-year-old male patient presents with epigastric pain aggravated by food for the past 2 weeks. He
denies vomiting blood or blood in the stool. Considering the most likely diagnosis, what is the most
common upper endoscopy finding in this case?
a. Gastritis
b. Gastric Ulceration
c. Duodenal ulceration
d. Gastric cancer
e. Normal endoscopy
Page - 788
Question 50/106
Question #50
A 30-year-old male patient presents with epigastric pain aggravated by food for the past 2 weeks. He
denies vomiting blood or blood in the stool. Considering the most likely diagnosis, what is the most
common upper endoscopy finding in this case?
a. Gastritis
b. Gastric Ulceration
c. Duodenal ulceration
d. Gastric cancer
e. Normal endoscopy √
Description
Functional dyspepsia is the most likely diagnosis in this patient. It presents with epigastric pain and
dyspepsia along with normal mucosa on upper endoscopy
Page - 789
Question 51/106
Question #51
A 66-year-old male patient has had increasing dyspepsia and dysphagia for the past 3 months. ese
symptoms are associated with 10 kg weight loss. What is the most important investigation that
leads to the diagnosis?
a. Barium swallow
b. Chest x-ray
c. Upper endoscopy
e. 24-hours PH monitoring
Page - 790
Question 51/106
Question #51
A 66-year-old male patient has had increasing dyspepsia and dysphagia for the past 3 months. ese
symptoms are associated with 10 kg weight loss. What is the most important investigation that
leads to the diagnosis?
a. Barium swallow
b. Chest x-ray
c. Upper endoscopy √
e. 24-hours PH monitoring
Description
is patient is older than 55 years, has weight loss (a red flag), and has unexplained dyspepsia.
Any patient older than 55 years or those with alarming symptoms should have upper endoscopy
regardless of the results of H pylori testing.
Endoscopy here is indicated to rule out malignant conditions.
Page - 791
Question 52/106
Question #52
negative, and he doesn’t use NSAIDs. e patient was on esomeprazole 40mg twice daily for the last
two months, but no improvement. Abdominal examination reveals mild epigastric tenderness.
What is the best next step in the management of this patient?

Page - 792
Question 52/106
Question #52
negative, and he doesn’t use NSAIDs. e patient was on esomeprazole 40mg twice daily for the last
two months, but no improvement. Abdominal examination reveals mild epigastric tenderness.

d. Perform an upper endoscopy √
Description
is is a patient who is suering from dyspepsia. e patient is less than 55-year-old and has no red
flags
In a patient with dyspepsia, less than 55-year-old and no red flags:
Try lifestyle changes and antacids

If there is no improvement and a negative H pylori test, start PPI for 4 weeks
If there is no improvement and a positive H pylori test, start PPI and H pylori eradication
If there is no improvement aer 4 weeks of PPI, start twice-daily PPI for additional 4 weeks
If there is no improvement, do an upper endoscopy
Page - 793
Question 53/106
Question #53
A 62-year-old male has had recurrent pain in the epigastrium for 2 months. e pain increases aer
food and is better on an empty stomach. What is the most appropriate to perform at this point?
a. Barium swallow
b. Stool antigen test for H pylori
c. Serology test for H pylori
d. Upper endoscopy
e. Start PPI
Page - 794
Question 53/106
Question #53
A 62-year-old male has had recurrent pain in the epigastrium for 2 months. e pain increases aer
food and is better on an empty stomach. What is the most appropriate to perform at this point?
a. Barium swallow
b. Stool antigen test for H pylori
c. Serology test for H pylori
d. Upper endoscopy √
e. Start PPI
Description
is patient is older than 55 years, and he has unexplained dyspepsia.
Any patient older than 55 years or those with alarming symptoms should have upper endoscopy
regardless of the results of H pylori testing.
Endoscopy here is indicated to rule out malignant conditions.
Page - 795
Question 54/106
Question #54
An alcoholic 33-year-old male patient presents with three episodes of bloody vomiting associated
with epigastric pain. He denies weight loss, anorexia, or night sweating. His physical examination is
normal except for epigastric tenderness on deep palpation. His ECG and cardiac enzymes are
normal. What is the next step to do with this patient?
a. Start lansoprazole
b. Test for H pylori
c. Upper endoscopy
d. Repeat ECG and cardiac enzymes
e. Provide liquid antacids
Page - 796
Question 54/106
Question #54
An alcoholic 33-year-old male patient presents with three episodes of bloody vomiting associated
with epigastric pain. He denies weight loss, anorexia, or night sweating. His physical examination is
normal except for epigastric tenderness on deep palpation. His ECG and cardiac enzymes are
normal. What is the next step to do with this patient?
a. Start lansoprazole
b. Test for H pylori √
c. Upper endoscopy
d. Repeat ECG and cardiac enzymes
e. Provide liquid antacids
Description
e most likely diagnosis in this patient is gastritis vs. peptic ulcer disease.
Alcoholism is the leading risk factor in this case
Test and treatment strategy for H pylori is the best next step for this patient
Page - 797
Question 55/106
Question #55
A 50-year-old lady has retrosternal chest pain and dysphagia, which is unpredictable and
intermittent. She feels the food stuck in her chest and has to clear it by drinking water. A barium
swallow shows a corkscrew pattern. What is the most likely diagnosis?
a. Achalasia
b. Esophageal spasm
c. Reflux esophagitis
d. Oropharyngeal dysphagia
e. Esophageal stricture
Page - 798
Internal Medicine - Gastroenterology - Esophageal spasm
Question 55/106
Question #55
swallow shows a corkscrew pattern. What is the most likely diagnosis?
a. Achalasia
b. Esophageal spasm √
d. Oropharyngeal dysphagia
e. Esophageal stricture
Description
Esophageal spasm is a motility disorder of the esophagus resulting in high-pressure peristalsis.
It is associated with dysphagia that is more prominent on drinking cold or hot liquids
Clinical features include chest pain (which may be typical) and dysphagia to solids and liquids
A barium swallow will demonstrate a Corkscrew appearance in the esophagus
Nitrates and calcium channel blockers are the most appropriate medical treatment for this
condition
Page - 799
Question 56/106
Question #56
A 33-year-old male has had central chest pain for 1 hour related to drinking a cold drink. e patient
is previously healthy, his ECG shows no acute changes, his cardiac enzymes are flat, and his vital
signs are within normal limits. What is the most likely diagnosis?

b. Acute pericarditis
c. Pneumothorax
d. Esophageal spasm
e. Pulmonary embolism
Page - 800
Question 56/106
Question #56
A 33-year-old male has had central chest pain for 1 hour related to drinking a cold drink. e patient
is previously healthy, his ECG shows no acute changes, his cardiac enzymes are flat, and his vital
signs are within normal limits. What is the most likely diagnosis?

b. Acute pericarditis
c. Pneumothorax
d. Esophageal spasm √
Description
condition
Page - 801
Question 57/106
Question #57
meal shows a corkscrew pattern. What is the most appropriate medical treatment to start at this
point?
a. Aspirin
b. Lansoprazole
c. Nifedipine
d. Enoxaparin
e. Amoxicillin
Page - 802
Question 57/106
Question #57
meal shows a corkscrew pattern. What is the most appropriate medical treatment to start at this
point?
a. Aspirin
b. Lansoprazole
c. Nifedipine √
d. Enoxaparin
e. Amoxicillin
Description
condition
Page - 803
Question 58/106
Question #58
A 33-year-old male patient complains of dysphagia and oral thrush. His medical history is significant
for HIV infection. What is the most appropriate next step?
a. Perform upper endoscopy and esophageal biopsy

b. Start treatment with Fluconazole
c. Start treatment with PPIs
d. Start treatment with Ganciclovir
e. Start treatment with acyclovir
Page - 804
Internal Medicine - Gastroenterology - Esophagitis
Question 58/106
Question #58
A 33-year-old male patient complains of dysphagia and oral thrush. His medical history is significant
for HIV infection. What is the most appropriate next step?
a. Perform upper endoscopy and esophageal biopsy

b. Start treatment with Fluconazole √
c. Start treatment with PPIs
d. Start treatment with Ganciclovir
e. Start treatment with acyclovir
Description
Candida albicans: is a normal commensal of mouth

It can cause oral thrush and esophagitis in immune-suppressed patients (e.g., DM, Steroid
users, HIV)
In an immunosuppressed patient with oral thrush and odynophagia, treat for candidiasis
without doing an upper endoscopy.
e absence of oral thrush does not rule out esophageal candidiasis
Fluconazole or Itraconazole ae the treatment of choice for candidiasis
Page - 805
Question 59/106
Question #59
e following agents are known to induce esophagitis except:
a. Tetracycline
b. Alendronate
c. NSAIDs
d. Quinidine
e. Lansoprazole
Page - 806
Question 59/106
Question #59
e following agents are known to induce esophagitis except:
a. Tetracycline
b. Alendronate
c. NSAIDs
d. Quinidine
e. Lansoprazole √
Description
Proton pump inhibitors are not known to cause drug-induced esophagitis
e following agents may cause Drug-induced esophagitis:
Potassium supplements
NSAIDs
Tetracyclines
Bisphosphonates
Page - 807
Question 60/106
Question #60
A 22-year-old male patient presents to your oce with recurrent dull aching chest pain for 6
months, associated with a bitter taste in his mouth. ere is no exercise intolerance, and his physical
examination and lab investigations are normal. What is the most likely diagnosis?
a. Myocardial ischemia
b. Muscular chest pain
d. Pneumonia
e. Anxiety
Page - 808
Question 60/106
Question #60
A 22-year-old male patient presents to your oce with recurrent dull aching chest pain for 6
months, associated with a bitter taste in his mouth. ere is no exercise intolerance, and his physical
examination and lab investigations are normal. What is the most likely diagnosis?
a. Myocardial ischemia
b. Muscular chest pain
c. Reflux esophagitis √
d. Pneumonia
e. Anxiety
Description
e most common non-cardiac cause of chest pain is GI pain. Note that the bitter taste in his mouth
will support the diagnosis of GERD, and esophageal esophagitis is the most likely diagnosis
Myocardial ischemia presents in older ages with risk factors and with an exertional chest pain
Pneumonia comes with fever, cough, and sputum, along with the chest pain.
Page - 809
Question 61/106
Question #61
A 22-year-old male patient has had intermittent and dull chest pain for the past 6 months. e pain
usually occurs at night, is associated with a bitter taste, and is unrelated to exercise. Physical
examination is normal. Which one of the following is the most likely diagnosis?
a. Generalized anxiety disorder

b. Transient myocardial ischemia
d. Myocardial infarction
e. Costochondritis
Page - 810
Internal Medicine - Gastroenterology - Gastroesophageal Reflux Disease (GERD)
Question 61/106
Question #61
A 22-year-old male patient has had intermittent and dull chest pain for the past 6 months. e pain
usually occurs at night, is associated with a bitter taste, and is unrelated to exercise. Physical
examination is normal. Which one of the following is the most likely diagnosis?
a. Generalized anxiety disorder

b. Transient myocardial ischemia
c. Reflux esophagitis √
d. Myocardial infarction
e. Costochondritis
Description
A central chest pain related to food and a bitter taste is most likely due to reflux-induced
esophagitis. CAD chest pain is usually related to exertion. Costochondritis is associated with chest
wall tenderness.
Gastroesophageal reflux disease (GERD):
Reflux disease: reflux of gastric acidity to the esophagus.

It happens due to inappropriate relaxation of the lower esophageal sphincter (LES)
Heartburn is the most common symptom
Gastric content regurgitation, Chest pain, and respiratory symptoms may manifest.
Hoarseness, metallic taste, and dental caries are not uncommon in GERD, but dysphagia is a
late sign.
e typical features and the improvement aer the trial of Proton pump inhibitors are usually
diagnostic, but 24-hour PH Monitoring is the best investigation
Upper endoscopy is indicated if the patient has any alarming symptoms.
Page - 811
Question 62/106
Question #62
A 32-year-old female presents to your oce with a 6-month history of cough. She denies fever,
weight loss, heartburn, or regurgitation of food. Her physical examination is unremarkable.
However, a trial of Salbutamol and antihistamine doesn’t improve the patient’s condition. What
would you do next?
a. Methacholine challenge test

b. Pulmonary function test
c. Chest high-resolution CT scan
d. A trial of PPI
e. 24-hour PH monitoring of the esophagus
Page - 812
Question 62/106
Question #62
A 32-year-old female presents to your oce with a 6-month history of cough. She denies fever,
weight loss, heartburn, or regurgitation of food. Her physical examination is unremarkable.
However, a trial of Salbutamol and antihistamine doesn’t improve the patient’s condition. What
would you do next?

c. Chest high-resolution CT scan
d. A trial of PPI √
e. 24-hour PH monitoring of the esophagus
Description
In patients with chronic cough and no suggestive signs or symptoms of respiratory or cardiac
disorder, using a twice-daily PPI for 3 months does demonstrate the causal relationship between
GERD and extraesophageal symptoms
e lack of response to SABA will rule out asthma, so the methacholine challenge test is not
indicated
ere is no suggestive history of lung disease in this patient, making PFT and Chest CT not indicated
at this time
Despite that, it is the most accurate test, but an initial therapeutic trial of proton pump inhibitors is
favored over 24-hour pH monitoring because it is less uncomfortable to the patient and has a better
clinical correlation.

late sign. Page - 813
Page - 814
Question 63/106
Question #63
A non-smoker 33-year-old male presents to your oce with recurrent wheezing for the past month.
He has no history of asthma or any medical illness. However, on examination, the patient has
hoarseness of voice and a red, inflamed larynx. What is the initial treatment of this patient’s
condition?
a. Antibiotics
b. Proton pump inhibitors
c. Steroids
d. Albuterol inhaler
e. Salmeterol inhaler
Page - 815
Question 63/106
Question #63
A non-smoker 33-year-old male presents to your oce with recurrent wheezing for the past month.
He has no history of asthma or any medical illness. However, on examination, the patient has
hoarseness of voice and a red, inflamed larynx. What is the initial treatment of this patient’s
condition?
a. Antibiotics
b. Proton pump inhibitors √
c. Steroids
d. Albuterol inhaler
e. Salmeterol inhaler
Description
e hoarseness of voice, inflamed larynx, and wheezes in the chest are extraesophageal
manifestations of GERD. erefore, the trial of PPI is the best initial treatment for this patient.

late sign.
Page - 816
Question 64/106
Question #64
A 39-year-old male patient has chronic cough for 6 months. ere is no fever, weight loss, or any
systemic manifestations. Auscultation of the lungs shows no evidence of acute disease. However, a
trial of inhaled bronchodilator doesn’t improve the symptoms. What is the most appropriate next
step?

c. Chest CT scan
d. A trial of proton pump inhibitor (PPI)
e. A 24-hours PH monitoring
Page - 817
Question 64/106
Question #64
A 39-year-old male patient has chronic cough for 6 months. ere is no fever, weight loss, or any
systemic manifestations. Auscultation of the lungs shows no evidence of acute disease. However, a
trial of inhaled bronchodilator doesn’t improve the symptoms. What is the most appropriate next
step?

c. Chest CT scan
d. A trial of proton pump inhibitor (PPI) √
e. A 24-hours PH monitoring
Description
is patient is typical for GERD; you have to try PPI.
A positive response to PPI indicates a higher probability of GERD.
Note that 24-hour PH monitoring is the most accurate test to diagnose GERD.
A pulmonary function test and methacholine challenge test are used when asthma is the most likely
diagnosis. e patient’s unresponsiveness to bronchodilators excludes asthma.

late sign.
Page - 818
Question 65/106
Question #65
A 62-year-old diabetic male patient presents with nausea, postprandial bloating, and early satiety
for 2 months. ere is no abdominal pain or heartburn. Physical examination and lab investigations
are all unremarkable. Which one of the following would help confirm the most likely diagnosis?
a. 24-hours PH monitoring
b. Abdominal ultrasound
c. Gastric emptying scintigraphy
d. H. pylori serology test
e. Upper endoscopy
Page - 819
Internal Medicine - Gastroenterology - Gastroparesis
Question 65/106
Question #65
are all unremarkable. Which one of the following would help confirm the most likely diagnosis?
a. 24-hours PH monitoring
b. Abdominal ultrasound
c. Gastric emptying scintigraphy √
d. H. pylori serology test
e. Upper endoscopy
Description
is patient is most likely suering from autonomic diabetic neuropathy causing gastroparesis. It
can be confirmed by a nuclear gastric emptying study
Gastroparesis:
It is a defective gastric emptying but without obstruction.

It can be an inherited or acquired disorder of the gastric pacemaker or an autonomic disorder
Longstanding diabetes leads to gastric dysmotility is the most common cause
e diagnosis is clinical, but a gastric emptying nuclear study is accurate and helpful in
showing reduced gastric emptying in these patients.
e treatment is achieved by drugs that enhance gastric emptying (e.g., erythromycin and
metoclopramide)
Page - 820
Question 66/106
Question #66
are all unremarkable. What is the next step in the management of this patient?
a. Domperidone
b. Omeprazole
c. H pylori eradication
d. Erythromycin
e. Famotidine
Page - 821
Internal Medicine - Gastroenterology - Gastroparesis
Question 66/106
Question #66
are all unremarkable. What is the next step in the management of this patient?
a. Domperidone
b. Omeprazole
c. H pylori eradication
d. Erythromycin √
e. Famotidine
Description
is patient is most likely suering from autonomic diabetic neuropathy causing gastroparesis. e
treatment is achieved by increasing gastric emptying by using erythromycin or metoclopramide
Gastroparesis:
It is a defective gastric emptying but without obstruction.

It can be an inherited or acquired disorder of the gastric pacemaker or an autonomic disorder
Longstanding diabetes leads to gastric dysmotility is the most common cause
e diagnosis is clinical, but a gastric emptying nuclear study is accurate and helpful in
showing reduced gastric emptying in these patients.
e treatment is achieved by drugs that enhance gastric emptying (e.g., erythromycin and
metoclopramide)
Page - 822
Question 67/106
Question #67
A 32-year-old female from Irbid, Jordan, presents to you with dyspepsia. She was diagnosed with a
duodenal ulcer secondary to H pylori. Which of the following would be the preferred treatment
option for her condition?
a. Lansoprazole alone
b. Combined antibiotics and PPI
c. Surgical management
d. Famotidine
e. Liquid aluminum-containing antacids
Page - 823
Internal Medicine - Gastroenterology - H. pylori Infection
Question 67/106
Question #67
A 32-year-old female from Irbid, Jordan, presents to you with dyspepsia. She was diagnosed with a
duodenal ulcer secondary to H pylori. Which of the following would be the preferred treatment
option for her condition?
a. Lansoprazole alone
b. Combined antibiotics and PPI √
c. Surgical management
d. Famotidine
e. Liquid aluminum-containing antacids
Description
H pylori is a bacterium that is highly resistant to antibiotics. It needs a combination of more than
one antibiotic along with PPI to eradicate it.
angularis)
NSAIDs
present.
Page - 824
Question 68/106
Question #68
A 35-year-old female has H pylori infection and epigastric pain. She has been treated for 14 days with
amoxicillin, clarithromycin, and lansoprazole. She is now asymptomatic. Which of the following is
recommended to test for H pylori eradication?

b. Rapid ureas test
c. IgG serology test
d. Barium meal
e. Stool antigen test
Page - 825
Question 68/106
Question #68
A 35-year-old female has H pylori infection and epigastric pain. She has been treated for 14 days with
amoxicillin, clarithromycin, and lansoprazole. She is now asymptomatic. Which of the following is
recommended to test for H pylori eradication?

b. Rapid ureas test
c. IgG serology test
d. Barium meal
e. Stool antigen test √
Description
A serology test is not appropriate to test for H pylori eradication because once positive, it will be
positive for a long time and will give a false-positive result.
It is too aggressive to use endoscopic tests. erefore, they are not indicated as there are no alarm
symptoms, and the patient is not elderly.
Barium meal has no rule in evaluating H pylori infection or its follow-up.
Page - 826
Question 69/106
Question #69
An endoscopy result of a 40-year-old male patient reveals gastritis and H pylori infection. What is
the standard treatment for this condition?
a. Amoxicillin-clavulanate, famotidine, and bismuth

b. Erythromycin, omeprazole, and metronidazole
c. Esomeprazole, Amoxicillin, and Clarithromycin
d. Fluconazole, omeprazole and metronidazole
e. Lansoprazole, omeprazole and metronidazole
Page - 827
Question 69/106
Question #69
An endoscopy result of a 40-year-old male patient reveals gastritis and H pylori infection. What is
the standard treatment for this condition?
a. Amoxicillin-clavulanate, famotidine, and bismuth

b. Erythromycin, omeprazole, and metronidazole
c. Esomeprazole, Amoxicillin, and Clarithromycin √
d. Fluconazole, omeprazole and metronidazole
e. Lansoprazole, omeprazole and metronidazole
Description
Treatment of H. pylori:
Triple therapy:
e first line of treatment
PPI bid, amoxicillin 1g bid, and clarithromycin 500 mg bid for 7 – 14 days
Quadruple therapy:
PPI + metronidazole + tetracycline + bismuth.
Indicated in the probability of clarithromycin resistance or penicillin allergy
Levofloxacin-based therapy: PPI bid + amoxicillin 1g bid + levofloxacin 500 mg qday for 10 – 14
days.
Page - 828
Question 70/106
Question #70
A 32-year-old male patient presents with epigastric pain related to eating. Upper endoscopy showed
a duodenal ulcer, and the test for H pylori was positive. Which is the best treatment option?
a. Metronidazole
b. Lansoprazole
c. Clarithromycin and amoxicillin
d. Metronidazole and amoxicillin
e. Lansoprazole, clarithromycin, and amoxicillin
Page - 829
Question 70/106
Question #70
A 32-year-old male patient presents with epigastric pain related to eating. Upper endoscopy showed
a duodenal ulcer, and the test for H pylori was positive. Which is the best treatment option?
a. Metronidazole
b. Lansoprazole
c. Clarithromycin and amoxicillin
d. Metronidazole and amoxicillin
e. Lansoprazole, clarithromycin, and amoxicillin √
Description
e triple therapy of amoxicillin, clarithromycin, and PPIs is the best initial treatment for H pylori
infection
Note that H pylori are resistant bacteria to most antibiotics and should be treated with a
combination of more than one antibiotic.
Triple therapy:
Quadruple therapy:
days.
Page - 830
Question 71/106
Question #71
A 32-year-old male patient was treated by triple therapy for H pylori infection 2 months ago, and
now he is asymptomatic. Another H pylori serology test was done yesterday, which came back
positive. What is the best management at this time?
a. Repeat the triple therapy

b. Start quadrable therapy
c. Start Levofloxacin-based therapy
e. Reassurance
Page - 831
Question 71/106
Question #71
A 32-year-old male patient was treated by triple therapy for H pylori infection 2 months ago, and
now he is asymptomatic. Another H pylori serology test was done yesterday, which came back
positive. What is the best management at this time?
a. Repeat the triple therapy

b. Start quadrable therapy
c. Start Levofloxacin-based therapy
e. Reassurance √
Description
Once it becomes positive, the serology test for H pylori will be positive for a long time (maybe for
more than 3 years), even in the absence of the bacteria itself
For follow-up of H pylori eradication, perform a stool antigen test or urea breath test instead of a
serology test.
Triple therapy:
Quadruple therapy:
days.
Page - 832
Question 72/106
Question #72
A 33-year-old male presented to you with a complaint of heartburn and reflux. e patient has no
altered bowel habits, dysphagia, night sweating, or weight loss. His history is only significant for H
pylori infection that was eradicated successfully. What is the most appropriate test to ensure the
eradication of the H pylori infection?
a. H pylori antibodies
c. C13 urea breath test
d. Blood culture for H pylori
e. Symptomatic response to PPI
Page - 833
Question 72/106
Question #72
A 33-year-old male presented to you with a complaint of heartburn and reflux. e patient has no
altered bowel habits, dysphagia, night sweating, or weight loss. His history is only significant for H
pylori infection that was eradicated successfully. What is the most appropriate test to ensure the
eradication of the H pylori infection?
a. H pylori antibodies
c. C13 urea breath test √
d. Blood culture for H pylori
e. Symptomatic response to PPI
Description
e question here is about H pylori eradication. e C13 urea breath test is the most appropriate of
the mentioned choices.
Serum antibodies for H pylori may remain positive for a long time in 50% of cases of H pylori, even
eradicated.
Upper endoscopy is not indicated in this patient because he is younger than 55-year-old, and there
are no alarming symptoms.
Blood culture is not used to diagnose H pylori infection or eradication.
Page - 834
Question 73/106
Question #73
A 22-year-old female is on sulfasalazine for Ulcerative colitis. She complains of severe diarrhea 7 – 9
times a day, abdominal pain, and fecal urgency. On examination, the abdomen is tender but not
distended and has no palpable masses. In addition, her temperature is 38.5 °C, her heart rate is 103
bpm, and her blood pressure is normal. What is the next step in the management of this patient?
a. Abdominal x-ray
b. Colonoscopy
c. Stool culture and sensitivity
d. Urgent laparotomy
e. Abdominal CT angiography
Page - 835
Internal Medicine - Gastroenterology - Inflammatory Bowel Diseases (IBD)
Question 73/106
Question #73
times a day, abdominal pain, and fecal urgency. On examination, the abdomen is tender but not
a. Abdominal x-ray √
b. Colonoscopy
c. Stool culture and sensitivity
d. Urgent laparotomy
Description
is lady has acute severe Ulcerative colitis (UC) relapse.
Abdominal x-ray is the best next step in investigating the complications of Ulcerative colitis (to rule
out toxic megacolon)
If the question asks about the best treatment to induce remission, intravenous steroids should be
used.
Page - 836
Question 74/106
Question #74
A patient has been diagnosed with Crohn’s disease. All the following complications are more
common in Crohn’s disease than Ulcerative colitis except:
a. Fistula formation
b. Perianal abscess
c. Malabsorption
d. Intestinal obstruction
e. Toxic megacolon
Page - 837
Question 74/106
Question #74
A patient has been diagnosed with Crohn’s disease. All the following complications are more
common in Crohn’s disease than Ulcerative colitis except:
a. Fistula formation
b. Perianal abscess
c. Malabsorption
d. Intestinal obstruction
e. Toxic megacolon √
Description
Toxic megacolon is a severe life-threatening complication of IBD seen more commonly in UC,
characterized by dilatation of the colon with a risk of rupture
Clinical features:
Abdominal pain
Abdominal distension
Fever
Shock, tachycardia
Treatment:
Treatment of the cause

Bowel decompression
IV fluid and electrolytes to prevent dehydration
Surgery (Colectomy) if no improvement within 48 – 72 hours
Page - 838
Question 75/106
Question #75
A 23-year-old female has chronic abdominal pain and diarrhea. Her rectal biopsy results show a
reduced number of goblet cells. What is the most likely diagnosis?
e. Pseudomembranous colitis
Page - 839
Question 75/106
Question #75
A 23-year-old female has chronic abdominal pain and diarrhea. Her rectal biopsy results show a
reduced number of goblet cells. What is the most likely diagnosis?
a. Ulcerative colitis √
Description
e reduced goblet cells is a histological sign of ulcerative colitis.
Goblet cells are increased in Crohn’s disease.
e following table shows the dierence between UC and CD.
Page - 840
Question 76/106
Question #76
A 33-year-old female complains of intermittent bloody diarrhea, tenesmus, and abdominal pain.
a. Irritable bowel syndrome

b. Bowel cancer
d. Endometriosis
e. Giardiasis
Page - 841
Question 76/106
Question #76
A 33-year-old female complains of intermittent bloody diarrhea, tenesmus, and abdominal pain.
a. Irritable bowel syndrome

b. Bowel cancer
c. Inflammatory bowel disease √
d. Endometriosis
e. Giardiasis
Description
is history suggests inflammatory bowel disease (IBD) as the most likely diagnosis.
Bowel cancer is unlikely to present in this age group.
Irritable bowel syndrome never presents with bloody diarrhea
Endometriosis presents with infertility, dysmenorrhea, and dyspareunia
Giardiasis presents with watery diarrhea, not bloody diarrhea.
Page - 842
Question 77/106
Question #77
A 23-year-old female has chronic abdominal pain and diarrhea. Her colonoscopy and biopsy show a
crypt abscess. What is the most likely diagnosis?
Page - 843
Question 77/106
Question #77
A 23-year-old female has chronic abdominal pain and diarrhea. Her colonoscopy and biopsy show a
crypt abscess. What is the most likely diagnosis?
Description
Crypt abscess is typical of Ulcerative colitis.
e following table shows the dierence between UC and CD.
Page - 844
Question 78/106
Question #78
A 39-year-old male with a known case of Crohn’s disease suers from low back pain. In addition, the
patient reports morning stiness in his back that is relieved aer getting up and doing some
exercises or by having a hot shower. What is the most likely cause of his pain?
a. Spondyloarthritis
b. Osteoarthritis
c. Osteoporosis
d. Avascular necrosis
e. Metastasis of colon cancer
Page - 845
Question 78/106
Question #78
A 39-year-old male with a known case of Crohn’s disease suers from low back pain. In addition, the
patient reports morning stiness in his back that is relieved aer getting up and doing some
exercises or by having a hot shower. What is the most likely cause of his pain?
a. Spondyloarthritis √
b. Osteoarthritis
c. Osteoporosis
d. Avascular necrosis
e. Metastasis of colon cancer
Description
Seronegative Spondyloarthritis is a well-known extra-intestinal manifestation of Crohn’s disease.
It may be characterized by back pain and limitation of spinal movement.
is kind of arthritis aects the large joints more than the small ones and has a negative RA factor in
the serology tests.
Page - 846
Question 79/106
Question #79
times daily, abdominal pain, and fecal urgency. On examination, the abdomen is tender but not
a. Mesalazine enema
b. Increase the dose of sulfasalazine
c. Intravenous hydrocortisone
d. Oral prednisolone
e. intravenous metronidazole
Page - 847
Question 79/106
Question #79
times daily, abdominal pain, and fecal urgency. On examination, the abdomen is tender but not
a. Mesalazine enema
b. Increase the dose of sulfasalazine
c. Intravenous hydrocortisone √
d. Oral prednisolone
e. intravenous metronidazole
Description
is lady has acute severe Ulcerative colitis (UC) relapse.
Intravenous steroid here is indicated to induce remission.
e following table shows the treatment options for Ulcerative colitis.
Page - 848
Question 80/106
Question #80
A 25-year-old male patient has had abdominal pain and diarrhea for 4 months. His lower endoscopy
demonstrates Deep ulcerations and skip lesions. What is the most likely diagnosis?
Page - 849
Question 80/106
Question #80
demonstrates Deep ulcerations and skip lesions. What is the most likely diagnosis?
b. Crohn’s disease √
Description
Crohn’s disease is characterized by transmural inflammation and skip lesions.
Ulcerative colitis is a superficial and continuous disease.
e following table shows the dierence between CD and UC.
Page - 850
Question 81/106
Question #81
demonstrates a cobblestone appearance. What is the most likely diagnosis?
Page - 851
Question 81/106
Question #81
demonstrates a cobblestone appearance. What is the most likely diagnosis?
b. Crohn’s disease √
Description
is is a direct clinical scenario of Crohn’s disease.
e cobblestone appearance of the mucosa is pathognomonic for Crohn’s disease.
Page - 852
Question 82/106
Question #82
A 24-year-old female complains of progressive abdominal pain, abdominal distension, and fever for
a few days. However, the patient has suered from abdominal discomfort, chronic diarrhea, and
malaise for several months. An erect abdominal x-ray shows dilated transverse colon and
edematous mucosa. Her lab investigations show high WBC, positive CRP, and mild microcytic
anemia. What is the most likely diagnosis?
b. C. dicile diarrhea
c. Ulcerative colitis
d. Ischemia colitis
e. Celiac disease
Page - 853
Question 82/106
Question #82
A 24-year-old female complains of progressive abdominal pain, abdominal distension, and fever for
a few days. However, the patient has suered from abdominal discomfort, chronic diarrhea, and
malaise for several months. An erect abdominal x-ray shows dilated transverse colon and
edematous mucosa. Her lab investigations show high WBC, positive CRP, and mild microcytic
anemia. What is the most likely diagnosis?
b. C. dicile diarrhea
c. Ulcerative colitis √
d. Ischemia colitis
e. Celiac disease
Description
Positive CRP and high WBC indicate an active inflammatory process that is with the clinical scenario,
suggestive of inflammatory bowel disease
is is a classic presentation of Ulcerative colitis complicated by toxic megacolon.
C. dicile diarrhea is usually present aer the use of antibiotics.
Crohn’s disease is less likely to present with toxic megacolon.
Page - 854
Question 83/106
Question #83
A 22-year-old female is suspected of having ulcerative colitis. Which of the following is the most
likely finding in barium enema?
a. Loss of haustrations
b. Rose thorn ulcer
c. Intestinal fistula
d. Intestinal stricture
e. Cobblestone appearance
Page - 855
Question 83/106
Question #83
A 22-year-old female is suspected of having ulcerative colitis. Which of the following is the most
likely finding in barium enema?
a. Loss of haustrations √
b. Rose thorn ulcer
c. Intestinal fistula
d. Intestinal stricture
e. Cobblestone appearance
Description
Loss of haustral markings is pathognomonic for Ulcerative colitis
Fistula, stricture, cobblestone appearance, and rose thorn ulcer are seen in the small bowel in
Crohn’s disease, not ulcerative colitis.
Page - 856
Question 84/106
Question #84
A 32-year-old female complains of abdominal pain and chronic diarrhea. Which of the following
suggests Crohn’s disease rather than ulcerative colitis?
a. Crypt abscess
b. Positive CRP
c. Pseudomembranes
d. Colonic mucosal involvement
e. Non-caseating granuloma
Page - 857
Question 84/106
Question #84
A 32-year-old female complains of abdominal pain and chronic diarrhea. Which of the following
suggests Crohn’s disease rather than ulcerative colitis?
a. Crypt abscess
b. Positive CRP
c. Pseudomembranes
d. Colonic mucosal involvement
e. Non-caseating granuloma √
Description
Noncaseating granuloma is pathognomonic for Crohn’s disease.
Crypt abscesses are typical of Ulcerative colitis.
Colonic mucosa can be involved in both CD and UC
CRP is not specific and can be elevated in any inflammatory disease
Pseudomembranes suggest the presence of C. dicile infection.
Page - 858
Question 85/106
Question #85
A 22-year-old male has complained of bloody diarrhea with mucous 4 times a day for 2 months
associated with abdominal pain. However, the patient denies weight loss. Colonoscopy was
performed. What is the most likely to be found in this patient?
c. Intestinal TB
d. Intestinal lymphoma
e. Colorectal carcinoma
Page - 859
Question 85/106
Question #85
A 22-year-old male has complained of bloody diarrhea with mucous 4 times a day for 2 months
associated with abdominal pain. However, the patient denies weight loss. Colonoscopy was
performed. What is the most likely to be found in this patient?
c. Intestinal TB
d. Intestinal lymphoma
e. Colorectal carcinoma
Description
e two main types of inflammatory bowel disease are Crohn’s disease (CD) and Ulcerative colitis
(UC).
Ulcerative colitis is more likely to present with bloody diarrhea and is usually not associated with
weight loss or malabsorption.
e best initial treatment in UC is mesalazine
Page - 860
Question 86/106
Question #86
A 19-year-old female complains of abdominal pain and bloody diarrhea. In addition, she has a
significant weight loss. However, her upper endoscopy, abdominal x-ray, and ultrasound are
unremarkable except for a thick intestinal wall. What is the most appropriate next step in the
management?
a. Colonoscopy
b. Abdominal CT scan
c. Stool analysis and culture
d. Repeat the upper endoscopy
Page - 861
Question 86/106
Question #86
A 19-year-old female complains of abdominal pain and bloody diarrhea. In addition, she has a
significant weight loss. However, her upper endoscopy, abdominal x-ray, and ultrasound are
unremarkable except for a thick intestinal wall. What is the most appropriate next step in the
management?
a. Colonoscopy √
c. Stool analysis and culture
d. Repeat the upper endoscopy
Description
is patient is suspected of having Crohn’s disease (CD).
CD most commonly aects the terminal ileum and colon but can occur in any part of the GI tract.
Colonoscopy with biopsy and barium contrast studies are used in the diagnosis of CD
A colonoscopy with biopsy is the most accurate and the best next step in this patient.
Page - 862
Question 87/106
Question #87
A 33-year-old male patient has complained of abdominal pain, weight loss, and diarrhea for 6
months. on examination, you noted clubbing fingers and abdominal tenderness at the right iliac
fossa. However, colonoscopy and biopsy show transmural granulomatous inflammation involving
the ileocecal junction. What is the most likely diagnosis?
c. Bowel carcinoma
d. Intestinal TB
e. Intestinal lymphoma
Page - 863
Question 87/106
Question #87
A 33-year-old male patient has complained of abdominal pain, weight loss, and diarrhea for 6
months. on examination, you noted clubbing fingers and abdominal tenderness at the right iliac
fossa. However, colonoscopy and biopsy show transmural granulomatous inflammation involving
the ileocecal junction. What is the most likely diagnosis?
a. Crohn’s disease √
c. Bowel carcinoma
d. Intestinal TB
e. Intestinal lymphoma
Description
(UC).
Crohn’s disease is a transmural disease that mainly aects the terminal ileum.
Note that non-caseating granuloma is accurate in dierentiating CD from UC.
Non-caseating granuloma means granulomatous lesions without necrosis
e histological findings of Crohn’s disease are as the following:
Right iliac fossa mass

Granulomas are seen in histology
Increased goblet cells
Transmural, skip lesions, cobbles stone appearance
Bowel enema will show: rose thorn ulcers and fistulae
Page - 864
Question 88/106
Question #88
A 30-year-old lady complains of chronic diarrhea. She has lost 10 kilograms of her weight in the past
2 months. Aer an appropriate workup, you noted perianal and colonic fistulae. What is the most
likely diagnosis?
b. Irritable bowel syndrome
d. Celiac disease
e. Diverticulosis of the colon
Page - 865
Question 88/106
Question #88
A 30-year-old lady complains of chronic diarrhea. She has lost 10 kilograms of her weight in the past
2 months. Aer an appropriate workup, you noted perianal and colonic fistulae. What is the most
likely diagnosis?
a. Crohn’s disease √
b. Irritable bowel syndrome
d. Celiac disease
e. Diverticulosis of the colon
Description
Crohn’s disease is the most likely diagnosis on this patient
Chronic diarrhea and weight loss are suggestive, but the presence of fistulae accurately
dierentiates Ulcerative colitis from Crohn’s disease.
Page - 866
Question 89/106
Question #89
A 22-year-old male patient has been diagnosed with inflammatory bowel disease (IBD). Which of the
following is not considered an extra-intestinal manifestation of IBD?
b. Uveitis
c. Primary sclerosing cholangitis
d. Erythema nodosum
e. Facial palsy
Page - 867
Question 89/106
Question #89
A 22-year-old male patient has been diagnosed with inflammatory bowel disease (IBD). Which of the
following is not considered an extra-intestinal manifestation of IBD?
b. Uveitis
c. Primary sclerosing cholangitis
d. Erythema nodosum
e. Facial palsy √
Description
Extra-intestinal manifestations of inflammatory bowel disease:
Eye: Uveitis, Scleritis, Episcleritis

Cutaneous: Erythema nodosum, Pyoderma gangrenosum
Hepatobiliary: Primary sclerosing cholangitis, Liver cirrhosis, Gallstones (Bile acid
malabsorption in CD)
Pancreas: Pancreatitis
Genitourinary: Nephrolithiasis
Pulmonary: Chronic bronchitis, Bronchiectasis
Musculoskeletal: Seronegative arthritis
Hematology: Anemia, Increased thromboembolic events
Page - 868
Question 90/106
Question #90
A patient has been diagnosed with Crohn’s disease and is suering from an isolated perianal
disease. Which of the following is the best treatment option for his condition?
a. Amoxicillin
b. Metronidazole
c. Methotrexate
d. Doxycycline
e. TMP/SMX
Page - 869
Question 90/106
Question #90
A patient has been diagnosed with Crohn’s disease and is suering from an isolated perianal
disease. Which of the following is the best treatment option for his condition?
a. Amoxicillin
b. Metronidazole √
c. Methotrexate
d. Doxycycline
e. TMP/SMX
Description
Metronidazole and ciprofloxacin are used for isolated perianal Crohn’s disease.
Amoxicillin, Doxycycline, and TMP/SMX are not helpful in this case scenario.
Page - 870
Question 91/106
Question #91
demonstrates a transmural cobblestone appearance. What is the most appropriate management?
a. Metronidazole
b. Paracetamol
c. Mesalazine
d. Diclofenac sodium
e. Vancomycin
Page - 871
Question 91/106
Question #91
demonstrates a transmural cobblestone appearance. What is the most appropriate management?
a. Metronidazole
b. Paracetamol
c. Mesalazine √
d. Diclofenac sodium
e. Vancomycin
Description
is is a direct clinical scenario of Crohn’s disease.
e cobblestone appearance of the mucosa is pathognomonic for Crohn’s disease.
e following table shows the treatment options for Crohn’s disease.
Page - 872
Question 92/106
Question #92
Incidentally, you found a mass in the cecum of a 22-year-old female while doing an appendectomy.
Laboratory analysis revealed transmural granulomatous lesion necrosis. What is the most likely
diagnosis?
a. Cecal cancer
b. Lymphoma
c. Crohn’s disease
e. Intestinal TB
Page - 873
Question 92/106
Question #92
Incidentally, you found a mass in the cecum of a 22-year-old female while doing an appendectomy.
Laboratory analysis revealed transmural granulomatous lesion necrosis. What is the most likely
diagnosis?
a. Cecal cancer
b. Lymphoma
c. Crohn’s disease √
e. Intestinal TB
Description
(UC).
Crohn’s disease is a transmural disease that mainly aects the terminal ileum.
Note that non-caseating granuloma is accurate in dierentiating CD from UC.
Non-caseating granuloma means granulomatous lesions without necrosis
e histological findings of Crohn’s disease are as the following:
Right iliac fossa mass

Granulomas are seen on histology
Increased goblet cells
Transmural, skip lesions, cobbles stone appearance
Bowel enema will show: rose thorn ulcers and fistulae
Page - 874
Question 93/106
Question #93
A 29-year-old female has been diagnosed with Crohn’s disease. e inflammatory changes are most
commonly found in which of the following sites?
a. Stomach
b. Esophagus
c. Duodenum
d. Terminal ileum
e. Rectum
Page - 875
Question 93/106
Question #93
A 29-year-old female has been diagnosed with Crohn’s disease. e inflammatory changes are most
commonly found in which of the following sites?
a. Stomach
b. Esophagus
c. Duodenum
d. Terminal ileum √
e. Rectum
Description
Crohn’s disease (CD) most commonly aects the terminal ileum, while Ulcerative Colitis (UC) most
commonly aects the rectum.
CD can involve any part of the GI tract (from mouth to anus), while UC only starts at the rectum and
extends proximally variably but never reaches beyond the ileocecal valve.
Page - 876
Question 94/106
Question #94
Which of the following, if present, excludes the diagnosis of irritable bowel syndrome?
a. Onset at the age of 24 years

b. Abdominal pain and bloating
c. Constipation
d. Bloody diarrhea
e. Relieved with defecation
Page - 877
Internal Medicine - Gastroenterology - Irritable Bowel syndrome (IBS)
Question 94/106
Question #94
Which of the following, if present, excludes the diagnosis of irritable bowel syndrome?
a. Onset at the age of 24 years

b. Abdominal pain and bloating
c. Constipation
d. Bloody diarrhea √
e. Relieved with defecation
Description
Bloody diarrhea is considered a red flag.
If any red flag manifests, you should consider a diagnosis other than IBS.
e following are the red flags for irritable bowel syndrome (IBS):
- Age of onset > 50 years
- A family history of IBD
- Weight loss, Anemia, Fever
- Blood or pus in the stool
- Nocturnal defecation
- Abnormal gross findings on flexible sigmoidoscopy
Irritable bowel syndrome:
It is a functional disorder of the large bowel, not explained by investigations.

IBS is the most common cause of GI referral
More in young adults, more in females than males
10-15% of the population
Diagnosis is achieved by Rome IV criteria.
Page - 878
Abdominal pain for at least 1 day per week, for at least 3 months in the past 6 months with 2 out of
the following:
Relieved with defecation

Associated with a change in consistency
Associated with a change in frequency
Page - 879
Question 95/106
Question #95
A 23-year-old female has a 1-year history of diarrhea and abdominal pain relieved by defecation. No
blood in stool and no weight loss. Her physical examination and lab investigations are
unremarkable. What is the best treatment option for this patient?
a. Gluten-free diet
b. Prednisolone
c. Loperamide
d. Colonoscopy and biopsy
e. Upper GI endoscopy
Page - 880
Question 95/106
Question #95
A 23-year-old female has a 1-year history of diarrhea and abdominal pain relieved by defecation. No
blood in stool and no weight loss. Her physical examination and lab investigations are
unremarkable. What is the best treatment option for this patient?
a. Gluten-free diet
b. Prednisolone
c. Loperamide √
d. Colonoscopy and biopsy
e. Upper GI endoscopy
Description
is is typical for Irritable Bowel Syndrome (IBS)

the following:

Loperamide is used to treat diarrhea-dominant IBS.
Page - 881
Question 96/106
Question #96
A 51-year-old male patient presents with abdominal pain and alternating diarrhea and constipation.
e pain is relieved by defecation. Which of the following would indicate further evaluation?
a. e age of onset
b. e presence of diarrhea
c. e presence of constipation
d. the pain relief by defecation
e. non-bloody nature of the diarrhea
Page - 882
Question 96/106
Question #96
A 51-year-old male patient presents with abdominal pain and alternating diarrhea and constipation.
e pain is relieved by defecation. Which of the following would indicate further evaluation?
a. e age of onset √
b. e presence of diarrhea
c. e presence of constipation
d. the pain relief by defecation
e. non-bloody nature of the diarrhea
Description
If any red flag manifests, you should think about a diagnosis other than IBS.
Page - 883
Question 97/106
Question #97
A 25-year-old female has 6 months history of abdominal pain relieved by defecation and associated
with alternating diarrhea and constipation. Which of the following would indicate a further
evaluation in this patient?
a. Symptoms relieved with defecation

b. Change in stool consistency
c. Change in stool frequency
d. Abdominal bloating and flatulence
e. Passage of mucus with the stool
Page - 884
Question 97/106
Question #97
A 25-year-old female has 6 months history of abdominal pain relieved by defecation and associated
with alternating diarrhea and constipation. Which of the following would indicate a further
evaluation in this patient?
a. Symptoms relieved with defecation

b. Change in stool consistency
c. Change in stool frequency
d. Abdominal bloating and flatulence
e. Passage of mucus with the stool √
Description
Mucus or blood in stool is considered a red flag.
If any red flag manifests, you should consider a diagnosis other than IBS.

Page - 885
the following:

Page - 886
Question 98/106
Question #98
A 45-year-old male patient from Amman, Jordan, presents with dyspepsia and epigastric pain
aggravated by food. You suspect a peptic ulcer disease. What is the most likely cause of his
condition?
a. H pylori
b. NSAIDs use
c. Gastrinoma
d. Crohn’s disease
e. Stress ulcer
Page - 887
Internal Medicine - Gastroenterology - Peptic ulcer disease (PUD)
Question 98/106
Question #98
A 45-year-old male patient from Amman, Jordan, presents with dyspepsia and epigastric pain
aggravated by food. You suspect a peptic ulcer disease. What is the most likely cause of his
condition?
a. H pylori √
b. NSAIDs use
c. Gastrinoma
e. Stress ulcer
Description
In developing countries, H pylori infection is the most common cause of peptic ulcer disease, while
NSAID use is the most common cause in developed countries
ere are no suggestive features of Crohn’s, Stress ulcer, or Gastrinoma.
angularis)
NSAIDs
present.
Page - 888
Question 99/106
Question #99
A 45-year-old male patient from America presents with dyspepsia and epigastric pain aggravated by
food. You suspect a peptic ulcer disease. What is the most likely cause of his condition?
a. H pylori
b. NSAIDs use
c. Gastrinoma
e. Stress ulcer
Page - 889
Question 99/106
Question #99
A 45-year-old male patient from America presents with dyspepsia and epigastric pain aggravated by
food. You suspect a peptic ulcer disease. What is the most likely cause of his condition?
a. H pylori
b. NSAIDs use √
c. Gastrinoma
e. Stress ulcer
Description
In developing countries, H pylori infection is the most common cause of peptic ulcer disease, while
NSAID use is the most common cause in developed countries
ere are no suggestive features of Crohn’s, Stress ulcer, or Gastrinoma.
angularis)
NSAIDs
present.
Page - 890
Question 100/106
Question #100
A patient has an endoscopy-confirmed chronic peptic ulcer disease, and the biopsy showed no
malignancy. Which of the following is the best method for curing his disease?
a. H pylori eradication
c. H2 blockers
d. Antacids
e. Nissen fundoplication
Page - 891
Question 100/106
Question #100
A patient has an endoscopy-confirmed chronic peptic ulcer disease, and the biopsy showed no
malignancy. Which of the following is the best method for curing his disease?
a. H pylori eradication √
c. H2 blockers
d. Antacids
e. Nissen fundoplication
Description
e disruption of the gastric mucosal defense mechanism caused by H pylori will make the
treatment dicult without the eradication of the bacteria
Patients with H pylori eradication have a much lower recurrence rate of peptic ulcer disease
compared with those without H pylori eradication.
angularis)
NSAIDs
present.
Page - 892
Question 101/106
Question #101
Which of the following drugs is the most potent in the mean of reducing stomach acidity in the
treatment of gastritis?
a. Vitamin C
b. Famotidine
c. Aluminum containing antacids
d. Itraconazole
e. Pantoprazole
Page - 893
Question 101/106
Question #101
Which of the following drugs is the most potent in the mean of reducing stomach acidity in the
treatment of gastritis?
a. Vitamin C
b. Famotidine
c. Aluminum containing antacids
d. Itraconazole
e. Pantoprazole √
Description
Proton Pump Inhibitors (PPIs) are the most eective in reducing stomach acidity and are the most
appropriate in treating gastritis and peptic ulcer disease.
Note that Itraconazole is an antifungal; it doesn’t reduce acidity. Furthermore, vitamin C (ascorbic
acid) will increase stomach acidity.
e following figure demonstrates the site of action of each drug used to reduce stomach acidity:
Page - 894
Question 102/106
Question #102
A 32-year-old male patient with a biopsy documented benign gastric ulcer disease was treated orally
for 4 weeks with lansoprazole with no improvement. His upper endoscopy was repeated and
revealed that the ulcer was still there. A second biopsy was sent, and no malignancy or H Pylori was
present. What would you do next in the management of this patient?
a. Stop lansoprazole and start famotidine

b. Continue treatment with lansoprazole for another 4 weeks
c. Endoscopic Pneumatic dilatation
d. Start triple therapy for H pylori
e. Perform a truncal vagotomy
Page - 895
Question 102/106
Question #102
A 32-year-old male patient with a biopsy documented benign gastric ulcer disease was treated orally
for 4 weeks with lansoprazole with no improvement. His upper endoscopy was repeated and
revealed that the ulcer was still there. A second biopsy was sent, and no malignancy or H Pylori was
present. What would you do next in the management of this patient?
a. Stop lansoprazole and start famotidine

b. Continue treatment with lansoprazole for another 4 weeks √
c. Endoscopic Pneumatic dilatation
d. Start triple therapy for H pylori
e. Perform a truncal vagotomy
Description
PPI’s healed duodenal ulcers in more than 95% of patients at 4 weeks and gastric ulcers in 80 – 90%
of patients at 8 weeks.
So, the patient should be given another 4-week chance to get better with no change in the
treatment
angularis)
NSAIDs
present.
Page - 896
Question 103/106
Question #103
A 52-year-old male comes to you with 2 episodes of coee-ground vomiting and epigastric pain. His
history is significant for rheumatoid arthritis, for which he takes NSAIDs. His blood pressure is
130/80, his pulse is 113bpm, and his hemoglobin is 13 g/dL (baseline was 14.5 g/dL). What is the most
a. Upper endoscopy
b. Intravenous proton pump inhibitor
c. Intravenous fluid
d. Serial HB, KFT, electrolytes
e. All of the above
Page - 897
Internal Medicine - Gastroenterology - Upper Gastrointestinal bleeding (UGIB)
Question 103/106
Question #103
A 52-year-old male comes to you with 2 episodes of coee-ground vomiting and epigastric pain. His
history is significant for rheumatoid arthritis, for which he takes NSAIDs. His blood pressure is
130/80, his pulse is 113bpm, and his hemoglobin is 13 g/dL (baseline was 14.5 g/dL). What is the most
a. Upper endoscopy
b. Intravenous proton pump inhibitor
d. Serial HB, KFT, electrolytes
Description
is patient has active upper GI bleeding. Tachycardia here indicates 15% blood loss; the patient may
have a shock.
e management of upper GI bleeding is as the following:
- Stabilize patient (ABC): NPO, fluid resuscitation
- Blood grouping and cross match and blood transfusion if there is a drop in HB
- Platelet transfusion if the platelet count is less than 50,000
- Vitamin K, FFP is used if there is a coagulopathy
- Serial HB, KFT, electrolytes, vitals monitoring for follow-up of the patient
- NG tube insertion (this will determine UGIB vs. LGIB)
- Treatment of the cause if present
- intravenous proton pump inhibitor
- Octreotide is used to reduce the portal pressure in the case of esophageal varices
- Metoclopramide or erythromycin to increase gastric emptying (used before endoscopy)

Page - 898
- Upper endoscopy (is the most accurate diagnostic and therapeutic procedure in upper GI
bleeding)
- Surgery may have a rule if endoscopic management fails to stop the bleeding
Page - 899
Question 104/106
Question #104
A 44-year-old female patient has had fatigue and easy tiredness for the past 4 months. e patient
also has painless dysphagia. Her investigations show microcytic hypochromic anemia. In addition,
her upper endoscopy demonstrates an esophageal web at the post-cricoid region. What is the most
likely diagnosis?
a. Plummer-Vinson syndrome
b. Barrett’s esophagus
d. Peptic ulcer disease
e. Esophageal cancer
Page - 900
Question 104/106
Question #104
A 44-year-old female patient has had fatigue and easy tiredness for the past 4 months. e patient
also has painless dysphagia. Her investigations show microcytic hypochromic anemia. In addition,
her upper endoscopy demonstrates an esophageal web at the post-cricoid region. What is the most
likely diagnosis?
a. Plummer-Vinson syndrome √
b. Barrett’s esophagus
d. Peptic ulcer disease
Description
Plummer-Vinson syndrome is the presence of esophageal web, dysphagia, and iron deficiency
anemia.
Anemia is due to recurrent bleeding from the web as the food enters through it.
Treatment should include dilating the esophageal web and correcting iron deficiency anemia.
Page - 901
Question 105/106
Question #105
A 60-year-old male patient with a known H Pylori infection has black stool and dizziness. His blood
pressure is 90/50 mmHg, pulse rate is 129 bpm. e initial investigations demonstrate hemoglobin
of 9.5 g/dL, normal electrolytes, and normal kidney function. e patient received intravenous PPI
and intravenous fluid, and a crossmatch for blood transfusion was sent. What is the next step in the
a. Surgical intervention
b. Start H Pylori eradication
c. Esophagogastroduodenoscopy
d. Administrate Vitamin K and FFP
e. Administrate intravenous octreotide
Page - 902
Question 105/106
Question #105
A 60-year-old male patient with a known H Pylori infection has black stool and dizziness. His blood
pressure is 90/50 mmHg, pulse rate is 129 bpm. e initial investigations demonstrate hemoglobin
of 9.5 g/dL, normal electrolytes, and normal kidney function. e patient received intravenous PPI
and intravenous fluid, and a crossmatch for blood transfusion was sent. What is the next step in the
a. Surgical intervention
b. Start H Pylori eradication
c. Esophagogastroduodenoscopy √
d. Administrate Vitamin K and FFP
e. Administrate intravenous octreotide
Description
is patient has active upper GI bleeding. In addition, the patient has tachycardia and hypotension;
this indicates active bleeding and hypovolemic shock.
Vitamin K and FFP are only used when there is coagulopathy
Octreotide is used if the GI bleeding is related to increased portal pressure, e.g., liver cirrhosis and
esophageal varices.
e management of upper GI bleeding is as the following:
- Stabilize patient (ABC): NPO, fluid resuscitation
- Blood grouping and cross match and blood transfusion if there is a drop in HB
- Platelet transfusion if the platelet count is less than 50,000
- Vitamin K, FFP is used if there is a coagulopathy
- Serial HB, KFT, electrolytes, vitals monitoring for follow-up of the patient
- NG tube insertion (this will determine UGIB vs. LGIB)
Page - 903
- Treatment of the cause if present
- intravenous proton pump inhibitor
- Octreotide is used to reduce the portal pressure in the case of esophageal varices
- Metoclopramide or erythromycin to increase gastric emptying (used before endoscopy)
- Upper endoscopy (is the most accurate diagnostic and therapeutic procedure in upper GI
bleeding)
- Surgery may have a rule if endoscopic management fails to stop the bleeding
Page - 904
Question 106/106
Question #106
A 53-year-old heavily alcoholic male patient presents with night blindness and dry hyperkeratotic
skin. In addition, he has conjunctival dryness and redness. Which of the following supplements
would most likely prevent the patient’s condition?
a. Retinoic acid
b. iamin
c. Cobalamin
d. Folic acid
e. Ascorbic acid
Page - 905
Internal Medicine - Gastroenterology - Vitamin A Deficiency
Question 106/106
Question #106
A 53-year-old heavily alcoholic male patient presents with night blindness and dry hyperkeratotic
skin. In addition, he has conjunctival dryness and redness. Which of the following supplements
would most likely prevent the patient’s condition?
a. Retinoic acid √
b. iamin
c. Cobalamin
d. Folic acid
e. Ascorbic acid
Description
Given the history of alcoholism, blindness, and hyperkeratosis, vitamin A (retinoic acid) deficiency is
the most likely diagnosis in this patient.
Usually, it occurs in patients with malabsorption or proteinuria, liver disease, alcoholics, and those
receiving total parenteral nutrition (TPN).
Page - 906
Hematology
Page - 907
Hematology
1) Anemia classification => 1 Questions

2) Anemia of chronic disease => 2 Questions
3) Anticoagulants => 10 Questions
4) Aplastic Anemia (AA) => 3 Questions
5) Autoimmune hemolytic anemia (AIHA) => 1 Questions
6) Blood transfusion => 4 Questions
7) Deep Vein rombosis (DVT) => 14 Questions
8) Disorders of hemostasis => 2 Questions
9) Disseminated intravascular coagulation (DIC) => 3 Questions
10) Essential rombocythemia (ET) => 1 Questions
11) HIT syndrome => 3 Questions
12) Hematologic investigations => 10 Questions
13) Hemolytic Anemia => 7 Questions
14) Hemophilia => 3 Questions
15) Hereditary Spherocytosis (HS) => 4 Questions
16) Idiopathic rombocytopenic Purpura (ITP) => 2 Questions
17) Iron Deficiency Anemia (IDA) => 9 Questions
18) Lead Poisoning => 2 Questions
19) Leukemia => 7 Questions
20) Lymphoma => 7 Questions
21) Macrocytic megaloblastic anemia => 15 Questions
22) Multiple Myeloma (MM) => 7 Questions
23) Myelofibrosis => 1 Questions
24) Normocytic anemia => 2 Questions
25) Platelet dysfunction => 1 Questions
26) Polycythemia Vera (PV) => 6 Questions
27) Pulmonary Embolism (PE) => 12 Questions
28) Secondary polycythemia => 3 Questions
29) Sickle Cell Anemia (SCA) => 2 Questions
30) alassemia => 5 Questions
31) rombotic rombocytopenic Purpura (TTP) => 2 Questions
32) Tumor lysis syndrome => 1 Questions
33) Von Willebrand Disease (vWD) => 3 Questions
Page - 908
Internal Medicine - Hematology
Question 1/155
Question #1
A 22-year-old female develops anemia with low mean corpuscular volume. Which of the following is
the least likely diagnosis?
a. Iron deficiency anemia

b. alassemia
c. Sideroblastic anemia
d. Anemia of chronic disease
e. Sickle cell anemia
Page - 909
Internal Medicine - Hematology - Anemia classification
Question 1/155
Question #1
A 22-year-old female develops anemia with low mean corpuscular volume. Which of the following is

b. alassemia
c. Sideroblastic anemia
e. Sickle cell anemia √
Description
Sickle cell anemia (SCA) is more likely to be associated with normocytic anemia.
Classifications: Anemia is classified according to MCV to
Microcytic anemia: (MCV < 80 fl)
Iron deficiency (the most common cause of anemia)

Anemia of chronic disease (30% of cases)
alassemia
Lead poisoning
Sideroblastic anemia (maybe macrocytic)
Normocytic anemia: (MCV 80-100 fl)
With High Reticulocytes count: Acute bleeding, hemolysis

With low Reticulocytes count
Anemia of chronic disease (most commonly normocytic (70%) but can be microcytic)
Renal/liver disease, Aplastic anemia, Myelofibrosis, Leukemia, Drugs (e.g.,

chemotherapy)
Macrocytic anemia: (MCV > 100 fl)
Megaloblastic: B12 deficiency, Folate deficiency, Drugs that impair DNA synthesis
(methotrexate, sulfa, chemotherapy)
Page - 910
Non-Megaloblastic: Liver disease, Alcoholism, Hypothyroidism, MDs
Page - 911
Question 2/155
Question #2
A 66-year-old female complains of fatigue and palpitation. She gave a history of chronic kidney
disease and almost daily alcohol consumption. On examination, she has tachycardia, tachypnea,
and pallor. Lab investigations show hemoglobin of 9 g/dL, MCV of 84 fl, and reticulocytes of 0.5%.

b. B12 deficiency
c. Alcoholism
d. Autoimmune hemolytic anemia
e. Anemia of chronic disease
Page - 912
Internal Medicine - Hematology - Anemia of chronic disease
Question 2/155
Question #2
A 66-year-old female complains of fatigue and palpitation. She gave a history of chronic kidney
disease and almost daily alcohol consumption. On examination, she has tachycardia, tachypnea,
and pallor. Lab investigations show hemoglobin of 9 g/dL, MCV of 84 fl, and reticulocytes of 0.5%.

b. B12 deficiency
c. Alcoholism
e. Anemia of chronic disease √
Description
is patient is most likely suering from anemia of chronic diseases.
e presence of chronic kidney disease and normocytic anemia in an elderly patient strongly
suggests the condition.
Anemia of chronic disease presents in chronic infections, chronic inflammations, and neoplasia (TB,
Osteomyelitis, endocarditis, IBD, Chronic renal failure, SLE, RA, Malignancy).
Iron deficiency anemia will present with microcytic anemia
Alcoholism and B12 deficiency present with macrocytic anemia
Hemolytic anemia presents with normal MCV, but high reticulocyte count, jaundice, and red urine
should be mentioned in the history.
Pathogenesis of anemia of chronic disease:
Decreased release of iron from Bone marrow to developing erythroblast

Decreased erythropoietin production and response
Decreased RBC survival (less than 120 days)
Treatment:
Page - 913
Treatment of the underlying cause
Erythropoietin injection (target Hb should not exceed 11 g/dl)
No response to ferrous treatment
Rarely need a Blood transfusion (usually mild anemia)
Page - 914
Question 3/155
Question #3
A 60-year-old male patient is known to have rheumatoid arthritis and is on methotrexate. Her lab
investigations show hemoglobin of 8g/dL, MCV of 75 fl, reticulocytes of 1%, and serum ferritin of 70
μmol/L. What is the most likely diagnosis?
a. Folate deficiency anemia

b. Chronic GI bleeding
c. B12 deficiency anemia
d. Lead poisoning
Page - 915
Internal Medicine - Hematology - Anemia of chronic disease
Question 3/155
Question #3
A 60-year-old male patient is known to have rheumatoid arthritis and is on methotrexate. Her lab
investigations show hemoglobin of 8g/dL, MCV of 75 fl, reticulocytes of 1%, and serum ferritin of 70
μmol/L. What is the most likely diagnosis?
a. Folate deficiency anemia

b. Chronic GI bleeding
c. B12 deficiency anemia
d. Lead poisoning
e. Anemia of chronic disease √
Description
is patient is most likely suering from anemia of chronic disease.
e presence of chronic disease (Rheumatoid arthritis) and normocytic anemia in an elderly patient
strongly suggests the condition.
Note that anemia of chronic disease is 70% normocytic and 30% microcytic.
Anemia of chronic disease presents in chronic infections, chronic inflammations, and neoplasia (TB,
Osteomyelitis, endocarditis, IBD, Chronic renal failure, SLE, RA, Malignancy).
Iron deficiency anemia will present with a low ferritin level.
e patient is taking methotrexate and is at risk of developing folic acid deficiency anemia. However,
folic acid deficiency will present with macrocytic rather than microcytic anemia.
Pathogenesis of anemia of chronic disease:
Decreased release of iron from Bone marrow to developing erythroblast

Decreased erythropoietin production and response
Decreased RBC survival (less than 120 days)
Treatment:
Treatment of the underlying cause

Page - 916
Erythropoietin injection (target Hb should not exceed 11 g/dl)
No response to ferrous treatment
Rarely need a Blood transfusion (usually mild anemia)
Page - 917
Question 4/155
Question #4
In which of the following conditions would you consider stopping warfarin and administration of
oral vitamin K for warfarin toxicity?
a. An INR of 5.5 without bleeding

b. An INR of 7.5 with intracranial bleeding
c. An INR of 9 without bleeding
d. An INR of 10 with minor bleeding
e. An INR of 12 with minor bleeding
Page - 918
Internal Medicine - Hematology - Anticoagulants
Question 4/155
Question #4
In which of the following conditions would you consider stopping warfarin and administration of
oral vitamin K for warfarin toxicity?
a. An INR of 5.5 without bleeding

b. An INR of 7.5 with intracranial bleeding
c. An INR of 9 without bleeding √
d. An INR of 10 with minor bleeding
e. An INR of 12 with minor bleeding
Description
Patients with INR of 5 – 8 without bleeding should be treated with oral vitamin K, while intravenous
vitamin K is indicated when bleeding is present.
e following points are the up-to-date protocol in the treatment of warfarin overdose.
Treatment of warfarin overdose if no bleeding:
INR 5 – 8:
Hold warfarin for 2 doses
Restart warfarin in lower dose when INR < 5
INR > 8:
Stop warfarin
Vitamin K 1 – 5 mg PO
Repeat Vitamin K dose if INR still > 8 for > 24 hours
Treatment of warfarin overdose with minor bleeding:
Stop warfarin
Vitamin K 1 – 3 mg intravenously
Treatment of warfarin overdose with major bleeding:

Page - 919
Stop warfarin
Vitamin K 5 mg intravenously
Provide Prothrombin complex concentrate
Provide FFP is Prothrombin complex concentrate is not available
Page - 920
Question 5/155
Question #5
A 32-year-old female presents to the emergency department with a suicidal attempt by ingestion of
40 tablets of warfarin. Which of the following is not indicated in the management of this patient?
a. Vitamin K administration
b. Provide Prothrombin complex concentrate
c. Gastric lavage
d. Fresh Frozen Plasma (FFP)
e. Salicylate to prevent skin necrosis
Page - 921
Question 5/155
Question #5
A 32-year-old female presents to the emergency department with a suicidal attempt by ingestion of
40 tablets of warfarin. Which of the following is not indicated in the management of this patient?
a. Vitamin K administration
b. Provide Prothrombin complex concentrate
c. Gastric lavage
d. Fresh Frozen Plasma (FFP)
e. Salicylate to prevent skin necrosis √
Description
Salicylate inhibits the CYP450 enzyme, reducing metabolization and enhancing the warfarin eect.
erefore, it increased the risk of bleeding and contraindicated in this situation.
Drug overdose should be treated by gastric lavage, activated charcoal, and providing antidote.
INR 5 – 8:
INR > 8:
Stop warfarin
Stop warfarin

Page - 922
Stop warfarin
Page - 923
Question 6/155
Question #6
Which of the following is the best to rapidly restore the normal coagulation in a patient with
warfarin overdose and brain hemorrhage?
a. Vitamin K
b. Fresh Frozen Plasma
c. Prothrombin complex concentrate
d. Tissue plasminogen activator
e. Packed RBC transfusion
Page - 924
Question 6/155
Question #6
Which of the following is the best to rapidly restore the normal coagulation in a patient with
warfarin overdose and brain hemorrhage?
a. Vitamin K
b. Fresh Frozen Plasma
c. Prothrombin complex concentrate √
d. Tissue plasminogen activator
e. Packed RBC transfusion
Description
Prothrombin complex concentrate is superior to fresh frozen plasma in reducing the INR and
returning the coagulability state.
INR 5 – 8:
INR > 8:
Stop warfarin
Stop warfarin

Page - 925
Stop warfarin
Page - 926
Question 7/155
Question #7
A 52-year-old female patient has been started on warfarin for mitral valve replacement. Which of
the following is recommended for the monitoring of her anticoagulation status?
a. International normalized ratio (INR)

b. Partial thromboplastin time (PTT)
c. Protein C level
d. Plasma factor Xa levels
e. No need for monitoring
Page - 927
Question 7/155
Question #7
A 52-year-old female patient has been started on warfarin for mitral valve replacement. Which of
the following is recommended for the monitoring of her anticoagulation status?
a. International normalized ratio (INR) √

c. Protein C level
Description
Monitoring of the Warfarin eect is best done by the international normalized ratio (INR)
INR is the ratio of the prothrombin time (PT) for the patient over the average PT.
e target INR in patients on warfarin:
Unprovoked DVT/PE: 2 – 3 for 6 months

Provoked DVT/PE: 2 – 3 for 3 months
Recurrent DVT/PE: 2 – 3 for life
Atrial fibrillation with high CHA2DS2VAS score: 2 – 3 lifelong
Aortic valve replacement: 2 – 3 lifelong
Mitral valve replacement: 2.5 – 3.5 lifelong
Page - 928
Question 8/155
Question #8
Which of the following is the most accurate in describing the mechanism of action of warfarin?
a. Interacts with the coagulation factors I and VI

b. Antagonizes the vitamin E production
c. Antagonizes vitamin K
d. Increases the level of protein C
e. Increase the level of vitamin K dependent clotting factors
Page - 929
Question 8/155
Question #8
Which of the following is the most accurate in describing the mechanism of action of warfarin?
a. Interacts with the coagulation factors I and VI

b. Antagonizes the vitamin E production
c. Antagonizes vitamin K √
d. Increases the level of protein C
e. Increase the level of vitamin K dependent clotting factors
Description
Mechanism of action of warfarin:
Warfarin is a vitamin K antagonist (VKA)

It inhibits clotting factors II, VII, IX, X, and protein C
Page - 930
Question 9/155
Question #9
A patient who is known case of valve replacement is on warfarin therapy. He recently started on
rifampicin for meningococcal prophylaxis as he was in direct contact with a patient. Which of the
following is the expected Drug-Drug interaction between warfarin and rifampicin?
a. Increased eect of warfarin causing bleeding

b. Reduced eect of warfarin causing thrombosis
c. Increased eect of rifampicin
d. Reduced eect of rifampicin
e. No known interaction
Page - 931
Question 9/155
Question #9
A patient who is known case of valve replacement is on warfarin therapy. He recently started on
rifampicin for meningococcal prophylaxis as he was in direct contact with a patient. Which of the
following is the expected Drug-Drug interaction between warfarin and rifampicin?
a. Increased eect of warfarin causing bleeding

b. Reduced eect of warfarin causing thrombosis √
c. Increased eect of rifampicin
d. Reduced eect of rifampicin
e. No known interaction
Description
Warfarin is metabolized by the Cytochrome P 450 enzyme system in the liver.
Many drugs and substances aect this enzyme system, leading to an alteration of warfarin eects.
Rifampicin is known to enhance the action of the CYP450 enzyme and increase the washout of
warfarin, leading to a reduction of its anticoagulation eect and lower INR.
e following table shows the most important interactants with warfarin:
Page - 932
Question 10/155
Question #10
A patient has mitral valve replacement with a prosthetic mechanical valve. Which of the following is
the most appropriate in his management?
a. Anticoagulation with warfarin at target INR 2 – 3

b. Anticoagulation with warfarin at target INR 2.5 – 3.5
c. Anticoagulation with warfarin at target INR 1 – 2
d. Low molecular weight heparin for 6 months
e. No anticoagulation required
Page - 933
Question 10/155
Question #10
A patient has mitral valve replacement with a prosthetic mechanical valve. Which of the following is
the most appropriate in his management?
a. Anticoagulation with warfarin at target INR 2 – 3

b. Anticoagulation with warfarin at target INR 2.5 – 3.5 √
c. Anticoagulation with warfarin at target INR 1 – 2
e. No anticoagulation required
Description
is patient carries a high risk of thrombosis and CVA; therefore, he needs anticoagulation (warfarin
is the first line anticoagulant of valvular heart disease)
e target INR in patients on warfarin:
Mitral valve replacement: 2.5 – 3.5 lifelong

Unprovoked DVT/PE: 2 – 3 for 6 months
Provoked DVT/PE: 2 – 3 for 3 months
Recurrent DVT/PE: 2 – 3 for life
Atrial fibrillation with high CHA2DS2VAS score: 2 – 3 lifelong
Aortic valve replacement: 2 – 3 lifelong
Page - 934
Question 11/155
Question #11
A 74-year-old female patient is on warfarin because of a history of atrial fibrillation. She presents
with an INR level of 7, but she denies bleeding. What is the most appropriate management?
a. Hold warfarin for 2 doses

b. Provide 5 mg of oral vitamin K
c. Provide 3 mg IV vitamin K
d. Provide 5 mg IV vitamin K
e. Provide Fresh Frozen Plasma (FFP)
Page - 935
Question 11/155
Question #11
A 74-year-old female patient is on warfarin because of a history of atrial fibrillation. She presents
with an INR level of 7, but she denies bleeding. What is the most appropriate management?
a. Hold warfarin for 2 doses √

b. Provide 5 mg of oral vitamin K
c. Provide 3 mg IV vitamin K
d. Provide 5 mg IV vitamin K
e. Provide Fresh Frozen Plasma (FFP)
Description
A patient warfarin overdose and an INR level of 5 – 8 is not an indication of warfarin or FFP
administration.
INR 5 – 8:
INR > 8:
Stop warfarin
Stop warfarin

Page - 936
Stop warfarin
Page - 937
Question 12/155
Question #12
A pregnant 29-year-old female has been prescribed low molecular weight heparin for prophylaxis
against venous thrombosis. Which of the following is recommended for the monitoring of her
anticoagulation status?

c. Prothrombin time (PT)
Page - 938
Question 12/155
Question #12
A pregnant 29-year-old female has been prescribed low molecular weight heparin for prophylaxis
against venous thrombosis. Which of the following is recommended for the monitoring of her
anticoagulation status?

c. Prothrombin time (PT)
e. No need for monitoring √
Description
ere is no needed monitoring for LMWH because the anticoagulation eect in LMWH is
predictable.
e monitoring indicated for warfarin eect by INR
e monitoring is needed for unfractionated heparin by PTT
Page - 939
Question 13/155
Question #13
A 66-year-old male patient is on warfarin to reduce the risk of stroke because he has atrial
fibrillation. However, in follow-up labs, he is found to have an INR level of 10. What is the most
appropriate treatment at this time if the patient has no bleeding?
a. Intravenous vitamin K
b. Oral vitamin K
c. Fresh Frozen plasma
d. Desmopressin (DDAVP)
e. Stop warfarin without additional treatment
Page - 940
Question 13/155
Question #13
A 66-year-old male patient is on warfarin to reduce the risk of stroke because he has atrial
fibrillation. However, in follow-up labs, he is found to have an INR level of 10. What is the most
appropriate treatment at this time if the patient has no bleeding?
a. Intravenous vitamin K
b. Oral vitamin K √
c. Fresh Frozen plasma
d. Desmopressin (DDAVP)
e. Stop warfarin without additional treatment
Description
is patient has an INR level of > 8 and no bleeding, so he needs to be treated with oral vitamin K.
INR 5 – 8:
INR > 8:
Stop warfarin
Stop warfarin

Page - 941
Stop warfarin
Page - 942
Question 14/155
Question #14
A previously healthy 19-year-old lady presents with bruises and petechial rashes. On examination,
she is pale, has a petechial rash, and has ecchymosis at her extensor surfaces. Lab investigations
show a hemoglobin level of 8 g/dL, WBC of 1.8*10^9/L, and platelet count of 22*10^9/L. Her blood
film shows a reduced platelet count, normocytic anemia, and absent reticulocytes. Her bone marrow
is hypocellular. What is the most likely diagnosis?
a. B12 deficiency anemia

b. Myelodysplastic syndrome
c. Aplastic anemia
d. Acute myeloid leukemia
e. Multiple myeloma
Page - 943
Internal Medicine - Hematology - Aplastic Anemia (AA)
Question 14/155
Question #14
A previously healthy 19-year-old lady presents with bruises and petechial rashes. On examination,
she is pale, has a petechial rash, and has ecchymosis at her extensor surfaces. Lab investigations
show a hemoglobin level of 8 g/dL, WBC of 1.8*10^9/L, and platelet count of 22*10^9/L. Her blood
film shows a reduced platelet count, normocytic anemia, and absent reticulocytes. Her bone marrow
is hypocellular. What is the most likely diagnosis?
a. B12 deficiency anemia

b. Myelodysplastic syndrome
c. Aplastic anemia √
d. Acute myeloid leukemia
e. Multiple myeloma
Description
In aplastic anemia, the patient develops pancytopenia, reduced or absence of the reticulocytes and
hypocellular bone marrow
Note that MDs and leukemia will show increased blast cells in the bone marrow
In Multiple Myeloma (MM), the bone marrow will show plasma cells of > 10%
B12 deficiency anemia may present with pancytopenia, and megaloblasts are in the bone marrow
but not hypocellular.
Page - 944
Question 15/155
Question #15
A 29-year-old female complains of fatigue and recurrent epistaxis. On examination, the patient is
pale and has a petechial rash on her extensor surfaces. e spleen and lymph nodes are not palpable.
Her CBC shows pancytopenia. A biopsy from which of the following tissues would be most helpful in
the diagnosis?
a. Lymph nodes
b. e liver
c. e bone marrow
d. Kidney
e. e spleen
Page - 945
Question 15/155
Question #15
A 29-year-old female complains of fatigue and recurrent epistaxis. On examination, the patient is
pale and has a petechial rash on her extensor surfaces. e spleen and lymph nodes are not palpable.
Her CBC shows pancytopenia. A biopsy from which of the following tissues would be most helpful in
the diagnosis?
a. Lymph nodes
b. e liver
c. e bone marrow √
d. Kidney
e. e spleen
Description
is lady is suspected of having aplastic anemia. You should perform a bone marrow biopsy to
confirm the diagnosis.
Hypocellular bone marrow, absent reticulocytes on the blood film, and pancytopenia in CBC are
classic presentations for Aplastic anemia.
Page - 946
Question 16/155
Question #16
A 29-year-old male patient was admitted with a case of pneumonia and started to receive
antibiotics. His further investigations demonstrate hemoglobin of 7 g/dL, WBC of 1*10^9/L, platelet
count of 15*10^9/L, and reticulocytes of 0.4%. In addition, bone marrow examination shows reduced
hematopoietic stem cells. What is the most likely diagnosis?
a. Pernicious anemia
b. Acute leukemia
c. Chronic leukemia
d. Multiple Myeloma
e. Aplastic Anemia
Page - 947
Question 16/155
Question #16
A 29-year-old male patient was admitted with a case of pneumonia and started to receive
antibiotics. His further investigations demonstrate hemoglobin of 7 g/dL, WBC of 1*10^9/L, platelet
count of 15*10^9/L, and reticulocytes of 0.4%. In addition, bone marrow examination shows reduced
hematopoietic stem cells. What is the most likely diagnosis?
b. Acute leukemia
c. Chronic leukemia
d. Multiple Myeloma
e. Aplastic Anemia √
Description
In aplastic anemia, the patient develops pancytopenia, reduced or absence of the reticulocytes and
hypocellular bone marrow
Note that MDs and leukemia will show increased blast cells in the bone marrow
In Multiple Myeloma (MM), the bone marrow will show plasma cells of > 10%
B12 deficiency anemia may present with pancytopenia, and megaloblasts are in the bone marrow
but not hypocellular.
Page - 948
Question 17/155
Question #17
A 46-year-old male patient was diagnosed with autoimmune hemolytic anemia. All the following
are true except:
a. Cold autoimmune hemolytic anemia is associated with mycoplasma pneumonia

b. Cold AIHA is mediated by IgM antibodies
c. Warm AIHA is extravascular
d. Coombs test is positive
e. Cold AIHA is treated by steroids or splenectomy
Page - 949
Internal Medicine - Hematology - Autoimmune hemolytic anemia (AIHA)
Question 17/155
Question #17
A 46-year-old male patient was diagnosed with autoimmune hemolytic anemia. All the following
are true except:
a. Cold autoimmune hemolytic anemia is associated with mycoplasma pneumonia

b. Cold AIHA is mediated by IgM antibodies
c. Warm AIHA is extravascular
d. Coombs test is positive
e. Cold AIHA is treated by steroids or splenectomy √
Description
Steroid and splenectomy do not have a role in cold Agglutinin Hemolytic anemia
Autoimmune hemolytic anemia (AIHA) is an RBC destruction by autoantibodies. It is divided into

‘warm’ and ‘cold’ types (according to which temperature the antibodies best cause hemolysis)
Both types of AIHA are characterized by a positive DAT (Coombs test).
Worm AIHA is IgG-mediated destruction of RBCs. It is extravascular and treated by steroids or

splenectomy.
Cold AIHA is IgM mediated, intravascular, and occurs at a temperature of 4 °C or less.
Page - 950
Question 18/155
Question #18
A 22-year-old male patient is donating blood for his sister, who has severe antepartum hemorrhage.
While donating blood, the patient suddenly passed out. Which of the following is not appropriate in
this scenario?
a. Intravenous fluid replacement with continuing blood donation

b. Ensure adequate hydration of the patient
c. Elevate the donor’s legs, as this is most commonly a vasovagal attack
d. Ensure that the donor meets the minimum required hematocrit level for blood donation
e. Monitoring of the donor’s blood pressure.
Page - 951
Internal Medicine - Hematology - Blood transfusion
Question 18/155
Question #18
A 22-year-old male patient is donating blood for his sister, who has severe antepartum hemorrhage.
While donating blood, the patient suddenly passed out. Which of the following is not appropriate in
this scenario?
a. Intravenous fluid replacement with continuing blood donation √

b. Ensure adequate hydration of the patient
c. Elevate the donor’s legs, as this is most commonly a vasovagal attack
d. Ensure that the donor meets the minimum required hematocrit level for blood donation
e. Monitoring of the donor’s blood pressure.
Description
You should never continue blood donation while the adverse eect is happening.
e vasovagal attack during blood donation is common; elevation of the patient’s legs will enhance
the blood perfusion in the brain (gravity eect)
Blood donors should be well hydrated and eat well before donation
People should not donate blood until you ensure that hemoglobin is above the minimum allowed
level.
Page - 952
Question 19/155
Question #19
While receiving a blood transfusion, a patient has a fever and shivering. Which of the following is
the most appropriate action?
a. Stop blood transfusion and provide paracetamol

b. Stop blood transfusion and provide mannitol
c. Stop blood transfusion and start IV fluid
d. Continue blood transfusion and provide paracetamol
e. Continue blood transfusion and ignore the complaint
Page - 953
Question 19/155
Question #19
While receiving a blood transfusion, a patient has a fever and shivering. Which of the following is
the most appropriate action?
a. Stop blood transfusion and provide paracetamol

b. Stop blood transfusion and provide mannitol
c. Stop blood transfusion and start IV fluid
d. Continue blood transfusion and provide paracetamol √
e. Continue blood transfusion and ignore the complaint
Description
e non-hemolytic febrile reaction is a common complaint during blood transfusions.
It occurs due to the presence of WBCs in the transfused blood.
Blood transfusion can be continued, and paracetamol should provide to control fever.
If the patient has a history of febrile reaction in a previous blood transfusion, giving filtered blood
without WBCs will reduce the recurrence.
Page - 954
Question 20/155
Question #20
A 22-year-old male patient has upper gastrointestinal bleeding and a rapid drop in hemoglobin. You
ordered to prepare and provide 4 units of blood. Which is the most likely test involved in preparing
the blood transfusion?
a. Indirect Coombs test

b. Direct Coombs test
c. Blood film
d. Osmotic fragility test
e. Glucose-6-phosphate dehydrogenase enzyme assay
Page - 955
Question 20/155
Question #20
A 22-year-old male patient has upper gastrointestinal bleeding and a rapid drop in hemoglobin. You
ordered to prepare and provide 4 units of blood. Which is the most likely test involved in preparing
the blood transfusion?
a. Indirect Coombs test √

c. Blood film
e. Glucose-6-phosphate dehydrogenase enzyme assay
Description
An indirect Coombs test (also known as an indirect antiglobulin test) would test the patient’s serum
(not the RBCs).
Indirect Antiglobulin Test (IAT) detects antibodies in plasma
Stage 1: Plasma mixed with RBCs with known antigen
Stage 2: then mixed with antibodies to human globulin
If agglutination → Plasma contains antibodies against that RBC’s
Page - 956
Question 21/155
Question #21
A 60-year-old female with aplastic anemia and recurrent blood transfusions had developed a febrile
reaction during her last blood transfusion. You ordered the subsequent transfusion through a filter
to prevent the reaction. Which mechanisms are most likely to explain the filter’s eect?
a. Reducing bacterial transmission

b. Reducing viral transmission
c. Reducing parasite transmission
d. Reducing leukocyte transfusion
e. Reducing reticulocyte transfusion
Page - 957
Question 21/155
Question #21
A 60-year-old female with aplastic anemia and recurrent blood transfusions had developed a febrile
reaction during her last blood transfusion. You ordered the subsequent transfusion through a filter
to prevent the reaction. Which mechanisms are most likely to explain the filter’s eect?
a. Reducing bacterial transmission

b. Reducing viral transmission
c. Reducing parasite transmission
d. Reducing leukocyte transfusion √
e. Reducing reticulocyte transfusion
Description
e non-hemolytic febrile reaction is a common complaint during a blood transfusion.
It occurs due to the presence of WBCs in the transfused blood.
Blood transfusion can be continued, and paracetamol should provide to control fever.
If the patient has a history of febrile reaction in a previous blood transfusion, giving filtered blood
without WBCs will reduce the recurrence.
Page - 958
Question 22/155
Question #22
A 36-year-old female patient has recurrent deep vein thrombosis. Which of the following is the most
common abnormality?
a. Antiphospholipid antibody syndrome

b. Anti-thrombin III deficiency
c. Factor V Leiden mutation
d. Protein C deficiency
e. Protein S deficiency
Page - 959
Internal Medicine - Hematology - Deep Vein rombosis (DVT)
Question 22/155
Question #22
A 36-year-old female patient has recurrent deep vein thrombosis. Which of the following is the most
common abnormality?

b. Anti-thrombin III deficiency
c. Factor V Leiden mutation √
d. Protein C deficiency
e. Protein S deficiency
Description
e mentioned choices are known to cause a hypercoagulable state and may result in DVT.
Factor V Leiden mutation is responsible for the most common hypercoagulable state
Additional notes:
Protein C, protein S, and antithrombin III are coagulation-inhibiting proteins

e levels of all three coagulation-inhibiting proteins can be reduced during the acute
thrombotic state.
Heparin suppresses the Antithrombin III
Warfarin suppresses protein C and protein S levels
Pregnancy and OCP use suppress protein S levels
Page - 960
Question 23/155
Question #23
A 39-year-old male patient develops le lower limb swelling, hotness, redness, and pain. His clinical
scenario started aer returning from his vacation in Aqaba. His CBC, CRP, and ESR are normal. What
is the most likely diagnosis?
a. Lower limb cellulitis

b. Erysipelas
c. Deep vein thrombosis
d. Cauda equina syndrome
Page - 961
Question 23/155
Question #23
A 39-year-old male patient develops le lower limb swelling, hotness, redness, and pain. His clinical
scenario started aer returning from his vacation in Aqaba. His CBC, CRP, and ESR are normal. What
a. Lower limb cellulitis

b. Erysipelas
c. Deep vein thrombosis √
d. Cauda equina syndrome
Description
e history of travel and the presence of hotness, redness, tenderness, and swelling in the lower
limb strongly suggests DVT.
e presence of normal CRP, WBC, and ESR will exclude cellulitis
Erysipelas is an infection of the superficial skin layers; it also presents with elevated acute phase
reactants.
Cauda equina syndrome is a rare condition in which there is compression on the lower spinal roots
Page - 962
Question 24/155
Question #24
A 66-year-old male patient has a 1-week right leg pain and swelling history. His records were
significant for a previous DVT two years ago, and he was treated with warfarin for 6 months. His D
dimer is positive, and his Doppler and duplex ultrasound demonstrate features of DVT again. Which
of the following is the most appropriate duration of anticoagulation therapy in his condition?
a. One month
b. ree months
c. Six months
d. 12 months
e. Indefinite
Page - 963
Question 24/155
Question #24
A 66-year-old male patient has a 1-week right leg pain and swelling history. His records were
significant for a previous DVT two years ago, and he was treated with warfarin for 6 months. His D
dimer is positive, and his Doppler and duplex ultrasound demonstrate features of DVT again. Which
of the following is the most appropriate duration of anticoagulation therapy in his condition?
a. One month
b. ree months
c. Six months
d. 12 months
e. Indefinite √
Description
Treatment of DVT:
DOAC (Apixaban or Rivaroxaban):

It should be started once the diagnosis is suspected
e first-line treatment for patients who do not have contraindications
In active malignancy patients, DOAC became preferred over LMWH.
Warfarin:
e second line treatment aer DOAC
Used in severe renal impairment (GFR < 15 mL/min).
Used as first-line if the patient has antiphospholipid syndrome.
LMWH:
Used as a bridge for warfarin (to prevent skin necrosis)
Used as monotherapy for 6 months in malignancy or pregnant patients (second line
aer DOAC)
Inferior vena cava filter indications:
Contraindications to anticoagulants
Recurrent emboli while on adequate anticoagulation
Right ventricular heart failure
Length of anticoagulation:
Page - 964
3 months: for provoked DVT/PE (known risk factor)
6 months: for unprovoked cases (unknown risk factor)
3 – 6 months: for people with active cancer
Lifelong: for recurrent DVT/PE
Page - 965
Question 25/155
Question #25
A 66-year-old male patient recently arrived from his trip to America and started to have calf pain
and swelling. His D dimer is positive, and his Doppler ultrasound confirms the presence of popliteal
vein DVT. However, he denies shortness of breath or chest pain. What is the most appropriate
treatment?
a. Inpatient warfarin and unfractionated heparin

b. Inpatient leg elevation and warfarin
c. Inpatient warfarin and low molecular weight heparin
d. Outpatient compression stockings and Apixaban
e. Outpatient unfractionated heparin and warfarin
Page - 966
Question 25/155
Question #25
A 66-year-old male patient recently arrived from his trip to America and started to have calf pain
and swelling. His D dimer is positive, and his Doppler ultrasound confirms the presence of popliteal
vein DVT. However, he denies shortness of breath or chest pain. What is the most appropriate
treatment?
a. Inpatient warfarin and unfractionated heparin

b. Inpatient leg elevation and warfarin
c. Inpatient warfarin and low molecular weight heparin
d. Outpatient compression stockings and Apixaban √
e. Outpatient unfractionated heparin and warfarin
Description
is patient requires Apixaban therapy for 3 months.
Compression stockings reduce the development of hyperpigmentation secondary to DVT. However,

this patient doesn’t need admission.
Unfractionated heparin is not suitable for outpatient use.
e indications for admission to DVT are:
Massive DVT (e.g., iliofemoral DVT)

Presence of pulmonary embolism
High risk of bleeding with anticoagulation
Comorbid conditions requiring admission
Treatment of DVT:

Warfarin:
Page - 967
LMWH:
aer DOAC)

Page - 968
Question 26/155
Question #26
A previously healthy 66-year-old female is started on warfarin for deep vein thrombosis acquired
aer a lower limb fracture. Which of the following is the recommended target INR in this condition?
a. 2 – 3 for 3 months
b. 2 – 3 for 6 months
c. 2.5 – 3.5 for 6 months
d. 3 – 4 for 3 months
Page - 969
Question 26/155
Question #26
A previously healthy 66-year-old female is started on warfarin for deep vein thrombosis acquired
aer a lower limb fracture. Which of the following is the recommended target INR in this condition?
a. 2 – 3 for 3 months √
Description
Patients who receive warfarin for DVT should have their target INR of 2 – 3 for 3 months in provoked
DVT and 6 months for unprovoked DVT.
Treatment of DVT:

Warfarin:
LMWH:
aer DOAC)
Page - 970
Page - 971
Question 27/155
Question #27
A 55-year-old female is started on warfarin for deep vein thrombosis. Two days later, she developed
a skin condition shown in the picture below. Which of the following is the most likely explanation?
a. Warfarin side eect

b. Embolization DVT
c. e patient is already hypercoagulable
d. Infection
e. e patient has sickle cell disease
Page - 972
Question 27/155
Question #27
A 55-year-old female is started on warfarin for deep vein thrombosis. Two days later, she developed
a skin condition shown in the picture below. Which of the following is the most likely explanation?
a. Warfarin side eect √

b. Embolization DVT
c. e patient is already hypercoagulable
d. Infection
e. e patient has sickle cell disease
Description
Warfarin-induced skin necrosis is rare due to acquired protein C deficiency following treatment with
anti-vitamin K anticoagulants.
is condition is treated by Fresh Frozen Plasma (FFP), pure activated protein C, and surgical
management of the necrotic area may be needed.
Page - 973
Question 28/155
Question #28
A 66-year-old female is started on Rivaroxaban for deep vein thrombosis acquired aer a lower limb
fracture. Which of the following is the recommended target INR in this condition?
Page - 974
Question 28/155
Question #28
A 66-year-old female is started on Rivaroxaban for deep vein thrombosis acquired aer a lower limb
fracture. Which of the following is the recommended target INR in this condition?
e. No need for monitoring √
Description
DOACs have become the first-line treatment of DVT over warfarin.
Compared to warfarin, DOACs carry a low risk of bleeding and do not need any monitoring.
Treatment of DVT:

Warfarin:
LMWH:
aer DOAC)
Page - 975

Page - 976
Question 29/155
Question #29
Which of the following isn’t considered a risk factor for venous thrombosis?
a. Combined oral contraceptive use

b. Lower limb fracture
c. Prostate cancer
d. Anemia
e. Traveling
Page - 977
Question 29/155
Question #29
Which of the following isn’t considered a risk factor for venous thrombosis?
a. Combined oral contraceptive use

b. Lower limb fracture
c. Prostate cancer
d. Anemia √
e. Traveling
Description
Virchow’s Triad is critically important in the development of venous thromboembolism.
Venous stasis: (major surgery, prolonged travel, pregnancy, lower limb injury)
Endothelial damage (i.e., trauma)
Hypercoagulability state:
History of DVT/PE
Hormone replacement therapy (e.g., estrogen)
Malignancy (of any kind)
Nephrotic syndrome (due to antithrombin III loss)
Coagulopathies (e.g., factor V Leiden)
Page - 978
Question 30/155
Question #30
A 35-year-old male patient with a history of spinal cord injury 3 weeks ago started to have right calf
swelling, pain, and tenderness. e diameter of his right calf is higher than the le one, and passive
movements cause pain. What is the most likely diagnosis?
a. Cellulitis
b. Deep vein thrombosis
c. Peripheral arterial disease
d. Superficial thrombophlebitis
e. Lower limb edema
Page - 979
Question 30/155
Question #30
A 35-year-old male patient with a history of spinal cord injury 3 weeks ago started to have right calf
swelling, pain, and tenderness. e diameter of his right calf is higher than the le one, and passive
movements cause pain. What is the most likely diagnosis?
a. Cellulitis
b. Deep vein thrombosis √
c. Peripheral arterial disease
d. Superficial thrombophlebitis
e. Lower limb edema
Description
Any element of Virchow’s Triad and leg swelling strongly suggests DVT.
is patient has venous stasis secondary to spinal cord injury and immobility; therefore, he is
hypercoagulable.
e calf having a larger diameter than the other is a known sign of a DVT.
Virchow’s Triad (Risk factors for DVT/PE):
Venous stasis: (major surgery, prolonged travel, pregnancy, lower limb injury)
Endothelial damage (i.e., trauma)
Hypercoagulability state:
History of DVT/PE
Hormone replacement therapy (e.g., estrogen)
Malignancy (of any kind)
Nephrotic syndrome (due to antithrombin III loss)
Coagulopathies (e.g., factor V Leiden)
Page - 980
Question 31/155
Question #31
A 39-year-old male patient develops swollen le lower limb swelling, hotness, redness, and pain. His
clinical scenario started aer returning from his vacation in Aqaba. His CBC, CRP, and ESR are
normal. However, Doppler ultrasound confirms incompressibility and echogenic material in the
femoral vein. What is the most appropriate management?
a. Elastic compression stockings and repeat ultrasound in 48 hours

b. Heparin bridge to and warfarin for 3 months
c. Insertion of inferior vena cava filter
d. Aspirin for 6 months duration
e. Start Apixaban
Page - 981
Question 31/155
Question #31
A 39-year-old male patient develops swollen le lower limb swelling, hotness, redness, and pain. His
clinical scenario started aer returning from his vacation in Aqaba. His CBC, CRP, and ESR are
normal. However, Doppler ultrasound confirms incompressibility and echogenic material in the
femoral vein. What is the most appropriate management?
a. Elastic compression stockings and repeat ultrasound in 48 hours

b. Heparin bridge to and warfarin for 3 months
c. Insertion of inferior vena cava filter
d. Aspirin for 6 months duration
e. Start Apixaban √
Description
Warfarin is no longer the first-line treatment in this case; Direct oral anticoagulants should be
started whenever the diagnosis is suspected.
Treatment of DVT:

Warfarin:
LMWH:
aer DOAC)
Page - 982

Page - 983
Question 32/155
Question #32
A 66-year-old male patient was admitted to the ICU as a case of interventricular hemorrhage. On
day 8 aer admission, he develops right lower limb swelling and pain. However, his imaging studies
confirm the presence of iliofemoral DVT. What is the most appropriate at this time?
a. Start LMWH and warfarin

b. Start Apixaban alone
c. Start unfractionated heparin and warfarin
d. Insert an inferior vena cava filter
e. Leg elevation and elastic compression stockings
Page - 984
Question 32/155
Question #32
A 66-year-old male patient was admitted to the ICU as a case of interventricular hemorrhage. On
day 8 aer admission, he develops right lower limb swelling and pain. However, his imaging studies
confirm the presence of iliofemoral DVT. What is the most appropriate at this time?
a. Start LMWH and warfarin

b. Start Apixaban alone
c. Start unfractionated heparin and warfarin
d. Insert an inferior vena cava filter √
e. Leg elevation and elastic compression stockings
Description
is patient suers from massive DVT, but he is contraindicated to have anticoagulation because of
a brain hemorrhage.
An inferior vena cava filter in his condition will prevent the development of pulmonary embolism.
Leg elevation and elastic compression stockings alone will not reduce the risk of PE in this patient.
Page - 985
Question 33/155
Question #33
A pregnant 32-year-old lady develops right leg DVT. Which of the following is the most appropriate
treatment?
a. Low molecular weight heparin and warfarin for 6 months

b. Low molecular weight heparin and warfarin for 3 months
c. Warfarin alone
d. Inferior vena cava filter insertion
e. Low molecular weight heparin for 6 months
Page - 986
Question 33/155
Question #33
A pregnant 32-year-old lady develops right leg DVT. Which of the following is the most appropriate
treatment?

b. Low molecular weight heparin and warfarin for 3 months
c. Warfarin alone
d. Inferior vena cava filter insertion
e. Low molecular weight heparin for 6 months √
Description
Pregnant ladies with DVT should be treated with low molecular weight heparin alone for 6 months.
Warfarin can cross the placenta; it is contraindicated in pregnancy.
Page - 987
Question 34/155
Question #34
A 66-year-old male patient with prostatic cancer developed swelling and pain in his le leg. His
Doppler ultrasound demonstrates monophasic blood flow, incompressibility, and echogenic
material in the femoral vein. What is the most appropriate treatment at this time?

b. Warfarin alone
c. Inferior vena cava filter insertion
e. Apixaban for 6 months
Page - 988
Question 34/155
Question #34
A 66-year-old male patient with prostatic cancer developed swelling and pain in his le leg. His
Doppler ultrasound demonstrates monophasic blood flow, incompressibility, and echogenic
material in the femoral vein. What is the most appropriate treatment at this time?

b. Warfarin alone
c. Inferior vena cava filter insertion
e. Apixaban for 6 months √
Description
In the past, LMWH for 6 months was the first line treatment in active malignancy patients, but
today DOAC became preferred over LMWH.
Treatment of DVT:

Warfarin:
LMWH:
aer DOAC)
Page - 989

Page - 990
Question 35/155
Question #35
An 87-year-old male patient is planning to travel on a long airline flight. Which of the following
should be considered in this situation?
a. Risk of hypoxia during flight

b. Risk of dehydration
c. Risk of thrombosis
d. Alcohol withdrawal symptoms
e. Risk of hyperglycemia
Page - 991
Question 35/155
Question #35
An 87-year-old male patient is planning to travel on a long airline flight. Which of the following
should be considered in this situation?
a. Risk of hypoxia during flight

b. Risk of dehydration
c. Risk of thrombosis √
d. Alcohol withdrawal symptoms
e. Risk of hyperglycemia
Description
DVT associated with long airline flights is a real concern in this situation.
Prophylactic use of ambulation and exercises during long flights is essential in high-risk patients to
prevent DVT and PE.
Venous stasis during long travels is a part of Virchow’s Triad; it increases the risk of DVT and PE.
Page - 992
Question 36/155
Question #36
A 29-year-old female patient complains of a 1-month duration of rash-like skin bruises and gum
bleeding aer brushing her teeth. e following investigations are appropriate at this time except:
a. Bleeding time (BT)

b. Complete blood count
c. Kidney function test
d. PT, PTT, and INR
e. D Dimer
Page - 993
Internal Medicine - Hematology - Disorders of hemostasis
Question 36/155
Question #36
A 29-year-old female patient complains of a 1-month duration of rash-like skin bruises and gum
bleeding aer brushing her teeth. e following investigations are appropriate at this time except:
a. Bleeding time (BT)

b. Complete blood count
c. Kidney function test
d. PT, PTT, and INR
e. D Dimer √
Description
is patient suers from a bleeding disorder due to an issue in her hemostasis. Bleeding time will
provide information about the primary hemostasis, while PT, PTT, And INR will be informative about
the secondary hemostasis. In addition, a kidney function test may be beneficial to exclude uremia-
induced platelet dysfunction.
D Dimer is a fibrinogen degradation product (FDP) that is elevated in the case of thrombosis, not a
bleeding tendency.
Page - 994
Question 37/155
Question #37
Which of the following drugs causes irreversible platelet dysfunction?
a. Aspirin
b. Ibuprofen
c. Warfarin
d. Heparin
e. Dipyridamole
Page - 995
Internal Medicine - Hematology - Disorders of hemostasis
Question 37/155
Question #37
Which of the following drugs causes irreversible platelet dysfunction?
a. Aspirin √
b. Ibuprofen
c. Warfarin
d. Heparin
e. Dipyridamole
Description
Several drugs inhibit the platelet function, but aspirin is the only one that inhibits the platelet
function for the life of the platelet.
Aspirin (Acetylsalicylic acid) is a non-selective and irreversible inhibitor of the cyclooxygenase

enzyme. is will inhibit the formation of prostaglandin, which causes pain. In addition, the
inhibition of prostaglandin will prevent the conversion of arachidonic acid to thromboxane A2, a
potent inducer of platelet aggregation.
Page - 996
Question 38/155
Question #38
A 38-year-old male patient developed sepsis and was admitted to the ICU for intravenous
management. On day 2 aer admission, he developed a rash, coee ground vomiting, elevated PT,
PTT, INR, D Dimer, and low platelet count. What is the most likely diagnosis?
a. Acute hepatic failure

b. Peptic ulcer disease
c. Disseminated intravascular coagulation
d. Aplastic anemia
e. rombotic thrombocytopenic purpura
Page - 997
Internal Medicine - Hematology - Disseminated intravascular coagulation (DIC)
Question 38/155
Question #38
A 38-year-old male patient developed sepsis and was admitted to the ICU for intravenous
management. On day 2 aer admission, he developed a rash, coee ground vomiting, elevated PT,
PTT, INR, D Dimer, and low platelet count. What is the most likely diagnosis?

c. Disseminated intravascular coagulation √
d. Aplastic anemia
Description
is patient is suering from DIC. e risk factor here is sepsis, and the lab investigations are typical
of DIC
Risk factors:
Sepsis, malignancy, drug toxicity

Burns, snake bites
Cancer
Obstetric problems (placental abruption, missed abortion, amniotic fluid embolism)
Pathogenesis:
Tissue factor released from destructed tissues causes widespread activation of coagulation →
consumption of coagulation factors and platelets → thrombocytopenia, and depletion of plasma
coagulation factors and fibrinogen, which cause bleeding.
Bleeding into organs and microvascular thromboses may cause dysfunction and failure in multiple
organs. In addition, delayed dissolution of fibrin polymers by fibrinolysis may result in the
mechanical disruption of RBCs, producing mild intravascular hemolysis.
Page - 998
Question 39/155
Question #39
A 40-year-old female patient develops massive bleeding from a venipuncture site. Her lab
investigations show hemoglobin of 10 g/dL, WBC of 10*10^9, platelet count of 35 *10^9/L, prolonged
PT, PTT, and BT. In addition, her fibrin level is reduced, and the fibrinogen degradation products are
elevated. What is the most likely diagnosis?

d. Aplastic anemia
Page - 999
Question 39/155
Question #39
A 40-year-old female patient develops massive bleeding from a venipuncture site. Her lab
investigations show hemoglobin of 10 g/dL, WBC of 10*10^9, platelet count of 35 *10^9/L, prolonged
PT, PTT, and BT. In addition, her fibrin level is reduced, and the fibrinogen degradation products are

d. Aplastic anemia
Description
e patient’s presentation and lab investigations are typical of DIC
Risk factors:

Burns, snake bites
Cancer
Pathogenesis:
Page - 1000
Question 40/155
Question #40
A 38-year-old pregnant woman develops missed abortion. She was admitted to the emergency unit
with purpura over her legs and arms. Her lab investigations show hemoglobin of 10g/dL, WBC of
16*10^9/L, platelet count of 31*10^9/L, Prolonged PT, PTT, and positive D Dimer. What is the most
likely diagnosis?
a. Septic abortion and septicemia

b. Pulmonary embolism
d. Factor V Leiden mutation
Page - 1001
Question 40/155
Question #40
A 38-year-old pregnant woman develops missed abortion. She was admitted to the emergency unit
with purpura over her legs and arms. Her lab investigations show hemoglobin of 10g/dL, WBC of
16*10^9/L, platelet count of 31*10^9/L, Prolonged PT, PTT, and positive D Dimer. What is the most
likely diagnosis?
a. Septic abortion and septicemia

d. Factor V Leiden mutation
Description
is patient is suering from DIC. e risk factor here is missed abortion, and the lab investigations
are typical of DIC
Risk factors:

Burns, snake bites
Cancer
Pathogenesis:
Page - 1002
Question 41/155
Question #41
Erythromelalgia is painful erythema on the hand that is relieved by aspirin. It is most likely found in:
a. Acute leukemia
b. Polycythemia Vera
c. Myelofibrosis
d. Essential thrombocythemia (ET)
e. Myelodysplastic syndrome
Page - 1003
Internal Medicine - Hematology - Essential rombocythemia (ET)
Question 41/155
Question #41
Erythromelalgia is painful erythema on the hand that is relieved by aspirin. It is most likely found in:
a. Acute leukemia
c. Myelofibrosis
d. Essential thrombocythemia (ET) √
Description
ET is a myeloproliferative disease characterized by the proliferation of megakaryocytes in the bone

marrow, leading to increased platelet production. It is more common in females and patients aged
50 – 60 years.
Erythromelalgia (painful erythema on the hand that is relieved by aspirin)
Page - 1004
Question 42/155
Question #42
A 49-year-old male patient was admitted to the CCU with acute non-ST elevation myocardial
infarction. On hospitalization day 7, he complained of le arm pain, paresthesia, and absent pulse.
His lab investigations show a platelet count of 30*10^9/L. What is the most likely diagnosis?
a. Heparin-induced thrombocytopenic purpura type 1

b. Heparin-induced thrombocytopenic purpura type 2
c. Brachial artery vasospasm
d. Hypercoagulable state due to immobilization
e. Embolization from infective endocarditis
Page - 1005
Internal Medicine - Hematology - HIT syndrome
Question 42/155
Question #42
A 49-year-old male patient was admitted to the CCU with acute non-ST elevation myocardial
infarction. On hospitalization day 7, he complained of le arm pain, paresthesia, and absent pulse.
His lab investigations show a platelet count of 30*10^9/L. What is the most likely diagnosis?
a. Heparin-induced thrombocytopenic purpura type 1

b. Heparin-induced thrombocytopenic purpura type 2 √
c. Brachial artery vasospasm
d. Hypercoagulable state due to immobilization
e. Embolization from infective endocarditis
Description
e patient received heparin to treat NSTEMI and developed low platelet and thrombosis (this is
typical for HIT syndrome)
Heparin-induced thrombocytopenia (HIT) syndrome is the platelet count drop≥ 50% aer heparin
therapy.
e following table shows the dierence between type 1 and type 2 HIT syndrome.
Page - 1006
Question 43/155
Question #43
A 66-year-old female patient undergoes elective knee replacement surgery and has received
prophylactic enoxaparin. As a result, 1 week later, she developed a pulmonary embolism. However,
her platelet count has dropped from 340 to 150*10^9/L in one week. What is the most appropriate at
this point?
a. Keep on the same dose of prophylactic enoxaparin

b. Increase heparin to a therapeutic dose and add warfarin
c. Stop heparin and start warfarin
d. Stop enoxaparin and start intravenous heparin
e. Stop enoxaparin and start argatroban
Page - 1007
Question 43/155
Question #43
A 66-year-old female patient undergoes elective knee replacement surgery and has received
prophylactic enoxaparin. As a result, 1 week later, she developed a pulmonary embolism. However,
her platelet count has dropped from 340 to 150*10^9/L in one week. What is the most appropriate at
this point?
a. Keep on the same dose of prophylactic enoxaparin

b. Increase heparin to a therapeutic dose and add warfarin
c. Stop heparin and start warfarin
d. Stop enoxaparin and start intravenous heparin
e. Stop enoxaparin and start argatroban √
Description
is is a classic scenario of Heparin-induced thrombocytopenia (HIT) syndrome.
A drop of platelet count ≥ 50% aer starting heparin therapy

is condition is not dose-dependent (can occur aer administration of any amount of
heparin)
Both types of heparins can cause HIT syndrome, but in LMWH, it is less likely
Treatment of HIT syndrome:
Stop heparin and use direct thrombin inhibitor (such as argatroban or lepirudin)
Because of 90% cross-reactivity, LMWH should not be substituted
Page - 1008
Question 44/155
Question #44
A 30-year-old female was started on low molecular weight heparin (LMWH) and warfarin to treat
deep venous thrombosis. On day 6 aer admission, she develops a drop in her platelet count of more
than 50% of the baseline. What is the most appropriate action at this time?
a. Stop LMWH and continue warfarin

b. Stop warfarin and continue LMWH
c. Switch to unfractionated heparin
d. Stop heparin and start argatroban
e. Stop anticoagulation and start aspirin
Page - 1009
Question 44/155
Question #44
A 30-year-old female was started on low molecular weight heparin (LMWH) and warfarin to treat
deep venous thrombosis. On day 6 aer admission, she develops a drop in her platelet count of more
than 50% of the baseline. What is the most appropriate action at this time?
a. Stop LMWH and continue warfarin

b. Stop warfarin and continue LMWH
c. Switch to unfractionated heparin
d. Stop heparin and start argatroban √
e. Stop anticoagulation and start aspirin
Description
is is a classic scenario of Heparin-induced thrombocytopenia (HIT) syndrome.
A drop of platelet count ≥ 50% aer starting heparin therapy

is condition is not dose-dependent (can occur aer administration of any amount of
heparin)
Both types of heparins can cause HIT syndrome, but in LMWH, it is less likely
Treatment of HIT syndrome:
Stop heparin and use direct thrombin inhibitor (such as argatroban or lepirudin)
Because of 90% cross-reactivity, LMWH should not be substituted
Page - 1010
Question 45/155
Question #45
A 62-year-old male patient develops pallor and fatigue. What is the best initial test to perform at
this time?
a. Full blood count

b. PT, PTT, and INR
c. HB electrophoresis
d. Serum ferritin level
e. Bone marrow examination
Page - 1011
Internal Medicine - Hematology - Hematologic investigations
Question 45/155
Question #45
A 62-year-old male patient develops pallor and fatigue. What is the best initial test to perform at
this time?
a. Full blood count √

b. PT, PTT, and INR
c. HB electrophoresis
d. Serum ferritin level
e. Bone marrow examination
Description
e first logical diagnosis in the presence of fatigue and pallor is anemia
CBC is the best, cheapest, and easiest way to know the hematocrit level and diagnose anemia
Serum ferritin, HB electrophoresis, and bone marrow examination may help dierentiate dierent
causes of anemia.
PT, PTT, and INR would help detect the cause of bleeding tendency in particular patients.
Page - 1012
Question 46/155
Question #46
A 17-year-old female develops a urinary tract infection. Her CBC show a WBC count of 13*10^9/L and
platelet count of 640*10^9/L, and her C-reactive protein is elevated. She was prescribed oral
antibiotics for her UTI. What would you do regarding her thrombocytosis?
a. Blood film
b. Bone marrow aspiration
c. Bone marrow biopsy
d. Repeat CBC in 4 weeks
e. Start aspirin therapy
Page - 1013
Question 46/155
Question #46
A 17-year-old female develops a urinary tract infection. Her CBC show a WBC count of 13*10^9/L and
platelet count of 640*10^9/L, and her C-reactive protein is elevated. She was prescribed oral
antibiotics for her UTI. What would you do regarding her thrombocytosis?
a. Blood film
d. Repeat CBC in 4 weeks √
e. Start aspirin therapy
Description
Platelets are acute-phase reactants that increase during infections and other inflammatory
conditions (reactive thrombocytosis).
e platelet count should be repeated a few weeks later; at that time, you will mostly find an
average Platelet count if reactive thrombocytosis is the diagnosis.
Examples of acute-phase reactants: are CRP, ESR, WBC, ferritin, and platelet count
Page - 1014
Question 47/155
Question #47
A 23-year-old male patient started to have a fever 4 days ago. His temperature is 38.9 °C, and he has
no localizing symptoms. His CBC show an elevated WBC with absolute lymphocytosis. Which is the
a. Bacterial infection
b. Viral infection
c. Parasitic infection
d. Connective tissue disease
e. Lymphoma
Page - 1015
Question 47/155
Question #47
A 23-year-old male patient started to have a fever 4 days ago. His temperature is 38.9 °C, and he has
no localizing symptoms. His CBC show an elevated WBC with absolute lymphocytosis. Which is the
a. Bacterial infection
b. Viral infection √
c. Parasitic infection
d. Connective tissue disease
e. Lymphoma
Description
e absolute lymphocyte count equals the total number of white blood cells multiplied by the
percentage of lymphocytes.
e most common cause of absolute lymphocytosis is a viral infection.
Connective tissue disorders infrequently cause reactive lymphocytosis.
Neoplastic hyperproliferation (e.g., Lymphoma) is a possible less common cause of lymphocytosis
Bacterial infections cause neutrophilia, not lymphocytosis, except Bordetella pertussis, which has
been known to cause absolute lymphocyte counts of up to 70,000/L
Page - 1016
Question 48/155
Question #48
e following figure shows a blood film. What is the finding you see?
a. Schistocytes
b. Target cells
c. Spherocytosis
d. Teardrop cells
e. Burr cells
Page - 1017
Question 48/155
Question #48
a. Schistocytes
b. Target cells √
c. Spherocytosis
d. Teardrop cells
e. Burr cells
Description
e normal RBC shape is a biconcave disk; it will typically appear under the microscope with a
central pallor
e figure shows target cells that may be found in the following diseases;
SCA/alassemia
Page - 1018
IDA
Hyposplenism
Liver disease
Page - 1019
Question 49/155
Question #49
A 22-year-old female has an accidental finding in her complete blood count; her platelet count is
30*10^9/L. e platelet is found to be clumped under the microscope. What would you do next?
a. Repeat CBC aer 2 weeks

b. Repeat CBC now with an alternative anticoagulant
c. Refer to the hematology clinic
d. HIV testing
e. Tell the patient that she has an ITP
Page - 1020
Question 49/155
Question #49
A 22-year-old female has an accidental finding in her complete blood count; her platelet count is
30*10^9/L. e platelet is found to be clumped under the microscope. What would you do next?
a. Repeat CBC aer 2 weeks

b. Repeat CBC now with an alternative anticoagulant √
c. Refer to the hematology clinic
d. HIV testing
e. Tell the patient that she has an ITP
Description
Clumped platelets are an artifact due to antibodies to the anticoagulant used in the CBC tube.
e CBC automated machine calculates the clumped group of platelets as one platelet.
You should repeat the test in an alternative heparin tube or citrate tube, and the test will
demonstrate the accurate platelet count.
Page - 1021
Question 50/155
Question #50
A patient’s blood film result shows a significant number of schistocytes. Which of the following is
not a likely diagnosis?
a. Disseminated intravascular coagulation (DIC)

b. Hemolytic uremic syndrome (HUS)
c. rombotic thrombocytopenic purpura (TTP)
d. Microangiopathic hemolytic anemia (MAHA)
e. Alpha thalassemia
Page - 1022
Question 50/155
Question #50
A patient’s blood film result shows a significant number of schistocytes. Which of the following is
not a likely diagnosis?
a. Disseminated intravascular coagulation (DIC)

b. Hemolytic uremic syndrome (HUS)
c. rombotic thrombocytopenic purpura (TTP)
d. Microangiopathic hemolytic anemia (MAHA)
e. Alpha thalassemia √
Description
Schistocytes (also known as Helmet cells or Fragmented RBCs) are expected to be found in
intravascular hemolysis.
Alpha thalassemia usually presents with Heinz bodies.
Page - 1023
Question 51/155
Question #51
A 22-year-old male patient develops severe diarrhea aer eating in a restaurant. His CBC shows
eosinophilia. What is the best next step in management?
a. Stool bacterial culture

b. Stool for ova or parasites
c. Stool WBC
d. Gastric lavage
e. Colonoscopy and biopsy
Page - 1024
Question 51/155
Question #51
A 22-year-old male patient develops severe diarrhea aer eating in a restaurant. His CBC shows
eosinophilia. What is the best next step in management?
a. Stool bacterial culture

b. Stool for ova or parasites √
c. Stool WBC
d. Gastric lavage
e. Colonoscopy and biopsy
Description
Eosinophilia indicates an allergic reaction or parasitic infection.
e clinical scenario fits with a parasitic infection acquired orally in the restaurant and manifested
as diarrhea.
Page - 1025
Question 52/155
Question #52
a. Schistocytes
b. Target cells
c. Spherocytosis
d. Teardrop cells
e. Burr cells
Page - 1026
Question 52/155
Question #52
a. Schistocytes
b. Target cells
c. Spherocytosis
d. Teardrop cells √
e. Burr cells
Description
central pallor
e figure shows teardrop cells that may be found in myelofibrosis
Page - 1027
Page - 1028
Question 53/155
Question #53
A 27-year-old female complains of menorrhagia and recurrent epistaxis. Her CBC shows a
hemoglobin of 12.1 g/dL, WBC of 7*10^9/L, and platelet count of 70*10^9/L. What is the most likely
diagnosis?
a. Polycythemia
b. rombocytosis
c. rombocytopenia
d. Leukocytosis
e. Leukopenia
Page - 1029
Question 53/155
Question #53
A 27-year-old female complains of menorrhagia and recurrent epistaxis. Her CBC shows a
hemoglobin of 12.1 g/dL, WBC of 7*10^9/L, and platelet count of 70*10^9/L. What is the most likely
diagnosis?
a. Polycythemia
b. rombocytosis
c. rombocytopenia √
d. Leukocytosis
e. Leukopenia
Description
rombocytopenia is defined as the presence of a low platelet count.
It may result in bleeding and elevation of the bleeding time.
Polycythemia is the presence of high hemoglobin level
rombocytosis is the presence of a high platelet count
Leukocytosis is the presence of an elevated WBC count, while leukopenia is the presence of a low
WBC count.
Page - 1030
Question 54/155
Question #54
a. Schistocytes
b. Target cells
c. Spherocytosis
d. Teardrop cells
e. Burr cells
Page - 1031
Question 54/155
Question #54
a. Schistocytes
b. Target cells
c. Spherocytosis √
d. Teardrop cells
e. Burr cells
Description
central pallor
e figure shows spherocytes which may be found in hereditary spherocytosis and autoimmune
hemolytic anemia.
Page - 1032
Page - 1033
Question 55/155
Question #55
Which of the following is the least likely diagnosis in a patient with hemolytic anemia and a positive
direct antiglobulin test?
a. Cold agglutinin hemolytic anemia

b. Warm agglutinin hemolytic anemia
c. Immediate blood transfusion reaction
d. Delayed blood transfusion reaction
e. Microangiopathic hemolytic anemia
Page - 1034
Internal Medicine - Hematology - Hemolytic Anemia
Question 55/155
Question #55
Which of the following is the least likely diagnosis in a patient with hemolytic anemia and a positive
direct antiglobulin test?
a. Cold agglutinin hemolytic anemia

b. Warm agglutinin hemolytic anemia
c. Immediate blood transfusion reaction
d. Delayed blood transfusion reaction
e. Microangiopathic hemolytic anemia √
Description
Positive Coombs test indicates immune-mediated destruction of the blood cells (autoimmune or
alloimmune).
Microangiopathic hemolytic anemia is not an immune-mediated disorder. Nevertheless, it is caused

by various conditions like (TTP, DIC, HUS, etc.)
Classifications according to the cause:
Congenital:
RBC membrane (Spherocytosis, Elliptocytosis)

RBC hemoglobin (thalassemia, sickle cell disease)
Metabolic (G6PD deficiency)
Acquired
Alloimmune:
Hemolytic transfusion reaction
Hemolytic disease of the newborn
Autoimmune:
Cold antibody
Warm antibody
Non-immune:
Paroxysmal nocturnal hemoglobinuria (PNH)
Page - 1035
Microangiopathic hemolytic anemia (MAHA)
Mechanical (prosthetic valve, burn, etc.)
Hypersplenism
March hemoglobinuria
Infections (malaria, sepsis, etc.)
Drugs and chemicals
Systemic diseases (renal failure, liver failure)
Page - 1036
Question 56/155
Question #56
e following disorders can cause intravascular hemolytic anemia except:
a. Microangiopathic hemolytic anemia

b. Paroxysmal nocturnal hemoglobinuria (PNH)
c. Cold agglutinin hemolytic anemia
d. Glucose-6-phosphate dehydrogenase enzyme deficiency
e. Hereditary spherocytosis
Page - 1037
Question 56/155
Question #56
e following disorders can cause intravascular hemolytic anemia except:
a. Microangiopathic hemolytic anemia

b. Paroxysmal nocturnal hemoglobinuria (PNH)
c. Cold agglutinin hemolytic anemia
d. Glucose-6-phosphate dehydrogenase enzyme deficiency
e. Hereditary spherocytosis √
Description
Classification according to the site of hemolysis:
Extravascular: RBC removed by liver and spleen prematurely

Intravascular: RBC lysis in circulation
Hereditary spherocytosis is a known cause of extravascular hemolysis, not intravascular.
Note that G6PD deficiency can cause intra- and extravascular hemolysis, but the intravascular part
is more prominent.
e following table shows the hemolytic anemias' classification according to the hemolysis site.
Page - 1038
Question 57/155
Question #57
A previously healthy 32-year-old female presents with fatigue, jaundice, and pallor. Her lab tests
show normocytic anemia, high reticulocyte count, and indirect hyperbilirubinemia. In addition, her
liver enzymes are normal. What is the best next step in the management of this patient?
a. Bone marrow aspiration

b. Direct antiglobulin test
c. Vitamin B12 level
d. Iron studies
e. Biliary ultrasound
Page - 1039
Question 57/155
Question #57
A previously healthy 32-year-old female presents with fatigue, jaundice, and pallor. Her lab tests
show normocytic anemia, high reticulocyte count, and indirect hyperbilirubinemia. In addition, her
liver enzymes are normal. What is the best next step in the management of this patient?

b. Direct antiglobulin test √
c. Vitamin B12 level
d. Iron studies
e. Biliary ultrasound
Description
is patient is suspected of having hemolytic anemia.
e first step in diagnosing the cause of hemolytic anemia is to do Coombs testing.
Direct antiglobulin test (Direct Coombs test) is used to detect antibodies bound to RBCs
It will be positive in case of autoimmune Hemolytic anemia, transfusion reaction, and hemolytic
disease of the newborn.
Blood sample mixed with antibodies to human globulin:
If agglutination → Positive DAT
If no agglutination → negative DAT
Page - 1040
Question 58/155
Question #58
A 30-year-old female presents with jaundice and fatigue. She told you that she had an upper
respiratory infection 10 days ago. However, her lab investigations show hemoglobin of 9 g/dL, MCV
of 97fl, bilirubin of 2mg/dL, AST 20u/L, ALT 22u/L, and Alkaline phosphatase of 73 U/L. In addition,
her blood film shows spherocytes and immature RBCs. What is the best next step in the

d. Abdominal ultrasound
e. Osmotic fragility test
Page - 1041
Question 58/155
Question #58
A 30-year-old female presents with jaundice and fatigue. She told you that she had an upper
respiratory infection 10 days ago. However, her lab investigations show hemoglobin of 9 g/dL, MCV
of 97fl, bilirubin of 2mg/dL, AST 20u/L, ALT 22u/L, and Alkaline phosphatase of 73 U/L. In addition,
her blood film shows spherocytes and immature RBCs. What is the best next step in the

b. Direct Coombs test √
d. Abdominal ultrasound
Description

Page - 1042
Question 59/155
Question #59
A 22-year-old female presents with jaundice, anemia, and high reticulocytes count. What is the most
appropriate at this time?
a. G6PD enzyme assay

c. Indirect Coombs test
d. Bone marrow biopsy
Page - 1043
Question 59/155
Question #59
A 22-year-old female presents with jaundice, anemia, and high reticulocytes count. What is the most
appropriate at this time?
a. G6PD enzyme assay

b. Direct Coombs test √
c. Indirect Coombs test
Description

Page - 1044
Question 60/155
Question #60
A 35-year-old female is admitted to the hematology ward with hemolytic anemia. Which of the
following is most characteristic of her condition?
a. Reduced LDH
b. Conjugated hyperbilirubinemia
d. Reticulocytosis
e. Elevated serum haptoglobin
Page - 1045
Question 60/155
Question #60
A 35-year-old female is admitted to the hematology ward with hemolytic anemia. Which of the
following is most characteristic of her condition?
a. Reduced LDH
b. Conjugated hyperbilirubinemia
d. Reticulocytosis √
e. Elevated serum haptoglobin
Description
A high reticulocyte count indicates either hemolytic anemia or acute bleeding.
Features of hemolytic anemia are:
Increase of Free hemoglobin, reticulocyte count (> 2%), LDH, Indirect bilirubin (unconjugated
hyperbilirubinemia), Urinary urobilinogen, Urine hemoglobin, and Urine hemosiderin.
Decrease of hemoglobin, Serum Haptoglobin, and RBC survival
Page - 1046
Question 61/155
Question #61
A 48-year-old male patient has features suggestive of hemolytic anemia. Which of the following
most likely fits with this diagnosis?
a. Elevated LDH, low haptoglobin, normal Indirect bilirubin

b. Elevated LDH, Elevated Haptoglobin, low Indirect bilirubin
c. Low LDH, Elevated Haptoglobin, Elevated Indirect bilirubin
d. Elevated LDH, low Haptoglobin, Elevated Indirect bilirubin
e. Low LDH, low Haptoglobin, Elevated Indirect bilirubin
Page - 1047
Question 61/155
Question #61
A 48-year-old male patient has features suggestive of hemolytic anemia. Which of the following
most likely fits with this diagnosis?
a. Elevated LDH, low haptoglobin, normal Indirect bilirubin

b. Elevated LDH, Elevated Haptoglobin, low Indirect bilirubin
c. Low LDH, Elevated Haptoglobin, Elevated Indirect bilirubin
d. Elevated LDH, low Haptoglobin, Elevated Indirect bilirubin √
e. Low LDH, low Haptoglobin, Elevated Indirect bilirubin
Description
High LDH, low haptoglobin, and indirect hyperbilirubinemia are the most likely lab results in
hemolytic anemia.
Features of hemolytic anemia are:
Increase of Free hemoglobin, reticulocyte count (> 2%), LDH, Indirect bilirubin (unconjugated
hyperbilirubinemia), Urinary urobilinogen, Urine hemoglobin, and Urine hemosiderin.
Decrease of hemoglobin, Serum Haptoglobin, and RBC survival
Page - 1048
Question 62/155
Question #62
A male patient with a known case of hemophilia A presents to you for genetic counseling. However,
his wife has no family history of hemophilia. Which of the following is the most factual statement?
a. Half of his daughters will be carriers of the disease

b. Half of his sons will be aected
c. All his sons will be aected
d. All his daughters will be carriers
e. Half of his children will be aected regardless of the gender
Page - 1049
Internal Medicine - Hematology - Hemophilia
Question 62/155
Question #62
A male patient with a known case of hemophilia A presents to you for genetic counseling. However,
his wife has no family history of hemophilia. Which of the following is the most factual statement?
a. Half of his daughters will be carriers of the disease

b. Half of his sons will be aected
c. All his sons will be aected
d. All his daughters will be carriers √
e. Half of his children will be aected regardless of the gender
Description
Hemophilia is an X-linked recessive disease (almost exclusively in males).
His sons will be XY (the X from the mother and the Y from the father), so their X chromosome will
not contain the abnormal gene.
His daughters will take the aected X chromosome from him and a normal X chromosome from
their mother. As a result, they will be in a carrier status.
So, his sons will not be aected, and all his daughters will be in a carrier status.
Page - 1050
Question 63/155
Question #63
A 25-year-old female patient presents with easy bruises and bleeding tendencies. However, she has
no family history of bleeding tendency. Based on this limited history, which diagnosis is the least
likely?
a. B12 deficiency
b. Leukemia
c. Hemophilia
d. Von Willebrand disease
e. Vitamin K deficiency
Page - 1051
Question 63/155
Question #63
A 25-year-old female patient presents with easy bruises and bleeding tendencies. However, she has
no family history of bleeding tendency. Based on this limited history, which diagnosis is the least
likely?
a. B12 deficiency
b. Leukemia
c. Hemophilia √
d. Von Willebrand disease
e. Vitamin K deficiency
Description
Being a female will make hemophilia less likely. Hemophilia is an X-linked recessive disease (almost
exclusively in males).
Hemophilia A is Factor VIII deficiency, while hemophilia B is factor IX deficiency (type B is known as
Christmas disease)
Patients with hemophilia present with bleeding tendency and prolonged aPTT.
e diagnosis is confirmed by testing for factor VIII level.
Page - 1052
Question 64/155
Question #64
In the routine preoperative assessment, A 22-year-old male patient is found to have prolonged aPTT.
His family history is unremarkable, and his lab investigations show normal PT, INR, and BT. What is
a. Warfarin overdose
b. Von Willebrand’s disease
c. Factor VIII deficiency
d. Factor XIII deficiency
e. rombocytopenia
Page - 1053
Question 64/155
Question #64
In the routine preoperative assessment, A 22-year-old male patient is found to have prolonged aPTT.
His family history is unremarkable, and his lab investigations show normal PT, INR, and BT. What is
a. Warfarin overdose
c. Factor VIII deficiency √
d. Factor XIII deficiency
e. rombocytopenia
Description
Being a male with elevated aPTT is suggestive of hemophilia A
Note that vWD presents with abnormal BT
Warfarin overdose and vitamin K deficiency present with prolonged PT and INR
Factor XIII deficiency presents with bleeding tendency and normal PTT, PT, and INR
rombocytopenia is simply diagnosed on CBC and presents with prolonged BT.
Hemophilia is an X-linked recessive disease (almost exclusively in males). Hemophilia A is

Factor VIII deficiency, while hemophilia B is factor IX deficiency (type B is known as Christmas
disease)
e patient presents with bleeding tendency and prolonged aPTT.
e diagnosis is confirmed by testing for factor VIII level.
Page - 1054
Question 65/155
Question #65
A 22-year-old male patient is suspected of having hereditary spherocytosis. Which is the most
accurate test to help detect the condition?

c. Flow cytometric EMA (eosin-5-maleimide) binding test
e. Laparoscopy
Page - 1055
Internal Medicine - Hematology - Hereditary Spherocytosis (HS)
Question 65/155
Question #65
A 22-year-old male patient is suspected of having hereditary spherocytosis. Which is the most
accurate test to help detect the condition?

c. Flow cytometric EMA (eosin-5-maleimide) binding test √
e. Laparoscopy
Description
In Hereditary Spherocytosis (HS), the most common abnormality is the deficiency of membrane
proteins (Beta-spectrin or ankyrin), leading to reduced RBC elasticity and destruction of the RBCs
when passing through the spleen.
Diagnosis of HS:
Hb: 6 – 10 g/dL (depends on the degree of compensation)

Reticulocytosis (usually 6 – 20%)
High indirect bilirubin and LDH
Blood film: Spherocytes (small round hyperchromic RBCs without central pallor)
Negative Coombs test
e osmotic fragility test is no longer recommended
Flow cytometric EMA (eosin-5-maleimide) binding test (the most accurate test)
Page - 1056
Question 66/155
Question #66
A 23-year-old male patient presents to your clinic with right upper quadrant recurrent abdominal
pain. His family history includes a father with a splenectomy at a young age. His lab investigations
show anemia, low MCV, and high MCH. In addition, abdominal ultrasound demonstrates
gallbladder stones. What is the most likely diagnosis?
a. G6PD deficiency
b. Beta thalassemia
c. Alpha thalassemia
d. Hereditary spherocytosis
e. Lead poisoning
Page - 1057
Question 66/155
Question #66
A 23-year-old male patient presents to your clinic with right upper quadrant recurrent abdominal
pain. His family history includes a father with a splenectomy at a young age. His lab investigations
show anemia, low MCV, and high MCH. In addition, abdominal ultrasound demonstrates
gallbladder stones. What is the most likely diagnosis?
a. G6PD deficiency
b. Beta thalassemia
c. Alpha thalassemia
d. Hereditary spherocytosis √
e. Lead poisoning
Description
e patient is suspected of having hereditary spherocytosis.
e family history of hemolytic anemia, microcytic anemia, high MCH, and gallstones strongly
suggest hereditary spherocytosis.
G6PD presents with episodic hemolysis aer exposure to oxidants.
Page - 1058
Question 67/155
Question #67
A 23-year-old female with a history of hereditary spherocytosis presents with fatigue and pallor. Her
blood tests show anemia of 5.1g/dL, leukopenia, thrombocytopenia, low MCV, and a reticulocyte
count of 0.2%. What is the most likely explanation?
a. Hemolytic crisis
b. Parvovirus B19 infection
c. Sequestration crisis
e. Megaloblastic crisis
Page - 1059
Question 67/155
Question #67
A 23-year-old female with a history of hereditary spherocytosis presents with fatigue and pallor. Her
blood tests show anemia of 5.1g/dL, leukopenia, thrombocytopenia, low MCV, and a reticulocyte
count of 0.2%. What is the most likely explanation?
a. Hemolytic crisis
b. Parvovirus B19 infection √
c. Sequestration crisis
e. Megaloblastic crisis
Description
Aplastic crisis is associated with parvovirus B19 infection.
It manifests as low HB, WBC, Platelet, and reticulocytes.
Hemolytic crisis presents with elevated reticulocytes not reduced.
Megaloblastic crisis will present with macrocytic anemia (not Low MCV)
Page - 1060
Question 68/155
Question #68
A 22-year-old male patient is suspected of having hereditary spherocytosis. Which of the following is
the most common mood inheritance for this condition?
a. Autosomal dominant
b. Autosomal recessive
c. X linked recessive
d. X linked dominant
e. Y linked
Page - 1061
Question 68/155
Question #68
A 22-year-old male patient is suspected of having hereditary spherocytosis. Which of the following is
the most common mood inheritance for this condition?
a. Autosomal dominant √
c. X linked recessive
d. X linked dominant
e. Y linked
Description
Approximately 75% of hereditary spherocytosis cases have an autosomal dominant inheritance

pattern; 25% are recessive forms and de novo mutations.
Page - 1062
Question 69/155
Question #69
A 22-year-old female presents with menorrhagia, bruises, and petechiae for a week. Her lab
investigations show a platelet count of 30*10^9/L and elevated bleeding time. What is the most
likely diagnosis?
a. Cytomegalovirus infection
b. HIV infection
c. Systemic lupus erythematosus
d. Idiopathic thrombocytopenic purpura
e. Acute leukemia
Page - 1063
Internal Medicine - Hematology - Idiopathic rombocytopenic Purpura (ITP)
Question 69/155
Question #69
A 22-year-old female presents with menorrhagia, bruises, and petechiae for a week. Her lab
investigations show a platelet count of 30*10^9/L and elevated bleeding time. What is the most
likely diagnosis?
a. Cytomegalovirus infection
b. HIV infection
d. Idiopathic thrombocytopenic purpura √
e. Acute leukemia
Description
Idiopathic rombocytopenic Purpura (ITP) is a disorder of primary hemostasis in which

autoantibodies against platelets lead to platelet destruction, thrombocytopenia, and bleeding.
e isolated thrombocytopenia in healthy persons strongly suggests the diagnosis of ITP.
Possible symptoms are: easy bruising, epistaxis, menorrhagia, and petechial rash
It is a diagnosis of exclusion. However, bone marrow examination is indicated in elderly patients to

exclude malignancy.
Page - 1064
Question 70/155
Question #70
A previously healthy 28-year-old male is brought to you by his friend, who noted a skin rash on his
neck. On examination, you noted a purpuric rash extending along with his necklace. His blood count
shows hemoglobin of 14.5 g/dL, WBC of 5*10^9/L, and platelet count of 3*10^9. What is the most
likely diagnosis?
a. Henoch Schönlein purpura

b. rombotic thrombocytopenic purpura
c. Idiopathic thrombocytopenic purpura (ITP)
d. Von Willebrand’s disease
e. Systemic lupus erythematosus
Page - 1065
Internal Medicine - Hematology - Idiopathic rombocytopenic Purpura (ITP)
Question 70/155
Question #70
A previously healthy 28-year-old male is brought to you by his friend, who noted a skin rash on his
neck. On examination, you noted a purpuric rash extending along with his necklace. His blood count
shows hemoglobin of 14.5 g/dL, WBC of 5*10^9/L, and platelet count of 3*10^9. What is the most
likely diagnosis?
a. Henoch Schönlein purpura

b. rombotic thrombocytopenic purpura
c. Idiopathic thrombocytopenic purpura (ITP) √
d. Von Willebrand’s disease
Description
Idiopathic rombocytopenic Purpura (ITP) is a disorder of primary hemostasis in which

autoantibodies against platelets lead to platelet destruction, thrombocytopenia, and bleeding.
e isolated thrombocytopenia in healthy persons strongly suggests the diagnosis of ITP.
Possible symptoms are: easy bruising, epistaxis, menorrhagia, and petechial rash
It is a diagnosis of exclusion. However, bone marrow examination is indicated in elderly patients to

exclude malignancy.
Page - 1066
Question 71/155
Question #71
A 48-year-old male patient was diagnosed with anemia. Which of the following most likely indicates
iron deficiency?
a. Reduced total iron-binding capacity

b. Elevated serum ferritin level
c. Elevated transferrin saturation
d. Reticulocytosis 1 week aer initiating oral iron
e. Reduced RDW
Page - 1067
Internal Medicine - Hematology - Iron Deficiency Anemia (IDA)
Question 71/155
Question #71
A 48-year-old male patient was diagnosed with anemia. Which of the following most likely indicates
iron deficiency?
a. Reduced total iron-binding capacity

b. Elevated serum ferritin level
c. Elevated transferrin saturation
d. Reticulocytosis 1 week aer initiating oral iron √
e. Reduced RDW
Description
In a patient with iron deficiency anemia (IDA), the diagnosis can be confirmed by providing an oral
iron and then one week later performing a reticulocyte count
Reticulocytosis peaks on the 7th – 10th day aer starting the therapy.
Iron deficiency anemia (IDA) is generally the most common cause of anemia.
It is characterized by microcytic hypochromic anemia.
Its causes include:
Poor intake
Decrease absorption (e.g., celiac disease, gastrectomy
Increased Iron demands (pregnancy, growing adolescent)
Chronic Blood loss (most common cause)
Laboratory investigations will show:
CBC: Low HB, MCV, MCH, and high RDW

Blood film: Poikilocytosis (Variable RBC shapes), Anisocytosis (Variable RBC sizes), and Target
cells
Serology: Low serum ferritin, Iron, Transferrin saturation, High transferrin level, and Total Iron
Binding Capacity (TIBC)
Specific features of IDA:

Page - 1068
Brittle nails and nail cracking
Koilonychia (flattening or concavity of the nails)
Angular stomatitis
Sore tongue
Pica (eating unusual substances like soil, ice, etc.)
Page - 1069
Question 72/155
Question #72
A 40-year-old woman complains of fatigue. Her complete blood count shows hemoglobin of 9.8
g/dL, MCV of 74 fl, serum ferritin of 8 mg/L, and total iron-binding capacity of 75 umol/L. What is the
a. alassemia major
b. alassemia minor
c. Iron deficiency anemia
e. B12 deficiency
Page - 1070
Question 72/155
Question #72
A 40-year-old woman complains of fatigue. Her complete blood count shows hemoglobin of 9.8
g/dL, MCV of 74 fl, serum ferritin of 8 mg/L, and total iron-binding capacity of 75 umol/L. What is the
a. alassemia major
b. alassemia minor
c. Iron deficiency anemia √
e. B12 deficiency
Description
Its causes include:
Poor intake

cells

Page - 1071
Angular stomatitis
Sore tongue
Page - 1072
Question 73/155
Question #73
A 32-year -old male patient develops easy fatigability and pallor for 3 months. His CBC shows
hemoglobin of 8.9 g/dL, MCV of 69 fl, and serum ferritin of 2 mg/L. What is the most likely
diagnosis?
a. B12 deficiency
b. Folic acid deficiency
c. Iron deficiency
d. Sideroblastic anemia
e. alassemia
Page - 1073
Question 73/155
Question #73
A 32-year -old male patient develops easy fatigability and pallor for 3 months. His CBC shows
hemoglobin of 8.9 g/dL, MCV of 69 fl, and serum ferritin of 2 mg/L. What is the most likely
diagnosis?
a. B12 deficiency
c. Iron deficiency √
e. alassemia
Description
Its causes include:
Poor intake

cells

Page - 1074
Angular stomatitis
Sore tongue
Page - 1075
Question 74/155
Question #74
Which of the following statements is true about iron absorption?
a. Iron is primarily absorbed in the terminal ileum

b. Diarrhea is a common complication of oral iron
c. It is absorbed better if taken aer meals
d. Proton pump inhibitors do not aect its absorption
e. Patients with celiac disease may develop iron deficiency
Page - 1076
Question 74/155
Question #74
Which of the following statements is true about iron absorption?
a. Iron is primarily absorbed in the terminal ileum

b. Diarrhea is a common complication of oral iron
c. It is absorbed better if taken aer meals
d. Proton pump inhibitors do not aect its absorption
e. Patients with celiac disease may develop iron deficiency √
Description
Patients with celiac disease will develop atrophic villi, which are more significant in the proximal
intestine (at the site of iron absorption). So, patients with celiac disease are likely to develop iron
deficiency secondary to malabsorption.
Factors that increase iron absorption:
Increased acidity
Alcohol
Use of vitamin C supplement
When iron is complemented with lactose
e iron of animal source (ferrous) is more absorbable than plant source (ferric)
Factors that decrease iron absorption:
Tea drinking
e use of PPIs or any acid suppressant
Plant-source iron
Page - 1077
Question 75/155
Question #75
A 42-year-old female is suering from iron deficiency anemia secondary to menorrhagia. Which of
the following laboratory findings fits with the diagnosis?
a. Ferritin low, TIBC high, MCV low, MCH high

b. Ferritin low, TIBC high, MCV high, MCH low
c. Ferritin high, TIBC low, MCV low, MCH low
d. Ferritin low, TIBC high, MCV low, MCH low
e. Ferritin low, TIBC low, MCV low, MCH low
Page - 1078
Question 75/155
Question #75
A 42-year-old female is suering from iron deficiency anemia secondary to menorrhagia. Which of
the following laboratory findings fits with the diagnosis?
a. Ferritin low, TIBC high, MCV low, MCH high

b. Ferritin low, TIBC high, MCV high, MCH low
c. Ferritin high, TIBC low, MCV low, MCH low
d. Ferritin low, TIBC high, MCV low, MCH low √
e. Ferritin low, TIBC low, MCV low, MCH low
Description
Laboratory investigations in iron deficiency anemia will show the following:

cells
Its causes include:
Poor intake

Angular stomatitis
Page - 1079
Sore tongue
Page - 1080
Question 76/155
Question #76
A 30-year-old female presents with fatigue and pallor. Which of the following is the most reliable
indicator of iron deficiency anemia?
a. How Total Iron Binding Capacity (TIBC)

b. Low serum iron
c. Low MCV
d. Low serum ferritin
e. Low MCH
Page - 1081
Question 76/155
Question #76
A 30-year-old female presents with fatigue and pallor. Which of the following is the most reliable
indicator of iron deficiency anemia?
a. How Total Iron Binding Capacity (TIBC)

b. Low serum iron
c. Low MCV
d. Low serum ferritin √
e. Low MCH
Description
Low serum ferritin level is diagnostic of iron deficiency anemia even in its early phase.
Its causes include:
Poor intake

cells

Koilonychia (flattening or concavity of the nails) Page - 1082
Angular stomatitis
Sore tongue
Page - 1083
Question 77/155
Question #77
A 48-year-old male patient presents with fatigue and shortness of breath. His complaints have been
progressive over the past 2 months. On examination, there are a red sore tongue, angular stomatitis,
and Koilonychia. His lab investigations are significant for a hematocrit of 24% and MCV of 66 fl.
a. B12 deficiency
c. Iron deficiency
e. alassemia
Page - 1084
Question 77/155
Question #77
A 48-year-old male patient presents with fatigue and shortness of breath. His complaints have been
progressive over the past 2 months. On examination, there are a red sore tongue, angular stomatitis,
and Koilonychia. His lab investigations are significant for a hematocrit of 24% and MCV of 66 fl.
a. B12 deficiency
c. Iron deficiency √
e. alassemia
Description
Its causes include:
Poor intake

cells

Page - 1085
Angular stomatitis
Sore tongue
Page - 1086
Question 78/155
Question #78
A 22-year-old female developed iron deficiency anemia. She started on oral iron one week ago.
Which of the following is appropriate to assess the response of oral iron at this time?
a. Repeat hemoglobin level

b. Perform hemoglobin electrophoresis
c. Check for the elevation of MCV
d. Check for reticulocyte count
e. Check for serum iron level
Page - 1087
Question 78/155
Question #78
A 22-year-old female developed iron deficiency anemia. She started on oral iron one week ago.
Which of the following is appropriate to assess the response of oral iron at this time?
a. Repeat hemoglobin level

b. Perform hemoglobin electrophoresis
c. Check for the elevation of MCV
d. Check for reticulocyte count √
e. Check for serum iron level
Description
In a patient with iron deficiency anemia (IDA), the diagnosis can be confirmed by providing an oral
iron and then one week later performing a reticulocyte count
Reticulocytosis peaks on the 7th – 10th day aer starting the therapy.
e hemoglobin level will not change for at least 2 weeks and can take 2 months to return to its
normal level.
Serum iron level is diet-sensitive, but it is not an indicator of response to the treatment. However, its
elevation aer oral iron intake indicates appropriate absorption of iron.
Page - 1088
Question 79/155
Question #79
A 52-year-old female is on methotrexate and diclofenac sodium for rheumatoid arthritis. Recently
she developed epigastric pain, especially aer eating, palpitation, and pallor. Her ECG and cardiac
enzymes are unremarkable. Her rest of the lab investigations show hemoglobin of 8.9 g/dL, MCV of
73 fl, and a serum ferritin level of 5 mg/L. What is the most likely diagnosis?
a. Chronic gastrointestinal bleeding

c. Chronic hemolytic anemia
d. Aplastic anemia
Page - 1089
Question 79/155
Question #79
A 52-year-old female is on methotrexate and diclofenac sodium for rheumatoid arthritis. Recently
she developed epigastric pain, especially aer eating, palpitation, and pallor. Her ECG and cardiac
enzymes are unremarkable. Her rest of the lab investigations show hemoglobin of 8.9 g/dL, MCV of
73 fl, and a serum ferritin level of 5 mg/L. What is the most likely diagnosis?
a. Chronic gastrointestinal bleeding √

c. Chronic hemolytic anemia
d. Aplastic anemia
Description
Its causes include:
Poor intake

cells

Page - 1090
Angular stomatitis
Sore tongue
Page - 1091
Question 80/155
Question #80
A 32-year-old male patient complains of fatigue, non-localized abdominal pain, tremor, and
insomnia. His symptoms started 6 weeks ago and are now getting worse. He works in a company
that manufactures bullets. On examination, the patient has a noticeable tremor and a wrist drop.
His lab investigations show microcytic anemia and high ferritin level. Which of the following is most
likely to present in his blood film examination?
a. Target cells
b. Schist cytosis
c. Spherocytosis
d. Teardrop cells
e. Basophilic stippling
Page - 1092
Internal Medicine - Hematology - Lead Poisoning
Question 80/155
Question #80
His lab investigations show microcytic anemia and high ferritin level. Which of the following is most
likely to present in his blood film examination?
a. Target cells
b. Schist cytosis
c. Spherocytosis
d. Teardrop cells
e. Basophilic stippling √
Description
Basophilic stippling: aggregation of RNA in RBC due to defect in enzyme pyrimidine 5-nucleotidase
caused by lead poisoning
is clinical scenario demonstrated a patient who develops anemia and has occupational exposure
to lead.
Lead poisoning may present with the following features that are typical for this case scenario:
Microcytic anemia
Autonomic neuropathy
Motor neuropathy
Abdominal pain
Consider lead poisoning in a patient with a microcytic anemia with normal or high ferritin
associated with neuropathy and abdominal pain when he is at risk of exposure to lead.
Page - 1093
Question 81/155
Question #81
His lab investigations show:
Hemoglobin: 9 g/dL
MCV: 65 fl
WBC: 5000 *10^9/L
Ferritin: 880 mic/L

b. Anemia of chronic disease
c. Lead poisoning
d. alassemia minor
e. Folate deficiency
Page - 1094
Internal Medicine - Hematology - Lead Poisoning
Question 81/155
Question #81
His lab investigations show:
Hemoglobin: 9 g/dL
MCV: 65 fl
WBC: 5000 *10^9/L
Ferritin: 880 mic/L

b. Anemia of chronic disease
c. Lead poisoning √
d. alassemia minor
e. Folate deficiency
Description
is clinical scenario demonstrated a patient who develops anemia and has occupational exposure
to lead.
Lead poisoning may present with the following features that are typical for this case scenario:
Microcytic anemia
Autonomic neuropathy
Motor neuropathy
Abdominal pain
Consider lead poisoning in a patient with a microcytic anemia with normal or high ferritin
associated with neuropathy and abdominal pain when he is at risk of exposure to lead.
Page - 1095
Question 82/155
Question #82
A 50-year-old male patient has anemia, thrombocytopenia, leukocytosis, and splenomegaly. His
Philadelphia chromosome is positive. What is the most likely diagnosis?
a. Acute lymphoblastic leukemia

b. Acute myeloid leukemia
c. Chronic lymphoid leukemia
d. Chronic myeloid leukemia
e. Non-Hodgkin lymphoma
Page - 1096
Internal Medicine - Hematology - Leukemia
Question 82/155
Question #82
A 50-year-old male patient has anemia, thrombocytopenia, leukocytosis, and splenomegaly. His
Philadelphia chromosome is positive. What is the most likely diagnosis?
a. Acute lymphoblastic leukemia

d. Chronic myeloid leukemia √
e. Non-Hodgkin lymphoma
Description
About 90% of CML patients have gene mutation t(9;22) called Philadelphia chromosome → leads to
the production of the BCR-ABL gene, which encodes for BCR-ABL protein with a tyrosine kinase
activity → abnormal cell dierentiation.
Page - 1097
Question 83/155
Question #83
A 19-year-old male patient with recurrent pneumonia presents to you with tiredness and low
energy. His complete blood count shows hemoglobin of 7 g/dL, WBC of 4*10^9/L, and platelet count
of 82*10^9/L. In addition, blood film shows numerous blast cells. What is the most likely diagnosis?
a. Chronic leukemia
b. Lymphoma
c. Acute leukemia
d. Multiple myeloma
e. HIV infection
Page - 1098
Question 83/155
Question #83
A 19-year-old male patient with recurrent pneumonia presents to you with tiredness and low
energy. His complete blood count shows hemoglobin of 7 g/dL, WBC of 4*10^9/L, and platelet count
of 82*10^9/L. In addition, blood film shows numerous blast cells. What is the most likely diagnosis?
a. Chronic leukemia
b. Lymphoma
c. Acute leukemia √
d. Multiple myeloma
e. HIV infection
Description
Leukemia results from the proliferation of Myeloblasts.
On lab investigations, the total WBC count is oen high. However, it may also be normal or even
low.
Bone marrow biopsy is the most accurate (will show > 20% blast cells).
Page - 1099
Question 84/155
Question #84
A 72-year-old male patient presents with cervical lymph node enlargements and recurrent infection.
His lab investigations show anemia, very high WBC, and smudge cells. What is the most likely
diagnosis?
a. Chronic myeloid leukemia

d. Acute lymphoid leukemia
e. Infectious mononucleosis
Page - 1100
Question 84/155
Question #84
A 72-year-old male patient presents with cervical lymph node enlargements and recurrent infection.
His lab investigations show anemia, very high WBC, and smudge cells. What is the most likely
diagnosis?
a. Chronic myeloid leukemia

c. Chronic lymphoid leukemia √
d. Acute lymphoid leukemia
Description
In CLL, there will be:
High WBC count > 20,000 in CLL (predominantly lymphocytes)

50% of patients have hypogammaglobulinemia
Smudge cells: lab artifact (the fragile nucleus is crushed by the coverslip)
Page - 1101
Question 85/155
Question #85
A 29-year-old male with recurrent infections develops severe bone pain, gum bleeding, and low
energy. Physical examination demonstrates hepatosplenomegaly. His lab investigations show a
hemoglobin level of 8 g/dL, WBC of 103*10^9/L, and numerous blast cells in the blood film and bone
marrow biopsy. What is the most likely diagnosis?
a. Infectious mononucleosis
b. Lymphoma
c. Acute myeloid leukemia
d. Multiple myeloma
e. HIV infection
Page - 1102
Question 85/155
Question #85
A 29-year-old male with recurrent infections develops severe bone pain, gum bleeding, and low
energy. Physical examination demonstrates hepatosplenomegaly. His lab investigations show a
hemoglobin level of 8 g/dL, WBC of 103*10^9/L, and numerous blast cells in the blood film and bone
marrow biopsy. What is the most likely diagnosis?
a. Infectious mononucleosis
b. Lymphoma
c. Acute myeloid leukemia √
d. Multiple myeloma
e. HIV infection
Description
High leukocyte count associated with bone pain and gum bleeding is common in AML (gum
bleeding can also occur in ALL).
AML is the most common leukemia in adults. It results from the proliferation of Myeloblasts.
On lab investigations, the total WBC count is oen high. However, it may also be normal or even
low.
Bone marrow biopsy is the most accurate (will show > 20% blast cells).
Page - 1103
Question 86/155
Question #86
Which of the following is the least likely cause of massive splenomegaly?
a. Chronic malaria
b. CML
c. Myelofibrosis
d. Kala-azar
e. Polycythemia Vera
Page - 1104
Question 86/155
Question #86
Which of the following is the least likely cause of massive splenomegaly?
a. Chronic malaria
b. CML
c. Myelofibrosis
d. Kala-azar
e. Polycythemia Vera √
Description
Polycythemia Vera presents with mild splenomegaly (not massive)
Causes of massive splenomegaly are:
CML
Myelofibrosis
Lymphoma
Kala-azar (visceral leishmaniasis)
Malaria (chronic)
Gaucher’s syndrome
Page - 1105
Question 87/155
Question #87
A 54-year-old male patient complains of weight loss, fatigue, and abdominal discomfort. Physical
examination demonstrates an enlarged spleen. Lab investigations show hemoglobin of 10g/dL, WBC
170*10^9/L (88% neutrophils), and the Philadelphia chromosome is positive. What is the most likely
diagnosis?
a. Chronic lymphoblastic leukemia

b. Chronic myeloid leukemia
d. Hodgkin lymphoma
e. Multiple myeloma
Page - 1106
Question 87/155
Question #87
A 54-year-old male patient complains of weight loss, fatigue, and abdominal discomfort. Physical
examination demonstrates an enlarged spleen. Lab investigations show hemoglobin of 10g/dL, WBC
170*10^9/L (88% neutrophils), and the Philadelphia chromosome is positive. What is the most likely
diagnosis?
a. Chronic lymphoblastic leukemia

b. Chronic myeloid leukemia √
d. Hodgkin lymphoma
e. Multiple myeloma
Description
e patient has very high WBC with a predominance of neutrophils and features suggestive of
leukemia. is scenario strongly suggests CML as the most likely diagnosis.
About 90% of CML patients have gene mutation t(9;22) called Philadelphia chromosome → leads to
the production of the BCR-ABL gene, which encodes for BCR-ABL protein with a tyrosine kinase
activity → abnormal cell dierentiation.
Page - 1107
Question 88/155
Question #88
Which of the following is the most characteristic of acute promyelocytic leukemia?
a. Reduced leukocyte alkaline phosphatase score

b. Translocation (9:22)
d. Positive nuclear TdT staining
e. It is the M2 type of AML
Page - 1108
Question 88/155
Question #88
Which of the following is the most characteristic of acute promyelocytic leukemia?
a. Reduced leukocyte alkaline phosphatase score

b. Translocation (9:22)
d. Positive nuclear TdT staining
e. It is the M2 type of AML
Description
Acute Promyelocytic Leukemia (APML):
It is the (M3) subtype of AML

Due to t(15:17) mutation
A high number of Auer rods and increased risk of coagulation
Can present with DIC
Treatment by vitamin A derivative (ATRA)
Page - 1109
Question 89/155
Question #89
A patient is suspected of having Hodgkin’s lymphoma. What is the most common initial clinical
feature of this condition?
a. Fever of unknown origin

b. Painless lymphadenopathy
c. Night sweats
d. Loss of weight
e. Anorexia
Page - 1110
Internal Medicine - Hematology - Lymphoma
Question 89/155
Question #89
A patient is suspected of having Hodgkin’s lymphoma. What is the most common initial clinical
feature of this condition?
a. Fever of unknown origin

b. Painless lymphadenopathy √
c. Night sweats
d. Loss of weight
e. Anorexia
Description
e most common presenting symptom of Hodgkin’s lymphoma is painless lymphadenopathy.
B symptoms present in 30% of patients with Hodgkin’s lymphoma
Page - 1111
Question 90/155
Question #90
A 60-year-old male patient complained of night sweats, weight loss, and anorexia for 6 months. on
examination, you found a palpable rubbery neck mass. Excisional LN biopsy demonstrates Hodgkin’s
lymphoma. What type of cells are most likely to be associated with this condition?
a. Plasma cells
b. Auer rods containing blast cells
c. Blast cells with positive nuclear TdT staining
d. Reed Sternberg cells
e. T-Lymphocytes
Page - 1112
Question 90/155
Question #90
examination, you found a palpable rubbery neck mass. Excisional LN biopsy demonstrates Hodgkin’s
lymphoma. What type of cells are most likely to be associated with this condition?
a. Plasma cells
b. Auer rods containing blast cells
c. Blast cells with positive nuclear TdT staining
d. Reed Sternberg cells √
e. T-Lymphocytes
Description
Histological evaluation of lymph node biopsy demonstrating Reed Sternberg cells is the most
accurate in confirming the diagnosis of Hodgkin’s lymphoma.
Plasma cells > 10% in bone marrow is characteristic of Multiple Myeloma
Blast cells with Auer rods in the bone marrow of > 20% are characteristic of acute myeloid leukemia
Positive TdT staining is present in lymphoblasts, so it is found in acute lymphoblastic leukemia.
Page - 1113
Question 91/155
Question #91
A 19-year-old female complains of non-tender neck mass, night sweats, weight loss, splenomegaly,
and fever. What is the most likely diagnosis?
a. Tuberculosis
b. Lipoma
c. Toxoplasmosis
d. yroglossal cyst
e. Hodgkin lymphoma
Page - 1114
Question 91/155
Question #91
A 19-year-old female complains of non-tender neck mass, night sweats, weight loss, splenomegaly,
and fever. What is the most likely diagnosis?
a. Tuberculosis
b. Lipoma
c. Toxoplasmosis
d. yroglossal cyst
e. Hodgkin lymphoma √
Description
e combination of cervical adenopathy and splenomegaly makes lymphoma the most likely in this
patient.
Despite it can also cause the same picture, in toxoplasmosis, weight loss is less prominent
Page - 1115
Question 92/155
Question #92
A 22-year-old male patient presents with painless, rubbery, and non-tender enlarged cervical lymph
nodes and hepatosplenomegaly. His lab investigations show anemia, leukocytosis, and normal
platelet count. Which of the following is the most important investigation to establish or exclude
the diagnosis of Hodgkin’s lymphoma?
a. Chest, Abdominal, and pelvic CT scans

c. Excisional biopsy of the lymph nodes
d. Leukocyte alkaline phosphatase score
e. ESR and CRP
Page - 1116
Question 92/155
Question #92
A 22-year-old male patient presents with painless, rubbery, and non-tender enlarged cervical lymph
nodes and hepatosplenomegaly. His lab investigations show anemia, leukocytosis, and normal
platelet count. Which of the following is the most important investigation to establish or exclude
the diagnosis of Hodgkin’s lymphoma?
a. Chest, Abdominal, and pelvic CT scans

c. Excisional biopsy of the lymph nodes √
d. Leukocyte alkaline phosphatase score
e. ESR and CRP
Description
CT scan is used for staging of lymphoma according to Ann Arbor staging system.
Leukocyte alkaline phosphatase score is used to dierentiate between leukemia and leukemoid
reaction.
ESR and CRP are acute phase reactants and are not specific investigations.
Page - 1117
Question 93/155
Question #93
examination, you found a palpable rubbery neck mass. Excisional LN biopsy demonstrates Reed
Sternberg cells. What is the most likely diagnosis?
a. Hodgkin’s lymphoma
b. Burkitt lymphoma
c. Immunoblastic lymphomas
d. Chronic lymphoid leukemia
Page - 1118
Question 93/155
Question #93
examination, you found a palpable rubbery neck mass. Excisional LN biopsy demonstrates Reed
Sternberg cells. What is the most likely diagnosis?
a. Hodgkin’s lymphoma √
b. Burkitt lymphoma
c. Immunoblastic lymphomas
d. Chronic lymphoid leukemia
Description
Burkitt lymphoma and Immunoblastic lymphomas are non-Hodgkin’s lymphoma types that do not
present with Reed Sternberg cells on LN biopsy.
Page - 1119
Question 94/155
Question #94
A 22-year-old male patient complains of shortness of breath, and a mediastinal mass is shown on his
chest x-ray. His physical examination shows cervical lymph node enlargement. What is the most
appropriate investigation?
a. Bronchoalveolar lavage
b. Barium swallow
c. Lymph node biopsy
d. CT Pulmonary Angiography
e. Laryngoscopy
Page - 1120
Question 94/155
Question #94
A 22-year-old male patient complains of shortness of breath, and a mediastinal mass is shown on his
chest x-ray. His physical examination shows cervical lymph node enlargement. What is the most
appropriate investigation?
a. Bronchoalveolar lavage
b. Barium swallow
c. Lymph node biopsy √
d. CT Pulmonary Angiography
e. Laryngoscopy
Description
is patient is most likely to have lymphoma.
A lymph node biopsy is the most accurate test to confirm or exclude the diagnosis.
Page - 1121
Question 95/155
Question #95
A 40-year-old male patient complains of general weakness, cervical adenopathy, and splenomegaly.
In addition, he lost 15 kilograms in the past 6 weeks. What is the most likely diagnosis?
a. Pneumococcal infection
b. H influenza infection
c. Lymphoma
d. Tuberculosis
e. Toxoplasmosis
Page - 1122
Question 95/155
Question #95
A 40-year-old male patient complains of general weakness, cervical adenopathy, and splenomegaly.
In addition, he lost 15 kilograms in the past 6 weeks. What is the most likely diagnosis?
a. Pneumococcal infection
b. H influenza infection
c. Lymphoma √
d. Tuberculosis
e. Toxoplasmosis
Description
e combination of cervical adenopathy and splenomegaly makes lymphoma the most likely in this
patient.
Despite it can also cause the same picture, in toxoplasmosis, weight loss is less prominent
Page - 1123
Question 96/155
Question #96
A 45-year-old male patient presents with signs of anemia, easy bruising, and peripheral numbness.
CBC shows Hemoglobin: 9.5 g/dl, Platelets 83*10^9/L, WBCs19*10^9/L, and MCV 125 fl. What would
be the most sensitive investigation of the most likely diagnosis?

b. Serum B12 level
c. Methylmalonic acid level
d. Low haptoglobin
e. Low homocysteine
Page - 1124
Internal Medicine - Hematology - Macrocytic megaloblastic anemia
Question 96/155
Question #96
A 45-year-old male patient presents with signs of anemia, easy bruising, and peripheral numbness.
CBC shows Hemoglobin: 9.5 g/dl, Platelets 83*10^9/L, WBCs19*10^9/L, and MCV 125 fl. What would
be the most sensitive investigation of the most likely diagnosis?

b. Serum B12 level
c. Methylmalonic acid level √
d. Low haptoglobin
e. Low homocysteine
Description
Vitamin B12 is a cofactor in synthesizing methionine and succinyl coenzyme A, and vitamin B12
deficiency leads to the accumulation of methylmalonic acid and homocysteine, the precursors of
these compounds. An elevated level of these substances is, therefore, more sensitive than a low
vitamin B12 level for vitamin B12 deficiency
Page - 1125
Question 97/155
Question #97
An alcoholic 62-year-old male complains of fatigue. His blood tests show hemoglobin of 8g/dL, and
his MCV is 108 fl. Which of the following is the most likely diagnosis?
a. alassemia
b. Iron deficiency anemia
c. Folic acid deficiency anemia
Page - 1126
Question 97/155
Question #97
An alcoholic 62-year-old male complains of fatigue. His blood tests show hemoglobin of 8g/dL, and
his MCV is 108 fl. Which of the following is the most likely diagnosis?
a. alassemia
c. Folic acid deficiency anemia √
Description
is is a case of macrocytic anemia. B12 and folate deficiency most commonly cause it.
Since the patient is alcoholic, folic acid deficiency is more common to cause this condition.
Folate deficiency is the most common cause of megaloblastic anemia in chronic alcoholics
Page - 1127
Question 98/155
Question #98
You are performing an anemia workup for a 54-year-old male patient. His blood film demonstrates
oval macrocytes, Hypersegmented neutrophils, and reduced platelet count. What is the most likely
diagnosis?

b. alassemia
c. B12 deficiency
d. Sickle cell anemia
e. Chronic liver disease
Page - 1128
Question 98/155
Question #98
You are performing an anemia workup for a 54-year-old male patient. His blood film demonstrates
oval macrocytes, Hypersegmented neutrophils, and reduced platelet count. What is the most likely
diagnosis?

b. alassemia
c. B12 deficiency √
d. Sickle cell anemia
e. Chronic liver disease
Description
is is a case of macrocytic anemia, hypersegmented neutrophils, and reduced platelets. ese
findings strongly suggest B12 deficiency.
In B12 deficiency, the involvement of neutrophils and platelet may present and can cause:
Macrocytic anemia (Normocytic if co-existent iron deficiency or thalassemia)
Pancytopenia
Hyper-segmented nuclei of neutrophils (6 lobes)
Hypercellularity and megaloblasts in bone marrow
Page - 1129
Question 99/155
Question #99
A 45-year-old female refuses to take injectable B12 to treat her pernicious anemia. Which of the
following is the main reason her disease does not respond to oral B12?
a. Bacteria in the ileum prevent B12 absorption

b. Chronic pancreatic insuciency
c. Intrinsic factor deficiency
d. Increased gastric acidity
e. Reduced gastric acidity
Page - 1130
Question 99/155
Question #99
A 45-year-old female refuses to take injectable B12 to treat her pernicious anemia. Which of the
following is the main reason her disease does not respond to oral B12?
a. Bacteria in the ileum prevent B12 absorption

b. Chronic pancreatic insuciency
c. Intrinsic factor deficiency √
d. Increased gastric acidity
e. Reduced gastric acidity
Description
Pernicious anemia is an autoimmune disease characterized by atrophy of gastric mucosa and failure
of the secretion of the intrinsic factor. is will lead to B12 malabsorption and megaloblastic anemia
Intrinsic factor antibodies in 50% or Anti-parietal cell antibodies can be detected
In pernicious anemia, the absence of the intrinsic factor is the primary mechanism for developing
anemia. In addition, it is the main cause that oral B12 will not be absorbed by the traditional intrinsic
factor terminal ilium pathway.
e non-intrinsic factor-terminal ilium pathway needs a high dose of oral vitamin B12 (1000
micrograms) to absorb B12.
Page - 1131
Question 100/155
Question #100
A 60-year-old female suers from fatigue and confusion. Her husband reports gradual confusion
over the past 6 months. Her lab investigations demonstrate macrocytic megaloblastic anemia, low
b12, and low folic acid levels. Which is the most appropriate course of treatment for this patient?
a. Start oral folate, then injectable B12 aer folic acid returns to normal
b. Start injectable B12, then oral folic acid aer B12 returns to normal
c. Start oral folic acid only
d. Start injectable B12 only
e. Refer to a hematologist
Page - 1132
Question 100/155
Question #100
A 60-year-old female suers from fatigue and confusion. Her husband reports gradual confusion
over the past 6 months. Her lab investigations demonstrate macrocytic megaloblastic anemia, low
b12, and low folic acid levels. Which is the most appropriate course of treatment for this patient?
a. Start oral folate, then injectable B12 aer folic acid returns to normal
b. Start injectable B12, then oral folic acid aer B12 returns to normal √
c. Start oral folic acid only
d. Start injectable B12 only
e. Refer to a hematologist
Description
Replacement of folate in a patient with B12 deficiency before correcting B12 will aggravate
neuropathy.
You should correct the B12 level first, then provide folic acid to avoid precipitating subacute
combined degeneration of the cord.
Page - 1133
Question 101/155
Question #101
A 22-year-old female decided to be a strict vegan. She watches the labels closely of everything before
she eats. Assuming her B12 level and methylmalonic acid today are normal, aer how long is she
expected to develop B12 deficiency?
a. Within days
b. Within months
c. Aer 1 year
d. Aer 2 years
e. Aer 3 years
Page - 1134
Question 101/155
Question #101
A 22-year-old female decided to be a strict vegan. She watches the labels closely of everything before
she eats. Assuming her B12 level and methylmalonic acid today are normal, aer how long is she
expected to develop B12 deficiency?
a. Within days
b. Within months
c. Aer 1 year
d. Aer 2 years
e. Aer 3 years √
Description
Vitamin B12 is naturally present in foods of animal origin.
Vegetarian and vegan persons are at risk of B12 deficiency. However, the liver stores B12 enough for 3
years; therefore, B12 deficiency takes 3 years to manifest
Page - 1135
Question 102/155
Question #102
A strict vegan 23-year-old female complains of fatigue and dyspnea. Her complete blood picture
shows hemoglobin of 9 g/dL, platelet count of 80 *10^9/l, WBC 2*10^9, and MCV of 107 fl. Which is
the most appropriate next step in managing this patient?
a. Iron study
b. Serum B12 level
c. Bone marrow aspiration
d. Hb electrophoresis
e. Coombs test
Page - 1136
Question 102/155
Question #102
A strict vegan 23-year-old female complains of fatigue and dyspnea. Her complete blood picture
shows hemoglobin of 9 g/dL, platelet count of 80 *10^9/l, WBC 2*10^9, and MCV of 107 fl. Which is
the most appropriate next step in managing this patient?
a. Iron study
b. Serum B12 level √
c. Bone marrow aspiration
d. Hb electrophoresis
e. Coombs test
Description
Pancytopenia and high MCV strongly suggest the presence of B12 deficiency
Vegan patients are at risk of B12 deficiency because vitamin B12 is naturally present in foods of
animal origin.
Involvement of neutrophils and platelet may present and can cause:
Macrocytic anemia (Normocytic if co-existent iron deficiency or thalassemia)

Pancytopenia
Hyper-segmented nuclei of neutrophils (6 lobes)
Hypercellularity and megaloblasts in bone marrow
Page - 1137
Question 103/155
Question #103
A 49-year-old male patient complains of fatigue and pallor. His history is significant for gastrectomy
1 year ago due to recurrent peptic ulcer disease. Lab investigations show hemoglobin of 8 g/dL, WBC
of 8*10^9/L, platelet of 160*10^9/L, and MCV of 121 fl. What is the most likely finding in his blood
film?
a. Hypochromic microcytic anemia

b. Numerous blast cells
c. Schistocytes
d. Target cells
e. Hypersegmented neutrophils
Page - 1138
Question 103/155
Question #103
A 49-year-old male patient complains of fatigue and pallor. His history is significant for gastrectomy
1 year ago due to recurrent peptic ulcer disease. Lab investigations show hemoglobin of 8 g/dL, WBC
of 8*10^9/L, platelet of 160*10^9/L, and MCV of 121 fl. What is the most likely finding in his blood
film?

c. Schistocytes
d. Target cells
e. Hypersegmented neutrophils √
Description
Given the fact that B12 is absorbed by the intrinsic factor terminal ileum pathway, patients with
gastrectomy or terminal ileum resection are at risk of B12 malabsorption and B12 deficiency.
B12 deficiency anemia in blood film will show macrocytosis, hypersegmented neutrophils, and
reduced platelet number
Page - 1139
Question 104/155
Question #104
A 22-year-old male patient presents with fatigue and palpitations. His history is significant for
epilepsy, for which he takes phenytoin. His lab investigations show hemoglobin of 9g/dL, the mean
corpuscular volume of 110 fl. Which of the following is the most likely diagnosis?
a. Sickle cell anemia

c. alassemia
d. Liver disease
e. Iron deficiency anemia
Page - 1140
Question 104/155
Question #104
A 22-year-old male patient presents with fatigue and palpitations. His history is significant for
epilepsy, for which he takes phenytoin. His lab investigations show hemoglobin of 9g/dL, the mean
corpuscular volume of 110 fl. Which of the following is the most likely diagnosis?
a. Sickle cell anemia

b. Folic acid deficiency √
c. alassemia
d. Liver disease
Description
Phenytoin intake here is the crucial point.
Phenytoin reduces folic acid levels leading to folic acid deficiency anemia
Folic acid deficiency anemia is characterized by macrocytic megaloblastic anemia.
Patients taking phenytoin should receive folic acid supplements to reduce the risk of folate
deficiency.
Pregnant women taking phenytoin should receive folic acid because they are at risk of folate
deficiency and neural tube defects.
Page - 1141
Question 105/155
Question #105
A 50-year-old female patient develops fatigue and palpitations. Her blood count demonstrates
macrocytic anemia, and her physical examination is significant for pallor and vitiligo. Which of the
following is the most likely diagnosis?
a. Folic acid deficiency

b. Dietary B12 deficiency
c. Pernicious anemia
e. Liver disease
Page - 1142
Question 105/155
Question #105
A 50-year-old female patient develops fatigue and palpitations. Her blood count demonstrates
macrocytic anemia, and her physical examination is significant for pallor and vitiligo. Which of the
following is the most likely diagnosis?
a. Folic acid deficiency

b. Dietary B12 deficiency
c. Pernicious anemia √
e. Liver disease
Description
is is typical for pernicious anemia.
Look for a female patient with associated autoimmune disorders and features of B12 deficiency.
Female patients are more likely to have autoimmune diseases
Autoimmune diseases are more likely to occur in association with other autoimmune diseases.
Page - 1143
Question 106/155
Question #106
A 32-year-old vegan female started to have paresthesia and fatigue for 3 months. Her physical
examination reveals angular stomatitis and a sore red tongue. Laboratory investigations were done,
and they demonstrated anemia. Which of the following is the most likely finding in blood film?
a. Numerous blast cells

b. Macrocytic RBCs
c. Microcytic hypochromic RBCs
d. Schistocytes
e. Spherocytes
Page - 1144
Question 106/155
Question #106
A 32-year-old vegan female started to have paresthesia and fatigue for 3 months. Her physical
examination reveals angular stomatitis and a sore red tongue. Laboratory investigations were done,
and they demonstrated anemia. Which of the following is the most likely finding in blood film?
a. Numerous blast cells

b. Macrocytic RBCs √
c. Microcytic hypochromic RBCs
d. Schistocytes
e. Spherocytes
Description
Because B12 is acquired from animal diet sources, vegan people are at risk of B12 deficiency.
Note that angular stomatitis is found in iron deficiency anemia. However, it sometimes manifests in
B12 deficiency anemia.
e tongue’s appearance in vitamin B12 deficiency is described as “beefy” or “fiery red and sore”.
Page - 1145
Question 107/155
Question #107
A 32-year-old female started to have paresthesia and fatigue for 3 months. Her medical history is
significant for repeated attacks of pancreatitis. Laboratory investigations were done, and they
demonstrated anemia. What is the most appropriate management?
a. Provide vitamin B12

b. Provide vitamin B1
c. Provide vitamin B6
d. Provide folic acid
e. Refer to a neurologist
Page - 1146
Question 107/155
Question #107
A 32-year-old female started to have paresthesia and fatigue for 3 months. Her medical history is
significant for repeated attacks of pancreatitis. Laboratory investigations were done, and they
demonstrated anemia. What is the most appropriate management?
a. Provide vitamin B12 √

b. Provide vitamin B1
c. Provide vitamin B6
d. Provide folic acid
Description
B12 deficiency can be caused by pancreatic insuciency since pancreatic secretions usually free B12
from carrier proteins.
e liver stores B12 enough for 3 years (B12 deficiency takes years to manifest)
B12 deficiency leads to:
Neurological disease (Gloves and stockings neuropathy, subacute combined degeneration of the
spinal cord – ataxia, dementia, optic atrophy)
Hematological disease (Megaloblastic anemia)
Page - 1147
Question 108/155
Question #108
A 49-year-old male patient complains of fatigue and pallor. His history is significant for terminal
ilium resection 1 year ago. Lab investigations show hemoglobin of 8 g/dL, WBC of 8*10^9/L, platelet
of 160*10^9/L, and MCV of 121 fl. What is the most likely finding in his blood film?

c. Schistocytes
d. Target cells
e. Hypersegmented neutrophils
Page - 1148
Question 108/155
Question #108
A 49-year-old male patient complains of fatigue and pallor. His history is significant for terminal
ilium resection 1 year ago. Lab investigations show hemoglobin of 8 g/dL, WBC of 8*10^9/L, platelet
of 160*10^9/L, and MCV of 121 fl. What is the most likely finding in his blood film?

c. Schistocytes
d. Target cells
e. Hypersegmented neutrophils √
Description
Given the fact that B12 is absorbed by the intrinsic factor terminal ileum pathway, patients with
gastrectomy or terminal ileum resection are at risk of B12 malabsorption and B12 deficiency.
Page - 1149
Question 109/155
Question #109
A 29-year-old female with hypothyroidism develops pins and needles sensation in her hands,
fatigue, and palpitation. In addition, her complete blood count shows macrocytic anemia. Which of
the following is the most likely cause of her anemia?
b. Hypothyroidism
e. Crohn’s disease
Page - 1150
Question 109/155
Question #109
A 29-year-old female with hypothyroidism develops pins and needles sensation in her hands,
fatigue, and palpitation. In addition, her complete blood count shows macrocytic anemia. Which of
the following is the most likely cause of her anemia?
a. Pernicious anemia √
b. Hypothyroidism
e. Crohn’s disease
Description
is is typical for pernicious anemia.
Look for a female patient with associated autoimmune disorders and features of B12 deficiency.
Female patients are more likely to have autoimmune diseases
Autoimmune diseases are more likely to occur in association with other autoimmune diseases
Page - 1151
Question 110/155
Question #110
A 54-year-old male patient complains of fatigue and palpitation. His history is significant
rheumatoid arthritis which is controlled by medications. However, his lab investigations show
macrocytic megaloblastic anemia. Which of the following is the most likely responsible for his
anemia?
a. Non-steroidal anti-inflammatory drugs (NSAIDs)

b. Steroids
c. e chronic disease
d. Methotrexate
e. Chronic blood loss
Page - 1152
Question 110/155
Question #110
A 54-year-old male patient complains of fatigue and palpitation. His history is significant
rheumatoid arthritis which is controlled by medications. However, his lab investigations show
macrocytic megaloblastic anemia. Which of the following is the most likely responsible for his
anemia?
a. Non-steroidal anti-inflammatory drugs (NSAIDs)

b. Steroids
c. e chronic disease
d. Methotrexate √
e. Chronic blood loss
Description
Methotrexate is a folate antagonist used in the treatment of rheumatoid arthritis. is drug can
cause folic acid deficiency, manifesting as macrocytic megaloblastic anemia.
NSAIDs may cause a peptic ulcer or gastritis with chronic bleeding and iron deficiency anemia with
low MCV (which is not the case here)
Rheumatoid arthritis, a chronic disease, may cause anemia of chronic disease, but it is associated
with normal MCV in 70% and low MCV in 30% of cases.
Page - 1153
Question 111/155
Question #111
A 64-year-old male patient presents with lower back pain and fatigue. His symptoms have been
progressive over the past 6 months. His lab investigations show mild anemia, elevated urea and
creatinine, and hypercalcemia. What is the most accurate test to confirm the most likely diagnosis?
a. Blood film
b. Bone marrow biopsy
c. Full blood picture
d. Urinary protein level
e. Skull x-ray
Page - 1154
Internal Medicine - Hematology - Multiple Myeloma (MM)
Question 111/155
Question #111
creatinine, and hypercalcemia. What is the most accurate test to confirm the most likely diagnosis?
a. Blood film
b. Bone marrow biopsy √
c. Full blood picture
d. Urinary protein level
e. Skull x-ray
Description
e most likely diagnosis here is Multiple Myeloma.
A bone marrow biopsy showing >10% plasma cells is the most accurate test.
ese abnormal Immunoglobulins in Multiple Myeloma (MM) lead to:
Infection
Renal deposition and renal failure
Bence-Jones proteinuria (detected by urine immunoelectrophoresis)
Hyperviscosity syndrome
Activation of osteolytic activity of the bone, which leads to hypercalcemia
Page - 1155
Question 112/155
Question #112
A 66-year-old male patient presents with polydipsia and polyuria, and His lab investigations show
hypercalcemia. On further questioning, the patient has back pain and fatigue for 6 weeks. e rest of
the lab investigations demonstrate hemoglobin of 9g/dL, alkaline phosphatase of 110 u/L, serum
creatinine of 2.3mg/dL, and ESR of 90mm/Hour. Which of the following are the most likely cells
found elevated in bone marrow biopsy?
a. Myeloblast cells
b. Lymphoblast cells
c. Megakaryocytes
d. Plasma cells
e. Bence-Johnse protein
Page - 1156
Question 112/155
Question #112
A 66-year-old male patient presents with polydipsia and polyuria, and His lab investigations show
hypercalcemia. On further questioning, the patient has back pain and fatigue for 6 weeks. e rest of
the lab investigations demonstrate hemoglobin of 9g/dL, alkaline phosphatase of 110 u/L, serum
creatinine of 2.3mg/dL, and ESR of 90mm/Hour. Which of the following are the most likely cells
found elevated in bone marrow biopsy?
a. Myeloblast cells
b. Lymphoblast cells
c. Megakaryocytes
d. Plasma cells √
e. Bence-Johnse protein
Description
is is a classic presentation of Multiple Myeloma (MM).
Infection
Elevated myeloblasts in the bone marrow are typical for myeloid leukemia
Elevated lymphoblasts are typical for lymphoid leukemia
Megakaryocytes elevation is typical for essential thrombocythemia
Bence-Johnse proteins are not cells; they are paraproteins detected in the plasma or urine in MM.
Page - 1157
Question 113/155
Question #113
creatinine, and hypercalcemia. What is the most likely diagnosis?
a. Acute leukemia
b. Chronic leukemia
c. Lymphoma
d. Multiple Myeloma
e. rombotic rombocytopenic Purpura
Page - 1158
Question 113/155
Question #113
creatinine, and hypercalcemia. What is the most likely diagnosis?
a. Acute leukemia
b. Chronic leukemia
c. Lymphoma
d. Multiple Myeloma √
e. rombotic rombocytopenic Purpura
Description
Infection
Page - 1159
Question 114/155
Question #114
A previously healthy 57-year-old male patient is diagnosed with Multiple Myeloma, but he is
asymptomatic and has no organ damage. What is the most appropriate treatment at this time?
a. Start chemotherapy
b. Start radiotherapy
c. Bone marrow transplantation
d. Imatinib
e. No treatment
Page - 1160
Question 114/155
Question #114
A previously healthy 57-year-old male patient is diagnosed with Multiple Myeloma, but he is
asymptomatic and has no organ damage. What is the most appropriate treatment at this time?
a. Start chemotherapy
b. Start radiotherapy
c. Bone marrow transplantation
d. Imatinib
e. No treatment √
Description
Treatment of Multiple Myeloma is as the following:
If asymptomatic → no Treatment
-Supportive therapy: high fluid intake, analgesia, allopurinol, protein plasmapheresis for
hyperviscosity
Specific treatment:
alidomide + melphalan + prednisolone: for older patients
Chemotherapy followed by HSCT: improves the quality of life but does not cure the
disease
Bisphosphonates: decrease bone pain and prevent bone fracture
Page - 1161
Question 115/155
Question #115
e following features are known to be found in Multiple Myeloma (MM) except:
a. Recurrent pneumonia
b. Osteoclastic activation
c. High serum alkaline phosphatase
d. Hypercalcemia
e. Light chain renal deposition
Page - 1162
Question 115/155
Question #115
e following features are known to be found in Multiple Myeloma (MM) except:
a. Recurrent pneumonia
c. High serum alkaline phosphatase √
d. Hypercalcemia
e. Light chain renal deposition
Description
Normal serum alkaline phosphatase level is expected in Multiple Myeloma.
Infection
Page - 1163
Question 116/155
Question #116
A 62-year-old female is a known case of multiple myeloma. However, she is confused, and her labs
show a corrected calcium level of three mmol/l. Which one of the following is the most significant
cause of the raised calcium level?
a. A side eect of the treatment

c. Osteoblastic activation
d. Deteriorating renal function
e. Vitamin D overactivation
Page - 1164
Question 116/155
Question #116
A 62-year-old female is a known case of multiple myeloma. However, she is confused, and her labs
show a corrected calcium level of three mmol/l. Which one of the following is the most significant
cause of the raised calcium level?
a. A side eect of the treatment

b. Osteoclastic activation √
c. Osteoblastic activation
d. Deteriorating renal function
e. Vitamin D overactivation
Description
In Multiple Myeloma, the activation of osteolytic activity leads to lytic lesions of the bone and
hypercalcemia
Page - 1165
Question 117/155
Question #117
A 72-year-old male patient develops back pain, confusion, and polyuria. Her lab investigations show
hemoglobin of 10 g/dL, serum creatinine of 2 mg/dL, and serum calcium of 3.1 mmol/L. In addition,
you ordered a lumbar spine lateral view x-ray, which is significant for lytic lesions. What is the most
likely diagnosis?
a. Sarcoidosis
b. Multiple myeloma
d. Primary hyperparathyroidism
e. Vitamin D intoxication
Page - 1166
Question 117/155
Question #117
A 72-year-old male patient develops back pain, confusion, and polyuria. Her lab investigations show
hemoglobin of 10 g/dL, serum creatinine of 2 mg/dL, and serum calcium of 3.1 mmol/L. In addition,
you ordered a lumbar spine lateral view x-ray, which is significant for lytic lesions. What is the most
likely diagnosis?
a. Sarcoidosis
b. Multiple myeloma √
d. Primary hyperparathyroidism
e. Vitamin D intoxication
Description
is is a classic presentation of Multiple Myeloma (MM).
Infection
Page - 1167
Question 118/155
Question #118
A 60-year-old male patient complains of night sweating, weight loss, easy bruises, and fever. His
abdominal examination demonstrates massive splenomegaly, and his lab investigations show
pancytopenia, bone marrow hypocellularity, and replacement of normal tissue with fibrous tissue.
a. Polycythemia Vera
b. Paroxysmal nocturnal hemoglobinuria
c. Essential thrombocythemia
d. Myelofibrosis
Page - 1168
Internal Medicine - Hematology - Myelofibrosis
Question 118/155
Question #118
A 60-year-old male patient complains of night sweating, weight loss, easy bruises, and fever. His
abdominal examination demonstrates massive splenomegaly, and his lab investigations show
pancytopenia, bone marrow hypocellularity, and replacement of normal tissue with fibrous tissue.
b. Paroxysmal nocturnal hemoglobinuria
d. Myelofibrosis √
Description
Myelofibrosis is a bone marrow fibrosis due to the increased production of fibroblasts. It usually
presents in patients > 50 years old.
Clinical features:
Weight loss, night sweat

Hepatomegaly, Massive splenomegaly
Features of anemia
Lab tests:
Pancytopenia (Platelets, WBC can be high early in the disease)

Teardrop poikilocytosis in blood film
Bone marrow aspiration and biopsy (replacement of normal tissue with fibrous tissue)
JAK-2 mutation
Others: Folate deficiency, High uric acid level
Treatment:
Supportive: blood transfusion, folic acid

Hydroxyurea: reduce splenomegaly and reduce WBC
Splenectomy may be required (reduce the risk of splenic rupture)
Page - 1169
HSCT (definitive treatment)
Page - 1170
Question 119/155
Question #119
A patient is diagnosed with normochromic anemia. e following statements are true except:
a. It may result from blood loss

b. e MCV is 80 – 100 fl
c. Renal disease is a possible cause
d. May result from folate deficiency
e. Hematocrit is reduced
Page - 1171
Internal Medicine - Hematology - Normocytic anemia
Question 119/155
Question #119
A patient is diagnosed with normochromic anemia. e following statements are true except:
a. It may result from blood loss

b. e MCV is 80 – 100 fl
c. Renal disease is a possible cause
d. May result from folate deficiency √
e. Hematocrit is reduced
Description
Normocytic anemia is the presence of low hematocrit and normal MCV (80 – 100 fl)
e following conditions can cause normocytic anemia:
Normocytic anemia with High Reticulocytes count:
Acute bleeding
Hemolysis
Normocytic anemia with low Reticulocytes count:
Anemia of chronic disease (most commonly normocytic (70%) but can be microcytic)
Renal/liver disease
Aplastic anemia
Myelofibrosis
Leukemia
Drugs (e.g., chemotherapy)
Page - 1172
Question 120/155
Question #120
A patient has low hematocrit, high reticulocyte count, and his MCV is normal. What is the most
likely diagnosis?
a. Alcoholism
b. Liver disease
c. Iron deficiency
d. Acute bleeding
e. Chronic bleeding
Page - 1173
Internal Medicine - Hematology - Normocytic anemia
Question 120/155
Question #120
A patient has low hematocrit, high reticulocyte count, and his MCV is normal. What is the most
likely diagnosis?
a. Alcoholism
b. Liver disease
c. Iron deficiency
d. Acute bleeding √
e. Chronic bleeding
Description
Normocytic anemia with a high reticulocyte count indicates either acute bleeding or acute
hemolytic anemia.
Alcoholism and liver disease usually cause macrocytic non-megaloblastic anemia
Chronic bleeding causes an Iron deficiency; they present with microcytic hypochromic anemia.
Page - 1174
Question 121/155
Question #121
A 43-year-old male patient is known to have ESRD and is on hemodialysis. He presents to you with
uncontrolled epistaxis. His lab investigations show a normal CBC, serum creatinine of 10 mg/dL,
urea of 100mg/dL, and prolonged bleeding time. What is the most appropriate next step in the
a. Fresh frozen plasma

b. Cryoprecipitate
c. Factor 8
d. Activated factor 7
e. Hemodialysis
Page - 1175
Internal Medicine - Hematology - Platelet dysfunction
Question 121/155
Question #121
A 43-year-old male patient is known to have ESRD and is on hemodialysis. He presents to you with
uncontrolled epistaxis. His lab investigations show a normal CBC, serum creatinine of 10 mg/dL,
urea of 100mg/dL, and prolonged bleeding time. What is the most appropriate next step in the
a. Fresh frozen plasma

b. Cryoprecipitate
c. Factor 8
d. Activated factor 7
e. Hemodialysis √
Description
is is a case of dysfunctional platelet secondary to uremia (uremic platelet dysfunction)
Uremia prevents the normal function of platelets
Look for a patient with uremia and platelet-type bleeding
BT is prolonged, but PT, PTT, INR, factor 8, and vWF are normal
Treatment: DDAVP, dialysis, and estrogen
Note that estrogen shortens the bleeding time in uremic platelet dysfunction; it may provide a more
sustained hemostatic eect over desmopressin.
Page - 1176
Question 122/155
Question #122
A 54-year-old male complains of headaches and blurry vision. He has a history of hypertension. In
addition, the patient reports pruritus and a burning sensation in his fingers, especially aer hot
baths. Abdominal examination demonstrates palpable spleen. His lab investigations show
polycythemia, thrombocytosis, leukocytosis, and low erythropoietin level. What is the SINGLE most
a. Splenectomy
b. Indomethacin
c. Phlebotomy
d. Heparin
e. Warfarin
Page - 1177
Internal Medicine - Hematology - Polycythemia Vera (PV)
Question 122/155
Question #122
addition, the patient reports pruritus and a burning sensation in his fingers, especially aer hot
baths. Abdominal examination demonstrates palpable spleen. His lab investigations show
polycythemia, thrombocytosis, leukocytosis, and low erythropoietin level. What is the SINGLE most
a. Splenectomy
b. Indomethacin
c. Phlebotomy √
d. Heparin
e. Warfarin
Description
In primary polycythemia, there will be reduced erythropoietin secondary to increased bone

marrow activity. is condition is caused by JAK 2 mutation
In secondary polycythemia, elevated erythropoietin will lead to elevated bone marrow activity.
Other findings in PV:
Mild splenomegaly
rombocytosis (> 400 * 10^9/L)
Leukocytosis (> 12 * 10^9/L)
Leukocyte alkaline phosphatase (> 100U but no fever or infection)
Treatment of polycythemia Vera includes:
Aspirin; to prevent peripheral arterial or cerebrovascular diseases

Venesection: to maintain Hb less than 15 g/dl, decrease symptoms of Hyperviscosity
Hydroxyurea, interferon-alpha to suppress myeloproliferation
Radioactive phosphate for the older patient (decrease transformation to acute leukemias)
Antihistamine (symptomatic treatment)
Allopurinol (protect against high uric acid)
Page - 1178
Question 123/155
Question #123
A 68-year-old male patient presented to your oce complaining of a hot, red, and inflamed first
metatarsal joint. e patient is not an alcoholic and never smoked. Upon further questioning, he
admitted to itching aer hot baths. Labs show hemoglobin 18.9, hematocrit 57%, and high uric acid
level. e bone marrow biopsy of this patient is most likely to show one of the following:
a. Normal examination
b. Blast cells 15%
c. Blast cells 25%
d. Hypercellular bone marrow
e. Hypocellular bone marrow
Page - 1179
Question 123/155
Question #123
A 68-year-old male patient presented to your oce complaining of a hot, red, and inflamed first
metatarsal joint. e patient is not an alcoholic and never smoked. Upon further questioning, he
admitted to itching aer hot baths. Labs show hemoglobin 18.9, hematocrit 57%, and high uric acid
level. e bone marrow biopsy of this patient is most likely to show one of the following:
a. Normal examination
b. Blast cells 15%
c. Blast cells 25%
d. Hypercellular bone marrow √
e. Hypocellular bone marrow
Description
is patient complains of acute gouty arthritis.
Polycythemia, hyperuricemia, and pruritus strongly suggest polycythemia Vera
In polycythemia Vera, bone marrow biopsy will show hypercellularity with prominent erythroid,
granulocytic, and megakaryocytic proliferation
Page - 1180
Question 124/155
Question #124
A previously healthy 58-year-old male patient complains of pruritus, especially aer a hot bath and
blurry vision. His hemoglobin level is 19.8 g/dL, and his erythropoietin level is below normal. What is
the most likely to be associated with this condition?
a. Reduced platelet count

b. Hypoxia
c. JAK2 mutation
d. Massive splenomegaly
e. Blast cells >20% in the bone marrow
Page - 1181
Question 124/155
Question #124
A previously healthy 58-year-old male patient complains of pruritus, especially aer a hot bath and
blurry vision. His hemoglobin level is 19.8 g/dL, and his erythropoietin level is below normal. What is
the most likely to be associated with this condition?
a. Reduced platelet count

b. Hypoxia
c. JAK2 mutation √
d. Massive splenomegaly
e. Blast cells >20% in the bone marrow
Description
Polycythemia Vera (PV) usually, in the age above 40 years
Results from a genetic problem caused by JAK2 mutation
is disorder can transform into acute leukemia or myelofibrosis in 25% of cases
e mutation will increase bone marrow activity and erythropoiesis despite a low erythropoietin
level.
Mild splenomegaly
Polycythemia Vera (PV) requires two major and one minor or the first major criterion together with
two minor criteria.
Major criteria:
HB > 18.5 g/dL in males or > 16.5 in females or elevated RBC mass > 25% above mean normal
predicted value
Presence of JAK2 mutation Page - 1182
Minor criteria:
BM biopsy with hypercellularity with prominent erythroid, granulocytic, and megakaryocytic

proliferation
Low serum erythropoietin
Endogenous erythroid colony formation in vitro
Page - 1183
Question 125/155
Question #125
A 52-year-old male patient complains of headaches. His history and physical examination are
unremarkable, but his lab investigations show a hematocrit level of 59%. In addition, his
erythropoietin level is low. What is the most likely diagnosis?
a. e patient lives in high altitude

b. e patient has COPD
c. e patient has renal cell carcinoma
d. e patient has Polycythemia Vera
e. e patient has lung fibrosis
Page - 1184
Question 125/155
Question #125
A 52-year-old male patient complains of headaches. His history and physical examination are
unremarkable, but his lab investigations show a hematocrit level of 59%. In addition, his
erythropoietin level is low. What is the most likely diagnosis?
a. e patient lives in high altitude

b. e patient has COPD
c. e patient has renal cell carcinoma
d. e patient has Polycythemia Vera √
e. e patient has lung fibrosis
Description
In the case of polycythemia, you should identify primary vs. secondary causes.
In primary polycythemia, there will be reduced erythropoietin secondary to increased bone marrow
activity. is condition is caused by JAK2 mutation.
Patients with COPD, lung fibrosis, or those living at a high altitude will develop a high erythropoietin
level due to hypoxia
Renal cell carcinoma may cause a paraneoplastic feature of polycythemia due to ectopic
erythropoietin secretion, but it also presents with renal impairment, hematuria, and other features
suggestive of the disease.
Page - 1185
Question 126/155
Question #126
addition, the patient reports pruritus and a burning sensation in his fingers, especially aer taking a
hot bath. Abdominal examination demonstrates palpable spleen. His lab investigations show
polycythemia, thrombocytosis, leukocytosis, and low erythropoietin level. What is the most likely
diagnosis?
a. Myelofibrosis
d. Acute leukemia
e. Chronic leukemia
Page - 1186
Question 126/155
Question #126
addition, the patient reports pruritus and a burning sensation in his fingers, especially aer taking a
hot bath. Abdominal examination demonstrates palpable spleen. His lab investigations show
polycythemia, thrombocytosis, leukocytosis, and low erythropoietin level. What is the most likely
diagnosis?
a. Myelofibrosis
b. Polycythemia Vera √
d. Acute leukemia
e. Chronic leukemia
Description
Mild splenomegaly
Polycythemia Vera (PV) requires two major and one minor or the first major criterion together with
two minor criteria.
Major criteria:
HB > 18.5 g/dL in males or > 16.5 in females or elevated RBC mass > 25% above mean normal
predicted value
Presence of JAK2 mutation
Page - 1187
Minor criteria:
BM biopsy with hypercellularity with prominent erythroid, granulocytic, and megakaryocytic

proliferation
Low serum erythropoietin
Endogenous erythroid colony formation in vitro
Page - 1188
Question 127/155
Question #127
A previously healthy 55-year-old male patient presents with typical chest pain and is diagnosed with
inferior STEMI. His lab investigations show positive cardiac enzymes, hematocrit of 60%, normal
kidney function test, and low erythropoietin levels. What is the most likely cause of his Myocardial
infarction?
a. Primary polycythemia
b. Secondary polycythemia
c. Ruptured plaque
d. Congenital vascular malformation
e. Embolization from a distant focus
Page - 1189
Question 127/155
Question #127
A previously healthy 55-year-old male patient presents with typical chest pain and is diagnosed with
inferior STEMI. His lab investigations show positive cardiac enzymes, hematocrit of 60%, normal
kidney function test, and low erythropoietin levels. What is the most likely cause of his Myocardial
infarction?
a. Primary polycythemia √
b. Secondary polycythemia
c. Ruptured plaque
d. Congenital vascular malformation
e. Embolization from a distant focus
Description
A hematocrit of 60% and a low erythropoietin level indicate polycythemia Vera (primary
polycythemia).
Polycythemia Vera increases the risk of thromboembolism; therefore, patients with PV should
receive aspirin therapy and be treated with phlebotomy to reduce the hematocrit to normal.
Page - 1190
Question 128/155
Question #128
A 23-year-old male with a known case of SLE presents with sudden onset of hemoptysis, pleuritic
chest pain, and tachycardia. Physical examination reveals a clear chest and a swollen erythematous
hot right lower limb. His chest x-ray and lab investigations are normal. What is the most appropriate
at this time?
a. Computed tomography pulmonary angiography

b. Ventilation-perfusion scan of the lung
c. Arterial blood gases
d. D-Dimer
e. Doppler and duplex scan of the leg
Page - 1191
Internal Medicine - Hematology - Pulmonary Embolism (PE)
Question 128/155
Question #128
A 23-year-old male with a known case of SLE presents with sudden onset of hemoptysis, pleuritic
chest pain, and tachycardia. Physical examination reveals a clear chest and a swollen erythematous
hot right lower limb. His chest x-ray and lab investigations are normal. What is the most appropriate
at this time?
a. Computed tomography pulmonary angiography √

d. D-Dimer
Description
According to the well’s criteria, this patient will get 1 point for hemoptysis, 1.5 points for tachycardia,
3 points for suspected DVT, and 3 points for the absence of an alternative diagnosis. erefore, the
total score is 8.5, which indicates a high probability of pulmonary embolism.
Unless contraindicated, the best test to confirm the diagnosis, in this case, is CTPA.
Page - 1192
Question 129/155
Question #129
An elderly man traveled to Jordan from America. Aer 5 days, he develops pleuritic chest pain,
dyspnea, and tachycardia. What is the most likely diagnosis?
b. Pneumonia
d. Aortic dissection
e. Muscular spasm
Page - 1193
Question 129/155
Question #129
An elderly man traveled to Jordan from America. Aer 5 days, he develops pleuritic chest pain,
dyspnea, and tachycardia. What is the most likely diagnosis?
a. Pulmonary embolism √
b. Pneumonia
d. Aortic dissection
e. Muscular spasm
Description
Pulmonary embolism is most likely due to the traveling history, pleuritic chest pain, and tachycardia.
PE is an occlusion of the pulmonary artery or its branches by an embolus

Virchow’s triad is a group of risk factors for venous thromboembolism (VTE).
Clot migration from the DVT site to lodge in the pulmonary artery
Less than 30% have clinical evidence of DVT
Page - 1194
Question 130/155
Question #130
A known case of malignancy 67-year-old male had surgery 10 days ago, and the surgery went
uneventfully. Today he presents with severe sudden dyspnea, pleuritic chest pain, diaphoresis, and
feeling panic. e chest is clear to examination, and the chest x-ray is normal. Which of the following
a. Atelectasis
b. Pulmonary edema
d. Pleural eusion
e. Lung abscess
Page - 1195
Question 130/155
Question #130
A known case of malignancy 67-year-old male had surgery 10 days ago, and the surgery went
uneventfully. Today he presents with severe sudden dyspnea, pleuritic chest pain, diaphoresis, and
feeling panic. e chest is clear to examination, and the chest x-ray is normal. Which of the following
a. Atelectasis
b. Pulmonary edema
c. Pulmonary embolism √
d. Pleural eusion
e. Lung abscess
Description
Malignancy and the history of recent surgery are the main risk factors for pulmonary embolism as
the most likely diagnosis in this patient.
Atelectasis usually presents with postoperative fever on the first day
Pleural eusion, lung abscess, and pulmonary edema will not present with a clear chest and normal
chest x-ray.
Page - 1196
Question 131/155
Question #131
A 39-year-old male came with a 2-day history of pleuritic right-side sharp chest pain of sudden
onset. He was previously healthy and had no record of travel. Physical examination is only
remarkable for pleural friction rub at the right middle zone. Vital signs, ECG, cardiac enzymes,
Oxygen saturation, and D Dimer levels are normal. What is the best initial test to do at this time?
a. No further testing
b. Chest x-ray
c. Repeat D Dimer level
d. CT pulmonary angiography
e. ANA and Anti-dsDNA
Page - 1197
Question 131/155
Question #131
A 39-year-old male came with a 2-day history of pleuritic right-side sharp chest pain of sudden
onset. He was previously healthy and had no record of travel. Physical examination is only
remarkable for pleural friction rub at the right middle zone. Vital signs, ECG, cardiac enzymes,
Oxygen saturation, and D Dimer levels are normal. What is the best initial test to do at this time?
a. No further testing
b. Chest x-ray √
c. Repeat D Dimer level
d. CT pulmonary angiography
e. ANA and Anti-dsDNA
Description
In the case of pleurisy, you must exclude life-threatening conditions like myocardial infarction,
pneumothorax, and pulmonary embolism.
e best initial test is a chest x-ray before going forward with the investigations.
Page - 1198
Question 132/155
Question #132
A 43-year-old male with a known case of CKD and SLE presents with sudden onset of hemoptysis,
pleuritic chest pain, and tachycardia. Physical examination reveals a clear chest and a swollen
erythematous hot right lower limb. His chest x-ray and lab investigations are normal. Which of the
following is the best study to confirm the diagnosis of his condition?
a. Conventional CT scan
b. VQ scan
c. Serum troponin level
e. Echocardiogram
Page - 1199
Question 132/155
Question #132
following is the best study to confirm the diagnosis of his condition?
a. Conventional CT scan
b. VQ scan √
c. Serum troponin level
e. Echocardiogram
Description
Of the above choices, the VQ scan is the best study to confirm the diagnosis of Pulmonary embolism
e conventional CT scan is not beneficial in pulmonary embolism, but CT pulmonary angiography,

which uses higher dose contrast and proper timing, is the imaging of choice unless contraindicated.
Page - 1200
Question 133/155
Question #133
A 45-year-old female presents to you with pleuritic chest pain. Her well’s score was 1.5 only for
tachycardia. Which of the following is the best next step for evaluating this patient?
a. CTPA
b. D Dimer
c. VQ scan
d. Troponin level
e. BNP
Page - 1201
Question 133/155
Question #133
A 45-year-old female presents to you with pleuritic chest pain. Her well’s score was 1.5 only for
tachycardia. Which of the following is the best next step for evaluating this patient?
a. CTPA
b. D Dimer √
c. VQ scan
d. Troponin level
e. BNP
Description
Low probability patients (score 4 or less on well’s criteria) should be investigated for D Dimer level
and then order CTPA if the D Dimer is elevated.
VQ scan used if the CTPA was contraindicated
Troponin level is used to evaluate whether the patient has MI and in case of massive PE
BNP is used at the ER to dierentiate cardiac vs. respiratory sources of dyspnea.
Page - 1202
Question 134/155
Question #134
A 33-year-old male with a history of complete immobilization for 4 weeks due to a lower limb
fracture presents to you with sudden onset right upper sharp pleuritic chest pain. e presence of
pleural friction rub in this patient suggests one of the following:
a. Pericarditis
b. Pneumothorax
c. Pneumonia
d. Pulmonary embolism with infarction
e. Pancreatitis
Page - 1203
Question 134/155
Question #134
A 33-year-old male with a history of complete immobilization for 4 weeks due to a lower limb
fracture presents to you with sudden onset right upper sharp pleuritic chest pain. e presence of
pleural friction rub in this patient suggests one of the following:
a. Pericarditis
b. Pneumothorax
c. Pneumonia
d. Pulmonary embolism with infarction √
e. Pancreatitis
Description
e pleural frictional rub is almost diagnostic of infarction of the overlying pleura.
Pericardial rub presents in case of pericarditis, while pneumonia presents with consolidation, fever,
and high WBC count
Pneumothorax and pulmonary embolism without infarction do not typically cause pleural friction
rub.
Page - 1204
Question 135/155
Question #135
A 45-year-old presents with sharp pleuritic chest pain for 3 hours with tachycardia and diaphoresis.
His ECG, chest x-ray, and lab investigations are normal, while his ABGs reveal PH 7.48, PaCO2 21
mmHg, and HCO3 of 26 mg/dL. Which of the following is false regarding this condition?
a. Pulmonary embolism is one of the dierential diagnoses

b. e patient has respiratory alkalosis
c. Myocardial infarction should be suspected in case of pleuritic chest pain
d. Hypotension indicates life-threatening pulmonary embolism
e. e chest x-ray is diagnostic in case of pulmonary embolism.
Page - 1205
Question 135/155
Question #135
A 45-year-old presents with sharp pleuritic chest pain for 3 hours with tachycardia and diaphoresis.
His ECG, chest x-ray, and lab investigations are normal, while his ABGs reveal PH 7.48, PaCO2 21
mmHg, and HCO3 of 26 mg/dL. Which of the following is false regarding this condition?
a. Pulmonary embolism is one of the dierential diagnoses

b. e patient has respiratory alkalosis
c. Myocardial infarction should be suspected in case of pleuritic chest pain
d. Hypotension indicates life-threatening pulmonary embolism
e. e chest x-ray is diagnostic in case of pulmonary embolism. √
Description
e chest x-ray is not specific or sensitive in PE patients. It is most commonly normal, but atelectasis,
oligemia, or Hampton hump sign may present.
5% of atypical chest pain is due to myocardial infarction, so ECG should be done in those who
develop pleuritic chest pain
Page - 1206
Question 136/155
Question #136
erythematous hot right lower limb. His chest x-ray and lab investigations are normal. What is the
most appropriate at this time?

d. D-Dimer
Page - 1207
Question 136/155
Question #136
erythematous hot right lower limb. His chest x-ray and lab investigations are normal. What is the
most appropriate at this time?

b. Ventilation-perfusion scan of the lung √
d. D-Dimer
Description
According to the well’s criteria, this patient will get 1 point for hemoptysis, 1.5 points for tachycardia,
3 points for suspected DVT, and 3 points for the absence of an alternative diagnosis. erefore, the
total score is 8.5, which indicates a high probability of pulmonary embolism.
CTPA is contraindicated due to CKD, so a VQ scan is the best test to confirm the diagnosis.
Page - 1208
Question 137/155
Question #137
following ABGs findings suggests the diagnosis of pulmonary embolism?
a. Decreased A-a gradient

b. Decreased PaCO2
c. Decreased PH
d. Decreased Bicarbonate level
e. Normal PaO2
Page - 1209
Question 137/155
Question #137
following ABGs findings suggests the diagnosis of pulmonary embolism?
a. Decreased A-a gradient

b. Decreased PaCO2 √
c. Decreased PH
d. Decreased Bicarbonate level
e. Normal PaO2
Description
Hypoxia, CO2 wash (reduced PaCO2), and respiratory alkalosis are the main features of pulmonary
embolism in ABGs.
Page - 1210
Question 138/155
Question #138
A known case of malignancy, a 55-year-old male has just been diagnosed with pulmonary embolism.
He has a blood pressure of 130/80 mmHg and a pulse rate of 130 bpm. Which of the following is the
best treatment option for this patient?
a. Apixaban for 6 months

b. Low molecular weight heparin for 6 months
c. Unfractionated heparin for 3 months
d. rombolytics
e. Warfarin for 3 months
Page - 1211
Question 138/155
Question #138
A known case of malignancy, a 55-year-old male has just been diagnosed with pulmonary embolism.
He has a blood pressure of 130/80 mmHg and a pulse rate of 130 bpm. Which of the following is the
best treatment option for this patient?
a. Apixaban for 6 months √

b. Low molecular weight heparin for 6 months
c. Unfractionated heparin for 3 months
d. rombolytics
e. Warfarin for 3 months
Description
LMWH for 6 months was the first line treatment of DVT and PE in patients with active malignancy.
However, the guidelines have recently changed, and the DOACs are now the first line.
Treatment of DVT/PE:

Warfarin:
LMWH:
aer DOAC)
Page - 1212

Page - 1213
Question 139/155
Question #139
A 55-year-old male just diagnosed with pulmonary embolism has a blood pressure of 70/50 mmHg
and a pulse rate of 130 bpm. Which of the following is the best treatment option for this patient?
a. Apixaban
b. Low molecular weight heparin
c. Unfractionated heparin
d. rombolytics
e. Warfarin
Page - 1214
Question 139/155
Question #139
A 55-year-old male just diagnosed with pulmonary embolism has a blood pressure of 70/50 mmHg
and a pulse rate of 130 bpm. Which of the following is the best treatment option for this patient?
a. Apixaban
b. Low molecular weight heparin
c. Unfractionated heparin
d. rombolytics √
e. Warfarin
Description
Hypotension is a sign of a massive pulmonary embolism. Unless contraindicated, it should be

treated with thrombolytic therapy.
Aspirin has no rule in the treatment of PE, while heparin and warfarin can be used in pulmonary
embolism according to the patient’s condition
Page - 1215
Question 140/155
Question #140
A heavy smoker 66-year-old male patient is found to have polycythemia on routine complete blood
count. However, the rest of the CBC findings are normal. What is the most likely diagnosis?
b. Essential thrombocythemia
c. Myelofibrosis
d. Chronic leukemia
e. Secondary polycythemia
Page - 1216
Internal Medicine - Hematology - Secondary polycythemia
Question 140/155
Question #140
A heavy smoker 66-year-old male patient is found to have polycythemia on routine complete blood
count. However, the rest of the CBC findings are normal. What is the most likely diagnosis?
b. Essential thrombocythemia
c. Myelofibrosis
d. Chronic leukemia
e. Secondary polycythemia √
Description
Heavy smoking is one of the most common causes of polycythemia.
If the patient is not a smoker and no cause of polycythemia is identified, you may think about
Polycythemia Vera.
In polycythemia Vera, bone marrow hyperactivity is due to JAK2 mutation leading to polycythemia.
However, the reduced erythropoietin level will dierentiate it from secondary polycythemia.
Page - 1217
Question 141/155
Question #141
A 55-year-old male patient has polycythemia and elevated erythropoietin. His blood pressure is
120/80, his pulse is 80 bpm, and his oxygen saturation is 89%. Which of the following is the most
likely diagnosis?
b. Pure red cell aplasia (PRCA)
c. Renal adenocarcinoma
d. Chronic obstructive pulmonary disease
e. Bone marrow lymphoma
Page - 1218
Question 141/155
Question #141
A 55-year-old male patient has polycythemia and elevated erythropoietin. His blood pressure is
120/80, his pulse is 80 bpm, and his oxygen saturation is 89%. Which of the following is the most
likely diagnosis?
b. Pure red cell aplasia (PRCA)
c. Renal adenocarcinoma
d. Chronic obstructive pulmonary disease √
e. Bone marrow lymphoma
Description
activity. is condition is caused by JAK 2 mutation.
Our patient, in this case, has elevated erythropoietin, indicating secondary polycythemia.
COPD will explain the presence of hypoxia, so it is the most likely diagnosis.
So, COPD will lead to hypoxia and hypoxia, resulting in elevated erythropoietin and, thus,
polycythemia.
Polycythemia Vera will present with low erythropoietin
Renal cell carcinoma will not explain hypoxia
PRCA will present with anemia and BM hypoactivity
Page - 1219
Question 142/155
Question #142
A 52-year-old male patient presents with tiredness, headache, shortness of breath, and persistent
cough. He drinks alcohol socially and has smoked 30 cigarettes daily for the past 30 years. His lab
investigations show hemoglobin of 19.9 mg/dL, WBC of 11*10^9/L, and platelet count of 240*10^9/L.
Which of the following will help establish the cause of polycythemia in this patient?
a. Dexamethasone suppression test

b. Growth hormone suppression test
c. Erythropoietin level
e. Blood film
Page - 1220
Question 142/155
Question #142
A 52-year-old male patient presents with tiredness, headache, shortness of breath, and persistent
cough. He drinks alcohol socially and has smoked 30 cigarettes daily for the past 30 years. His lab
investigations show hemoglobin of 19.9 mg/dL, WBC of 11*10^9/L, and platelet count of 240*10^9/L.
Which of the following will help establish the cause of polycythemia in this patient?
a. Dexamethasone suppression test

b. Growth hormone suppression test
c. Erythropoietin level √
e. Blood film
Description
Heavy smoking is one of the most common causes of polycythemia.
If the patient is not a smoker and no cause of polycythemia, you may think about Polycythemia Vera.
In polycythemia Vera, bone marrow hyperactivity is due to JAK2 mutation leading to polycythemia.
However, the reduced erythropoietin level will dierentiate it from secondary polycythemia.
Page - 1221
Question 143/155
Question #143
A 21-year-old male patient with sickle cell anemia presents with fatigue, pallor, and flu-like
symptoms. His lab tests show hemoglobin of 5 g/dL and positive specific parvovirus B19 IgM
antibodies. What is the most likely diagnosis?
a. Hemolytic crisis
b. Aplastic crisis
c. Splenic sequestration crisis
d. Vaso-occlusive crisis
e. Acute chest syndrome
Page - 1222
Internal Medicine - Hematology - Sickle Cell Anemia (SCA)
Question 143/155
Question #143
A 21-year-old male patient with sickle cell anemia presents with fatigue, pallor, and flu-like
symptoms. His lab tests show hemoglobin of 5 g/dL and positive specific parvovirus B19 IgM
antibodies. What is the most likely diagnosis?
a. Hemolytic crisis
b. Aplastic crisis √
c. Splenic sequestration crisis
d. Vaso-occlusive crisis
e. Acute chest syndrome
Description
is patient complains of acutely low hemoglobin and parvovirus B19 infection consisting of an
aplastic crisis.
In aplastic crisis, the patient develops pancytopenia and low reticulocyte count related to parvovirus
infection.
Any question mentions sickle cell anemia and parvovirus B19 infection, think about aplastic crisis
Types of crises in sickle cell anemia:
Vaso-occlusive (thrombotic) crisis
It is the most common crisis in sickle cell anemia

It is precipitated by infection, cold, or dehydration
Obstructed microcirculation leads to ischemia and may commonly manifest as:
Severe bone pain
Painful infarction of the spleen (leading to autosplenectomy)
Papillary necrosis and renal impairment
Mesenteric infarction (mimicking abdominal pain)
Chest Pain (Bone involvement or pulmonary infarction)
Penile involvement (Priapism: persistent painful erection of the penis)
Avascular necrosis of the femoral head
Page - 1223
Pain crisis:
Acute severe pain caused by vaso-occlusion

It may aect any part of the body according to the site of vaso-occlusion
Aplastic crisis:
Transient cessation of erythropoiesis caused by parvovirus B19 infection

Hemoglobin, reticulocytes, WBC, and Platelets are low
Hemolytic crisis:
Increased rate of hemolysis

RBCs count will be low, but high reticulocytes count
Page - 1224
Question 144/155
Question #144
A 19-year-old male patient with sickle cell anemia presents with severe abdominal pain and high
temperature. You started intravenous fluids and obtained lab tests, including cultures. What is the
best next step in this situation?
a. Oxygen supplementation
b. Parenteral opiate
c. Hydroxyurea
d. Blood transfusion
e. Intravenous paracetamol
Page - 1225
Internal Medicine - Hematology - Sickle Cell Anemia (SCA)
Question 144/155
Question #144
A 19-year-old male patient with sickle cell anemia presents with severe abdominal pain and high
temperature. You started intravenous fluids and obtained lab tests, including cultures. What is the
best next step in this situation?
a. Oxygen supplementation
b. Parenteral opiate √
c. Hydroxyurea
d. Blood transfusion
e. Intravenous paracetamol
Description
To avoid developing chronic pain syndrome in patients with sickle cell anemia, you should treat the
acute pain crisis appropriately.
Pain crisis is treated by the following steps:
Parenteral opiate (started at fixed intervals, not as needed)

Oral analgesia aer tapering the intravenous opiate
Intravenous fluid
Treatment of the precipitant
Incentive spirometry
For frequent and severe pain, long-term hydroxyurea
Hypoxia is only indicated if the patient is hypoxic.
Types of crises in sickle cell anemia:
Vaso-occlusive (thrombotic) crisis
It is the most common crisis in sickle cell anemia

It is precipitated by infection, cold, or dehydration
Obstructed microcirculation leads to ischemia and may commonly manifest as:
Severe bone pain
Painful infarction of the spleen (leading to autosplenectomy)
Page - 1226
Papillary necrosis and renal impairment
Mesenteric infarction (mimicking abdominal pain)
Chest Pain (Bone involvement or pulmonary infarction)
Penile involvement (Priapism: persistent painful erection of the penis)
Avascular necrosis of the femoral head
Pain crisis:
Acute severe pain caused by vaso-occlusion

It may aect any part of the body according to the site of vaso-occlusion
Aplastic crisis:
Transient cessation of erythropoiesis caused by parvovirus B19 infection

Hemoglobin, reticulocytes, WBC, and Platelets are low
Hemolytic crisis:
Increased rate of hemolysis

RBCs count will be low, but high reticulocytes count
Page - 1227
Question 145/155
Question #145
A 19-year-old male with a Hemoglobin concentration of 9.9 g/dl and microcytosis, serum iron, TIBC,
serum ferritin, and Hb-electrophoresis are normal. Which of the following is the most likely
diagnosis?

b. Sideroblastic anemia
c. Beta-thalassemia
d. Alpha-thalassemia trait
Page - 1228
Internal Medicine - Hematology - alassemia
Question 145/155
Question #145
A 19-year-old male with a Hemoglobin concentration of 9.9 g/dl and microcytosis, serum iron, TIBC,
serum ferritin, and Hb-electrophoresis are normal. Which of the following is the most likely
diagnosis?

b. Sideroblastic anemia
c. Beta-thalassemia
d. Alpha-thalassemia trait √
Description
Alpha thalassemia trait is the only cause of thalassemia presenting normal HB electrophoresis.
In Iron deficiency anemia, serum iron and ferritin will be low, and the TIBC will be high.
In Beta-thalassemia, the HB electrophoresis will be abnormal
In sideroblastic anemia, serum iron and ferritin will be elevated.
ere is no evidence of chronic disease in this young man.
Page - 1229
Question 146/155
Question #146
A 19-year-old female was accidentally found to have microcytic anemia, her iron study is normal, but
her Hb electrophoresis shows elevated hemoglobin A2. What is the most likely diagnosis?
a. Alpha-thalassemia
b. Beta-thalassemia
c. Sickle cell trait
Page - 1230
Question 146/155
Question #146
A 19-year-old female was accidentally found to have microcytic anemia, her iron study is normal, but
her Hb electrophoresis shows elevated hemoglobin A2. What is the most likely diagnosis?
a. Alpha-thalassemia
b. Beta-thalassemia √
c. Sickle cell trait
Description
Beta-thalassemia is a genetic disorder of hemoglobin synthesis leading to abnormal hemoglobin,

membrane damage, and decreased RBC survival
In beta-alassemia, there is a reduced beta chains synthesis
Hb electrophoresis is the most accurate test in beta-thalassemia
In thalassemia minor (Hb A: 80-95%, Hb A2 4-8%, and Hb F: 1-5%)

In thalassemia major (Hb A: 0%, Hb A2: 4-10%, and Hb F: 90-96%)
Once the iron study is normal, this excludes iron deficiency anemia.
Page - 1231
Question 147/155
Question #147
A 21-year-old female was tested for a complete blood count during her routine examination. She is
found to have a hemoglobin level of 10.5 g/dL and an RDW of 14. Based on these limited lab results,
what is the most likely diagnosis?

b. B12 deficiency anemia
c. Anemia of chronic disease
d. Lead poisoning
e. alassemia
Page - 1232
Question 147/155
Question #147
A 21-year-old female was tested for a complete blood count during her routine examination. She is
found to have a hemoglobin level of 10.5 g/dL and an RDW of 14. Based on these limited lab results,
what is the most likely diagnosis?

b. B12 deficiency anemia
c. Anemia of chronic disease
d. Lead poisoning
e. alassemia √
Description
e causes of microcytic anemia are:
Iron deficiency anemia

alassemia
Anemia of chronic disease (but mostly normocytic)
Lead poisoning
Sideroblastic anemia
Causes of high RDW:
Iron deficiency anemia (low MCV)

Sideroblastic anemia (Low MCV)
Mixed Iron and B12 deficiency anemia (Normal MCV)
Folate and B12 deficiency (high MCV)
Recent hemorrhage (Normal MCV)
e RDW will be normal in thalassemia and elevated in iron deficiency and sideroblastic anemia.
So, thalassemia is the most likely diagnosis in this scenario.
Page - 1233
Question 148/155
Question #148
A 17-year-old male is complaining of jaundice, pallor, and skull bossing. He has been dependent on
blood transfusion since childhood. What is the most likely diagnosis?
a. Hereditary spherocytosis
c. Beta alassemia major
d. Beta thalassemia minor
e. Sideroblastic anemia
Page - 1234
Question 148/155
Question #148
A 17-year-old male is complaining of jaundice, pallor, and skull bossing. He has been dependent on
blood transfusion since childhood. What is the most likely diagnosis?
c. Beta alassemia major √
d. Beta thalassemia minor
e. Sideroblastic anemia
Description
Beta-thalassemia is a genetic disorder of hemoglobin synthesis leading to abnormal hemoglobin,

membrane damage, and decreased RBC survival
In beta-alassemia, there is a reduced beta chains synthesis
e clinical picture of beta-thalassemia major:
Severe anemia requiring transfusion in the first year of life

Intermittent infections
Bone marrow hyperplasia causing bossing of the head and prominent malar eminence
(alassemic face)
Splenomegaly (early), Hepatomegaly (slow)
Iron overload in a transfusion-dependent patient (usually aer 20 units of blood transfusion) →
resulting in features of hemochromatosis
Beta-thalassemia minor is usually asymptomatic and does not require a blood transfusion.
Page - 1235
Question 149/155
Question #149
A 30-year-old male patient is a known case of beta-thalassemia major. He presents to you with lung
crepitations and gray skin. His lab investigations show hemoglobin of 7.3 g/dL and fasting glucose of
230mg/dL. What is the most appropriate at this time?
a. Blood transfusion
b. Phlebotomy
c. Oral iron and vitamin C
d. Hydroxyurea
e. Erythropoietin injection
Page - 1236
Question 149/155
Question #149
A 30-year-old male patient is a known case of beta-thalassemia major. He presents to you with lung
crepitations and gray skin. His lab investigations show hemoglobin of 7.3 g/dL and fasting glucose of
230mg/dL. What is the most appropriate at this time?
b. Phlebotomy
c. Oral iron and vitamin C
d. Hydroxyurea √
e. Erythropoietin injection
Description
e patient is a known case of beta-thalassemia major that indicates recurrent blood transfusion. As
a result, those patients are at risk of iron overload.
Iron overload may aect several organs, including the heart, liver, pancreas, and skin. So, the
presence of features of liver failure, heart failure, gray skin, and hyperglycemia in a patient with
recurrent blood transfusion strongly suggests iron overload in this patient.
In this case, hydroxyurea will increase the formation of hemoglobin F, reducing the need for blood
transfusion and, thus, the risk of iron overload.
Phlebotomy is indicated in the case of hemochromatosis when the hemoglobin is elevated, but it is
contraindicated because it will worsen anemia.
Blood transfusion, oral iron, and vitamin C will increase the iron load and worsen the condition
Erythropoietin is used in anemia of chronic disease, not in thalassemia.
Page - 1237
Question 150/155
Question #150
A 33-year-old male presents with headache, red urine, fatigue, and jaundice. His lab investigations
show prolonged bleeding time, low platelet, low hemoglobin, renal impairment, and indirect
hyperbilirubinemia. However, his PT, PTT, INR, and D Dimer are normal. What is the most likely
diagnosis?
a. Idiopathic thrombocytopenic purpura

d. rombotic thrombocytopenic purpura
e. Acute liver disease
Page - 1238
Internal Medicine - Hematology - rombotic rombocytopenic Purpura (TTP)
Question 150/155
Question #150
A 33-year-old male presents with headache, red urine, fatigue, and jaundice. His lab investigations
show prolonged bleeding time, low platelet, low hemoglobin, renal impairment, and indirect
hyperbilirubinemia. However, his PT, PTT, INR, and D Dimer are normal. What is the most likely
diagnosis?
a. Idiopathic thrombocytopenic purpura

d. rombotic thrombocytopenic purpura √
e. Acute liver disease
Description
is is a typical scenario of rombotic rombocytopenic purpura (TTP)
PT, aPTT, D-dimer, and fibrinogen levels are normal in TTP-HUS and abnormal in DIC.
TTP:
Both TTP and HUS are dierent versions of the same basic disease (deficiency of
metalloproteinase ADAMTS 13)
Hemolytic Uremic Syndrome (HUS) is associated with E. coli O157:H7 → more frequent in
children (see pediatrics)
Pathogenesis:
TTP patient has an ADAMTS13 (vWF-cleaving protease) deficiency

TTP can occur in patients with cancer, transplant recipients, HIV, SLE, and those who receive
quinine, clopidogrel, ticlopidine, or cyclosporine.
Platelets and fibrin adhesion deposited in arterioles lead to the destruction of RBCs when
passing through these arterioles (Microangiopathic hemolytic anemia - MAHA).
Clinical presentation and diagnosis:
Fever
Page - 1239
Neurological manifestations (headache, confusion, ataxia, seizures, and mental status and
focal abnormalities)
Microangiopathic hemolytic anemia
Fragmented RBCs (schistocytes)
High reticulocytes and LDH levels
Indirect hyperbilirubinemia
Other features of intravascular hemolysis
Coombs test is negative
rombocytopenia
Renal impairment
Treatment:
Immediate discontinuation of the causative drug.

Emergency plasma exchange
Page - 1240
Question 151/155
Question #151
You are seeing a 40-year-old female patient in the emergency department. She has a fever and
decreased level of consciousness. On examination, you note a petechial rash, mild jaundice, and
splenomegaly. Her lab investigations show hemoglobin of 8.6 g/dL, reticulocytes of 11%, platelet
count of 15*10^9/L, creatinine of 2.9 mg/dL, urea of 40 mg/dL, normal PT and PTT, indirect
hyperbilirubinemia, and LDH of 860 u/L. In addition, her blood film shows numerous schistocytes.
a. Renal dialysis
b. Start oral aspirin
c. Platelet transfusion
d. Plasmapheresis and fresh frozen plasma
e. Blood transfusion
Page - 1241
Internal Medicine - Hematology - rombotic rombocytopenic Purpura (TTP)
Question 151/155
Question #151
You are seeing a 40-year-old female patient in the emergency department. She has a fever and
decreased level of consciousness. On examination, you note a petechial rash, mild jaundice, and
splenomegaly. Her lab investigations show hemoglobin of 8.6 g/dL, reticulocytes of 11%, platelet
count of 15*10^9/L, creatinine of 2.9 mg/dL, urea of 40 mg/dL, normal PT and PTT, indirect
hyperbilirubinemia, and LDH of 860 u/L. In addition, her blood film shows numerous schistocytes.
a. Renal dialysis
b. Start oral aspirin
c. Platelet transfusion
d. Plasmapheresis and fresh frozen plasma √
e. Blood transfusion
Description
is is a typical scenario of rombotic rombocytopenic purpura (TTP)
Treatment of TTP is by emergency plasma exchange.
Platelet transfusion in TTP-HUS can exacerbate microvascular occlusion.
PT, aPTT, D-dimer, and fibrinogen levels are normal in TTP-HUS and abnormal in DIC.
TTP:
Both TTP and HUS are dierent versions of the same basic disease (deficiency of
metalloproteinase ADAMTS 13)
Hemolytic Uremic Syndrome (HUS) is associated with E. coli O157:H7 → more frequent in
children (see pediatrics)
Pathogenesis:
TTP patient has an ADAMTS13 (vWF-cleaving protease) deficiency

TTP can occur in patients with cancer, transplant recipients, HIV, SLE, and those who receive
quinine, clopidogrel, ticlopidine, or cyclosporine.
Page - 1242
Platelets and fibrin adhesion deposited in arterioles lead to the destruction of RBCs when
passing through these arterioles (Microangiopathic hemolytic anemia - MAHA).
Clinical presentation and diagnosis:
Fever
Neurological manifestations (headache, confusion, ataxia, seizures, and mental status and
focal abnormalities)
Microangiopathic hemolytic anemia
Fragmented RBCs (schistocytes)
High reticulocytes and LDH levels
Indirect hyperbilirubinemia
Other features of intravascular hemolysis
Coombs test is negative
rombocytopenia
Renal impairment
Page - 1243
Question 152/155
Question #152
A 30-year-old male patient with Burkitt’s lymphoma is undergoing chemotherapy. As a result, he

develops tumor lysis syndrome. All the following are expected manifestations except:
a. Hyperuricemia
b. Hyperkalemia
c. Hypercalcemia
d. Hyperphosphatemia
e. Arrhythmias and sudden death
Page - 1244
Internal Medicine - Hematology - Tumor lysis syndrome
Question 152/155
Question #152
A 30-year-old male patient with Burkitt’s lymphoma is undergoing chemotherapy. As a result, he

develops tumor lysis syndrome. All the following are expected manifestations except:
a. Hyperuricemia
b. Hyperkalemia
c. Hypercalcemia √
e. Arrhythmias and sudden death
Description
Hypocalcemia, not hypercalcemia, is expected to manifest in tumor lysis syndrome.
Calcium acts as a chelating agent for phosphate leading to reduced calcium level
Tumor lysis syndrome is a side eect of chemotherapy due to the rapid destruction of a large
number of cells
Clinical features include:
Hyperkalemia
Hyperphosphatemia
Hyperuricemia
Hypocalcemia
Acute renal failure
Page - 1245
Question 153/155
Question #153
A 19-year-old female develops prolonged bleeding aer an appendectomy. Her father and parental
uncle have experienced the same condition. What is the most likely mode of inheritance of this
disorder?
a. Autosomal dominant
c. X Linked recessive
d. Y linked
e. Mitochondrial gene defect
Page - 1246
Internal Medicine - Hematology - Von Willebrand Disease (vWD)
Question 153/155
Question #153
A 19-year-old female develops prolonged bleeding aer an appendectomy. Her father and parental
uncle have experienced the same condition. What is the most likely mode of inheritance of this
disorder?
a. Autosomal dominant √
c. X Linked recessive
d. Y linked
e. Mitochondrial gene defect
Description
vWD is the most common inherited bleeding disorder resulting from an autosomal dominant
mutation. As a result, there will be a decreased level of functioning vWF and bleeding tendency.
vWD has 3 main types. Type 1 is the most common (80% of cases) and is inherited autosomal
dominant, while types 2 and 3 are mainly inherited in an autosomal recessive manner. Type 3 is the
most severe form.
Type 1: reduced vWF (autosomal dominant)
Type 2: abnormal quality of vWF (certain subtypes are autosomal recessive)
Type 3: absent vWF (the most severe) (autosomal recessive)
vWF is a protein that has two functions:
Carrier for factor VIII (if deficient vWF → decreased factor VIII in plasma)
Binding platelets to sub-endothelial collagen (primary hemostasis)
e coagulation profile of vWD will be as the following:
High BT
High PTT (50% of cases)
Low Factor 8
Low vWF
Page - 1247
Normal platelet count and PT
Treatment of vWD:
Mild bleeding: Tranexamic acid

Desmopressin (DDAVP) increases the level of vWF
Severe bleeding: Cryoprecipitate or Factor VIII
Page - 1248
Question 154/155
Question #154
A 22-year-old male patient started to have heavy bleeding aer a tooth extraction. His medical
history reveals easy bruising and gum bleeding aer brushing his teeth. In addition, a family history
of a similar condition in his father is present. What is the most likely diagnosis?
a. Hemophilia A
b. Hemophilia B
c. Von Willebrand’s disease
d. Factor 12 deficiency
e. Factor 13 deficiency
Page - 1249
Question 154/155
Question #154
A 22-year-old male patient started to have heavy bleeding aer a tooth extraction. His medical
history reveals easy bruising and gum bleeding aer brushing his teeth. In addition, a family history
of a similar condition in his father is present. What is the most likely diagnosis?
a. Hemophilia A
b. Hemophilia B
c. Von Willebrand’s disease √
d. Factor 12 deficiency
e. Factor 13 deficiency
Description
Patients with bleeding tendency and positive family history are most likely suering from Von
Willebrand’s disease (vWD)
High BT
Low Factor 8
Low vWF
Treatment of vWD:

Page - 1250
Page - 1251
Question 155/155
Question #155
A 19-year-old female was diagnosed with recurrent prolonged bleeding and ecchymosis secondary
to Von Willebrand’s disease. Which of the following is the most appropriate at this time?
a. Vitamin K
b. Fresh frozen plasma
c. Desmopressin
d. Platelet transfusion
e. Protamine sulfate
Page - 1252
Question 155/155
Question #155
A 19-year-old female was diagnosed with recurrent prolonged bleeding and ecchymosis secondary
to Von Willebrand’s disease. Which of the following is the most appropriate at this time?
a. Vitamin K
b. Fresh frozen plasma
c. Desmopressin √
d. Platelet transfusion
e. Protamine sulfate
Description
High BT
Low Factor 8
Low vWF
Treatment of vWD:

Page - 1253
Hepatology
Page - 1254
Hepatology
1) Alcoholic liver disease => 1 Questions

2) Ascites => 2 Questions
3) Autoimmune hepatitis => 2 Questions
4) Hemochromatosis => 12 Questions
5) Hepatic Encephalopathy => 3 Questions
6) Hepatitis => 13 Questions
7) Jaundice => 5 Questions
8) Liver Cirrhosis => 3 Questions
9) Liver function tests (LFT) => 3 Questions
10) Non-alcoholic Fatty Liver Disease (NAFLD) => 2 Questions
11) Paracetamol poisoning => 2 Questions
12) Portal HTN and esophageal varices => 6 Questions
13) Primary Biliary Cholangitis (PBC) => 2 Questions
14) Primary Sclerosing Cholangitis (PSC) => 2 Questions
15) Spontaneous Bacterial Peritonitis (SBP) => 3 Questions
16) Wilson Disease => 5 Questions
Page - 1255
Internal Medicine - Hepatology
Question 1/66
Question #1
A 36-year-old alcoholic male patient was referred to you by a family physician because he suspected
alcoholic liver disease. Which of the following is the most sensitive in evaluating this patient?
a. e history of alcoholism
b. Low platelet and high MCV count
c. Alkaline phosphatase level
d. Aspartate to Alanine aminotransferase ratio
e. Direct to total bilirubin level
Page - 1256
Internal Medicine - Hepatology - Alcoholic liver disease
Question 1/66
Question #1
A 36-year-old alcoholic male patient was referred to you by a family physician because he suspected
alcoholic liver disease. Which of the following is the most sensitive in evaluating this patient?
a. e history of alcoholism
b. Low platelet and high MCV count
c. Alkaline phosphatase level
d. Aspartate to Alanine aminotransferase ratio √
e. Direct to total bilirubin level
Description
Alcoholic liver diseases are 3 conditions: alcoholic fatty liver, alcoholic hepatitis, and alcoholic liver
cirrhosis.
If AST > ALT and AST/ALT ratio > 2, then the alcoholic liver disease is the diagnosis
High MCV level is a less sensitive indicator for alcoholic liver diseases
Page - 1257
Question 2/66
Question #2
A 62-year-old female has been heavily alcoholic for 30 years. She presents to your oce complaining
of abdominal distention, shiing dullness, and positive fluid thrill in the abdomen. Which of the
following is false?
a. Sodium restriction is the most important initial treatment

b. Paracentesis is the most accurate test
c. Spironolactone is the most eective diuretic in the treatment
d. Liver cirrhosis presents with high SAAG
e. Spontaneous bacterial peritonitis never presents without abdominal pain
Page - 1258
Internal Medicine - Hepatology - Ascites
Question 2/66
Question #2
A 62-year-old female has been heavily alcoholic for 30 years. She presents to your oce complaining
of abdominal distention, shiing dullness, and positive fluid thrill in the abdomen. Which of the
following is false?
a. Sodium restriction is the most important initial treatment

b. Paracentesis is the most accurate test
c. Spironolactone is the most eective diuretic in the treatment
d. Liver cirrhosis presents with high SAAG
e. Spontaneous bacterial peritonitis never presents without abdominal pain √
Description
All patients with ascites should have paracentesis to rule out SBP (30% of patients are
asymptomatic)
High SAAG indicates liver cirrhosis, CHF, or Budd-Chiari syndrome, while low SAAG indicates
nephrotic syndrome, malignancy, pancreatitis, or tuberculosis.
Treatment of ascites:
Stop ACE-I, ARB, and NSAIDs in patients with ascites

Treatment of the cause
Sodium restriction
Diuretics (spironolactone is the best, but furosemide may be used)
Paracentesis
TIPSS (Trans-jugular intrahepatic portosystemic shunt)
Page - 1259
Question 3/66
Question #3
You ordered Serum Ascites Albumin Gradient (SAAG) for a patient with ascites, the SAAG was 1.3,
and the ascitic protein level was 1.9 g/dL. What is the most likely cause of his ascites?
a. Liver cirrhosis
b. Nephrotic syndrome
c. Congestive heart failure
d. Pancreatitis
e. Peritoneal tuberculosis
Page - 1260
Internal Medicine - Hepatology - Ascites
Question 3/66
Question #3
You ordered Serum Ascites Albumin Gradient (SAAG) for a patient with ascites, the SAAG was 1.3,
and the ascitic protein level was 1.9 g/dL. What is the most likely cause of his ascites?
a. Liver cirrhosis √
b. Nephrotic syndrome
c. Congestive heart failure
d. Pancreatitis
e. Peritoneal tuberculosis
Description
e above choices can cause ascites, but SAAG and ascitic protein levels would dierentiate the
cause.
e following table shows the dierential diagnosis of ascites according to SAAG and ascitic protein
level.
Page - 1261
Question 4/66
Question #4
A 29-year-old female develops secondary amenorrhea for 6 months. Her pregnancy test is negative.
Serum bilirubin is 2.8 mg/dL, ALT is 120 iu/L, AST is 83 iu/L, and Alp is 190 iu/L. What is the most likely
diagnosis?
a. Primary sclerosing cholangitis (PSC)

b. Primary biliary cholangitis (PBC)
c. Gilbert syndrome
d. Autoimmune hepatitis
e. Dubin-Johnson Syndrome
Page - 1262
Internal Medicine - Hepatology - Autoimmune hepatitis
Question 4/66
Question #4
A 29-year-old female develops secondary amenorrhea for 6 months. Her pregnancy test is negative.
Serum bilirubin is 2.8 mg/dL, ALT is 120 iu/L, AST is 83 iu/L, and Alp is 190 iu/L. What is the most likely
diagnosis?
a. Primary sclerosing cholangitis (PSC)

b. Primary biliary cholangitis (PBC)
c. Gilbert syndrome
d. Autoimmune hepatitis √
e. Dubin-Johnson Syndrome
Description
Consider autoimmune hepatitis in a young woman with hepatitis or hepatic failure who is serology
negative to hepatitis viruses and has other associated autoimmune conditions.
e serum alkaline phosphatase should be normal or minimally elevated in autoimmune hepatitis. A

more than two-fold elevation suggests an alternative or additional diagnosis.
PSC and PBC are associated with higher alkaline phosphatase level
Gilbert syndrome never aects the AST and ALT levels (only isolated unconjugated
hyperbilirubinemia)
Page - 1263
Question 5/66
Question #5
A 23-year-old female patient is known to have hypothyroidism and is receiving thyroxine

replacement. She presents with fever, fatigue, and jaundice. Her hepatitis serology test is negative,
serum bilirubin is 2.8 mg/dL, ALT is 105 iu/L, ALP is 200 iu/L, and her PT and INR are prolonged. What
a. Drug-induced hepatitis
b. Autoimmune hepatitis
c. Acute liver failure
d. Alcoholic liver disease
e. Hyperacute liver failure
Page - 1264
Internal Medicine - Hepatology - Autoimmune hepatitis
Question 5/66
Question #5
A 23-year-old female patient is known to have hypothyroidism and is receiving thyroxine

replacement. She presents with fever, fatigue, and jaundice. Her hepatitis serology test is negative,
serum bilirubin is 2.8 mg/dL, ALT is 105 iu/L, ALP is 200 iu/L, and her PT and INR are prolonged. What
a. Drug-induced hepatitis
b. Autoimmune hepatitis √
c. Acute liver failure
d. Alcoholic liver disease
e. Hyperacute liver failure
Description
Consider autoimmune hepatitis in a young woman with hepatitis or hepatic failure who is serology
negative to hepatitis viruses and has other associated autoimmune conditions.
yroid disease here is the associated autoimmune disease.
e serum alkaline phosphatase should be normal or minimally elevated in autoimmune hepatitis. A

more than two-fold elevation suggests an alternative or additional diagnosis.
Page - 1265
Question 6/66
Question #6
A patient is suspected of having hereditary hemochromatosis. Which of the following is the best
initial test in his management?
a. Serum ferritin
b. Serum transferrin saturation
c. Serum ceruloplasmin level
d. serum Iron level
e. HFE gene mutation
Page - 1266
Internal Medicine - Hepatology - Hemochromatosis
Question 6/66
Question #6
A patient is suspected of having hereditary hemochromatosis. Which of the following is the best
initial test in his management?
a. Serum ferritin
b. Serum transferrin saturation √
c. Serum ceruloplasmin level
d. serum Iron level
e. HFE gene mutation
Description
e most appropriate screening test for hereditary hemochromatosis is fasting serum transferrin
saturation
Hemochromatosis (also known as bronze diabetes) is an autosomal recessive disorder; HFE gene
mutation leads to increased iron absorption.
e iron will accumulate in the body and deposit in the liver, heart, skin, pancreas, testes, and
endocrine glands.
Symptoms usually start at the age of 40 years and will show:
Fatigue and Arthropathy (early symptoms)

DM, HF, arrhythmias, Impotence, loss of libido, testicular atrophy
Destructive Arthropathy of the second MCP joints with Hook-like osteophytes
Unusual sites Osteoarthritis (e.g., ankle, shoulder, etc.)
Liver cirrhosis may be complicated by Hepatocellular carcinoma
Gray skin pigmentation (bronzed diabetes)
Page - 1267
Question 7/66
Question #7
A 40-year-old male presents with fatigue and darkening of his skin, his liver is enlarged, and his
urine dipstick shows glucosuria. His father died 12 years ago of liver cirrhosis. Which of the following
would help in the diagnosis?
a. Serum ceruloplasmin level

b. Alpha-1-antitrypsin level
c. Ferritin level
d. Schilling test
e. Karyotyping
Page - 1268
Question 7/66
Question #7
A 40-year-old male presents with fatigue and darkening of his skin, his liver is enlarged, and his
urine dipstick shows glucosuria. His father died 12 years ago of liver cirrhosis. Which of the following
would help in the diagnosis?
a. Serum ceruloplasmin level

b. Alpha-1-antitrypsin level
c. Ferritin level √
d. Schilling test
e. Karyotyping
Description
e presence of dark skin and the family history of liver diseases strongly suggest hemochromatosis
as the most likely diagnosis.

Page - 1269
Question 8/66
Question #8
A 42-year-old female develops polyuria, polyphagia, and polydipsia. His father died due to liver
cirrhosis at the age of 55 years. On examination, the patient has dark skin and hepatomegaly. What
a. Wilson disease
b. Hemochromatosis
c. Addison disease
d. Alpha-1-antitrypsin deficiency
e. Hepatocellular carcinoma
Page - 1270
Question 8/66
Question #8
A 42-year-old female develops polyuria, polyphagia, and polydipsia. His father died due to liver
cirrhosis at the age of 55 years. On examination, the patient has dark skin and hepatomegaly. What
a. Wilson disease
b. Hemochromatosis √
c. Addison disease
Description
endocrine glands.

Page - 1271
Question 9/66
Question #9
A 43-year-old male patient develops gynecomastia and fatigue. On examination, he has dark skin,
hepatomegaly, and palmar erythema. His lab tests show an HbA1c level of 8%. What is the most
likely diagnosis?
a. Idiopathic gynecomastia
b. Hemochromatosis
c. Wilson disease
d. Hepatocellular carcinoma
e. Chronic hepatitis
Page - 1272
Question 9/66
Question #9
A 43-year-old male patient develops gynecomastia and fatigue. On examination, he has dark skin,
hepatomegaly, and palmar erythema. His lab tests show an HbA1c level of 8%. What is the most
likely diagnosis?
a. Idiopathic gynecomastia
c. Wilson disease
d. Hepatocellular carcinoma
e. Chronic hepatitis
Description
Gynecomastia, hepatomegaly, and palmar erythema suggest chronic liver disease.
Chronic liver disease, DM, and bronze skin strongly suggest hemochromatosis
endocrine glands.

Page - 1273
Question 10/66
Question #10
A 41-year-old male patient has DM, heart failure, chronic liver disease, and bronze skin. He was
diagnosed with hemochromatosis. He asked you about the chance that his children may have the
condition. e most appropriate answer is:
a. All of his sons will get the disease

b. All of his daughters will get the disease
c. All his sons and daughters will be carriers of the disease
d. 50% of his children will get the disease
e. 25% of his children will get the disease
Page - 1274
Question 10/66
Question #10
A 41-year-old male patient has DM, heart failure, chronic liver disease, and bronze skin. He was
diagnosed with hemochromatosis. He asked you about the chance that his children may have the
condition. e most appropriate answer is:
a. All of his sons will get the disease

b. All of his daughters will get the disease
c. All his sons and daughters will be carriers of the disease √
d. 50% of his children will get the disease
e. 25% of his children will get the disease
Description
Knowing that hemochromatosis is an autosomal recessive condition, the patient will have (hh)
genotype.
Assuming his mother is a normal (HH) genotype, all his children will be (Hh).
(Hh) genotype is heterozygous; it indicates carrier status.
Page - 1275
Question 11/66
Question #11
A 45-year-old male patient develops arthralgia, fatigue, and erectile dysfunction. His physical
examination reveals hepatomegaly, and his lab investigations show elevated transaminases. What
a. Wilson disease
b. Hemochromatosis
c. Addison disease
Page - 1276
Question 11/66
Question #11
A 45-year-old male patient develops arthralgia, fatigue, and erectile dysfunction. His physical
examination reveals hepatomegaly, and his lab investigations show elevated transaminases. What
a. Wilson disease
c. Addison disease
Description
endocrine glands.

Page - 1277
Question 12/66
Question #12
A 40-year-old man develops orthopnea and fatigue. Recently, he was diagnosed with diabetes, for
which he received insulin therapy. On examination, the patient has lung crepitation, hepatomegaly,
and bronze skin. In addition, his blood tests show a high ferritin level. What is the most likely
diagnosis?
a. Ischemic heart disease

b. Wilson disease
c. Hemochromatosis
d. Addison disease
e. Alpha-1-antitrypsin deficiency
Page - 1278
Question 12/66
Question #12
and bronze skin. In addition, his blood tests show a high ferritin level. What is the most likely
diagnosis?
a. Ischemic heart disease

b. Wilson disease
c. Hemochromatosis √
d. Addison disease
e. Alpha-1-antitrypsin deficiency
Description
endocrine glands.

Page - 1279
Question 13/66
Question #13
A 40-year-old male patient presents with a darkening of his skin. His history is significant for
paternal death with liver cirrhosis, and his physical examination shows hepatomegaly. What is the
a. Alpha-1-antitrypsin deficiency
b. Hemochromatosis
c. Hepatocellular carcinoma
d. Liver cirrhosis
e. Wilson disease
Page - 1280
Question 13/66
Question #13
A 40-year-old male patient presents with a darkening of his skin. His history is significant for
paternal death with liver cirrhosis, and his physical examination shows hepatomegaly. What is the
a. Alpha-1-antitrypsin deficiency
c. Hepatocellular carcinoma
d. Liver cirrhosis
e. Wilson disease
Description
e presence of dark skin and the family history of liver diseases strongly suggest hemochromatosis
as the most likely diagnosis.
endocrine glands.

Page - 1281
Question 14/66
Question #14
A 41-year-old male patient has DM, heart failure, chronic liver disease, and bronze skin. As a result,
he was diagnosed with hemochromatosis. He asked you about the chance that his children may
have the disease. What is the treatment of choice for this condition?
b. A chelating agent (penicillamine)
c. Recurrent phlebotomy
d. Only insulin and digoxin
e. Ferrous sulfate oral tablets
Page - 1282
Question 14/66
Question #14
A 41-year-old male patient has DM, heart failure, chronic liver disease, and bronze skin. As a result,
he was diagnosed with hemochromatosis. He asked you about the chance that his children may
have the disease. What is the treatment of choice for this condition?
b. A chelating agent (penicillamine)
c. Recurrent phlebotomy √
d. Only insulin and digoxin
e. Ferrous sulfate oral tablets
Description
e management of hemochromatosis is by recurrent phlebotomy (venesection) weekly 500 ml (250

mg iron) – until serum iron is normal, then as required
Aer treatment, the liver and heart will improve, but DM is irreversible
Blood transfusion and ferrous sulfate will exacerbate the condition and cause more iron load.
Penicillamine is a cooper chelating agent used in Wilson disease, not hemochromatosis.
Insulin and digoxin will control heart failure and DM, but without reducing the body’s iron, they will
not control the patient’s condition
Page - 1283
Question 15/66
Question #15
A 45-year-old female is found to have abnormal liver function tests. Her liver biopsy demonstrates a
considerable amount of iron in the hepatocytes. What is the most likely diagnosis?
a. Wilsons disease
b. Alpha-1-antitrypsin deficiency
c. Hemochromatosis
d. McArdle’s disease
e. Autoimmune hepatitis
Page - 1284
Question 15/66
Question #15
A 45-year-old female is found to have abnormal liver function tests. Her liver biopsy demonstrates a
considerable amount of iron in the hepatocytes. What is the most likely diagnosis?
a. Wilsons disease
b. Alpha-1-antitrypsin deficiency
c. Hemochromatosis √
d. McArdle’s disease
Description
e presence of high iron content in Hepatocytes (the liver cells) is diagnostic of hemochromatosis.
endocrine glands.

Page - 1285
Question 16/66
Question #16
A 45-year-old male patient is a known case of hemochromatosis. He presents with hematemesis. On

examination, the patient is confused and drowsy. His blood pressure is 112/80, the pulse is 113 bpm,
and the spleen is palpable. Which of the following is true?
a. e patient has liver cirrhosis

b. e patient mostly has portal HTN
c. e patient mostly has bleeding esophageal varices
d. e patient has hepatic encephalopathy
e. All of the above
Page - 1286
Question 16/66
Question #16
A 45-year-old male patient is a known case of hemochromatosis. He presents with hematemesis. On

examination, the patient is confused and drowsy. His blood pressure is 112/80, the pulse is 113 bpm,
and the spleen is palpable. Which of the following is true?
a. e patient has liver cirrhosis

b. e patient mostly has portal HTN
c. e patient mostly has bleeding esophageal varices
d. e patient has hepatic encephalopathy
Description
Splenomegaly suggests portal HTN
e presence of hemochromatosis in this scenario makes liver cirrhosis more likely.
e presence of hematemesis in a patient with liver cirrhosis suggests bleeding esophageal varices
e presence of confusion and upper GI bleeding in a patient with liver cirrhosis suggest hepatic
encephalopathy.
Note that shock is a possible cause of confusion, but confusion results aer the drop in blood
pressure (unlike this case).
Page - 1287
Question 17/66
Question #17
and bronze skin. His blood tests show a high ferritin level. However, the patient refuses any
treatment. Which of the following organs would most likely develop cancer in this patient?
a. e pancreas
b. e heart
c. e liver
d. e testes
e. e skin
Page - 1288
Question 17/66
Question #17
and bronze skin. His blood tests show a high ferritin level. However, the patient refuses any
treatment. Which of the following organs would most likely develop cancer in this patient?
a. e pancreas
b. e heart
c. e liver √
d. e testes
e. e skin
Description
Hemochromatosis is a known cause of liver cirrhosis and liver cancer.
endocrine glands.

Page - 1289
Question 18/66
Question #18
A 55-year-old male patient comes to the emergency department with bloody vomiting and
confusion. His history includes hemochromatosis and diabetes. On examination, the patient is
flushed and has a blood pressure of 120/80 mmHg. e pulse is 110 bpm, the abdominal wall shows a
venous pattern, and the patient is drowsy and confused with no neurological deficit. Which of the
following is not used in the treatment of this patient?
a. Oral lactulose and lactulose enema

b. Intravenous antibiotics (Rifaximin)
d. Keep the patient NPO
e. Endoscopic banding of the esophageal varices
Page - 1290
Internal Medicine - Hepatology - Hepatic Encephalopathy
Question 18/66
Question #18
venous pattern, and the patient is drowsy and confused with no neurological deficit. Which of the
following is not used in the treatment of this patient?
a. Oral lactulose and lactulose enema

b. Intravenous antibiotics (Rifaximin) √
d. Keep the patient NPO
e. Endoscopic banding of the esophageal varices
Description
Rifaximin is a non-absorbable antibiotic used in cases like hepatic encephalopathy, traveler’s

diarrhea, and IBS with diarrhea.
It is administrated orally, no intravenously
is patient should be treated for both upper GI bleeding and hepatic encephalopathy.
IV fluids and the endoscopic band are used to control bleeding (mostly due to varices in this
patient).
NPO, lactulose, and Rifaximin are used to treat hepatic encephalopathy.
e following is a summary of the treatment of hepatic encephalopathy:
Treatment of the precipitating cause

Lactulose (laxative)
Decrease colon PH → decrease ammonia absorption
Decrease protein content in the GI tract
Antibiotics (Rifaximin 400 mg TID), Non-absorbable antibiotic, Decrease GUT bacteria → less
ammonia
Page - 1291
Question 19/66
Question #19
A patient with liver cirrhosis had a heavy protein meal yesterday. Today, he has developed
drowsiness and aggressive behavior. Which of the following is false about this condition?
a. Plasma ammonia level is elevated in this patient

b. EEG will show slow alpha waves
c. Loperamide should be administrated in this patient
d. is patient has grade 2 encephalopathy
e. Lactulose and antibiotics are required for the treatment
Page - 1292
Question 19/66
Question #19
A patient with liver cirrhosis had a heavy protein meal yesterday. Today, he has developed
drowsiness and aggressive behavior. Which of the following is false about this condition?
a. Plasma ammonia level is elevated in this patient

b. EEG will show slow alpha waves
c. Loperamide should be administrated in this patient √
d. is patient has grade 2 encephalopathy
e. Lactulose and antibiotics are required for the treatment
Description
is patient has hepatic encephalopathy.
Loperamide is an antidiarrheal agent that is not appropriate in this case.
Loperamide will increase constipation and the protein’s length of stay in the gut, leading to more
ammonia production.
e following is a summary of the treatment of hepatic encephalopathy:
Treatment of the precipitating cause

Lactulose (laxative)
Decrease colon PH → decrease ammonia absorption
Decrease protein content in the GI tract
Antibiotics (Rifaximin 400 mg TID), Non-absorbable antibiotic, Decrease GUT bacteria → less
ammonia
Page - 1293
Question 20/66
Question #20
venous pattern, and the patient is drowsy and confused with no neurological deficit. What is the
a. Stroke
b. Subarachnoid hemorrhage
c. Hepatic encephalopathy
d. Hypoglycemia
e. Vitamin B12 deficiency
Page - 1294
Question 20/66
Question #20
venous pattern, and the patient is drowsy and confused with no neurological deficit. What is the
a. Stroke
c. Hepatic encephalopathy √
d. Hypoglycemia
e. Vitamin B12 deficiency
Description
e history of hemochromatosis and the physical finding of abdominal wall venous pattern (caput-
medusae) strongly suggest liver cirrhosis in this patient.
Bloody vomiting is suggestive of upper GI bleeding.
e GI bleeding will increase the protein content in the intestine and increase ammonia production
by the intestinal bacteria.
e ammonia level in the blood will increase due to two mechanisms:
e cirrhotic liver can’t process ammonia

e blood is shunted from the portal to systemic circulation.
As a result, ammonia will accumulate in the brain and cause neurological symptoms (confusion and
drowsiness).
Page - 1295
Question 21/66
Question #21
A 35-year-old female was diagnosed with latent TB and started INH treatment 3 months ago. Today,
her liver function test shows significantly elevated serum AST, ALT, and minimally elevated Alkaline
phosphatase. Which of the following is the most likely diagnosis?
a. Gilbert syndrome
b. Viral hepatitis
c. Drug-induced hepatitis
d. Liver cirrhosis
e. Obstructive liver disease
Page - 1296
Internal Medicine - Hepatology - Hepatitis
Question 21/66
Question #21
A 35-year-old female was diagnosed with latent TB and started INH treatment 3 months ago. Today,
her liver function test shows significantly elevated serum AST, ALT, and minimally elevated Alkaline
phosphatase. Which of the following is the most likely diagnosis?
a. Gilbert syndrome
b. Viral hepatitis
c. Drug-induced hepatitis √
d. Liver cirrhosis
e. Obstructive liver disease
Description
e significantly elevated AST and ALT, along with minimal Alkaline phosphatase elevation, indicate
hepatitis.
Note that the timing here is important, and the presence of hepatitis features aer INH
administration is a clue.
INH is neurotoxic and hepatotoxic
Gilbert syndrome will present with normal AST, ALT, and Alkaline phosphatase (only minimally
elevated indirect bilirubin level)
Viral hepatitis is still a possibility here, but the presence of hepatotoxic drug history here is
important
e obstructive liver disease presents with minimal elevation of AST and ALT and significant
elevation of the Alkaline phosphatase.
Liver cirrhosis is a chronic condition, and no signs of chronic liver disease here to suspect this
diagnosis
Page - 1297
Question 22/66
Question #22
A 32-year-old female with multiple sex partners was investigated for general fatigue and anorexia.
e blood tests show the following: negative HBsAg, positive HBcAb, positive Anti-HBs, positive
Anti-HCV, and HCV RNA is detected. In addition, liver biopsy demonstrated moderate inflammation
with steatosis. What is the most likely cause for these findings?
a. Current HBV infection

b. Current HCV infection
c. Concomitant HBV and HCV infection
d. HIV infection
e. CMV hepatitis
Page - 1298
Question 22/66
Question #22
A 32-year-old female with multiple sex partners was investigated for general fatigue and anorexia.
e blood tests show the following: negative HBsAg, positive HBcAb, positive Anti-HBs, positive
Anti-HCV, and HCV RNA is detected. In addition, liver biopsy demonstrated moderate inflammation
with steatosis. What is the most likely cause for these findings?
a. Current HBV infection

b. Current HCV infection √
c. Concomitant HBV and HCV infection
d. HIV infection
e. CMV hepatitis
Description
e patient has recovered from hepatitis B (the anti-HBs and anti-HBc indicate a previous infection)
Hepatitis C antibodies and RNA indicate active infection with the hepatitis C virus
Anti-HCV indicates infection, while HCV RNA indicates active disease
e following table shows dierent laboratory findings in HRV infection and immunity and their
results.
Page - 1299
Question 23/66
Question #23
A previously healthy male patient presents for follow-up. On examination, he is afebrile with normal
vital signs, and his body mass index is 42 Kg/M2. His AST and ALT today are 75 and 103 U/L,
respectively. Which of the following is the best next step in management?
a. Liver biopsy
b. Liver CT scan
c. Liver Ultrasound
d. Testing for viral hepatitis
e. Repeat AST and ALT aer 6 months
Page - 1300
Question 23/66
Question #23
A previously healthy male patient presents for follow-up. On examination, he is afebrile with normal
vital signs, and his body mass index is 42 Kg/M2. His AST and ALT today are 75 and 103 U/L,
respectively. Which of the following is the best next step in management?
a. Liver biopsy
b. Liver CT scan
c. Liver Ultrasound
d. Testing for viral hepatitis √
e. Repeat AST and ALT aer 6 months
Description
Even though the most likely diagnosis is a non-alcoholic fatty liver disease (NAFLD), hepatitis B and C
infection should be ruled out first
A liver ultrasound should be done if hepatitis B and C tests are negative, it will show increased
echogenicity of the liver if there is a fatty liver disease
A liver biopsy is not appropriate initially at this time
A Liver CT scan is appropriate if a mass is found during ultrasonography.
Page - 1301
Question 24/66
Question #24
A 32-year-old nurse presents with fatigue and anorexia for several days; his lab investigations show
an ALT of 1438 U/L. You performed a hepatitis profile which showed positive HBsAg, Positive anti-
HBc IgM. What is the most likely diagnosis?
a. Acute HBV infection

b. Chronic HBV infection
c. e patient has a previous HBV infection
d. e patient is recovering from an HBV infection
e. e patient is vaccinated against HBV
Page - 1302
Question 24/66
Question #24
A 32-year-old nurse presents with fatigue and anorexia for several days; his lab investigations show
an ALT of 1438 U/L. You performed a hepatitis profile which showed positive HBsAg, Positive anti-
HBc IgM. What is the most likely diagnosis?
a. Acute HBV infection √

b. Chronic HBV infection
c. e patient has a previous HBV infection
d. e patient is recovering from an HBV infection
e. e patient is vaccinated against HBV
Description
HBsAg means infection, while IgM anti-HBc means acute.
results.
Page - 1303
Question 25/66
Question #25
Which of the following laboratory tests will first become abnormal in the case of acute hepatitis B
infection?
a. ALT and AST elevation

b. Anti-HBc ab
c. Anti-Hbe ab
d. HBsAg
e. Serum bilirubin level
Page - 1304
Question 25/66
Question #25
Which of the following laboratory tests will first become abnormal in the case of acute hepatitis B
infection?
a. ALT and AST elevation

b. Anti-HBc ab
c. Anti-Hbe ab
d. HBsAg √
Description
e first abnormal serology test that occurs in Hepatitis B infection is HBsAg.
HBeAg and HBV DNA appear soon aer HBsAg.
ALT and Anti-HBc (IgM) appear simultaneously aer the onset of symptoms.
Page - 1305
Question 26/66
Question #26
Aer his blood donation, a 22-year-old male patient was informed that his routine blood screening
showed positive HBsAg and Anti-HBc with negative anti-HBs antibodies. He presents to you for
consultation regarding these results. What would you tell him?
a. He has an acute infection of HBV

b. He has an acute or chronic infection of HBV
c. He is immune to HBV and can donate his blood again
d. He is susceptible to HBV infection
e. e patient should be vaccinated against HBV immediately
Page - 1306
Question 26/66
Question #26
Aer his blood donation, a 22-year-old male patient was informed that his routine blood screening
showed positive HBsAg and Anti-HBc with negative anti-HBs antibodies. He presents to you for
consultation regarding these results. What would you tell him?
a. He has an acute infection of HBV

b. He has an acute or chronic infection of HBV √
c. He is immune to HBV and can donate his blood again
d. He is susceptible to HBV infection
e. e patient should be vaccinated against HBV immediately
Description
is patient has acute or chronic HBV infection and should never donate his blood.
Vaccination will do nothing aer the patient’s infection, but it is recommended aer a needle stick,
blood reception, or sexual intercourse with someone who already has an active HBV infection. In
addition, it is recommended for babies of HBV mothers aer delivery.
Page - 1307
Question 27/66
Question #27
A 17-year-old male patient is suspected of having acute hepatitis A infection. What is the most
important test to be done for diagnosis?
a. Anti-HAV IgG antibody

b. Serum bilirubin level
c. Anti-HAV IgM antibody
d. AST, ALT, and Alkaline phosphatase
e. PT and INR
Page - 1308
Question 27/66
Question #27
A 17-year-old male patient is suspected of having acute hepatitis A infection. What is the most
important test to be done for diagnosis?
a. Anti-HAV IgG antibody

b. Serum bilirubin level
c. Anti-HAV IgM antibody √
d. AST, ALT, and Alkaline phosphatase
e. PT and INR
Description
Anti-HAV IgM antibody titer is the best way to diagnose hepatitis A infection
A high titer of IgG antibodies against HAV indicates a previous infection
AST, ALT, Alkaline phosphatase, PT, INR, and bilirubin level are all parts of LFT but are not specific to
hepatitis A infection
Page - 1309
Question 28/66
Question #28
A patient received an HBV vaccination 6 months ago. Which of the following is the best indicator of
acquired immunity?
a. HBsAg
b. HBeAg
c. Anti-HBc (IgG)
d. Anti-HBs
e. HBV DNA
Page - 1310
Question 28/66
Question #28
A patient received an HBV vaccination 6 months ago. Which of the following is the best indicator of
acquired immunity?
a. HBsAg
b. HBeAg
c. Anti-HBc (IgG)
d. Anti-HBs √
e. HBV DNA
Description
Anti-HBs antibody is the best indicator of immunity in patients who have received vaccinations or
been exposed to HBV infection previously
results.
Page - 1311
Question 29/66
Question #29
A patient’s hepatitis serology results are positive for HBsAg, HBeAg, and Anti-HBc (IgG). You can tell
him that he has:
a. Chronic infective HBV

b. Acute infective HBV
c. Chronic inactive HBV
d. Recovered from HBV
e. Immune against HBV
Page - 1312
Question 29/66
Question #29
A patient’s hepatitis serology results are positive for HBsAg, HBeAg, and Anti-HBc (IgG). You can tell
him that he has:
a. Chronic infective HBV √

b. Acute infective HBV
c. Chronic inactive HBV
d. Recovered from HBV
e. Immune against HBV
Description
HBsAg means infection, IgM anti-HBc means acute, HBeAg means active or infective
results.
Page - 1313
Question 30/66
Question #30
A 34-year-old nurse presents for routine antenatal care, she has received two doses of her hepatitis B
vaccine, but her pregnancy test was positive before taking the 3rd dose. Which of the following
indicates vaccine immunization in this lady?
a. Negative HBsAg, negative Anti-HBc, negative Anti-HBs

b. Negative HBsAg, negative Anti-HBc, positive Anti-HBs
c. Negative HBsAg, positive Anti-HBc, positive Anti-HBs
d. Positive HBsAg, positive Anti-HBc, negative Anti-HBs
e. Positive HBsAg, positive Anti-HBc, positive Anti-HBs
Page - 1314
Question 30/66
Question #30
A 34-year-old nurse presents for routine antenatal care, she has received two doses of her hepatitis B
vaccine, but her pregnancy test was positive before taking the 3rd dose. Which of the following
indicates vaccine immunization in this lady?
a. Negative HBsAg, negative Anti-HBc, negative Anti-HBs

b. Negative HBsAg, negative Anti-HBc, positive Anti-HBs √
c. Negative HBsAg, positive Anti-HBc, positive Anti-HBs
d. Positive HBsAg, positive Anti-HBc, negative Anti-HBs
e. Positive HBsAg, positive Anti-HBc, positive Anti-HBs
Description
e HBV vaccine contains the HBsAg only, so it will enhance the production of Anti-HBs by the
immune system but never trigger the production of anti-HBc or Anti-Hbe antibodies
results.
Page - 1315
Question 31/66
Question #31
A male patient had a history of hepatitis A infection 5 years ago. Today on a routine visit, his physical
examination is normal, but his AST level is 93 U/L. You ordered further investigations that show the
following: positive Anti-HAV, negative Anti-HBs, Positive HBsAg, and Positive Anti-HBc IgM. Which
of the following is the best description for this patient?
a. He has both HAV and HBV infection

b. He is immune to HBV
c. He has a chronic hepatitis B infection
d. is patient has chronic hepatitis A infection
e. HBsAg appears aer infection and 1 – 6 weeks before the symptoms develop.
Page - 1316
Question 31/66
Question #31
A male patient had a history of hepatitis A infection 5 years ago. Today on a routine visit, his physical
examination is normal, but his AST level is 93 U/L. You ordered further investigations that show the
following: positive Anti-HAV, negative Anti-HBs, Positive HBsAg, and Positive Anti-HBc IgM. Which
of the following is the best description for this patient?
a. He has both HAV and HBV infection

b. He is immune to HBV
c. He has a chronic hepatitis B infection
d. is patient has chronic hepatitis A infection
e. HBsAg appears aer infection and 1 – 6 weeks before the symptoms develop. √
Description
e presence of Anti-HAV indicates a previous infection in this patient
Positive HBsAg and Anti-HBc IgM mean that there is an acute infection with HBV in this patient
Aer infection and 1 to 6 weeks before symptoms occur, HBsAg appears.
Page - 1317
Question 32/66
Question #32
A 43-year-old male patient has a chronic hepatitis infection. Which of the following indicates that
the infection is active?
a. Detectable levels of HBeAb

b. Detectable levels of Anti-HBe
c. High levels of AST and ALT
d. Undetectable levels of HBV DNA
e. Normal liver biopsy
Page - 1318
Question 32/66
Question #32
A 43-year-old male patient has a chronic hepatitis infection. Which of the following indicates that
the infection is active?
a. Detectable levels of HBeAb

b. Detectable levels of Anti-HBe
c. High levels of AST and ALT √
d. Undetectable levels of HBV DNA
e. Normal liver biopsy
Description
HBeAg, not HBeAb, is an indication of active HBV infection
Note that the signs of active infection in the case of HBV are evidenced by elevated liver enzymes,
indicating liver inflammation, and the presence of HBeAg, indicating high levels of HBV DNA
Page - 1319
Question 33/66
Question #33
A 30-year-old male patient has positive Anti-HCV. Which of the following would be most beneficial
to determine the stage of this disease?
a. Hepatic transaminases
b. PT and INR
c. Liver biopsy
d. Liver CT scan
Page - 1320
Question 33/66
Question #33
A 30-year-old male patient has positive Anti-HCV. Which of the following would be most beneficial
to determine the stage of this disease?
a. Hepatic transaminases
b. PT and INR
c. Liver biopsy √
d. Liver CT scan
Description
A liver biopsy is the best way to determine the stage of HCV disease.
Hepatitis C infection:
HCV is the most common hepatitis transmitted by a blood transfusion

Acute HCV is asymptomatic, and patients usually present with signs and symptoms of chronic
liver disease
ALT and AST are normal in 40% of HCV infection cases
Order Anti-HCV to diagnose its presence
Order HCV RNA (if positive, indicates active disease)
HCV genotyping should be performed at the time of diagnosis to help to choose the treatment
regimen
Page - 1321
Question 34/66
Question #34
A patient develops a yellowish discoloration of her sclera and mucous membranes. Which of the
following is not accurate about this condition?
a. Carotenemia is one of the dierentials

b. Hemolytic anemia presents with conjugated hyperbilirubinemia
c. Glucuronyltransferase enzyme inactivity is one of the possible causes
d. Conjugated bilirubin is water-soluble
e. Hepatitis serology tests can help in detecting the cause
Page - 1322
Internal Medicine - Hepatology - Jaundice
Question 34/66
Question #34
A patient develops a yellowish discoloration of her sclera and mucous membranes. Which of the
following is not accurate about this condition?
a. Carotenemia is one of the dierentials

b. Hemolytic anemia presents with conjugated hyperbilirubinemia √
c. Glucuronyltransferase enzyme inactivity is one of the possible causes
d. Conjugated bilirubin is water-soluble
e. Hepatitis serology tests can help in detecting the cause
Description
Hemolytic anemia manifests as unconjugated (indirect) hyperbilirubinemia.
Increased beta-carotene levels in the blood (carotenemia) can cause a yellowish discoloration of the
skin and mucous membranes (mimicking jaundice)
Glucuronyltransferase enzyme in the liver is responsible for the conjugation of bilirubin (converts it
to water-soluble conjugated form)
Page - 1323
Question 35/66
Question #35
A 35-year-old male patient has been found to have intermittent jaundice for several years. His lab
investigations always show isolated mild, indirect hyperbilirubinemia and normal CBC. His physical
examination is normal except for mild jaundice. Which of the following is the most likely diagnosis?
a. Chronic hepatitis C infection

b. Hemolytic anemia
c. Gilbert syndrome
d. Obstructive jaundice
Page - 1324
Question 35/66
Question #35
A 35-year-old male patient has been found to have intermittent jaundice for several years. His lab
investigations always show isolated mild, indirect hyperbilirubinemia and normal CBC. His physical
examination is normal except for mild jaundice. Which of the following is the most likely diagnosis?
a. Chronic hepatitis C infection

b. Hemolytic anemia
c. Gilbert syndrome √
d. Obstructive jaundice
Description
Isolated hyperbilirubinemia in an otherwise healthy young man is Gilbert’s syndrome until proven
otherwise.
Gilbert syndrome:
An autosomal dominant familial condition

Decreased UDP-glucuronosyltransferase enzyme
Mild jaundice (< 3 mg/dl unconjugated hyperbilirubinemia), more prominent if dehydration or
stress occurs
Normal AST and ALT and absence of hemolysis along with indirect hyperbilirubinemia is
enough for diagnosis (without extensive testing)
Patient otherwise asymptomatic
No need for treatment
Page - 1325
Question 36/66
Question #36
A 26-year-old male recently diagnosed with multiple sclerosis has a routine liver function test before
starting on the disease-modifying drug “Fingolimod”. His LFT shows an isolated mild elevation of
the indirect bilirubin and normal AST, ALT, and ALP levels. Physical examination is unremarkable,
and the rest of the lab investigations are normal. What is the most likely cause of this patient’s
hyperbilirubinemia?
b. Non-alcoholic fatty liver
c. Hepatitis A infection
d. Obstructive liver disease
e. Gilbert syndrome
Page - 1326
Question 36/66
Question #36
A 26-year-old male recently diagnosed with multiple sclerosis has a routine liver function test before
starting on the disease-modifying drug “Fingolimod”. His LFT shows an isolated mild elevation of
the indirect bilirubin and normal AST, ALT, and ALP levels. Physical examination is unremarkable,
and the rest of the lab investigations are normal. What is the most likely cause of this patient’s
hyperbilirubinemia?
e. Gilbert syndrome √
Description
otherwise.
Gilbert syndrome:

stress occurs
Page - 1327
Question 37/66
Question #37
During a routine examination, an alcoholic 35-year-old male is found to have a total bilirubin level of
2.7mg/dL and direct bilirubin of 0.5mg/dL. His physical examination, CBC, AST, ALT, and ALP are all
within normal limits. Which of the following is the most likely diagnosis?
a. Alcoholic liver disease

e. Gilbert syndrome
Page - 1328
Question 37/66
Question #37
During a routine examination, an alcoholic 35-year-old male is found to have a total bilirubin level of
2.7mg/dL and direct bilirubin of 0.5mg/dL. His physical examination, CBC, AST, ALT, and ALP are all
within normal limits. Which of the following is the most likely diagnosis?
a. Alcoholic liver disease

e. Gilbert syndrome √
Description
otherwise.
Gilbert syndrome:

stress occurs
Page - 1329
Question 38/66
Question #38
A 21-year-old male patient complains of flu-like symptoms and dry coughs. Physical examination is
normal except for mild scleral yellowish discoloration. His total bilirubin level is 2mg/dL, and the
direct potion is 0.4 mg/dL. His ALT, AST, ALP, and urine dipstick are normal. What is the most likely
diagnosis?
a. Acute viral hepatitis

b. Dubin Johnson Syndrome
c. G6PD deficiency
d. Gilbert syndrome
e. Obstructive jaundice
Page - 1330
Question 38/66
Question #38
A 21-year-old male patient complains of flu-like symptoms and dry coughs. Physical examination is
normal except for mild scleral yellowish discoloration. His total bilirubin level is 2mg/dL, and the
direct potion is 0.4 mg/dL. His ALT, AST, ALP, and urine dipstick are normal. What is the most likely
diagnosis?
a. Acute viral hepatitis

b. Dubin Johnson Syndrome
c. G6PD deficiency
d. Gilbert syndrome √
e. Obstructive jaundice
Description
It is not uncommon to diagnose Gilbert syndrome for the first time during an acute illness.
In this disease, jaundice is exacerbated by acute infections of dehydration.
e presence of isolated indirect hyperbilirubinemia here is the clue.
Isolated indirect hyperbilirubinemia means high indirect bilirubin in otherwise normal liver function
tests.
Gilbert syndrome:

stress occurs
Page - 1331
Question 39/66
Question #39
A 43-year-old male patient presents with gradual onset lethargy and weakness, and you diagnose
him with liver cirrhosis. All the following are possible causes for his condition except:
a. Hepatitis A
b. Hepatitis C
c. Hepatitis B
d. Alcohol abuse
e. Alpha 1 antitrypsin deficiency
Page - 1332
Internal Medicine - Hepatology - Liver Cirrhosis
Question 39/66
Question #39
him with liver cirrhosis. All the following are possible causes for his condition except:
a. Hepatitis A √
b. Hepatitis C
c. Hepatitis B
d. Alcohol abuse
e. Alpha 1 antitrypsin deficiency
Description
Liver cirrhosis is a chronic liver disease that is usually occurring due to chronic liver disease
Note that Hepatitis A infection is always acute and never be chronic
e causes of liver cirrhosis are the following:
Chronic hepatitis (B, C, B+D) BUT NOT hepatitis A and E

Alcoholic and Non-alcoholic fatty liver disease
Autoimmune hepatitis
Alpha-1-antitrypsin deficiency (10% cause liver disease)
Drug-induced liver cirrhosis.
Right-side Heart failure (chronic liver congestion and cardiac cirrhosis)
Page - 1333
Question 40/66
Question #40
One of the following diseases is not a cause of liver cirrhosis:
a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. Wilson disease
e. Hemochromatosis
Page - 1334
Question 40/66
Question #40
One of the following diseases is not a cause of liver cirrhosis:
a. Hepatitis A √
b. Hepatitis B
c. Hepatitis C
d. Wilson disease
e. Hemochromatosis
Description
HAV is the most common hepatotropic virus. It can only cause acute hepatitis (no chronicity and no
risk of liver cirrhosis).
Hepatitis B and C cause chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma.
Wilson disease is the accumulation of copper, while hemochromatosis is the iron accumulation in
the liver and other organs, increasing the risk of liver cirrhosis.
Page - 1335
Question 41/66
Question #41
him with liver cirrhosis. All the following are poor prognostic factors for this patient except:
a. e presence of ascites
b. High bilirubin level
c. High albumin level
d. Prolonged PT and INR
e. e presence of encephalopathy
Page - 1336
Question 41/66
Question #41
him with liver cirrhosis. All the following are poor prognostic factors for this patient except:
a. e presence of ascites
b. High bilirubin level
c. High albumin level √
d. Prolonged PT and INR
e. e presence of encephalopathy
Description
e poor prognostic factors of liver cirrhosis are summarized in the child-pugh score to interpret the
mortality rate in these patients.
Page - 1337
Question 42/66
Question #42
A 35-year-old male patient has elevated AST and ALT levels for the second time during the last 8
months. e patient is asymptomatic and has a normal physical examination. Which of the
following is the next step in managing this patient?
a. Liver biopsy
b. Liver CT scan
c. Abdominal U/S with doppler
d. Positive emission tomography (PET) scan
e. Abdominal MRI
Page - 1338
Internal Medicine - Hepatology - Liver function tests (LFT)
Question 42/66
Question #42
A 35-year-old male patient has elevated AST and ALT levels for the second time during the last 8
months. e patient is asymptomatic and has a normal physical examination. Which of the
following is the next step in managing this patient?
a. Liver biopsy
b. Liver CT scan
c. Abdominal U/S with doppler √
d. Positive emission tomography (PET) scan
e. Abdominal MRI
Description
Ultrasound is the next step because of the following reasons:
Easy to be reached (widely available)

No radiation exposure
No need for contrast media
Inexpensive
Provides helpful information regarding liver morphology and portal and hepatic flow
CT scan is beneficial to assess the hepatic nodules (if revealed in ultrasound), whether benign or
malignant
Liver biopsy is not the initial study for this case but can be used to know the type of tissue in any
mass (benign or malignant)
PET scans can detect the presence of liver metastases from certain cancers but are not used as an
initial test for evaluating liver disease.
MRI can assess the changes in the appearance or size of any liver mass, not initially in this case
Page - 1339
Question 43/66
Question #43
About the liver function test, all the following are true except:
a. Prothrombin time reflects the ability of the liver to synthesize protein

b. Serum albumin is a specific test to determine the liver function
c. AST is more elevated than ALT in alcoholic liver diseases
d. Alkaline phosphatase will be markedly elevated in obstructive liver disease
e. In acute viral hepatitis, AST and ALT may be as high as 1000 u/l
Page - 1340
Question 43/66
Question #43
About the liver function test, all the following are true except:
a. Prothrombin time reflects the ability of the liver to synthesize protein

b. Serum albumin is a specific test to determine the liver function √
c. AST is more elevated than ALT in alcoholic liver diseases
d. Alkaline phosphatase will be markedly elevated in obstructive liver disease
e. In acute viral hepatitis, AST and ALT may be as high as 1000 u/l
Description
Serum albumin is not specific to liver diseases. However, it can be reduced in the case of
malnutrition, nephrotic syndrome, protein-losing enteropathy, sepsis, and other conditions not
related to the liver.
Page - 1341
Question 44/66
Question #44
A female patient presents with jaundice, dark urine, bilirubinuria, and pale stool. Her biliary
ultrasound demonstrates a dilated common bile duct. Which of the following would support the
a. High Reticulocyte count

b. High AST and ALT levels
c. Low Serum albumin level
d. High Alkaline phosphatase level
e. Low Hemoglobin level
Page - 1342
Question 44/66
Question #44
A female patient presents with jaundice, dark urine, bilirubinuria, and pale stool. Her biliary
ultrasound demonstrates a dilated common bile duct. Which of the following would support the
a. High Reticulocyte count

b. High AST and ALT levels
c. Low Serum albumin level
d. High Alkaline phosphatase level √
e. Low Hemoglobin level
Description
Jaundice, dark urine, and pale stool indicate obstructive (post-hepatic) jaundice.
Alkaline phosphatase (ALP) is an indicator of obstructive liver disease if very high with less
prominent elevated AST and ALT (Confirm obstructive liver disease by elevated GGT)
Additional notes:
If isolated high ALP is present, consider a bone disease

ALP can be produced by the placenta and is elevated in the case of pregnancy.
Page - 1343
Question 45/66
Question #45
A 49-year-old alcoholic male patient with DM and HTN presents for a routine examination. His BMI
is 37 kg/m2. His blood pressure is 140/89. e pulse is 89. His lab tests show an A1C level of 9.5%, AST
of 94 U/mL, and ALT of 150 u/mL. What is the most likely diagnosis?
a. Alcoholic fatty liver disease

b. Non-alcoholic fatty liver disease
c. Acute Viral hepatitis
d. Normal liver function test
Page - 1344
Internal Medicine - Hepatology - Non-alcoholic Fatty Liver Disease (NAFLD)
Question 45/66
Question #45
A 49-year-old alcoholic male patient with DM and HTN presents for a routine examination. His BMI
is 37 kg/m2. His blood pressure is 140/89. e pulse is 89. His lab tests show an A1C level of 9.5%, AST
of 94 U/mL, and ALT of 150 u/mL. What is the most likely diagnosis?
a. Alcoholic fatty liver disease

b. Non-alcoholic fatty liver disease √
c. Acute Viral hepatitis
d. Normal liver function test
Description
Minimal ALT and AST elevation in patients with risk factors for fatty liver (DM, dyslipidemia, high
BMI) indicate non-alcoholic fatty liver disease.
Alcoholic fatty liver diseases present with high ALT and AST with an AST/ALT ratio of > 2:1
Page - 1345
Question 46/66
Question #46
A previously healthy male patient presents for his AST and ALT follow-up. On examination, he is
afebrile with normal vital signs, and his body mass index is 42 Kg/m2. His AST and ALT today are 75
and 103 U/L, respectively. Which of the following is the most likely diagnosis?
a. Viral hepatitis
b. Alcoholic fatty liver
c. Non-alcoholic fatty liver
d. Liver cirrhosis
Page - 1346
Internal Medicine - Hepatology - Non-alcoholic Fatty Liver Disease (NAFLD)
Question 46/66
Question #46
A previously healthy male patient presents for his AST and ALT follow-up. On examination, he is
afebrile with normal vital signs, and his body mass index is 42 Kg/m2. His AST and ALT today are 75
and 103 U/L, respectively. Which of the following is the most likely diagnosis?
a. Viral hepatitis
b. Alcoholic fatty liver
c. Non-alcoholic fatty liver √
d. Liver cirrhosis
Description
Elevated ALT, more than AST, minimally indicates non-alcoholic fatty liver disease (NAFLD) as the
most likely diagnosis
Alcoholic fatty liver is unlikely because the AST is not more than double the ALT
Viral hepatitis is still a possibility here and should be ruled out, but NAFLD is the most likely
Page - 1347
Question 47/66
Question #47
A 55-year-old male patient has chronic back pain, usually relieved by paracetamol oral tablets.
However, he is concerned that he may tack too much and asked you for his maximum daily
recommended dose of paracetamol. What would be your appropriate answer?
a. 7 grams
b. 6 grams
c. 4 grams
d. 3 grams
e. 2 grams
Page - 1348
Internal Medicine - Hepatology - Paracetamol poisoning
Question 47/66
Question #47
A 55-year-old male patient has chronic back pain, usually relieved by paracetamol oral tablets.
However, he is concerned that he may tack too much and asked you for his maximum daily
recommended dose of paracetamol. What would be your appropriate answer?
a. 7 grams
b. 6 grams
c. 4 grams √
d. 3 grams
e. 2 grams
Description
Four grams of paracetamol is the adult’s maximum recommended dose of paracetamol. Note that
amount above 7 grams or 140mg/Kg is considered hepatotoxic
Page - 1349
Question 48/66
Question #48
Which of the following is considered the toxic dose for paracetamol for a 78 kilograms previously
healthy adult?
a. 7 grams
b. 6 grams
c. 4 grams
d. 3 grams
e. 2 grams
Page - 1350
Internal Medicine - Hepatology - Paracetamol poisoning
Question 48/66
Question #48
Which of the following is considered the toxic dose for paracetamol for a 78 kilograms previously
healthy adult?
a. 7 grams √
b. 6 grams
c. 4 grams
d. 3 grams
e. 2 grams
Description
A dose of more than 7 grams or 140mg/Kg is considered hepatotoxic
If the patient is alcoholic or has liver disease, the toxic dose may be lower than that
e maximum allowed dose to be taken daily for the treatment of pain is 4 grams
Page - 1351
Question 49/66
Question #49
A 50-year-old female with a biopsy documented liver cirrhosis presents with vomiting of bright red
blood. Her blood pressure is 80/30 mmHg, the pulse is 130 bpm, and gastric aspiration contains
blood. Which of the following is the most appropriate at this time?
a. Octreotide and noradrenaline

b. Terlipressin and Intravenous saline
c. Endoscopic sclerotherapy
d. Administration of omeprazole and propranolol
e. Test for H pylori infection
Page - 1352
Internal Medicine - Hepatology - Portal HTN and esophageal varices
Question 49/66
Question #49
A 50-year-old female with a biopsy documented liver cirrhosis presents with vomiting of bright red
blood. Her blood pressure is 80/30 mmHg, the pulse is 130 bpm, and gastric aspiration contains
blood. Which of the following is the most appropriate at this time?
a. Octreotide and noradrenaline

b. Terlipressin and Intravenous saline √
c. Endoscopic sclerotherapy
d. Administration of omeprazole and propranolol
e. Test for H pylori infection
Description
e priority in actively bleeding patients is to control the bleeding and stabilize the patient as soon
as possible.
e first line here is to introduce 2 large-bore cannulae and start intravenous fluid.
e source of bleeding is most likely due to esophageal varices secondary to liver cirrhosis.
In this case, you should use Terlipressin to reduce portal pressure and control the bleeding.
Crossmatch and blood transfusion
Endoscopy is both diagnostic and therapeutic in this case.
Endoscopic sclerotherapy is not done in actively bleeding patients.
Page - 1353
Question 50/66
Question #50
A 45-year-old alcoholic man comes into the emergency room with upper gastrointestinal bleeding.
Urgent endoscopy shows dilated esophageal veins. Which of the following is the best treatment
option?
a. Start Propranolol
b. Nissen fundoplication
c. Endoscopic ligation
d. Vancomycin and lactulose
e. Trans-jugular intrahepatic portosystemic shunt (TIPSS)
Page - 1354
Question 50/66
Question #50
Urgent endoscopy shows dilated esophageal veins. Which of the following is the best treatment
option?
a. Start Propranolol
b. Nissen fundoplication
c. Endoscopic ligation √
d. Vancomycin and lactulose
e. Trans-jugular intrahepatic portosystemic shunt (TIPSS)
Description
e patient has esophageal varices confirmed by upper endoscopy.
e treatment of choice is to perform endoscopic ligation.
Propranolol is not used in acute variceal bleeding but to control portal HTN in non-bleeding patients.
Nissen fundoplication is used in the treatment of GERD to strengthen the lower esophageal
sphincter
Vancomycin and lactulose are used in the treatment of hepatic encephalopathy.
TIPSS is reserved for recurrent esophageal bleeding with end-stage liver disease.
Page - 1355
Question 51/66
Question #51
Urgent endoscopy is shown in the picture below. Which of the following is the most likely diagnosis?
a. Esophageal varices
c. A foreign body in the esophagus
d. Esophageal stricture
e. Barrett’s esophagus
Page - 1356
Question 51/66
Question #51
Urgent endoscopy is shown in the picture below. Which of the following is the most likely diagnosis?
a. Esophageal varices √
c. A foreign body in the esophagus
d. Esophageal stricture
e. Barrett’s esophagus
Description
e patient has esophageal varices confirmed by upper endoscopy.
Alcohol intake is the risk factor in this case.
Page - 1357
Question 52/66
Question #52
A 62-year-old female with liver cirrhosis presents with bright red vomits and black stools. Her vital
signs show tachycardia and orthostatic hypotension. Which of the following is the best diagnostic
and therapeutic procedure in this clinical scenario?
b. Upper gastrointestinal series
c. Standing chest x-ray
d. Esophagogastroduodenoscopy
e. Trans-Jugular intrahepatic Portosystemic Shunt (TIPSS)
Page - 1358
Question 52/66
Question #52
A 62-year-old female with liver cirrhosis presents with bright red vomits and black stools. Her vital
signs show tachycardia and orthostatic hypotension. Which of the following is the best diagnostic
and therapeutic procedure in this clinical scenario?
b. Upper gastrointestinal series
c. Standing chest x-ray
d. Esophagogastroduodenoscopy √
e. Trans-Jugular intrahepatic Portosystemic Shunt (TIPSS)
Description
is clinical scenario strongly suggests esophageal variceal bleeding.
is condition is characterized by dilated veins in the distal esophagus or proximal stomach.
e history of liver cirrhosis and upper GI bleeding is suggestive.
Upper gastrointestinal endoscopy (also known as Esophagogastroduodenoscopy) is the best

diagnostic and therapeutic procedure to diagnose this condition
Endoscopic banding is the primary treatment for this condition
Octreotide or Terlipressin may be used to reduce the portal pressure in acutely bleeding patients
Intravenous fluid and blood transfusion should be started to restore circulation and treat shock.
TIPSS should be reserved for recurrent Upper GI bleedings secondary to esophageal varices in a
patient with end-stage liver disease; it can exacerbate hepatic encephalopathy due to shunting
blood from the portal to the systemic circulation.
Page - 1359
Question 53/66
Question #53
A 47-year-old alcoholic male patient had bloody vomiting this morning. On examination, his blood
pressure is 99/70 mmHg, his pulse is 109 bpm, his abdomen is positive for shiing dullness, and he
has spider nevi on his chest. What is the most likely diagnosis?
a. Peptic ulcer disease

b. Stomach cancer
c. Esophageal cancer
d. Esophageal varices
e. Gastritis
Page - 1360
Question 53/66
Question #53
A 47-year-old alcoholic male patient had bloody vomiting this morning. On examination, his blood
pressure is 99/70 mmHg, his pulse is 109 bpm, his abdomen is positive for shiing dullness, and he
has spider nevi on his chest. What is the most likely diagnosis?
a. Peptic ulcer disease

b. Stomach cancer
c. Esophageal cancer
d. Esophageal varices √
e. Gastritis
Description
e presence of chronic liver disease and hematemesis strongly suggests esophageal varices.
e patient has features suggestive of liver cirrhosis (alcoholism, spider nevi, and ascites).
e presence of liver cirrhosis will result in portal HTN.
When portal pressure is high, → collaterals will appear to shunt blood to the systemic circulation →
esophageal Variceal, Caput medusa, rectal varices
Page - 1361
Question 54/66
Question #54
A 55-year-old male heavy drinker presents to you with hematemesis and orthostatic hypotension.
Which of the following is the most eective treatment, at the point of endoscopy, for esophageal
varices?
a. Endoscopic sclerotherapy
b. Tranexamic acid
c. Endoscopic banding
d. Adrenalin injection
e. Proton pump inhibitor
Page - 1362
Question 54/66
Question #54
A 55-year-old male heavy drinker presents to you with hematemesis and orthostatic hypotension.
Which of the following is the most eective treatment, at the point of endoscopy, for esophageal
varices?
a. Endoscopic sclerotherapy
b. Tranexamic acid
c. Endoscopic banding √
d. Adrenalin injection
e. Proton pump inhibitor
Description
Endoscopic banding is the most eective treatment to stop bleeding varices.
Treatment of Upper GI bleeding due to esophageal varices:
e priority is to restore circulation with IV fluids, Blood, and plasma

e hemoglobin transfusion goal is 7 g/dl (increasing Hb more than 7 will lead to increased
portal pressure and thus more bleeding)
All should receive prophylactic antibiotics, “ciprofloxacin,” to prevent hepatic encephalopathy
and SBP.
Terlipressin or Octreotide:
Vasopressin analog reduces the portal pressure
Terlipressin reduces mortality in Variceal bleeding
Endoscopy:
Diagnostic and therapeutic
Banding can be used to stop bleeding
Balloon tamponade:
Sengstaken-Blakemore tube can be inserted and inflated to stop bleeding. It should be

deflated 10 minutes every 3 hours to avoid esophageal necrosis
Transjugular intrahepatic portosystemic shunt (TIPSS):
A stent inserted between the portal and hepatic vein
Page - 1363
It increases the risk of hepatic encephalopathy
Page - 1364
Question 55/66
Question #55
A 42-year-old female has had jaundice and pruritus for a long history. Her history is significant for
Sjögren syndrome, and her lab tests show elevated alkaline phosphatase. What is the most
appropriate test to perform at this time?
a. Rheumatoid factor (RA)

b. Anti-nuclear antibody (ANA)
c. Anti-smooth muscle antibodies (ASMA)
d. Anti-mitochondrial antibodies (AMA)
e. Anti-neutrophil cytoplasmic antibodies (ANCA)
Page - 1365
Internal Medicine - Hepatology - Primary Biliary Cholangitis (PBC)
Question 55/66
Question #55
A 42-year-old female has had jaundice and pruritus for a long history. Her history is significant for
Sjögren syndrome, and her lab tests show elevated alkaline phosphatase. What is the most
appropriate test to perform at this time?
a. Rheumatoid factor (RA)

b. Anti-nuclear antibody (ANA)
c. Anti-smooth muscle antibodies (ASMA)
d. Anti-mitochondrial antibodies (AMA) √
e. Anti-neutrophil cytoplasmic antibodies (ANCA)
Description
is is a direct question pointing to Primary Biliary Cholangitis (PBC).
Anti-mitochondrial antibodies should be done to support the diagnosis further.
e classic presentation contains the following:
Middle-aged woman
Oen asymptomatic, but the itching and jaundice may present
High alkaline phosphatase level
Positive anti-mitochondrial antibodies
Association with Sjögren syndrome is common
e following table shows the dierence between PBC and PSC:
Page - 1366
Question 56/66
Question #56
A 38-year-old lady is known to have Sjögren syndrome. She develops jaundice, high alkaline
phosphatase, and positive anti-mitochondrial antibodies. What is the most likely diagnosis?
a. Common bile duct stone

b. Hepatitis B infection
c. Hepatitis C infection
d. Primary biliary cholangitis
e. Primary sclerosing cholangitis
Page - 1367
Internal Medicine - Hepatology - Primary Biliary Cholangitis (PBC)
Question 56/66
Question #56
A 38-year-old lady is known to have Sjögren syndrome. She develops jaundice, high alkaline
phosphatase, and positive anti-mitochondrial antibodies. What is the most likely diagnosis?
a. Common bile duct stone

b. Hepatitis B infection
c. Hepatitis C infection
d. Primary biliary cholangitis √
e. Primary sclerosing cholangitis
Description
is is a direct question pointing to Primary Biliary Cholangitis (PBC).
e classic presentation contains the following:
Middle-aged woman
Oen asymptomatic, but the itching and jaundice may present
High alkaline phosphatase level
Positive anti-mitochondrial antibodies
Association with Sjögren syndrome is common
e following table shows the dierence between PBC and PSC:
Page - 1368
Question 57/66
Question #57
A 46-year-old female complains of abdominal pain, itching, and yellowish discoloration of the skin
and sclera. Her history includes ulcerative Colitis. On examination, she is jaundiced, and abdominal
tenderness on deep palpation is noted at the right upper and lower quadrants, but her vital signs
and the rest of the physical examination are normal. Her alkaline phosphatase is 420 u/L, and her
bilirubin is 2.9 mg/dL. What is the most likely diagnosis?
a. Primary sclerosing cholangitis

b. Primary biliary cholangitis
c. Autoimmune hepatitis
d. Common bile duct stone
e. Liver cirrhosis
Page - 1369
Internal Medicine - Hepatology - Primary Sclerosing Cholangitis (PSC)
Question 57/66
Question #57
bilirubin is 2.9 mg/dL. What is the most likely diagnosis?
a. Primary sclerosing cholangitis √

b. Primary biliary cholangitis
c. Autoimmune hepatitis
d. Common bile duct stone
e. Liver cirrhosis
Description
Ulcerative Colitis, elevated alkaline phosphatase, and jaundice are typical for primary sclerosing
cholangitis (PSC).
PSC is the most common chronic liver disease in patients with Ulcerative Colitis.
PSC is characterized by progressive cholestasis with inflammation and fibrosis of the intrahepatic
and extrahepatic bile ducts
Page - 1370
Question 58/66
Question #58
bilirubin is 2.9 mg/dL. What is the most appropriate investigation to confirm the diagnosis?
a. Abdominal ultrasonography
c. Magnetic resonance cholangiopancreatography
d. Endoscopic retrograde cholangiopancreatography
e. Upper endoscopy
Page - 1371
Internal Medicine - Hepatology - Primary Sclerosing Cholangitis (PSC)
Question 58/66
Question #58
bilirubin is 2.9 mg/dL. What is the most appropriate investigation to confirm the diagnosis?
a. Abdominal ultrasonography
c. Magnetic resonance cholangiopancreatography √
d. Endoscopic retrograde cholangiopancreatography
e. Upper endoscopy
Description
e presence of Ulcerative Colitis, elevated alkaline phosphatase, and jaundice is a typical scenario
for primary sclerosing cholangitis (PSC).
PSC is the most common chronic liver disease in patients with Ulcerative Colitis.
PSC is characterized by progressive cholestasis with inflammation and fibrosis of the intrahepatic
and extrahepatic bile ducts
ERCP and MRCP are both eective in the diagnosis of PSC, but ERCP has a higher rate of
complications
Page - 1372
Question 59/66
Question #59
A 59-year-old male with liver cirrhosis is complaining of abdominal discomfort and fever. His history
started 2 weeks ago. His medications include spironolactone and furosemide. His examination
reveals a fever of 38.0 °C, vague abdominal tenderness, and shiing dullness. What is the most
appropriate to establish the diagnosis of Spontaneous Bacterial Peritonitis (SBP)?
a. Ascitic PH < 7.2

b. Bloody looking ascitic fluid
c. Absolute Neutrophil Count (ANC) > 250*10^6 cells/L
d. Total protein of 2 g/dL
e. History of abdominal pain and fever
Page - 1373
Internal Medicine - Hepatology - Spontaneous Bacterial Peritonitis (SBP)
Question 59/66
Question #59
A 59-year-old male with liver cirrhosis is complaining of abdominal discomfort and fever. His history
started 2 weeks ago. His medications include spironolactone and furosemide. His examination
reveals a fever of 38.0 °C, vague abdominal tenderness, and shiing dullness. What is the most
appropriate to establish the diagnosis of Spontaneous Bacterial Peritonitis (SBP)?
a. Ascitic PH < 7.2

b. Bloody looking ascitic fluid
c. Absolute Neutrophil Count (ANC) > 250*10^6 cells/L √
d. Total protein of 2 g/dL
e. History of abdominal pain and fever
Description
Spontaneous bacterial peritonitis (SBP) is diagnosed by the following findings:
High ANC (Absolute neutrophil count) in ascites (best initial test)

Culture 80% sensitivity (usually not needed for diagnosis) (most accurate test)
Note that the ascitic PH doesn’t go down until the ANC is elevated, so it is less reliable than ANC
Bloody-looking ascites may be associated with malignancy or traumatic paracentesis, but it is not
specific to SBP.
e history of abdominal pain and fever is not highly specific and may be absent in 30% of PBP cases.
Page - 1374
Question 60/66
Question #60
A 53-year-old male complains of fever and confusion. On examination, ascites is easily verified, and
the liver edge is firm and irregular. Serology tests show serum albumin of 23g/L and a Total protein
of 45 g/L. Paracentesis is done and shows cloudy-looking fluid with albumin of 6 g/L, total protein of
10 g/L, absolute neutrophil count of 540*10^6 cells/L, and the cytology is negative for malignant
cells. Ascitic fluid culture is positive for gram-negative bacilli. What is the most likely diagnosis?
a. Pancreatitis related ascites

b. Tuberculous peritonitis
c. Intestinal perforation and peritonitis
d. Spontaneous bacterial peritonitis
e. Peritoneal cancer
Page - 1375
Question 60/66
Question #60
A 53-year-old male complains of fever and confusion. On examination, ascites is easily verified, and
the liver edge is firm and irregular. Serology tests show serum albumin of 23g/L and a Total protein
of 45 g/L. Paracentesis is done and shows cloudy-looking fluid with albumin of 6 g/L, total protein of
10 g/L, absolute neutrophil count of 540*10^6 cells/L, and the cytology is negative for malignant
cells. Ascitic fluid culture is positive for gram-negative bacilli. What is the most likely diagnosis?
a. Pancreatitis related ascites

b. Tuberculous peritonitis
c. Intestinal perforation and peritonitis
d. Spontaneous bacterial peritonitis √
e. Peritoneal cancer
Description
Serum ascites albumin gradient (SAAG) = 23 – 6 = 17 g/L = 1.7 g/dL
e total ascitic protein is 10g/L = 1g/dL
SAAG is more than 1.1 g/dL, and total protein is less than 2.5 g/dL.
So, the diagnosis is liver cirrhosis.
e ANC and the presence of gram-negative bacilli (E. coli) strongly suggest spontaneous bacterial
peritonitis
ere are no features suggestive of intestinal perforation.
Malignancy is unlikely because the ascitic fluid is negative for malignant cells.
e following table shows the dierential diagnosis of ascites according to SAAG and total ascitic
protein level.
Page - 1376
Page - 1377
Question 61/66
Question #61
A patient with liver cirrhosis and ascites has abdominal discomfort and mild fever. Which of the
following is not consistent with spontaneous bacterial peritonitis?
a. Abdominal discomfort
b. e temperature of 37.8 °C
c. Multiple organisms in ascitic fluid culture
d. Ascitic neutrophil count of 400*10^6 cells/L
e. WBC count in the ascitic fluid of 650*10^6 cell/L
Page - 1378
Question 61/66
Question #61
A patient with liver cirrhosis and ascites has abdominal discomfort and mild fever. Which of the
following is not consistent with spontaneous bacterial peritonitis?
a. Abdominal discomfort
b. e temperature of 37.8 °C
c. Multiple organisms in ascitic fluid culture √
d. Ascitic neutrophil count of 400*10^6 cells/L
e. WBC count in the ascitic fluid of 650*10^6 cell/L
Description
Spontaneous bacterial peritonitis (SBP) is a bacterial infection in patients with ascites but without
bowel perforation.
It is common in cirrhotic ascites, especially in alcoholics.
SBP is more common in patients with GI bleeding.
e most common bacteria causing SBP is E. coli
Streptococcus pneumonia is another possible cause.
Usually, a single organism causes SBP (polymicrobial infection is rare)
Page - 1379
Question 62/66
Question #62
A 30-year-old female is diagnosed with Wilson disease and started on a copper chelating agent.
Which of the following would be the best to monitor the treatment response?
a. Serum ceruloplasmin
c. Liver function test
d. Urinary copper excretion
e. No need to monitor
Page - 1380
Internal Medicine - Hepatology - Wilson Disease
Question 62/66
Question #62
A 30-year-old female is diagnosed with Wilson disease and started on a copper chelating agent.
Which of the following would be the best to monitor the treatment response?
c. Liver function test
d. Urinary copper excretion √
e. No need to monitor
Description
Wilson disease is an autosomal recessive disorder of copper metabolism on chromosome 13

Copper is normally absorbed in the stomach and proximal small intestine, → taken to the liver, →
stored → incorporated into ceruloplasmin → secreted to the blood
In Wilsons disease: no synthesis of ceruloplasmin → copper accumulation
Treatment:
Low copper diet

A chelating agent (penicillamine for life)
Liver transplant, if indicated
e best test to monitor the treatment response is to measure the urinary excretion of copper.
Normal urinary copper excretion is less than 40 micrograms/day
In patients with Wilson disease, urinary copper excretion is above 100
microgram/day.
e use of copper chelating agents (D-penicillamine) promotes the 24-hour excretion of

approximately 2 mg of copper in the urine to induce a negative copper balance.
Page - 1381
Question 63/66
Question #63
A 21-year-old woman presents to the clinic with new symptoms of tremors and incoordination for 2
months. Symptoms have progressively worsened to the point that she fell 1 week ago. An
ophthalmologic examination reveals a brownish-pigmented ring at the corneal margin. Which of
the following is the treatment of choice for this condition?
a. Deferoxamine
b. Edetate-Disodium
c. Penicillin
d. Penicillamine
e. Phlebotomy
Page - 1382
Question 63/66
Question #63
A 21-year-old woman presents to the clinic with new symptoms of tremors and incoordination for 2
months. Symptoms have progressively worsened to the point that she fell 1 week ago. An
ophthalmologic examination reveals a brownish-pigmented ring at the corneal margin. Which of
the following is the treatment of choice for this condition?
a. Deferoxamine
b. Edetate-Disodium
c. Penicillin
d. Penicillamine √
e. Phlebotomy
Description
e neurological symptoms and Kayser-Fleischer ring in the eye strongly suggest Wilson’s disease.
It is an autosomal recessive disorder of copper metabolism on chromosome 13

Treatment:
Low copper diet

Page - 1383
Question 64/66
Question #64
A 22-year-old male patient develops memory changes and diculty in speaking. His family history is
significant for a paternal uncle who had a similar condition and died at 45. On examination, you
noted hepatomegaly. In addition, the slit lamp examination of the eye shows a hyperpigmented ring
around the cornea. What is the most accurate test to establish the diagnosis?
b. Urinary copper level
c. Serum copper level
d. Liver biopsy
e. Liver function test
Page - 1384
Question 64/66
Question #64
around the cornea. What is the most accurate test to establish the diagnosis?
b. Urinary copper level
c. Serum copper level
d. Liver biopsy √
e. Liver function test
Description
Liver disease, neurological symptoms, and Kayser-Fleischer ring in the eye strongly suggest Wilson’s
disease.

Diagnosis of Wilson disease:
Low serum ceruloplasmin (best lab for diagnosis)

High free serum copper
High urine copper
Very high hepatic copper (biopsy) (the best)
Page - 1385
Question 65/66
Question #65
A patient develops dementia and is diagnosed with Wilson disease. Which of the following is
accurate about this condition?
a. e main aected organ is the heart

b. It is a disease of copper overabsorption
c. Low serum ceruloplasmin level is characteristic
d. It is an autosomal dominant condition
e. e chelating agent Edetate-disodium is used to treat the condition
Page - 1386
Question 65/66
Question #65
A patient develops dementia and is diagnosed with Wilson disease. Which of the following is
accurate about this condition?
a. e main aected organ is the heart

b. It is a disease of copper overabsorption
c. Low serum ceruloplasmin level is characteristic √
d. It is an autosomal dominant condition
e. e chelating agent Edetate-disodium is used to treat the condition
Description
Low serum ceruloplasmin is the best lab for diagnosis of Wilson’s disease
Wilson disease is an autosomal recessive “Not dominant” disorder of copper metabolism on

chromosome 13
e main aected organs are the Liver, Basal ganglia of the brain, Eye, Kidney, and Skeleton
Pathogenesis:
Treatment:
Low copper diet

Page - 1387
Question 66/66
Question #66
around the cornea. What is the most likely diagnosis?
a. Hemochromatosis
b. Wilson disease
c. Sarcoidosis
d. Ischemic stroke
e. Subarachnoid hemorrhage
Page - 1388
Question 66/66
Question #66
around the cornea. What is the most likely diagnosis?
a. Hemochromatosis
b. Wilson disease √
c. Sarcoidosis
d. Ischemic stroke
e. Subarachnoid hemorrhage
Description
Liver disease, neurological symptoms, and Kayser-Fleischer ring in the eye strongly suggest Wilson’s
disease.

Page - 1389
Infectious diseases
Page - 1390
Infectious diseases
1) Brucellosis => 1 Questions

2) Chlamydia => 2 Questions
3) Gonorrhea => 3 Questions
4) HIV Infection => 6 Questions
5) Herpes Simplex virus => 3 Questions
6) Herpes Zoster infection => 5 Questions
7) Infectious Mononucleosis => 2 Questions
8) Lyme Disease => 3 Questions
9) Malaria => 2 Questions
10) Rabies => 1 Questions
11) Sepsis => 3 Questions
12) Staphylococcus infection => 2 Questions
13) Syphilis => 2 Questions
14) Tetanus => 2 Questions
15) e Antibiotics => 5 Questions
16) Typhoid fever (Enteric fever) => 2 Questions
Page - 1391
Internal Medicine - Infectious diseases
Question 1/44
Question #1
A 22-year-old male patient drank un-boiled milk yesterday. He came to your oce and asked which
diseases are transmitted by milk. Your answer will be all the following except:
a. Brucellosis
b. Tuberculosis
c. Staphylococcus food poisoning
d. Toxoplasmosis
Page - 1392
Internal Medicine - Infectious diseases - Brucellosis
Question 1/44
Question #1
A 22-year-old male patient drank un-boiled milk yesterday. He came to your oce and asked which
diseases are transmitted by milk. Your answer will be all the following except:
a. Brucellosis
b. Tuberculosis
c. Staphylococcus food poisoning
d. Toxoplasmosis √
Description
Brucellosis is also known as undulant fever or Malta fever

e cause: Brucella organism (gram-negative coccobacilli)
Rout of infection: Ingestion of raw milk from infected cattle or goats
e bacteria travel in the lymphatic system and infect lymph nodes, then spread by the
hematogenous route to localize in the reticuloendothelial system
e most common cause of death is endocarditis
Page - 1393
Question 2/44
Question #2
A 22-year-old male presented with purulent urethral discharge and was treated with ceriaxone
aer being diagnosed with gonorrhea. One week later, he came with dysuria and urethral discharge.
What would you do next?
a. Repeat the treatment with ceriaxone

b. Give Azithromycin 500mg orally – single dose
c. Give a single dose of benzylpenicillin intramuscular
d. Give ciprofloxacin orally 500mg bid of r7 days
e. Start treatment with nitrofurantoin
Page - 1394
Internal Medicine - Infectious diseases - Chlamydia
Question 2/44
Question #2

b. Give Azithromycin 500mg orally – single dose √
Description
Chlamydia is suspected in a patient who is not improving on gonorrhea treatment
Chlamydia infection:
It is a bacterial infection that is transmitted similarly to gonorrhea

Clinically also similar to gonorrhea
In men, urethral symptoms are mild, and < 50% of cases
In women, the most common sites are the cervix and urethra
Chlamydia is treated by Azithromycin 1g PO single dose (first line), or Doxycycline 100mg bd for
7 days
Page - 1395
Question 3/44
Question #3

b. Give doxycycline 100 mg Bid for 7 days
Page - 1396
Internal Medicine - Infectious diseases - Chlamydia
Question 3/44
Question #3

b. Give doxycycline 100 mg Bid for 7 days √
Description
Chlamydia is suspected in a patient who is not improving on gonorrhea treatment
Chlamydia infection:
It is a bacterial infection that is transmitted similarly to gonorrhea

Clinically also similar to gonorrhea
In men, urethral symptoms are mild, and < 50% of cases
In women, the most common sites are the cervix and urethra
Chlamydia is treated by Azithromycin 1g PO single dose (first line), or Doxycycline 100mg bd for
7 days
Page - 1397
Question 4/44
Question #4
Which of the following is the most eective for treating a 20-year-old male patient with purulent
urethral discharge who is confirmed to have gonorrhea?
a. Once-daily amoxicillin of 3 grams dose

b. One dose of ciprofloxacin 500 mg orally
c. One dose of ceriaxone 500 mg intramuscular
d. 3 days course of twice daily 100 mg doxycycline
e. One dose of Azithromycin 1 gram orally
Page - 1398
Internal Medicine - Infectious diseases - Gonorrhea
Question 4/44
Question #4
Which of the following is the most eective for treating a 20-year-old male patient with purulent
urethral discharge who is confirmed to have gonorrhea?

c. One dose of ceriaxone 500 mg intramuscular √
Description
One dose of ceriaxone 500 mg intramuscular is the eective treatment of gonorrhea
Page - 1399
Question 5/44
Question #5
A 23-year-old female patient with multiple sex partners is suspected of having gonorrhea. What is
the treatment of choice for her condition?
a. Ceriaxone for her and all her sex partners

b. Azithromycin for her and all her sex partners
c. Ceriaxone for her and her symptomatic sex partners
d. Azithromycin for her and her symptomatic sex partners
e. Penicillin for her and her symptomatic sex partners
Page - 1400
Question 5/44
Question #5
A 23-year-old female patient with multiple sex partners is suspected of having gonorrhea. What is
the treatment of choice for her condition?
a. Ceriaxone for her and all her sex partners √

b. Azithromycin for her and all her sex partners
c. Ceriaxone for her and her symptomatic sex partners
d. Azithromycin for her and her symptomatic sex partners
e. Penicillin for her and her symptomatic sex partners
Description
e patient and all the sex partners should receive treatment for gonorrhea regardless of the
symptoms.
Page - 1401
Question 6/44
Question #6
A 29-year-old female with multiple sex partners presents with migratory arthropathy, papular rash,
and tenosynovitis. What is the treatment of choice for this condition?

c. One dose of ceriaxone 500 mg intramuscular
Page - 1402
Question 6/44
Question #6
A 29-year-old female with multiple sex partners presents with migratory arthropathy, papular rash,
and tenosynovitis. What is the treatment of choice for this condition?

c. One dose of ceriaxone 500 mg intramuscular √
Description
One dose of ceriaxone 500 mg intramuscular is the eective treatment of gonorrhea
Page - 1403
Question 7/44
Question #7
A 40-year-old male patient is a known case of HIV and latent TB. What is the most appropriate
treatment regimen for an HIV-positive patient with latent TB?
a. INH for 9 months

b. INH, Rifampicin, pyrazinamide, and ethambutol
c. Rifampicin for 6 moths
d. Rifampin plus pyrazinamide daily for 4 months
e. Streptomycin for 4 months duration
Page - 1404
Internal Medicine - Infectious diseases - HIV Infection
Question 7/44
Question #7
A 40-year-old male patient is a known case of HIV and latent TB. What is the most appropriate
treatment regimen for an HIV-positive patient with latent TB?
a. INH for 9 months √

b. INH, Rifampicin, pyrazinamide, and ethambutol
c. Rifampicin for 6 moths
d. Rifampin plus pyrazinamide daily for 4 months
e. Streptomycin for 4 months duration
Description
Isoniazid monotherapy is the treatment of choice for patients with latent TB.
Page - 1405
Question 8/44
Question #8
In a patient with HIV, which organism can cause retinitis, encephalitis, enterocolitis, and interstitial
pneumonia?
a. Mycobacterium avium-intercellulare
b. Pneumocystis carinii
c. CMV
d. EBV
e. Mycoplasma pneumonia
Page - 1406
Question 8/44
Question #8
In a patient with HIV, which organism can cause retinitis, encephalitis, enterocolitis, and interstitial
pneumonia?
a. Mycobacterium avium-intercellulare
b. Pneumocystis carinii
c. CMV √
d. EBV
Description
CMV can cause those conditions in an HIV patient with CD4 less than 50 cells/mm3
e most important opportunistic infections in HIV are shown in the following table:
Page - 1407
Question 9/44
Question #9
A 22-year-old female is a known case of HIV. Despite taking antiviral therapy, her CD4 count is 35
cells/mm3. Which of the following is the most appropriate prophylactic agent to be added to this
patient’s treatment at this point?
a. Azithromycin
b. TMP/SMX
c. Ceriaxone
d. Ciprofloxacin
e. Amphotericin B
Page - 1408
Question 9/44
Question #9
A 22-year-old female is a known case of HIV. Despite taking antiviral therapy, her CD4 count is 35
cells/mm3. Which of the following is the most appropriate prophylactic agent to be added to this
patient’s treatment at this point?
a. Azithromycin √
b. TMP/SMX
c. Ceriaxone
d. Ciprofloxacin
e. Amphotericin B
Description
Any HIV patient with CD4 less than 50 cells/mm3 should receive Azithromycin as prophylaxis for
Mycobacterium avium-intercellulare
Page - 1409
Question 10/44
Question #10
A 36-year-old male patient with a known case of HIV is suspected of having an opportunistic
organism. His CD4 count was ordered, and we are waiting for the results. What is the least likely
cause?
a. Candida albicans
b. Aspergillus fumigatus
c. Cytomegalovirus
d. Pneumocystis carinii
Page - 1410
Question 10/44
Question #10
A 36-year-old male patient with a known case of HIV is suspected of having an opportunistic
organism. His CD4 count was ordered, and we are waiting for the results. What is the least likely
cause?
a. Candida albicans
b. Aspergillus fumigatus
c. Cytomegalovirus
d. Pneumocystis carinii
e. Mycoplasma pneumonia √
Description
Mycoplasma pneumonia is not one of the opportunistic organisms in HIV patients.
Page - 1411
Question 11/44
Question #11
A 34-year-old IV drug user presents with fever, SOB, cough with sputum, and is diagnosed with
tuberculosis. Which of the following conditions is the most likely associated with this illness?
a. Beta-thalassemia
b. Alcoholism
c. Drug abuse
d. HIV infection
e. Lymphoma
Page - 1412
Question 11/44
Question #11
A 34-year-old IV drug user presents with fever, SOB, cough with sputum, and is diagnosed with
tuberculosis. Which of the following conditions is the most likely associated with this illness?
a. Beta-thalassemia
b. Alcoholism
c. Drug abuse
d. HIV infection √
e. Lymphoma
Description
Tuberculosis and HIV have been strongly associated with each other
Page - 1413
Question 12/44
Question #12
An HIV 33-year-old male patient presented with oral thrush and dysphagia. What is the most likely
diagnosis?
a. Candida esophagitis
b. Viral glossitis
c. Vitamin A deficiency
d. Achalasia
Page - 1414
Question 12/44
Question #12
An HIV 33-year-old male patient presented with oral thrush and dysphagia. What is the most likely
diagnosis?
a. Candida esophagitis √
b. Viral glossitis
c. Vitamin A deficiency
d. Achalasia
Description
Oral thrush and dysphagia in an immunocompromised patient are the classic presentation of
Esophageal candidiasis
Page - 1415
Question 13/44
Question #13
A 22-year-old female patient who was previously healthy presented with a skin condition on her lips
(see the picture). What is the most likely diagnosis?
a. Angioedema
b. Herpes simplex virus
c. Impetigo
d. Basal cell carcinoma
e. Squamous cell carcinoma
Page - 1416
Internal Medicine - Infectious diseases - Herpes Simplex virus
Question 13/44
Question #13
A 22-year-old female patient who was previously healthy presented with a skin condition on her lips
(see the picture). What is the most likely diagnosis?
a. Angioedema
b. Herpes simplex virus √
c. Impetigo
d. Basal cell carcinoma
e. Squamous cell carcinoma
Description
is is an HSV infection aecting the lips.
Herps simple virus (HSV):
Organism: Herpesvirus type 1 and type 2
It can be a primary or recurrent infection

Primary: ulcerative stomatitis, Keratitis, Finger infection, Vulvovaginitis, Balanitis, encephalitis
Recurrent infection: commonest at Lips (herpes labialis) or genital lesions.
Usually, no need for treatment, but acyclovir can be used in severe or systemic diseases.
Page - 1417
Question 14/44
Question #14
A 30-year-old dentist presented with painful blisters at his distal phalanx of the right index finger,
shown in the following picture. In addition, he has a low-grade fever and tender enlarged right
axillary lymph nodes. Which one of the following is the most likely diagnosis?
a. Herpetic whitlow
b. Traumatic lesion
c. Felon
d. Tenosynovitis
e. Basal cell carcinoma
Page - 1418
Question 14/44
Question #14
A 30-year-old dentist presented with painful blisters at his distal phalanx of the right index finger,
shown in the following picture. In addition, he has a low-grade fever and tender enlarged right
axillary lymph nodes. Which one of the following is the most likely diagnosis?
a. Herpetic whitlow √
b. Traumatic lesion
c. Felon
d. Tenosynovitis
e. Basal cell carcinoma
Description
Herpetic whitlow results from inoculation of type 1 or type 2 herpes simplex virus into broken skin
Herpes simplex virus (HSV):

Page - 1419
Page - 1420
Question 15/44
Question #15
A 22-year-old pregnant female presents at her 37-week gestation with labor pain. Her examination
shows vaginal blisters consistent with active herpes simplex lesions. What would you do regarding
her delivery?
a. Vaginal delivery without additional intervention

b. Vaginal delivery with the use of acyclovir cream before delivery
c. Give tocolytics and treat the lesion, then proceed with vaginal delivery
d. Cesarean section delivery
e. Vaginal delivery and administration of acyclovir to the newborn
Page - 1421
Question 15/44
Question #15
A 22-year-old pregnant female presents at her 37-week gestation with labor pain. Her examination
shows vaginal blisters consistent with active herpes simplex lesions. What would you do regarding
her delivery?
a. Vaginal delivery without additional intervention

b. Vaginal delivery with the use of acyclovir cream before delivery
c. Give tocolytics and treat the lesion, then proceed with vaginal delivery
d. Cesarean section delivery √
e. Vaginal delivery and administration of acyclovir to the newborn
Description
Active herpes lesion at the genitalia is a contraindication for vaginal delivery.
Herpes simplex virus (HSV):

Page - 1422
Question 16/44
Question #16
A 55-year-old male patient developed a burning pain followed by a vesicular rash on the le side of
the chest. What is the best treatment for his condition?
a. Only pain killer

b. Oral acyclovir
c. Systemic steroids
d. Topical acyclovir
e. Topical steroids
Page - 1423
Internal Medicine - Infectious diseases - Herpes Zoster infection
Question 16/44
Question #16
A 55-year-old male patient developed a burning pain followed by a vesicular rash on the le side of
the chest. What is the best treatment for his condition?
a. Only pain killer

b. Oral acyclovir √
c. Systemic steroids
d. Topical acyclovir
e. Topical steroids
Description
e treatment of choice for acute herpes zoster is oral acyclovir, valacyclovir, or famciclovir for 7
days.
Shingles:
is virus may become latent aer primary infection, then later in adulthood, will reactivate
and present with (Shingles)
Present with severe burning pain at a specific dermatome site with a vesicular rash that does
not cross the Medline of the body
Shingles are not contagious
It may be followed by neuropathic pain aer resolution (Gabapentin or Pregabalin is the drug
of choice for neuropathic pain)
Treatment: Analgesia and antiviral (acyclovir, valacyclovir, famciclovir)
Page - 1424
Question 17/44
Question #17
A 56-year-old male patient presents with a skin rash on his right thigh (on a specific dermatome)
consistent with shingles. What is the most appropriate treatment?
a. Only symptomatic and painkillers

b. Acyclovir oral tablets 800 mg five times a day for 7 days
c. Topical acyclovir 5 days duration for 7 days
d. Oral prednisolone 30mg for 2 1 week
e. Ganciclovir 1000 mg tid for a 1-week duration
Page - 1425
Question 17/44
Question #17
A 56-year-old male patient presents with a skin rash on his right thigh (on a specific dermatome)
consistent with shingles. What is the most appropriate treatment?
a. Only symptomatic and painkillers

b. Acyclovir oral tablets 800 mg five times a day for 7 days √
c. Topical acyclovir 5 days duration for 7 days
d. Oral prednisolone 30mg for 2 1 week
e. Ganciclovir 1000 mg tid for a 1-week duration
Description
e treatment of choice for acute herpes zoster is oral acyclovir, valacyclovir, or famciclovir for 7
days.
Shingles:
Page - 1426
Question 18/44
Question #18
A 55-year-old male patient develops atypical right-side chest burning pain in his skin provoked by
touching or when the area is rubbed by his shirt. In addition, the patient had shingles about 3 weeks
ago. Which is the best treatment for the patient’s condition?
a. Oral Acyclovir
b. Topical acyclovir
c. Prednisolone
d. Amitriptyline
e. Ibuprofen
Page - 1427
Question 18/44
Question #18
A 55-year-old male patient develops atypical right-side chest burning pain in his skin provoked by
touching or when the area is rubbed by his shirt. In addition, the patient had shingles about 3 weeks
ago. Which is the best treatment for the patient’s condition?
a. Oral Acyclovir
b. Topical acyclovir
c. Prednisolone
d. Amitriptyline √
e. Ibuprofen
Description
Tricyclic antidepressants are used to treat post-herpetic neuralgia.
Shingles:
Page - 1428
Question 19/44
Question #19
A 52-year-old male presents with le frontal headaches for 6 days. His frontal area and nose show
blisters on a specific dermatome (see picture). In addition to your treatment for his condition, you
should refer the patient to which of the following specialties?
a. Allergist
b. General internist
c. Neurologist
d. Ophthalmologist
e. Otolaryngologist
Page - 1429
Question 19/44
Question #19
A 52-year-old male presents with le frontal headaches for 6 days. His frontal area and nose show
blisters on a specific dermatome (see picture). In addition to your treatment for his condition, you
should refer the patient to which of the following specialties?
a. Allergist
b. General internist
c. Neurologist
d. Ophthalmologist √
e. Otolaryngologist
Description
is is a case of herpes zoster ophthalmicus. e possibility of corneal involvement warrants an

ophthalmologist consultation
Shingles:
Page - 1430
Page - 1431
Question 20/44
Question #20
A 32-year-old female patient presents with burning blisters extending from the epigastrium to the
midline of her back. e most likely diagnosis is:
a. Contact dermatitis
b. Cholecystitis
c. Herpes zoster
d. Herpes simplex
e. Acute pancreatitis
Page - 1432
Question 20/44
Question #20
A 32-year-old female patient presents with burning blisters extending from the epigastrium to the
midline of her back. e most likely diagnosis is:
a. Contact dermatitis
b. Cholecystitis
c. Herpes zoster √
d. Herpes simplex
e. Acute pancreatitis
Description
Band-like painful blisters on a specific dermatome are a classic presentation for shingles.
Shingles:
Page - 1433
Page - 1434
Question 21/44
Question #21
A 19-year-old male patient developed a fever and sore throat associated with fatigue and cervical
lymphadenopathy. What is the most common cause of his condition if the rapid streptococcal
antigen test was negative?
a. Streptococcal pharyngitis
b. Infectious mononucleosis
c. Lymphoma
d. Adenovirus infection
e. Acute sinusitis
Page - 1435
Internal Medicine - Infectious diseases - Infectious Mononucleosis
Question 21/44
Question #21
A 19-year-old male patient developed a fever and sore throat associated with fatigue and cervical
lymphadenopathy. What is the most common cause of his condition if the rapid streptococcal
antigen test was negative?
a. Streptococcal pharyngitis
b. Infectious mononucleosis √
c. Lymphoma
d. Adenovirus infection
e. Acute sinusitis
Description
Fever, fatigue, and lymphadenopathy is the classic presentation of EBV infection
Infectious mononucleosis (Glandular fever):
Organism: EBV (DNA virus)

e virus spreads via infected droplets but is rarely blood-borne (It is also known as Kissing
disease)
Incubation period: 30-50 days
Page - 1436
Question 22/44
Question #22
A 19-year-old male football player presents with fever, fatigue, and a sore throat. Physical
examination shows posterior cervical lymphadenitis and splenomegaly. e monospot test is
positive. He asked you, “when can I play football again?”. e most appropriate answer would be?
a. When the WBC level returns to normal

b. When the physical examination is normal
c. When symptoms disappear
d. When the Monospot test is negative
e. Aer 4 weeks
Page - 1437
Internal Medicine - Infectious diseases - Infectious Mononucleosis
Question 22/44
Question #22
A 19-year-old male football player presents with fever, fatigue, and a sore throat. Physical
examination shows posterior cervical lymphadenitis and splenomegaly. e monospot test is
positive. He asked you, “when can I play football again?”. e most appropriate answer would be?
a. When the WBC level returns to normal

b. When the physical examination is normal √
c. When symptoms disappear
d. When the Monospot test is negative
e. Aer 4 weeks
Description
To avoid splenic rupture, he can play contact sports only when the splenomegaly resolves.
Infectious mononucleosis (Glandular fever):
Organism: EBV (DNA virus)

e virus spreads via infected droplets but is rarely blood-borne (It is also known as Kissing
disease)
Incubation period: 30-50 days
Page - 1438
Question 23/44
Question #23
A 32-year-old male patient developed a fever, myalgia, and a skin rash (see the picture below!).
About 1 week ago, he went on a hike, and the skin rash was noted 2 days later. What is the first-line
treatment for this patient?
a. Azithromycin
b. Doxycycline
c. Clindamycin
d. Clarithromycin
e. Erythromycin
Page - 1439
Internal Medicine - Infectious diseases - Lyme Disease
Question 23/44
Question #23
About 1 week ago, he went on a hike, and the skin rash was noted 2 days later. What is the first-line
treatment for this patient?
a. Azithromycin
b. Doxycycline √
c. Clindamycin
d. Clarithromycin
e. Erythromycin
Description
is picture shows erythema migrans which is associated with Lyme disease
Lyme disease is caused by the bacteria Borrelia burgdorferi. However, it is transmitted to humans via
Page - 1440
an infected tick bite (Ixodes).
Clinical diagnosis is important with a history of travel to specific areas
Lyme disease is treated with doxycycline or Amoxicillin for 14 days.
Page - 1441
Question 24/44
Question #24
About 1 week ago, he went on a hike, and the skin rash was noted 2 days later. What is this skin rash
called?
a. Erythema migrans
b. Erythema marginatum
c. Erythema infectiosum
d. Erythema nodosum
e. Erythema multiform
Page - 1442
Question 24/44
Question #24
About 1 week ago, he went on a hike, and the skin rash was noted 2 days later. What is this skin rash
called?
a. Erythema migrans √
b. Erythema marginatum
c. Erythema infectiosum
d. Erythema nodosum
e. Erythema multiform
Description
is picture shows erythema migrans which is associated with Lyme disease.
Page - 1443
Page - 1444
Question 25/44
Question #25
About 1 week ago, he went on a hike, and the skin rash was noted 2 days later. What is the best
treatment for this lady?
a. Azithromycin
b. Clarithromycin
c. Clindamycin
d. Amoxicillin
e. Erythromycin
Page - 1445
Question 25/44
Question #25
About 1 week ago, he went on a hike, and the skin rash was noted 2 days later. What is the best
treatment for this lady?
a. Azithromycin
b. Clarithromycin
c. Clindamycin
d. Amoxicillin √
e. Erythromycin
Description
is picture shows erythema migrans which is associated with Lyme disease
Page - 1446
Page - 1447
Question 26/44
Question #26
A 22-year-old businessman who traveled to Africa 2 months ago presents with a headache and cyclic
fever for a 1-week duration. Which of the following diagnosis is most likely?
a. Meningococcal meningitis
b. Tuberculosis
c. Malaria
d. HIV
e. Syphilis
Page - 1448
Internal Medicine - Infectious diseases - Malaria
Question 26/44
Question #26
A 22-year-old businessman who traveled to Africa 2 months ago presents with a headache and cyclic
fever for a 1-week duration. Which of the following diagnosis is most likely?
a. Meningococcal meningitis
b. Tuberculosis
c. Malaria √
d. HIV
e. Syphilis
Description
History of travel and cyclic fever are suggestive of malaria
Malaria:
A parasitic infection transmitted by Mosquito (Anopheles) aects blood and liver cells
Patients with sickle cell anemia are protected against malaria
e mosquito has the plasmodium in their saliva → and injects it into the human bloodstream →
Sporozoites reach the liver and engage in Asexual reproduction (this is called the extra-
erythrocytic phase) → erythrocytic phase: parasite enters the RBCs → asexual replication and
hemolytic anemia
Page - 1449
Question 27/44
Question #27
e antimalarial agent Primaquine is indicated in which one of the following?
a. Plasmodium falciparum
b. Plasmodium vivax
c. Plasmodium malariae
d. Plasmodium knowlesi
Page - 1450
Internal Medicine - Infectious diseases - Malaria
Question 27/44
Question #27
e antimalarial agent Primaquine is indicated in which one of the following?
a. Plasmodium falciparum
b. Plasmodium vivax √
c. Plasmodium malariae
d. Plasmodium knowlesi
Description
Primaquine is used in the treatment of Ovale or Vivax malaria (to destroy liver hypnozoite and
prevent relapse)
Malaria:
A parasitic infection transmitted by Mosquito (Anopheles) aects blood and liver cells
Patients with sickle cell anemia are protected against malaria
e mosquito has the plasmodium in their saliva → and injects it into the human bloodstream →
Sporozoites reach the liver and engage in Asexual reproduction (this is called the extra-
erythrocytic phase) → erythrocytic phase: parasite enters the RBCs → asexual replication and
hemolytic anemia
Page - 1451
Question 28/44
Question #28
A 22-year-old male came aer a dog bite on his leg. Regarding the postexposure immunization
against rabies, it is given in 6 doses as which of the following?
a. At 0, 5, 9, 14, 60, 90 days

b. At 0, 5, 14, 21, 30, 120 days
c. At 0, 3, 7, 14, 30, 90 days
d. At 0, 3, 10, 21, 60,120 days
e. At 0, 3, 30, 60, 90,120 days
Page - 1452
Internal Medicine - Infectious diseases - Rabies
Question 28/44
Question #28
A 22-year-old male came aer a dog bite on his leg. Regarding the postexposure immunization
against rabies, it is given in 6 doses as which of the following?
a. At 0, 5, 9, 14, 60, 90 days

b. At 0, 5, 14, 21, 30, 120 days
c. At 0, 3, 7, 14, 30, 90 days √
d. At 0, 3, 10, 21, 60,120 days
e. At 0, 3, 30, 60, 90,120 days
Description
e anti-rabies serum is given in 6 doses at 0, 3, 7, 14, 30, and 90 days.
Rabies:
It is a viral infection that can cause brain infection

Rabies is a DNA rhabdovirus
Most transmitted by a dog bite then, the virus travels up at nerve axons to CNS
e incubation period is 1-2 months
Page - 1453
Question 29/44
Question #29
A 70-year-old male develops septicemia due to gram-negative bacteria secondary to UTI. You started
IV fluid therapy, but the patient is still hypotensive. e blood pressure now is 65/30. What would
you do next?
a. Vasopressin
b. Adrenalin
c. Noradrenalin
d. Dopamine
e. Dobutamine
Page - 1454
Internal Medicine - Infectious diseases - Sepsis
Question 29/44
Question #29
A 70-year-old male develops septicemia due to gram-negative bacteria secondary to UTI. You started
IV fluid therapy, but the patient is still hypotensive. e blood pressure now is 65/30. What would
you do next?
a. Vasopressin
b. Adrenalin
c. Noradrenalin √
d. Dopamine
e. Dobutamine
Description
If there is no response to fluid in a septic shock patient, start vasopressors.
Noradrenalin here is the best choice
Dobutamine is better for cardiogenic shock
Dopamine can be used, but it is arrhythmogenic
Page - 1455
Question 30/44
Question #30
A 49-year-old male patient presents with fever and weakness. Aer an appropriate workup, he is
diagnosed with sepsis. Which of the following is expected to be decreased?
a. Ferritin level
b. C-reactive protein
c. Erythrocyte sedimentation rate
d. Serum albumin
e. Fibrin degradation products
Page - 1456
Question 30/44
Question #30
A 49-year-old male patient presents with fever and weakness. Aer an appropriate workup, he is
diagnosed with sepsis. Which of the following is expected to be decreased?
a. Ferritin level
b. C-reactive protein
c. Erythrocyte sedimentation rate
d. Serum albumin √
e. Fibrin degradation products
Description
e synthesis of acute-phase proteins by hepatocytes is altered, leading to decreased serum levels of

several proteins, including albumin and transferrin.
Note that ferritin, ESR, and CRP are acute-phase reactants and are expected to be high
D Dimer and other FDPs are expected to be high in sepsis
Page - 1457
Question 31/44
Question #31
A 78-year-old male patient developed flank pain, dysuria, and diculty voiding. However, 1 day aer
starting treatment, he developed lethargy, fever, hypotension, and tachycardia. What is the most
likely cause of his recent symptoms?
a. Urinary retention
b. Respiratory infection
c. Septic shock
d. Pulmonary edema
Page - 1458
Question 31/44
Question #31
A 78-year-old male patient developed flank pain, dysuria, and diculty voiding. However, 1 day aer
starting treatment, he developed lethargy, fever, hypotension, and tachycardia. What is the most
likely cause of his recent symptoms?
a. Urinary retention
b. Respiratory infection
c. Septic shock √
d. Pulmonary edema
Description
e presence of hypotension and evidence of infection is suggestive of septic shock as the most
likely diagnosis
is is a classic presentation of septic shock secondary to UTI
Page - 1459
Question 32/44
Question #32
A 20-year-old IV drug user presents to you with severe infective arthritis. His temperature is 39°C, his
blood pressure is 85/50 mmHg, and his pulse is 119 bpm. You started IV fluids. What is the best
empirical antibiotic to use in this condition?
a. IV Linezolid and Gentamycin

b. IV Meropenem
c. IV Oxacillin and Clindamycin
d. IV Vancomycin and Ceriaxone
e. PO Vancomycin and IV Ceriaxone
Page - 1460
Internal Medicine - Infectious diseases - Staphylococcus infection
Question 32/44
Question #32
A 20-year-old IV drug user presents to you with severe infective arthritis. His temperature is 39°C, his
blood pressure is 85/50 mmHg, and his pulse is 119 bpm. You started IV fluids. What is the best
empirical antibiotic to use in this condition?
a. IV Linezolid and Gentamycin

b. IV Meropenem
c. IV Oxacillin and Clindamycin
d. IV Vancomycin and Ceriaxone √
e. PO Vancomycin and IV Ceriaxone
Description
IV Vancomycin to cover MRASA
Oral vancomycin can’t be absorbed by the gut
Linezolid is reserved for MRSA that become resistant to vancomycin
Page - 1461
Question 33/44
Question #33
A 50-year-old male patient came with a new-onset murmur and fever; his blood culture result
shows gram-positive cocci in clusters. Antibiotic sensitivity is still not known. e most appropriate
antibiotic treatment would be:
a. Amoxicillin
b. Nafcillin
c. Streptomycin and penicillin
d. Ceriaxone
e. Vancomycin and gentamicin
Page - 1462
Internal Medicine - Infectious diseases - Staphylococcus infection
Question 33/44
Question #33
A 50-year-old male patient came with a new-onset murmur and fever; his blood culture result
shows gram-positive cocci in clusters. Antibiotic sensitivity is still not known. e most appropriate
antibiotic treatment would be:
a. Amoxicillin
b. Nafcillin
c. Streptomycin and penicillin
d. Ceriaxone
e. Vancomycin and gentamicin √
Description
e patient is most likely suering from infective endocarditis. It is most commonly caused by staph
aureus bacteria, so MRSA should be suspected.
Major infections with MRSA should be treated with vancomycin intravenously
Page - 1463
Question 34/44
Question #34
A sexually active 29-year-old male presents with a painless 1*1 cm ulcer in his penis. It is associated
with painless lymphadenopathy. e rest of the physical examination is normal. What is the best
diagnostic test for this patient?
a. Seminal analysis
b. Urine culture
c. Blood culture
d. Darkfield microscopy
e. Lymph node biopsy
Page - 1464
Internal Medicine - Infectious diseases - Syphilis
Question 34/44
Question #34
A sexually active 29-year-old male presents with a painless 1*1 cm ulcer in his penis. It is associated
with painless lymphadenopathy. e rest of the physical examination is normal. What is the best
diagnostic test for this patient?
a. Seminal analysis
b. Urine culture
c. Blood culture
d. Darkfield microscopy √
e. Lymph node biopsy
Description
In the case of Syphilis, Darkfield microscopy of the lesion scraping shows the spirochetes with their
characteristic corkscrew appearance.
Syphilis:
It is mainly a sexually transmitted disease

Transmitted by sex, blood transfusion, vertical (transplacental)
Organism: the spirochete Treponema Pallidum, incubation period: between 9-90 days
Page - 1465
Question 35/44
Question #35
A 25-year-old male presents with a rash involving the chest, abdomen, palms, and soles. He has
painless penile ulceration with indurated base. His inguinal lymph nodes are painlessly enlarged. A
patchy hair loss on his scalp is noted. Darkfield microscopy confirms the diagnosis. What is the most
appropriate treatment?
a. Penicillin
b. Doxycycline
c. Topical steroids
d. Itraconazole
e. Systemic steroids
Page - 1466
Internal Medicine - Infectious diseases - Syphilis
Question 35/44
Question #35
A 25-year-old male presents with a rash involving the chest, abdomen, palms, and soles. He has
painless penile ulceration with indurated base. His inguinal lymph nodes are painlessly enlarged. A
patchy hair loss on his scalp is noted. Darkfield microscopy confirms the diagnosis. What is the most
appropriate treatment?
a. Penicillin √
b. Doxycycline
c. Topical steroids
d. Itraconazole
e. Systemic steroids
Description
Penicillin is the drug of choice for syphilis.
Syphilis:
It is mainly a sexually transmitted disease

Transmitted by sex, blood transfusion, vertical (transplacental)
Organism: the spirochete Treponema Pallidum, incubation period: between 9-90 days
Page - 1467
Question 36/44
Question #36
A 15-year-old male patient presents with a cut wound in his forearm during a quarrel. e wound is
contaminated with soil. All the following about tetanus are true except:
a. Trismus is feature
b. Mild tetanus has less than 1% mortality
c. Cephalic tetanus has a short incubation period
d. Temperature is very high
e. Laryngeal spasm may occur, requiring intubation
Page - 1468
Internal Medicine - Infectious diseases - Tetanus
Question 36/44
Question #36
A 15-year-old male patient presents with a cut wound in his forearm during a quarrel. e wound is
contaminated with soil. All the following about tetanus are true except:
a. Trismus is feature
b. Mild tetanus has less than 1% mortality
c. Cephalic tetanus has a short incubation period
d. Temperature is very high √
e. Laryngeal spasm may occur, requiring intubation
Description
Fever is not a feature of Tetanus infection.
Tetanus:
Clostridium tetani is a gram-positive spore-forming anaerobic bacteria

It is excreted by animal feces to contaminate soil, dust, water, and wounds, including the
umbilical stump. Vaccination site... etc.
Aer contamination, the spores germinate and proliferate locally and produce 2 toxins
(tetanospasmin and tetanolysin) which travel along the nerve trunks and bloodstream to CNS
and redistribute to the spinal cord, brain, and motor system
e Incubation period is 1-14 days, and maybe longer
Page - 1469
Question 37/44
Question #37
A 24-year-old male patient developed diculty opening his mouth due to tetanus aer wound
contamination 2 weeks ago. What is the cause of death in a patient with established tetanus?
a. Septic shock
b. Heart failure
c. Renal failure
d. Liver failure
e. Respiratory failure
Page - 1470
Internal Medicine - Infectious diseases - Tetanus
Question 37/44
Question #37
A 24-year-old male patient developed diculty opening his mouth due to tetanus aer wound
contamination 2 weeks ago. What is the cause of death in a patient with established tetanus?
a. Septic shock
b. Heart failure
c. Renal failure
d. Liver failure
e. Respiratory failure √
Description
Respiratory muscle involvement and respiratory failure are the most likely to cause death in tetanus.
Tetanus:
Clostridium tetani is a gram-positive spore-forming anaerobic bacteria

It is excreted by animal feces to contaminate soil, dust, water, and wounds, including the
umbilical stump. Vaccination site, etc.
Aer contamination, the spores germinate and proliferate locally and produce 2 toxins
(tetanospasmin and tetanolysin) which travel along the nerve trunks and bloodstream to CNS
and redistribute to the spinal cord, brain, and motor system
e Incubation period is 1-14 days, and maybe longer
Page - 1471
Question 38/44
Question #38
A 48-year-old male patient is treated for sepsis with vancomycin and ceriaxone. What would you
do to prevent red man syndrome?
a. Give only half the calculated dose of vancomycin

b. Slow infusion of ceriaxone
c. Provide ceriaxone in the morning and vancomycin in the evening
d. Administrate vancomycin over 90 minutes
e. Give hydrocortisone before vancomycin infusion
Page - 1472
Internal Medicine - Infectious diseases - e Antibiotics
Question 38/44
Question #38
A 48-year-old male patient is treated for sepsis with vancomycin and ceriaxone. What would you
do to prevent red man syndrome?
a. Give only half the calculated dose of vancomycin

b. Slow infusion of ceriaxone
c. Provide ceriaxone in the morning and vancomycin in the evening
d. Administrate vancomycin over 90 minutes √
e. Give hydrocortisone before vancomycin infusion
Description
Red-man syndrome: a side eect of vancomycin will occur if vancomycin is given as a rapid infusion.
Vancomycin must be given over 90 minutes to avoid this syndrome.
Page - 1473
Question 39/44
Question #39
A 67-year-old male patient was admitted to the ICU as a case of septic shock. He was started on
empirical antibiotic therapy. e blood culture result is available three days later and shows
Methicillin-Resistant Staph aureus. Of the following, which is the most eective drug to be used?
a. Methicillin
b. Amoxicillin
c. Vancomycin
d. Amoxicillin with clavulanic acid
e. TMP/SMX
Page - 1474
Question 39/44
Question #39
empirical antibiotic therapy. e blood culture result is available three days later and shows
Methicillin-Resistant Staph aureus. Of the following, which is the most eective drug to be used?
a. Methicillin
b. Amoxicillin
c. Vancomycin √
d. Amoxicillin with clavulanic acid
e. TMP/SMX
Description
MRSA: Methicillin-resistant Staph. aureus:
Minor infection with MRSA treated with: TMP/SMX, doxycycline, clindamycin, or Linezolid
Major infection treated with vancomycin
Page - 1475
Question 40/44
Question #40
empirical antibiotic therapy. ree days later, the blood culture result is available and shows
pseudomonas. Which of the following drugs is not used to treat pseudomonas?
a. Cefepime
b. Gentamycin
c. Levofloxacin
d. Ertapenem
e. Meropenem
Page - 1476
Question 40/44
Question #40
empirical antibiotic therapy. ree days later, the blood culture result is available and shows
pseudomonas. Which of the following drugs is not used to treat pseudomonas?
a. Cefepime
b. Gentamycin
c. Levofloxacin
d. Ertapenem √
e. Meropenem
Description
All Carbapenems are eective against pseudomonas, except Ertapenem
Some antibiotics that are active against pseudomonas:
Carbapenems (except Ertapenem) (the first line)

Tigecycline
Cefepime (4th generation cephalosporin)
Aminoglycosides (gentamycin, Amikacin)
Fluoroquinolones (Except Moxifloxacin)
Page - 1477
Question 41/44
Question #41
e following antibiotics act by inhibiting protein synthesis, except:
a. Penicillin
b. Gentamycin
c. Clarithromycin
d. Tetracycline
e. Neomycin
Page - 1478
Question 41/44
Question #41
e following antibiotics act by inhibiting protein synthesis, except:
a. Penicillin √
b. Gentamycin
c. Clarithromycin
d. Tetracycline
e. Neomycin
Description
Antibiotics act on dierent target sites in the targeted bacteria.
Penicillin inhibits cell wall formation.
e following table demonstrates the site of action of the most used antibiotics in clinical practice.
Page - 1479
Question 42/44
Question #42
All the following are bacteriostatic antibiotics except:
a. Azithromycin
b. Chloramphenicol
c. Isoniazid.
d. Trimethoprim
e. Tetracycline
Page - 1480
Question 42/44
Question #42
All the following are bacteriostatic antibiotics except:
a. Azithromycin
b. Chloramphenicol
c. Isoniazid. √
d. Trimethoprim
e. Tetracycline
Description
Antibiotics are classified into cidal and static types according to their mode of action. Bactericidal
antibiotics kill the bacteria, while bacteriostatic antibiotics suppress the bacterial growth.
Isoniazid is a bactericidal antibiotic.
e following table demonstrates examples of these types.
Page - 1481
Question 43/44
Question #43
A 23-year-old man presents with 5 days history of fever, headache, and constipation. Which of the
following tests is the best to confirm a diagnosis of typhoid fever?
a. Blood culture
b. Urine culture
c. Stool culture
d. History and Clinical examination
e. CSF culture
Page - 1482
Internal Medicine - Infectious diseases - Typhoid fever (Enteric fever)
Question 43/44
Question #43
A 23-year-old man presents with 5 days history of fever, headache, and constipation. Which of the
following tests is the best to confirm a diagnosis of typhoid fever?
a. Blood culture √
b. Urine culture
c. Stool culture
d. History and Clinical examination
e. CSF culture
Description
In the case of typhoid fever, blood culture is positive in 40 – 60 % in the first week.
Diagnosis of typhoid fever:
CBC: anemia and leucopenia (due to toxic depression of the bone marrow)
Positive blood culture (40 – 60 % in the 1st week)
In the 2nd week:
Positive stool culture
Positive Widal test (not specific)
In the 3rd week: urine culture
PCR
Bone marrow cells culture (if aected)
Page - 1483
Question 44/44
Question #44
e following facts are true about typhoid fever except:
a. It is caused by Salmonella typhi

b. It is associated with leucopenia
c. Blood culture is positive in 40 – 60^ in the first week
d. Stool culture is better than urine culture for the diagnosis in the second week
e. Diarrhea is a prominent symptom
Page - 1484
Internal Medicine - Infectious diseases - Typhoid fever (Enteric fever)
Question 44/44
Question #44
e following facts are true about typhoid fever except:
a. It is caused by Salmonella typhi

b. It is associated with leucopenia
c. Blood culture is positive in 40 – 60^ in the first week
d. Stool culture is better than urine culture for the diagnosis in the second week
e. Diarrhea is a prominent symptom √
Description
Constipation, not diarrhea, is a feature of typhoid fever
Typhoid fever (Enteric fever):
Organism: salmonella typhi and paratyphi (A, B, C), gram-negative bacilli

Humans are only reservoirs
Route: oral-fecal transmission
Bacteria proliferate in Peyer's patches in the small intestine, then cause primary bacteremia
and redistribute to the reticuloendothelial system.
Page - 1485
Nephrology
Page - 1486
Nephrology
1) Acid-Base Disorders => 9 Questions

2) Acute Kidney Injury (AKI) => 15 Questions
3) Chronic Kidney disease (CKD) => 6 Questions
4) Kidney function test. => 4 Questions
5) Nephrotic Syndrome => 4 Questions
6) Renal Artery Stenosis => 6 Questions
7) Renal glomerular diseases => 12 Questions
8) Cystic diseases of the kidney => 4 Questions
9) Electrolytes disturbances => 17 Questions
10) Hypertension (HTN) => 19 Questions
Page - 1487
Internal Medicine - Nephrology
Question 1/96
Question #1
Based on limited data from the following ABGs results: Ph 7.30, PaCO2 66 mmHg, PaO2 50 mmHg.
b. Chronic obstructive pulmonary disease
c. Mild asthma exacerbation
d. Renal impairment
e. Salicylate overdose
Page - 1488
Internal Medicine - Nephrology - Acid-Base Disorders
Question 1/96
Question #1
Based on limited data from the following ABGs results: Ph 7.30, PaCO2 66 mmHg, PaO2 50 mmHg.
b. Chronic obstructive pulmonary disease √
c. Mild asthma exacerbation
d. Renal impairment
e. Salicylate overdose
Description
is is respiratory acidosis and hypoxia that, from the above choices, fits with the diagnosis of COPD.
Mild asthma and pulmonary embolism present with respiratory alkalosis
Renal impairment and salicylate poisoning present with high anion gap metabolic acidosis.
Page - 1489
Question 2/96
Question #2
A 22-year-old male patient presents with severe persistent vomiting. His arterial blood gas results
are as the following: PH 7.42, HCO3 24mmol/L, PaCO2 40 mmHg, serum sodium 140 mEq/L, serum
potassium 4 mEq/L, serum Cl 93 mEq/L. What is the correct interpretation of arterial blood gas?
a. Normal ABGs result

b. Mixed metabolic acidosis with respiratory acidosis
c. Mixed metabolic acidosis with respiratory alkalosis
d. Mixed metabolic acidosis with metabolic alkalosis
e. Mixed respiratory alkalosis and respiratory acidosis
Page - 1490
Question 2/96
Question #2
A 22-year-old male patient presents with severe persistent vomiting. His arterial blood gas results
are as the following: PH 7.42, HCO3 24mmol/L, PaCO2 40 mmHg, serum sodium 140 mEq/L, serum
potassium 4 mEq/L, serum Cl 93 mEq/L. What is the correct interpretation of arterial blood gas?
a. Normal ABGs result

b. Mixed metabolic acidosis with respiratory acidosis
c. Mixed metabolic acidosis with respiratory alkalosis
d. Mixed metabolic acidosis with metabolic alkalosis √
e. Mixed respiratory alkalosis and respiratory acidosis
Description
Apparently, the ABGs here are normal, but here is how to solve this issue.
On calculating anion gap, AG = Na – (Cl + HCO3) = 140 – (93 + 24) = 23.
high plasma anion gap means that there are unmeasured anions indicating high anion gap
metabolic acidosis.
e presence of metabolic alkalosis is considered for two reasons: the first evidence is the presence
of severe recurrent vomiting. e second evidence is the presence of normal PH and HCO3 in the
presence of metabolic acidosis.
Page - 1491
Question 3/96
Question #3
A patient with intestinal obstruction develops severe persistent vomiting. What is the most likely
ABGs finding in this case?
a. Ph 7.49, HCO3 30 mmol/L, K 3 mEq/L, Cl 87 mEq/L

b. Ph 7.32, HCO3 12 mmol/L, K 5.7 mEq/L, Cl 90 mEq/L
c. Ph 7.25, HCO3 27 mmol/L, K 2.9 mEq/l, Cl 111 mEq/L
d. Ph 7.44, HCO3 13 mmol/L, K 3.2 mEq/L, Cl 100 mEq/L
e. Ph 7.56, HCO3 15 mmol/L, K 4mEq/L, Cl 92 mEq/L
Page - 1492
Question 3/96
Question #3
A patient with intestinal obstruction develops severe persistent vomiting. What is the most likely
ABGs finding in this case?
a. Ph 7.49, HCO3 30 mmol/L, K 3 mEq/L, Cl 87 mEq/L √

b. Ph 7.32, HCO3 12 mmol/L, K 5.7 mEq/L, Cl 90 mEq/L
c. Ph 7.25, HCO3 27 mmol/L, K 2.9 mEq/l, Cl 111 mEq/L
d. Ph 7.44, HCO3 13 mmol/L, K 3.2 mEq/L, Cl 100 mEq/L
e. Ph 7.56, HCO3 15 mmol/L, K 4mEq/L, Cl 92 mEq/L
Description
Vomiting will lead to loss of potassium, chloride, and H ions (Acid)
is will lead to hypokalemia, hypochloremic, metabolic Alkalosis.
Choice A is typical for this finding.
Page - 1493
Question 4/96
Question #4
An arterial blood gas results are as the following: PH 7.32, HCO3 15mmol/L, PaCO2 29 mmHg, serum
sodium 135 mEq/L, serum potassium 4 mEq/L, serum Cl 110 mEq/L. Which of the following is the
a. Diabetic ketoacidosis
b. Renal impairment
c. Starvation
d. Diarrhea
e. Aspirin overdose
Page - 1494
Question 4/96
Question #4
An arterial blood gas results are as the following: PH 7.32, HCO3 15mmol/L, PaCO2 29 mmHg, serum
sodium 135 mEq/L, serum potassium 4 mEq/L, serum Cl 110 mEq/L. Which of the following is the
a. Diabetic ketoacidosis
b. Renal impairment
c. Starvation
d. Diarrhea √
e. Aspirin overdose
Description
e most important causes of non-anion gap metabolic acidosis are diarrhea and renal tubular
acidosis.
e rest of the options cause high anion gap metabolic acidosis
Causes of metabolic acidosis with wide anion gap (MUD PILS):
Methanol overdose
Uremia: renal failure
DKA
Phosphate, paraldehyde, propylene glycol
Ischemia
Lactate: hypotension, hypoperfusion
Starvation, Salicylate overdose
Causes of metabolic acidosis with a normal anion gap (HARDASS):
Hyperalimentation
Addison’s disease
Renal tubular acidosis (RTA)
Diarrhea, ileostomies, fistula.
Acetazolamide
Page - 1495
Spironolactone
Saline infusion
Page - 1496
Question 5/96
Question #5
A 72-year-old female sustained a femoral neck fracture 10 days ago. She presents today with
shortness of breath, tachypnea, and tachycardia. In addition, her right calf is swollen, tender, red,
and hot. What is the most likely ABGs finding in this situation?
a. Ph 7.30, PaCO2 15 mmHg, PaO2 100 mmHg

b. Ph 7.32, PaCO2 40 mmHg, PaO2 70mmHg
c. Ph 7.47, PaCO2 20 mmHg, PaO2 140 mmHg
d. Ph 7.30, PaCO2 60 mmHg, PaO2 150 mmHg
e. Ph 7.56, PaCO2 17 mmHg, PaO2 60 mmHg
Page - 1497
Question 5/96
Question #5
A 72-year-old female sustained a femoral neck fracture 10 days ago. She presents today with
shortness of breath, tachypnea, and tachycardia. In addition, her right calf is swollen, tender, red,
and hot. What is the most likely ABGs finding in this situation?

e. Ph 7.56, PaCO2 17 mmHg, PaO2 60 mmHg √
Description
e patient has a high probability of pulmonary embolism, which manifests as respiratory alkalosis
and hypoxia. erefore, choice (e) fits well with the diagnosis.
Page - 1498
Question 6/96
Question #6
e following diseases are matched correctly with their ABGs finding except:
a. Severe asthma and respiratory acidosis

b. Mild asthma and respiratory alkalosis
c. DKA and non-anion gap metabolic acidosis
d. Vomiting and metabolic alkalosis
e. Obstructive sleep apnea and respiratory acidosis
Page - 1499
Question 6/96
Question #6
e following diseases are matched correctly with their ABGs finding except:
a. Severe asthma and respiratory acidosis

b. Mild asthma and respiratory alkalosis
c. DKA and non-anion gap metabolic acidosis √
d. Vomiting and metabolic alkalosis
e. Obstructive sleep apnea and respiratory acidosis
Description
Diabetic ketoacidosis (DKA) manifests as high anion gap metabolic acidosis.
Causes of metabolic acidosis with wide anion gap (MUD PILS):
Methanol overdose
Uremia: renal failure
DKA
Phosphate, paraldehyde, propylene glycol
Ischemia
Lactate: hypotension, hypoperfusion
Starvation, Salicylate overdose
Causes of metabolic acidosis with a normal anion gap (HARDASS):
Hyperalimentation
Addison’s disease
Renal tubular acidosis (RTA)
Diarrhea, ileostomies, fistula.
Acetazolamide
Spironolactone
Saline infusion
Causes of metabolic alkalosis:
Page - 1500
GI loss of acid: vomiting, NG tube suction
Increased aldosterone: Conn’s, Cushing’s
Diuretics and Hypokalemia
Milk-alkali syndrome: high-volume liquid antacids
Causes of respiratory alkalosis:
Anemia
Anxiety and Pain
Fever
Interstitial lung disease
Pulmonary embolism
Mild Asthma
Causes of respiratory acidosis:
COPD
Drowning
Opiate overdose
Kyphoscoliosis
Sleep apnea
Life-threatening Asthma
Page - 1501
Question 7/96
Question #7
A 29-year-old man with type 1 diabetes presented to the emergency room complaining of abdominal
pain and vomiting for several hours. Has arterial blood gas been PH 7.35, PaCO2 23 mmHg, HCO3 10
mEq/L. what is the acid base condition he has?
a. Compensated metabolic acidosis

b. Uncompensated metabolic acidosis
c. Compensated metabolic alkalosis
d. Uncompensated respiratory acidosis
e. Compensated respiratory alkalosis
Page - 1502
Question 7/96
Question #7
A 29-year-old man with type 1 diabetes presented to the emergency room complaining of abdominal
pain and vomiting for several hours. Has arterial blood gas been PH 7.35, PaCO2 23 mmHg, HCO3 10
mEq/L. what is the acid base condition he has?
a. Compensated metabolic acidosis √

b. Uncompensated metabolic acidosis
c. Compensated metabolic alkalosis
d. Uncompensated respiratory acidosis
e. Compensated respiratory alkalosis
Description
is patient is most likely complaining of DKA.
Regardless of his condition, the question is focusing on the ABGs interpretation.
Low HCO3 here is the primary abnormality making the answer is metabolic acidosis.
e PH in compensated cases will return to near normal results and in this case it is 7.35 which
makes is compensated metabolic acidosis.
e expected PaCO2 here is (1.5*10 + 8) = 23.
Page - 1503
Question 8/96
Question #8
A 75-year-old male patient with shortness of breath and general weakness was investigated at the
ER. His ABGs results are pH 7.16, HCO3 16 mmol/L, PaCO2 32 mmHg, PO2 90 mmHg, serum urea 90
mg/dL, creatinine 4 mg/dL. What is the most likely interpretation?
a. Metabolic acidosis
b. Respiratory acidosis
c. Metabolic acidosis and respiratory acidosis
d. Normal ABGs
e. No adequate information
Page - 1504
Question 8/96
Question #8
A 75-year-old male patient with shortness of breath and general weakness was investigated at the
ER. His ABGs results are pH 7.16, HCO3 16 mmol/L, PaCO2 32 mmHg, PO2 90 mmHg, serum urea 90
mg/dL, creatinine 4 mg/dL. What is the most likely interpretation?
a. Metabolic acidosis √
b. Respiratory acidosis
c. Metabolic acidosis and respiratory acidosis
d. Normal ABGs
e. No adequate information
Description
is is a case of metabolic acidosis
PH shows acidosis
e PaCO2 (same direction) – metabolic
e estimated PaCO2 = the actual PaCO2
Page - 1505
Question 9/96
Question #9
A lady develops a severe anxiety attack aer a stressful event. What is the most likely ABGs finding
in this scenario?

Page - 1506
Question 9/96
Question #9
A lady develops a severe anxiety attack aer a stressful event. What is the most likely ABGs finding
in this scenario?

c. Ph 7.47, PaCO2 20 mmHg, PaO2 140 mmHg √
Description
is patient has hyperventilation syndrome, resulting in respiratory alkalosis without hypoxia or
even high PaO2. erefore, choice (c) fits with the diagnosis.
Page - 1507
Question 10/96
Question #10
You are reviewing a patient with acute kidney injury. His lab results show the following: elevated
urea and creatinine, serum sodium of 150 mEq/L, serum potassium of 5.1 mEq/L, FENa is 0.70%,
specific gravity is 1030, and urine osmolality is 850 mOsm/kg. What is the most likely cause of AKI in
this patient?
a. Drug-induced
b. Rhabdomyolysis
c. Hemolytic anemia
d. Post-renal obstruction
e. Renal hypoperfusion
Page - 1508
Internal Medicine - Nephrology - Acute Kidney Injury (AKI)
Question 10/96
Question #10
You are reviewing a patient with acute kidney injury. His lab results show the following: elevated
urea and creatinine, serum sodium of 150 mEq/L, serum potassium of 5.1 mEq/L, FENa is 0.70%,
specific gravity is 1030, and urine osmolality is 850 mOsm/kg. What is the most likely cause of AKI in
this patient?
a. Drug-induced
b. Rhabdomyolysis
c. Hemolytic anemia
d. Post-renal obstruction
e. Renal hypoperfusion √
Description
e presence of low FENa (<1%), high urine osmolality, and specific gravity strongly suggest pre-renal
etiology of the acute kidney injury.
e following table dierentiates pre-renal vs. acute tubular necrosis according to urine chemistry.
Page - 1509
Question 11/96
Question #11
An epileptic 35-year-old male patient was admitted to the hospital for generalized weakness,
muscle pains, and red urine. However, the day before admission he had an episode of convulsions.
Unfortunately, he developed elevated kidney function. What is the most likely finding in his urine
chemistry in this situation?
a. Urine osmolality of 65m mOsm/L

b. Specific gravity of 1035
c. Urine sodium of 15 mEq/L
d. Fractional sodium excretion of 4%
e. Fractional urea excretion of 25%
Page - 1510
Question 11/96
Question #11
An epileptic 35-year-old male patient was admitted to the hospital for generalized weakness,
muscle pains, and red urine. However, the day before admission he had an episode of convulsions.
Unfortunately, he developed elevated kidney function. What is the most likely finding in his urine
chemistry in this situation?
a. Urine osmolality of 65m mOsm/L

b. Specific gravity of 1035
c. Urine sodium of 15 mEq/L
d. Fractional sodium excretion of 4% √
e. Fractional urea excretion of 25%
Description
is is a typical scenario of rhabdomyolysis complicated by acute tubular necrosis (ATN).
In ATN the urinary osmolality and specific gravity will be reduced and equal to that of the patient’s
plasma (isosthenuria)
In ATN, the urinary sodium and the fractional excretion of sodium and the fractional excretion of
sodium and urea will be high due to loss of reabsorption function of the necrotic tubular cells.
e following table demonstrates the dierence between prerenal acute kidney injury and Acute
tubular necrosis.
Page - 1511
Question 12/96
Question #12
A 30-year-old male patient presents to you with macular skin rash, arthralgia, and fever. He thinks
his condition started 6 days ago with a streptococcal throat infection confirmed by culture and
treated with penicillin. His lab tests show deterioration of renal function, eosinophilia, proteinuria,
and eosinophiluria. However, his urinary protein excretion is 700 mg/day, and no RBC casts are in his
urine. What is the most likely diagnosis?
a. Post-streptococcal glomerulonephritis
b. IgA nephropathy
c. Membranous glomerulonephritis
d. Drug-induced interstitial nephritis
e. Polyarteritis nodosa
Page - 1512
Question 12/96
Question #12
A 30-year-old male patient presents to you with macular skin rash, arthralgia, and fever. He thinks
his condition started 6 days ago with a streptococcal throat infection confirmed by culture and
treated with penicillin. His lab tests show deterioration of renal function, eosinophilia, proteinuria,
and eosinophiluria. However, his urinary protein excretion is 700 mg/day, and no RBC casts are in his
urine. What is the most likely diagnosis?
b. IgA nephropathy
d. Drug-induced interstitial nephritis √
e. Polyarteritis nodosa
Description
Penicillin is one of the causes of acute interstitial nephritis (AIN).
e presence of arthralgia, skin rash, fever, renal impairment, eosinophilia, and eosinophiluria are
typical of AIN
70% of AIN cases are caused by hypersensitivity to a medication
Causes of AIN:
Drugs (70%) – (Penicillin, PPI’s, Phenytoin, Cephalosporin, Sulfa drugs, Rifampicin, NSAIDs,
Furosemide, Quinolones, streptomycin, Allopurinol).
Systemic diseases (SLE, sarcoidosis, multiple myeloma, Sjögren’s syndrome)
Infections (streptococci, TB, CMV)
Page - 1513
Question 13/96
Question #13
A 44-year-old male patient came with recurrent severe diarrhea and dehydration. His lab
investigations demonstrate serum creatinine of 3.0 mg/dL, urine sodium of 45 mEq/L, urine
osmolality of 270 mOsm/L, and fractional sodium excretion of 3%. What is the most likely
diagnosis?
a. Prerenal acute kidney injury

b. Acute tubular necrosis
c. Acute interstitial nephritis
d. IgA nephropathy
e. Membranous glomerulopathy
Page - 1514
Question 13/96
Question #13
A 44-year-old male patient came with recurrent severe diarrhea and dehydration. His lab
investigations demonstrate serum creatinine of 3.0 mg/dL, urine sodium of 45 mEq/L, urine
osmolality of 270 mOsm/L, and fractional sodium excretion of 3%. What is the most likely
diagnosis?
a. Prerenal acute kidney injury

b. Acute tubular necrosis √
d. IgA nephropathy
e. Membranous glomerulopathy
Description
For the first impression, the history of recurrent diarrhea and dehydration may lead to the diagnosis
of prerenal acute kidney injury, but the urine chemistry do not fit with the diagnosis.
e presence of untreated prerenal AKI may lead to intra-renal acute tubular necrosis (ischemic
type).
e following table demonstrates the dierence between prerenal acute kidney injury and Acute
tubular necrosis:
Page - 1515
Question 14/96
Question #14
An athletic female develops muscle aches and weakness aer a day of vigorous training. Her urine is
positive for myoglobin, and her creatinine kinase level is significantly elevated. In addition, her
kidney function is deteriorating. What is the most likely cause of elevated creatinine kinase in this
patient?
a. Renal impairment
b. Renal tubular cell damage
c. Muscle destruction
d. Urinary tract infection
e. Myocardial infarction
Page - 1516
Question 14/96
Question #14
An athletic female develops muscle aches and weakness aer a day of vigorous training. Her urine is
positive for myoglobin, and her creatinine kinase level is significantly elevated. In addition, her
kidney function is deteriorating. What is the most likely cause of elevated creatinine kinase in this
patient?
a. Renal impairment
b. Renal tubular cell damage
c. Muscle destruction √
e. Myocardial infarction
Description
Rhabdomyolysis occurs due to severe destruction or necrosis of the muscles, which leads to a release
of a large amount of myoglobin which has a toxic eect on renal tubules
Vigorous exercise in this patient is a precipitant.
In a patient with known precipitant, renal impairment and myoglobinuria indicate the disease.
e muscle cells contain a significant amount of creatinine kinase (CK); therefore, CK is elevated
because the muscle destruction
Page - 1517
Question 15/96
Question #15
Aer a day of vigorous training, a tennis player develops weakness, muscle pain, and red urine. His
serum creatinine kinase was significantly elevated, his creatinine level was 1.9mg/dL, and his serum
potassium was 6.9 mEq/L. His ECG shows wide QRS, peaked T wave, and small P. What is the most
important initial management in this patient?

b. Intravenous insulin and glucose
d. Hemodialysis
e. Pain relief with diclofenac sodium
Page - 1518
Question 15/96
Question #15
Aer a day of vigorous training, a tennis player develops weakness, muscle pain, and red urine. His
serum creatinine kinase was significantly elevated, his creatinine level was 1.9mg/dL, and his serum
potassium was 6.9 mEq/L. His ECG shows wide QRS, peaked T wave, and small P. What is the most
important initial management in this patient?

b. Intravenous insulin and glucose
c. Intravenous calcium gluconate √
d. Hemodialysis
e. Pain relief with diclofenac sodium
Description
Vigorous exercise in this patient is a precipitant.
ECG is the most urgent step to do (to rule out arrhythmia secondary to hyperkalemia).
is patient has confirmed hyperkalemia with ECG changes that may lead to arrhythmia and death.
So, the patient should receive calcium gluconate as soon as possible to stabilize the cell membrane
and reduce the risk of arrhythmia.
Intravenous normal saline is indicated to reduce the contact time of myoglobin with the renal
tubular cells to reduce nephrotoxicity.
Hemodialysis is indicated only in hyperkalemia ≥ 7, which is refractory to treatment.
Insulin is the most eective step to reduce serum potassium but calcium gluconate, to prevent
arrhythmia, is a more important step.
Diclofenac sodium should be avoided because it exacerbates nephrotoxicity and worsens this
condition.
Page - 1519
Page - 1520
Question 16/96
Question #16
A diabetic 66-year-old female is suspected of pulmonary embolism, and you would like to order CT
pulmonary angiography. What is the most appropriate to prevent contrast-induced nephropathy in
this patient?
a. Diabetic control with metformin and insulin before imaging

b. Administrate furosemide intravenously
c. intravenous steroids
d. Intravenous 0.9% saline
Page - 1521
Question 16/96
Question #16
A diabetic 66-year-old female is suspected of pulmonary embolism, and you would like to order CT
pulmonary angiography. What is the most appropriate to prevent contrast-induced nephropathy in
this patient?

d. Intravenous 0.9% saline √
Description
Contrast-induced nephropathy is preventable by good hydration because the condition is more

likely to develop in dehydrated patients.
e best practice is to administer normal saline 0.9% 12 before the contrast administration and
continue for 24 hours at a rate of 1ml/kg/hour.
N-Acetylcysteine is another option used in medical practice.
Page - 1522
Question 17/96
Question #17
Which of the following drugs should be held before intravenous contrast media administration?
a. Metformin
b. Paracetamol
c. Insulin
d. Glyburide
e. Pioglitazone
Page - 1523
Question 17/96
Question #17
Which of the following drugs should be held before intravenous contrast media administration?
a. Metformin √
b. Paracetamol
c. Insulin
d. Glyburide
e. Pioglitazone
Description
e elimination of metformin primarily occurs in the kidneys.
It should be held before intravenous contrast media administration because of the risk of
exacerbation of renal impairment and lactic acidosis.
Page - 1524
Question 18/96
Question #18
A 60-year-old male patient was admitted with a case of acute kidney injury. His renal biopsy
confirms the presence of acute interstitial nephritis (AIN). What is the most common cause of this
condition?
a. Diabetes mellitus
b. Hypertension
c. Renal hypoperfusion
d. Hypersensitivity to medication
e. Infectious process
Page - 1525
Question 18/96
Question #18
A 60-year-old male patient was admitted with a case of acute kidney injury. His renal biopsy
confirms the presence of acute interstitial nephritis (AIN). What is the most common cause of this
condition?
a. Diabetes mellitus
b. Hypertension
c. Renal hypoperfusion
d. Hypersensitivity to medication √
e. Infectious process
Description
Although infection and systemic disorders like SLE, sarcoidosis, and Sjögren’s syndrome can cause
acute interstitial nephritis, 70% of the cases result from hypersensitivity to drugs.
Causes of AIN:
Drugs (70%) – (Penicillin, PPI’s, Phenytoin, Cephalosporin, Sulfa drugs, Rifampicin, NSAIDs,
Furosemide, Quinolones, streptomycin, Allopurinol).
Systemic diseases (SLE, sarcoidosis, multiple myeloma, Sjögren’s syndrome)
Infections (streptococci, TB, CMV)
Page - 1526
Question 19/96
Question #19
A previously healthy 32-year-old lady developed an antepartum hemorrhage 3 days ago, requiring a
massive blood transfusion. Today, her serum creatinine is 4.1 mg/dL, and her serum potassium is 5
mEq/L. What is the most likely diagnosis?
a. Rhabdomyolysis
b. Acute tubular necrosis
d. Addison crisis
e. Sheehan syndrome
Page - 1527
Question 19/96
Question #19
A previously healthy 32-year-old lady developed an antepartum hemorrhage 3 days ago, requiring a
massive blood transfusion. Today, her serum creatinine is 4.1 mg/dL, and her serum potassium is 5
mEq/L. What is the most likely diagnosis?
a. Rhabdomyolysis
b. Acute tubular necrosis √
d. Addison crisis
e. Sheehan syndrome
Description
e elevated creatinine in a previously healthy patient is a characteristic of acute renal failure
is patient had massive bleeding and renal hypoperfusion, which later resulted in ischemic acute
tubular necrosis (ATN)
Page - 1528
Question 20/96
Question #20
An alcoholic 22-year-old male patient was found unconscious on the floor and brought to the
emergency department. He was very confused and disoriented; his blood pressure was 110/70, and
his pulse was 90bpm. His lab investigations demonstrate a creatinine level of 10 mg/dL, serum
potassium of 6 mEq/L, and the urine dipstick shows hematuria. What is the best investigation to
perform next?

b. Creatinine kinase level
c. Renal ultrasound
d. Renal biopsy
e. Serum amylase level
Page - 1529
Question 20/96
Question #20
An alcoholic 22-year-old male patient was found unconscious on the floor and brought to the
emergency department. He was very confused and disoriented; his blood pressure was 110/70, and
his pulse was 90bpm. His lab investigations demonstrate a creatinine level of 10 mg/dL, serum
potassium of 6 mEq/L, and the urine dipstick shows hematuria. What is the best investigation to
perform next?

b. Creatinine kinase level √
c. Renal ultrasound
d. Renal biopsy
e. Serum amylase level
Description
Prolonged immobility in this patient is a precipitant.
Note that myoglobin has heme that results in a positive dipstick for RBCs, but microscopy will fail to
show any RBCs in the urine in the case of myoglobinuria
In the case of rhabdomyolysis, creatinine kinase level will be elevated to more than three times the
normal upper limit.
Page - 1530
Question 21/96
Question #21
A 30-year-old male patient was rescued aer being trapped under heavy rocks for 12 hours aer a
building had fallen in an earthquake. His urine dipstick shows red urine with numerous RBCs, but
urine microscopy shows no erythrocytes. In addition, his creatinine is 1.5 mg/dL, but he has normal
serum electrolyte levels. What is the most likely cause of his elevated creatinine?
a. Pre-renal acute renal failure

b. Rhabdomyolysis
c. Postrenal obstruction
d. Direct renal injury
e. Normal kidney function
Page - 1531
Question 21/96
Question #21
A 30-year-old male patient was rescued aer being trapped under heavy rocks for 12 hours aer a
building had fallen in an earthquake. His urine dipstick shows red urine with numerous RBCs, but
urine microscopy shows no erythrocytes. In addition, his creatinine is 1.5 mg/dL, but he has normal
serum electrolyte levels. What is the most likely cause of his elevated creatinine?
a. Pre-renal acute renal failure

b. Rhabdomyolysis √
c. Postrenal obstruction
d. Direct renal injury
e. Normal kidney function
Description
In crush injury, reperfusion injury may occur to any limb aer being released leading to more
damage and rhabdomyolysis.
Myoglobin released from the damaged muscles is spelled into the circulation. Note that myoglobin
has heme that results in a positive dipstick for RBCs, but microscopy will fail to show any RBCs in the
urine in the case of myoglobinuria.
Myoglobin is nephrotoxic and can lead to acute tubular necrosis, renal impairment, electrolyte
disturbances, and maybe death.
Page - 1532
Question 22/96
Question #22
A 39-year-old female had gastric sleeve surgery 1 week ago. She has recurrent vomiting, which
occurs almost aer eating or drinking anything. Today she presents to you with dizziness when
standing and general fatigue. Her physical examination is significant for moderate dehydration,
blood pressure of 90/49 mmHg, and pulse of 105 bpm. Her lab results show serum creatinine of 2.3
mg/dL, urea of 90 mg/dL, and normal electrolytes. What is the most appropriate initial therapy at
this time?
a. Intravenous furosemide
b. Blood transfusion
c. Start dopamine (renal dose)
d. Intravenous fluid
e. Hemodialysis
Page - 1533
Question 22/96
Question #22
A 39-year-old female had gastric sleeve surgery 1 week ago. She has recurrent vomiting, which
occurs almost aer eating or drinking anything. Today she presents to you with dizziness when
standing and general fatigue. Her physical examination is significant for moderate dehydration,
blood pressure of 90/49 mmHg, and pulse of 105 bpm. Her lab results show serum creatinine of 2.3
mg/dL, urea of 90 mg/dL, and normal electrolytes. What is the most appropriate initial therapy at
this time?
a. Intravenous furosemide
b. Blood transfusion
c. Start dopamine (renal dose)
d. Intravenous fluid √
e. Hemodialysis
Description
is is a clear condition of pre-renal acute kidney injury (AKI)
e presence of vomiting, dehydration, and hypotension followed by renal failure is a typical

scenario of AKI.
e priority is to restore circulation and renal perfusion by intravenous fluid.
e patient is not a candidate for hemodialysis at this time (no indication)
Blood transfusion is indicated when the cause is bleeding (hypovolemic shock), which is not the
scenario in this case.
Page - 1534
Question 23/96
Question #23
A 55-year-old diabetic male patient presents with typical chest pain, ST elevation on ECG, and
positive cardiac enzymes. You transferred him to the cardiac unit for PCI. What is the most
appropriate measure to prevent renal impairment secondary to contrast use in PCI?

d. Intravenous 0.9% saline
e. N-acetylcysteine
Page - 1535
Question 23/96
Question #23
A 55-year-old diabetic male patient presents with typical chest pain, ST elevation on ECG, and
positive cardiac enzymes. You transferred him to the cardiac unit for PCI. What is the most
appropriate measure to prevent renal impairment secondary to contrast use in PCI?

d. Intravenous 0.9% saline √
e. N-acetylcysteine
Description

Page - 1536
Question 24/96
Question #24
A diabetic 66-year-old female is suspected of having a pulmonary embolism, and you would like to
order CT pulmonary angiography. What is the most appropriate to prevent contrast-induced
nephropathy in this patient?
a. Reduce the dose of contrast

c. ACE inhibitors
d. Plenty of fluid
e. Intravenous dextrose
Page - 1537
Question 24/96
Question #24
A diabetic 66-year-old female is suspected of having a pulmonary embolism, and you would like to
order CT pulmonary angiography. What is the most appropriate to prevent contrast-induced
nephropathy in this patient?
a. Reduce the dose of contrast

c. ACE inhibitors
d. Plenty of fluid √
e. Intravenous dextrose
Description

Page - 1538
Question 25/96
Question #25
During the routine annual screening of a diabetic 55-year-old male patient, you found an
albumin:creatinine ratio of 3.2. However, his blood pressure is 115/65. What is the most appropriate
treatment?
a. Start oral enalapril

b. Tight glycemic control only
c. Start oral nifedipine
d. Start oral carvedilol
e. Reassurance and follow-up aer 1 year
Page - 1539
Internal Medicine - Nephrology - Chronic Kidney disease (CKD)
Question 25/96
Question #25
During the routine annual screening of a diabetic 55-year-old male patient, you found an
albumin:creatinine ratio of 3.2. However, his blood pressure is 115/65. What is the most appropriate
treatment?
a. Start oral enalapril √

b. Tight glycemic control only
c. Start oral nifedipine
d. Start oral carvedilol
e. Reassurance and follow-up aer 1 year
Description
Persistent albuminuria of 30 – 299 mg/day (previously called microalbuminuria) is an early sign of

diabetic nephropathy
Albumin:creatinine ratio of more than 2.5 indicates microalbuminuria.
Screening: by albumin creatinine ratio (ACR):
It should be done annually for all patients

It should be done by the early morning specimen
ACR > 2.5 is considered microalbuminuria
Management:
Diabetic control is the most important step in the management

Strict blood pressure control (< 140/90)
ACE inhibitors or ARBs are the treatments of choice to reduce the progression of the disease
and to reduce the level of microalbuminuria
e strict control of dyslipidemia
Page - 1540
Question 26/96
Question #26
A 55-year-old male patient with Type 2 DM presents for a routine checkup. Which of the following is
the best test to screen for diabetic nephropathy?
a. Urinalysis for proteinuria

b. Renal ultrasound
c. Creatinine and glomerular filtration rate (GFR)
d. Urinary albumin:creatinine ratio
e. HbA1C level
Page - 1541
Question 26/96
Question #26
A 55-year-old male patient with Type 2 DM presents for a routine checkup. Which of the following is
the best test to screen for diabetic nephropathy?
a. Urinalysis for proteinuria

b. Renal ultrasound
c. Creatinine and glomerular filtration rate (GFR)
d. Urinary albumin:creatinine ratio √
e. HbA1C level
Description
Persistent albuminuria of 30 – 299 mg/day (previously called microalbuminuria) is an early sign of

diabetic nephropathy
Albumin:creatinine ratio of more than 2.5 indicates microalbuminuria.
Screening: by albumin creatinine ratio (ACR):

Note that GFR will be elevated in the early stages of diabetic nephropathy (hyperfiltration), so it is
not a good predictor in this case
Urinalysis can’t detect microalbuminuria and is not used for the screening of this patient
Renal ultrasound may show enlarged kidneys, but this is not specific and has no value in screening
DM nephropathy.
Page - 1542
Question 27/96
Question #27
About diabetic nephropathy, all the following are true except:
a. e rate of progression of renal impairment can be reduced with the use of ACE inhibitors or ARBs
b. Microalbuminuria is defined as persistent proteinuria of 30 – 299 mg/day
c. Hyperfiltration is the earliest sign of diabetic nephropathy
d. e disease primarily aects the glomeruli
e. Annual screening for microalbuminuria is done by urinalysis
Page - 1543
Question 27/96
Question #27
About diabetic nephropathy, all the following are true except:
a. e rate of progression of renal impairment can be reduced with the use of ACE inhibitors or ARBs
b. Microalbuminuria is defined as persistent proteinuria of 30 – 299 mg/day
c. Hyperfiltration is the earliest sign of diabetic nephropathy
d. e disease primarily aects the glomeruli
e. Annual screening for microalbuminuria is done by urinalysis √
Description
Persistent albuminuria 30–299 mg/day (Microalbuminuria)
Occurs aer 5 – 10 years aer DM onset

May progress to macroalbuminuria (≥ 300 mg/day)
It can’t be detected by urinalysis
Screening for diabetic nephropathy is recommended by albumin creatinine ratio (ACR):

Page - 1544
Question 28/96
Question #28
A 55-year-old male patient has been a known case of chronic kidney disease (CKD) for a long time. He
presents with fatigue, and his physical examination shows pallor. His anemia workup demonstrates
normal serum iron and ferritin, normocytic anemia of 8g/dL, and normal B12 and folate. What is the
most eective treatment in this scenario?
a. Folate supplementation
b. B12 supplementation
c. Iron supplementation
d. Erythropoietin administration
e. Hemodialysis
Page - 1545
Question 28/96
Question #28
A 55-year-old male patient has been a known case of chronic kidney disease (CKD) for a long time. He
presents with fatigue, and his physical examination shows pallor. His anemia workup demonstrates
normal serum iron and ferritin, normocytic anemia of 8g/dL, and normal B12 and folate. What is the
most eective treatment in this scenario?
a. Folate supplementation
b. B12 supplementation
c. Iron supplementation
d. Erythropoietin administration √
e. Hemodialysis
Description
In patients with CKD, the endocrine function of the kidney is impaired, and erythropoietin (EPO)
production is reduced. is will result in normocytic anemia, called anemia of chronic disease.
e treatment of choice for anemia of chronic disease in the presence of normal ferritin level is
erythropoietin (EPO) administration.
Iron supplementation should be given before EPO administration if low serum ferritin is present.
Page - 1546
Question 29/96
Question #29
A 48-year-old male patient with a history of chronic kidney disease presents with bone pain. Aer an
appropriate workup, you diagnosed him with hypocalcemia and vitamin D deficiency. Which of the
following is the main cause of vitamin D deficiency in CKD patients?
a. Reduced vitamin D absorption from the gut

b. Reduced 25(OH)D3 level
c. Reduced 1,25(OH)D3 activity
d. Reduced transformation of dehydrocholesterol to calciferol in the skin
e. Excessive vitamin D loss in urine
Page - 1547
Question 29/96
Question #29
A 48-year-old male patient with a history of chronic kidney disease presents with bone pain. Aer an
appropriate workup, you diagnosed him with hypocalcemia and vitamin D deficiency. Which of the
following is the main cause of vitamin D deficiency in CKD patients?
a. Reduced vitamin D absorption from the gut

b. Reduced 25(OH)D3 level
c. Reduced 1,25(OH)D3 activity √
d. Reduced transformation of dehydrocholesterol to calciferol in the skin
e. Excessive vitamin D loss in urine
Description
e enzyme 1-alpha-hydroxylase in the kidneys is responsible for the hydroxylation of 25(oh)D3 to

become the active form of vitamin D “1.25(OH)D3”.
In the case of CKD, this enzyme is reduced, leading to reduced levels of the active form of vitamin D
“1,25(OH)D3”.
In the case of CKD, vitamin D replacement with active 1,25(OH)D3 or a related analog, along with
calcium supplementation, are required to prevent hypocalcemia and bone pain.
Page - 1548
Question 30/96
Question #30
A 55-year-old male patient has a history of chronic kidney disease and DM. he presents with loss of
sensation in his fingers and muscle cramping. His lab investigations show serum sodium of 139
mEq/L, serum potassium of 5.8 mEq/L, serum calcium of 1.5 mmol/L, normal PTH, and alkaline
phosphatase. What is the most likely cause of his symptoms?
a. Hyperkalemia
b. 1,25 (OH)D3 deficiency
c. Metabolic acidosis
e. Hypernatremia
Page - 1549
Question 30/96
Question #30
A 55-year-old male patient has a history of chronic kidney disease and DM. he presents with loss of
sensation in his fingers and muscle cramping. His lab investigations show serum sodium of 139
mEq/L, serum potassium of 5.8 mEq/L, serum calcium of 1.5 mmol/L, normal PTH, and alkaline
phosphatase. What is the most likely cause of his symptoms?
a. Hyperkalemia
b. 1,25 (OH)D3 deficiency √
e. Hypernatremia
Description
is is a typical feature of hypocalcemia.
e enzyme 1-alpha-hydroxylase in the kidneys is responsible for the hydroxylation of 25(oh)D3 to

become the active form of vitamin D “1.25(OH)D3”.
In the case of CKD, this enzyme is reduced, leading to reduced levels of the active form of vitamin D
“1,25(OH)D3” and thus hypocalcemia.
Page - 1550
Question 31/96
Question #31
A 40-year-old male patient is found to have microscopic hematuria of 7 RBCs/hpf. His history and
physical examination are unremarkable. What is the next step in management?
a. Perform renal biopsy

b. 24-hour urinary collection for protein
c. Repeat the test 1 – 2 weeks later
d. Urine culture
e. Cystoscopy
Page - 1551
Internal Medicine - Nephrology - Kidney function test.
Question 31/96
Question #31
physical examination are unremarkable. What is the next step in management?

c. Repeat the test 1 – 2 weeks later √
d. Urine culture
e. Cystoscopy
Description
Description:
When you encounter microscopic hematuria in an otherwise asymptomatic and healthy patient,
you should confirm the diagnosis by repeating the urinalysis 1 – 2 weeks later. If the repeated test
returns as normal, nothing to do.
If the repeat comes back positive for hematuria again, you should identify the cause.
e most common cause is an infection, so urine culture should be done for all hematuria patients.
Note that glomerulonephritis, cancers, trauma, stones, and other pathologies could cause
hematuria, so you should perform your investigations according to your patient’s associated
symptoms and signs.
Page - 1552
Question 32/96
Question #32
A 33-year-old male patient has +1 proteinuria on routine urine dipstick analysis. He has no
symptoms, his vital signs are normal, and he was previously healthy. What is the most appropriate
next step in the management of this patient?
a. Refer to a nephrologist
b. Start Enalapril
c. Perform 24-hour urine collection for protein
d. Perform the same test again
e. No further evaluation
Page - 1553
Question 32/96
Question #32
A 33-year-old male patient has +1 proteinuria on routine urine dipstick analysis. He has no
symptoms, his vital signs are normal, and he was previously healthy. What is the most appropriate
next step in the management of this patient?
a. Refer to a nephrologist
b. Start Enalapril
c. Perform 24-hour urine collection for protein
d. Perform the same test again √
Description
You should repeat the test if the urine dipstick shows trace to +1 proteinuria without other evidence
of renal disease. is is because transient proteinuria and false-positive proteinuria are common.
Transient proteinuria is common in young patients; the following are possible causes of false-
positive or transient proteinuria:
Alkaline urine
Semen, vaginal secretion, or pus in the urine
If the dipstick is immersed for too long
Exercises
If you repeat the test and it is again positive for proteinuria, the next step will be 24-hours urine
collection for protein or protein creatinine ratio.
ACE inhibitors or ARBs are used in diabetic patients with proteinuria.
Referral to a nephrologist is indicated that 24-hour urinary protein is high.
Page - 1554
Question 33/96
Question #33
physical examination are unremarkable. However, you decided to repeat the test 1 week later, and
the result returned positive again. What is the next step in management?

d. Urine culture
e. Cystoscopy
Page - 1555
Question 33/96
Question #33
physical examination are unremarkable. However, you decided to repeat the test 1 week later, and
the result returned positive again. What is the next step in management?

d. Urine culture √
e. Cystoscopy
Description
When you encounter microscopic hematuria in an otherwise asymptomatic and healthy patient,
you should confirm the diagnosis by repeating the urinalysis 1 – 2 weeks later. If the repeated test
returns as normal, then nothing to do.
If the repeat comes back positive for hematuria again, you should identify the cause.
e most common cause is an infection, so urine culture should be done for all hematuria patients.
Note that glomerulonephritis, cancers, trauma, stones, and other pathologies could cause
hematuria, so you should perform your investigations according to your patient’s associated
symptoms and signs.
Page - 1556
Question 34/96
Question #34
On routine examination, a 22-year-old male patient was found to have proteinuria of +2, which was
later confirmed 2 times to be present. You ordered a 24-hour urinary protein split collection, and the
result was 1.9 g/day (Total), normal 8 hours of urine protein excretion at night, and elevated 16 hours
of daytime protein excretion. In addition, creatinine clearance was normal. What is the most likely
diagnosis?
a. Nephrotic syndrome
b. Acute renal impairment
c. Nephritic syndrome
d. Orthostatic proteinuria
e. IgA nephropathy
Page - 1557
Question 34/96
Question #34
On routine examination, a 22-year-old male patient was found to have proteinuria of +2, which was
later confirmed 2 times to be present. You ordered a 24-hour urinary protein split collection, and the
result was 1.9 g/day (Total), normal 8 hours of urine protein excretion at night, and elevated 16 hours
of daytime protein excretion. In addition, creatinine clearance was normal. What is the most likely
diagnosis?
a. Nephrotic syndrome
b. Acute renal impairment
c. Nephritic syndrome
d. Orthostatic proteinuria √
e. IgA nephropathy
Description
You should assess for orthostatic proteinuria for any < 30-year-old patient with < 2g/day proteinuria
and normal creatinine clearance.
Orthostatic proteinuria is a benign condition that occurs in adolescents and young adults.
It is characterized by increased protein excretion during the upright position but normal protein
excretion at the supine position.
Page - 1558
Question 35/96
Question #35
A 40-year-old male presents with generalized edema, hypoalbuminemia, and proteinuria. What is
the most accurate test to reach the final diagnosis?
a. Protein creatinine ratio

b. Urine culture
c. Abdominal CT scan with contrast
d. Renal biopsy
e. Serum total protein level
Page - 1559
Internal Medicine - Nephrology - Nephrotic Syndrome
Question 35/96
Question #35
A 40-year-old male presents with generalized edema, hypoalbuminemia, and proteinuria. What is
the most accurate test to reach the final diagnosis?
a. Protein creatinine ratio

b. Urine culture
c. Abdominal CT scan with contrast
d. Renal biopsy √
e. Serum total protein level
Description
Based on this limited data, the patient is most likely suering from nephrotic syndrome.
To address the cause of Nephrotic Syndrome, the most accurate test to be done is renal biopsy.
Page - 1560
Question 36/96
Question #36
About nephrotic syndrome, the following statements are true except:
a. Diabetes Mellitus is a possible cause

b. Renal vein thrombosis is a known complication
c. Proteinuria is usually > 3.5 g/day
d. Hypoalbuminemia will lead to generalized edema
e. RBC casts and dysmorphic RBCs are characteristic
Page - 1561
Question 36/96
Question #36
About nephrotic syndrome, the following statements are true except:
a. Diabetes Mellitus is a possible cause

b. Renal vein thrombosis is a known complication
c. Proteinuria is usually > 3.5 g/day
d. Hypoalbuminemia will lead to generalized edema
e. RBC casts and dysmorphic RBCs are characteristic √
Description
RBC casts and dysmorphic RBCs are characteristic findings in nephritic (not nephrotic) syndrome
Features of nephrotic syndrome include the following:
Proteinuria > 3.5 grams/day

Hypoalbuminemia leads to edema
Hypercholesterolemia (due to liver compensation)
Decreased renal perfusion due to reduced plasma volume → activation of the renin-angiotensin
system → sodium water retention
Increased risk of infection (due to protein loss)
Hypercoagulability due to:
Loss of anti-thrombin III in urine
Altered levels of protein C and S
Hyperfibrinogenemia (increased hepatic secretion)
Increased platelet tendency to aggregate
Page - 1562
Question 37/96
Question #37
A 70-year-old male patient presents with bilateral lower limb swelling and frothy looking urine. His
medical history is significant for lung cancer for which he receives palliative chemotherapy. On
examination, his blood pressure is 145/80 mmHg, and his pulse is 90 bpm. In addition, his lab
investigations demonstrate hemoglobin of 12g/dL, platelet count of 300 *10^9, WBC of 5 * 10^9,
serum albumin of 19g/L, serum creatinine of 3mg/dL, serum urea of 66 mg/dL, and 24-hour urine
collection for protein is 5 grams. What is the most likely diagnosis?
a. Post-streptococcal Glomerulonephritis
b. IgA nephropathy
d. Focal segmental glomerulosclerosis
e. Minimal change disease
Page - 1563
Question 37/96
Question #37
A 70-year-old male patient presents with bilateral lower limb swelling and frothy looking urine. His
medical history is significant for lung cancer for which he receives palliative chemotherapy. On
examination, his blood pressure is 145/80 mmHg, and his pulse is 90 bpm. In addition, his lab
investigations demonstrate hemoglobin of 12g/dL, platelet count of 300 *10^9, WBC of 5 * 10^9,
serum albumin of 19g/L, serum creatinine of 3mg/dL, serum urea of 66 mg/dL, and 24-hour urine
collection for protein is 5 grams. What is the most likely diagnosis?
a. Post-streptococcal Glomerulonephritis
b. IgA nephropathy
c. Membranous glomerulonephritis √
e. Minimal change disease
Description
e patient has nephrotic range proteinuria, lower limb swellings, and hypoalbuminemia. erefore,
he has a nephrotic syndrome.
e indication for the diagnosis of membranous glomerulonephritis here is the presence of

malignancy.
Malignancy can cause secondary membranous nephropathy, and the presence of nephrotic
syndrome in elderly patients increases the likelihood of malignancy.
Page - 1564
Question 38/96
Question #38
Which is considered the most common cause of secondary nephrotic syndrome?
a. Amyloidosis
b. Multiple myeloma
c. Diabetes mellitus
d. Hepatitis C
e. Post-infectious state
Page - 1565
Question 38/96
Question #38
Which is considered the most common cause of secondary nephrotic syndrome?
a. Amyloidosis
b. Multiple myeloma
c. Diabetes mellitus √
d. Hepatitis C
e. Post-infectious state
Description
DM is the most common cause of Nephrotic Syndrome
Features of nephrotic syndrome include the following:
Proteinuria > 3.5 grams/day

Hypoalbuminemia → leads to edemas
Hypercholesterolemia (due to liver compensation)
Decreased renal perfusion due to reduced plasma volume → activation of the renin-angiotensin
system → sodium water retention
Increased risk of infection (due to protein loss)
Hypercoagulability due to:
Loss of anti-thrombin III in urine
Altered levels of protein C and S
Hyperfibrinogenemia (increased hepatic secretion)
Increased platelet tendency to aggregate
Page - 1566
Question 39/96
Question #39
A 24-year-old male patient with a history of chronic kidney disease was recently diagnosed with
HTN and was started on hydrochlorothiazide. What is the best next step in the management of this
patient?
a. Urinary metanephrine level

b. Dexamethasone suppression test
c. Insulin-like growth factor
d. Renal doppler ultrasound
Page - 1567
Internal Medicine - Nephrology - Renal Artery Stenosis
Question 39/96
Question #39
A 24-year-old male patient with a history of chronic kidney disease was recently diagnosed with
HTN and was started on hydrochlorothiazide. What is the best next step in the management of this
patient?
a. Urinary metanephrine level

b. Dexamethasone suppression test
c. Insulin-like growth factor
d. Renal doppler ultrasound √
Description
is patient is most commonly suering from renal artery stenosis and secondary HTN. Consider
renal artery stenosis in a young patient with HTN
Renal artery stenosis:
e most common cause in the elderly is atherosclerosis,

e most common cause in young patients is fibromuscular dysplasia
Suspect RAS if deteriorating renal function (> 30% increase in creatinine) in a patient with HTN
and newly put on ACEI/ARBs
Diagnosis: abdominal bruit (O/E), Doppler U/S, angiography (best)
Treatment: angioplasty with stenting
ACEI is contraindicated in bilateral disease (they lead to an increase in creatinine)
Page - 1568
Question 40/96
Question #40
In a patient with renal artery stenosis, azotemia can develop due to taking which of the following
medications?
a. Nifedipine
b. Doxazocin
c. Valsartan
d. Metoprolol
e. Indapamide
Page - 1569
Question 40/96
Question #40
In a patient with renal artery stenosis, azotemia can develop due to taking which of the following
medications?
a. Nifedipine
b. Doxazocin
c. Valsartan √
d. Metoprolol
e. Indapamide
Description
ACE inhibitors and ARBs can induce renal insuciency in the presence of renal artery stenosis.
Elevation of creatinine > 30% above the baseline aer 1 week of ACE inhibitors or ARBs use should
raise the suspicion of renal artery stenosis.
Renal artery stenosis (RAS):

Page - 1570
Question 41/96
Question #41
A 32-year-old female is seen for refractory HTN. Her physical examination demonstrates abdominal
bruits bilaterally. What is the most likely diagnosis?
a. Pheochromocytoma
c. Cushing syndrome
e. Liddle syndrome
Page - 1571
Question 41/96
Question #41
A 32-year-old female is seen for refractory HTN. Her physical examination demonstrates abdominal
bruits bilaterally. What is the most likely diagnosis?
a. Pheochromocytoma
c. Cushing syndrome
d. Renal artery stenosis √
e. Liddle syndrome
Description
is patient is most commonly suering from renal artery stenosis and secondary HTN
Consider renal artery stenosis in a young patient with HTN

Page - 1572
Question 42/96
Question #42
In a 40-year-old male patient with severe HTN and renal failure, which of the following is the most
appropriate to reach the diagnosis?
a. Renal ultrasonography
b. Brain CT scan with contrast
c. Renal doppler scan
d. Renal biopsy
e. Urinary metanephrine levels
Page - 1573
Question 42/96
Question #42
In a 40-year-old male patient with severe HTN and renal failure, which of the following is the most
appropriate to reach the diagnosis?
a. Renal ultrasonography
c. Renal doppler scan √
d. Renal biopsy
e. Urinary metanephrine levels
Description
Suspect renal artery stenosis in a young patient with HTN and renal impairment.

Page - 1574
Question 43/96
Question #43
Which of the following options best states the pathophysiology of renal artery stenosis?
a. Renin ↑, Angiotensin II ↓, Aldosterone ↑, Sodium excretion ↓, Renal blood flow ↓

b. Renin ↓, Angiotensin II ↑, Aldosterone ↓, Sodium excretion ↓, Renal blood flow ↓
c. Renin ↑, Angiotensin II ↑, Aldosterone ↑, Sodium excretion ↓, Renal blood flow ↓
d. Renin ↑, Angiotensin II ↑, Aldosterone ↑, Sodium excretion ↑, Renal blood flow ↓
e. Renin ↑, Angiotensin II ↑, Aldosterone ↑, Sodium excretion ↓, Renal blood flow ↑
Page - 1575
Question 43/96
Question #43
Which of the following options best states the pathophysiology of renal artery stenosis?
a. Renin ↑, Angiotensin II ↓, Aldosterone ↑, Sodium excretion ↓, Renal blood flow ↓

b. Renin ↓, Angiotensin II ↑, Aldosterone ↓, Sodium excretion ↓, Renal blood flow ↓
c. Renin ↑, Angiotensin II ↑, Aldosterone ↑, Sodium excretion ↓, Renal blood flow ↓ √
d. Renin ↑, Angiotensin II ↑, Aldosterone ↑, Sodium excretion ↑, Renal blood flow ↓
e. Renin ↑, Angiotensin II ↑, Aldosterone ↑, Sodium excretion ↓, Renal blood flow ↑
Description
In renal artery stenosis, there will be a reduction in the blood supply to the kidney due to the
stenosed artery (reduced renal flow)
e reduction in the renal flow will result in renin-angiotensin-aldosterone system activation; this
means high renin, high angiotensin, and high aldosterone levels
e high aldosterone level will lead to sodium and water retention, i.e., reduced-sodium urinary
excretion.
GFR is maintained in the early phase of the disease.
Page - 1576
Question 44/96
Question #44
A 72-year-old male patient with chronic kidney disease (baseline creatinine is 1.4 mg/dL) and HTN
was started on Enalapril 10 mg for uncontrolled blood pressure. 2 weeks later, his blood pressure
was found to be 145/92, and his serum creatinine level was found to be 4 mg/dL. What is the most
appropriate step in the management of this patient?
a. Stop Enalapril and start valsartan

b. Stop enalapril and perform renal doppler ultrasound
c. Increase the dose of enalapril
d. No change in his medications
e. Hemodialysis
Page - 1577
Question 44/96
Question #44
A 72-year-old male patient with chronic kidney disease (baseline creatinine is 1.4 mg/dL) and HTN
was started on Enalapril 10 mg for uncontrolled blood pressure. 2 weeks later, his blood pressure
was found to be 145/92, and his serum creatinine level was found to be 4 mg/dL. What is the most
appropriate step in the management of this patient?
a. Stop Enalapril and start valsartan

b. Stop enalapril and perform renal doppler ultrasound √
c. Increase the dose of enalapril
d. No change in his medications
e. Hemodialysis
Description
Suspect renal artery stenosis when deteriorating renal function (> 30% increase in creatinine aer 1
week) in a patient with HTN and newly put on ACEI/ARB

Page - 1578
Question 45/96
Question #45
A 32-year-old male patient has recurrent hematuria related to an upper respiratory infection. Today,
he presented with a fever and sore throat for 2 days, and was again associated with hematuria. His
blood pressure is 175/99 mmHg. His urine test shows numerous RBCs, heavy proteinuria, and RBC
casts. What is the most likely diagnosis?
b. Acute interstitial nephritis
c. IgA nephropathy
e. Membranous glomerulonephritis
Page - 1579
Internal Medicine - Nephrology - Renal glomerular diseases
Question 45/96
Question #45
he presented with a fever and sore throat for 2 days, and was again associated with hematuria. His
blood pressure is 175/99 mmHg. His urine test shows numerous RBCs, heavy proteinuria, and RBC
casts. What is the most likely diagnosis?
b. Acute interstitial nephritis
c. IgA nephropathy √
e. Membranous glomerulonephritis
Description
IgA nephropathy results from IgA deposition in the mesangial tissue of the glomeruli. It is the most
common cause of glomerulonephritis in the world.
IgA nephropathy usually occurs in relation to upper respiratory infections with a time interval of 1 –
2 days aer the infection.
Note that Post-streptococcal glomerulonephritis occurs 1 – 2 weeks aer a throat infection and is
associated with low complement proteins C3 and C4.
Interstitial nephritis is common aer streptococcal infection as well but usually presents with skin
rash, fever, arthralgia, and eosinophilia.
e following table describes the dierence between IgA nephropathy and PSGN:
Page - 1580
Question 46/96
Question #46
A 22-year-old female develops red urine without dysuria or abdominal pain. During the last 2 days,
she has been suering from fever and sore throat. Her lab tests today show 17 RBCs /hpf and
otherwise normal urinalysis. Which of the following is the most accurate test to confirm the
diagnosis of this lady?
a. ASO titer
b. roat swap and culture
c. Renal biopsy
d. Renal ultrasound
e. Kidney function test
Page - 1581
Question 46/96
Question #46
A 22-year-old female develops red urine without dysuria or abdominal pain. During the last 2 days,
she has been suering from fever and sore throat. Her lab tests today show 17 RBCs /hpf and
otherwise normal urinalysis. Which of the following is the most accurate test to confirm the
diagnosis of this lady?
a. ASO titer
b. roat swap and culture
c. Renal biopsy √
d. Renal ultrasound
Description
is lady is most likely suering from IgA nephropathy.
e most accurate test to confirm the diagnosis is renal biopsy
Berger’s disease is also known as IgA nephropathy.
Page - 1582
Question 47/96
Question #47
A 25-year-old male patient complains of tea-colored urine for a 1-day duration. His history is only
significant for sore throat and fever 2 weeks ago. However, his lab tests show positive ASO titer.
a. Focal segmental glomerulosclerosis

b. Minimal change disease
c. IgA nephropathy
d. Post-streptococcal glomerulonephritis
e. Granulomatosis with polyangiitis
Page - 1583
Question 47/96
Question #47
A 25-year-old male patient complains of tea-colored urine for a 1-day duration. His history is only
significant for sore throat and fever 2 weeks ago. However, his lab tests show positive ASO titer.
a. Focal segmental glomerulosclerosis

b. Minimal change disease
c. IgA nephropathy
d. Post-streptococcal glomerulonephritis √
e. Granulomatosis with polyangiitis
Description
is patient is most likely suering from Post streptococcal glomerulonephritis (PSGN).
e presence of sore throat and fever 2 weeks ago, followed by hematuria and positive ASO titer,
suggests the disease.
Page - 1584
Question 48/96
Question #48
A 21-year-old male patient presents with generalized edema and frothy-looking urine. His urine tests
show 5g/day proteinuria, hypercholesterolemia, and hypoalbuminemia. A renal biopsy is done and
shows a normal examination under the light microscope. However, the electronic microscope shows
eacement of epithelial foot processes. What is the most likely diagnosis?
a. Minimal change disease

b. Membranous glomerulonephritis
c. Membranoproliferative glomerulonephritis
e. Diuse proliferative glomerulonephritis
Page - 1585
Question 48/96
Question #48
A 21-year-old male patient presents with generalized edema and frothy-looking urine. His urine tests
show 5g/day proteinuria, hypercholesterolemia, and hypoalbuminemia. A renal biopsy is done and
shows a normal examination under the light microscope. However, the electronic microscope shows
eacement of epithelial foot processes. What is the most likely diagnosis?
a. Minimal change disease √

Description
Minimal change disease is the most common cause of primary Nephrotic syndrome in children.
It is characterized by eacement of podocytes foot processes seen by the electronic microscope but
no changes seen on the light microscope.
Minimal change disease is the most responsive to steroids.
Page - 1586
Question 49/96
Question #49
A 22-year-old male patient is suspected of having acute glomerulonephritis. Which of the following
would most strongly support the diagnosis?
a. RBCs in urine
b. WBCs in urine
c. Positive myoglobinuria
d. Urinary eosinophilia
e. Erythrocyte cast in urine
Page - 1587
Question 49/96
Question #49
A 22-year-old male patient is suspected of having acute glomerulonephritis. Which of the following
would most strongly support the diagnosis?
a. RBCs in urine
b. WBCs in urine
c. Positive myoglobinuria
d. Urinary eosinophilia
e. Erythrocyte cast in urine √
Description
e presence of RBC casts indicates glomerular disease.
Acute glomerulonephritis usually presents with hypertension, edema, and hematuria.
RBCs in urine (Hematuria) is not specific and may occur in urinary tract conditions like trauma,
tumors, stones, injuries, and infections.
WBCs in the urine suggest infection, while eosinophiluria may present with acute interstitial
nephritis.
Myoglobinuria presents with rhabdomyolysis that may lead to acute tubular necrosis.
Page - 1588
Question 50/96
Question #50
About 48 hours aer an upper respiratory illness, a 19-year-old male patient develops hematuria. His
urine dipstick shows proteinuria and red blood cells. Dysmorphic RBCs and RBCs cast are shown in
urine microscopy. What is the most likely diagnosis?
a. Post streptococcal glomerulonephritis

b. Berger’s disease
c. Minimal change disease
d. Henoch-Schönlein purpura
e. Acute interstitial nephritis
Page - 1589
Question 50/96
Question #50
About 48 hours aer an upper respiratory illness, a 19-year-old male patient develops hematuria. His
urine dipstick shows proteinuria and red blood cells. Dysmorphic RBCs and RBCs cast are shown in
urine microscopy. What is the most likely diagnosis?
a. Post streptococcal glomerulonephritis

b. Berger’s disease √
c. Minimal change disease
d. Henoch-Schönlein purpura
e. Acute interstitial nephritis
Description
Berger’s disease is also known as IgA nephropathy.
Page - 1590
Question 51/96
Question #51
A 55-year-old male patient develops pedal edema, nephrotic range proteinuria,

hypercholesterolemia, and hypoalbuminemia. His renal biopsy was done, but the result has not
come back yet. What is the most likely cause of his nephrotic syndrome?

d. Focal segmental glomerulonephritis
e. IgA nephropathy
Page - 1591
Question 51/96
Question #51
A 55-year-old male patient develops pedal edema, nephrotic range proteinuria,

hypercholesterolemia, and hypoalbuminemia. His renal biopsy was done, but the result has not
come back yet. What is the most likely cause of his nephrotic syndrome?

b. Membranous glomerulonephritis √
d. Focal segmental glomerulonephritis
e. IgA nephropathy
Description
Membranous glomerulonephritis is the most common form of primary nephrotic syndrome in

adults
Minimal change disease is the most common in children, while focal segmental glomerulosclerosis
is more in immunosuppressed patients (HIV patients)
Page - 1592
Question 52/96
Question #52
he presented with a fever and sore throat for 2 days which was again associated with hematuria. His
blood pressure is 175/99 mmHg. His urine test shows numerous RBCs, heavy proteinuria, and
dysmorphic RBCs with RBC casts. e presence of dysmorphic RBCs is suggestive of:
a. Urinary bladder mucosal bleeding

b. Glomerular bleeding
c. Ureteral stone
d. Renal malignancy
e. Urinary tract infection
Page - 1593
Question 52/96
Question #52
he presented with a fever and sore throat for 2 days which was again associated with hematuria. His
blood pressure is 175/99 mmHg. His urine test shows numerous RBCs, heavy proteinuria, and
dysmorphic RBCs with RBC casts. e presence of dysmorphic RBCs is suggestive of:
a. Urinary bladder mucosal bleeding

b. Glomerular bleeding √
c. Ureteral stone
d. Renal malignancy
e. Urinary tract infection
Description
e presence of dysmorphic RBCs suggests glomerular hematuria.
e patient most likely has IgA nephropathy.
Page - 1594
Page - 1595
Question 53/96
Question #53
A 35-year-old male patient develops coughs and hemoptysis for 2 months. His lab tests show
elevated urea and creatinine levels, urinalysis shows red urine that is positive for numerous RBCs,
and his arterial blood gases are normal. Which of the following is the most helpful to confirm the
diagnosis?
a. Anti-mitochondrial antibodies
b. Anti-GBM antibodies
c. Anti-neutrophil cytoplasmic antibodies
d. Anti-smooth muscle antibodies
e. Anti-nuclear antibodies
Page - 1596
Question 53/96
Question #53
A 35-year-old male patient develops coughs and hemoptysis for 2 months. His lab tests show
elevated urea and creatinine levels, urinalysis shows red urine that is positive for numerous RBCs,
and his arterial blood gases are normal. Which of the following is the most helpful to confirm the
diagnosis?
a. Anti-mitochondrial antibodies
b. Anti-GBM antibodies √
c. Anti-neutrophil cytoplasmic antibodies
d. Anti-smooth muscle antibodies
e. Anti-nuclear antibodies
Description
is is a typical case scenario of Goodpasture syndrome.
Goodpasture syndrome is a clinical syndrome that comprises glomerulonephritis and pulmonary

hemorrhage due to injury mediated by Anti-glomerular basement membrane antibody (Anti-GBM)
e presence of hemoptysis and hematuria without upper respiratory involvement strongly

suggests the disease
If upper respiratory involvement is present, you should consider granulomatosis with polyangiitis as
the most likely diagnosis.
Page - 1597
Question 54/96
Question #54
A 33-year-old male patient presents with 2 weeks history of hemoptysis. In the last 48 hours, he has
developed hematuria, breathlessness, and oliguria. His chest x-ray shows patchy interstitial
infiltrates aecting mainly the lower zones. His lab investigations show renal impairment and mild
hyperkalemia. What is the most appropriate management at this point?
a. Anti-glomerular basement membrane antibodies test

b. Abdominal x-ray
d. Abdominal and chest CT scan
e. Cystoscopy and bronchoscopy
Page - 1598
Question 54/96
Question #54
A 33-year-old male patient presents with 2 weeks history of hemoptysis. In the last 48 hours, he has
developed hematuria, breathlessness, and oliguria. His chest x-ray shows patchy interstitial
infiltrates aecting mainly the lower zones. His lab investigations show renal impairment and mild
hyperkalemia. What is the most appropriate management at this point?
a. Anti-glomerular basement membrane antibodies test √

b. Abdominal x-ray
d. Abdominal and chest CT scan
e. Cystoscopy and bronchoscopy
Description
is is a typical case scenario of Goodpasture syndrome.
Goodpasture syndrome is a clinical syndrome that comprises glomerulonephritis and pulmonary

hemorrhage due to injury mediated by Anti-glomerular basement membrane antibody (Anti-GBM)
e presence of hemoptysis and hematuria without upper respiratory involvement strongly

suggests the disease
If upper respiratory involvement is present, you should consider granulomatosis with polyangiitis as
the most likely diagnosis.
Page - 1599
Question 55/96
Question #55
A 30-year-old male patient presents with generalized edema. His lab tests show hypoalbuminemia,
heavy proteinuria, and hypercholesterolemia. His past medical history includes advanced HIV
infection. However, his blood pressure is 140/90, his pulse is 90bpm, and he is afebrile. What is the
most likely cause of his condition?

Page - 1600
Question 55/96
Question #55
A 30-year-old male patient presents with generalized edema. His lab tests show hypoalbuminemia,
heavy proteinuria, and hypercholesterolemia. His past medical history includes advanced HIV
infection. However, his blood pressure is 140/90, his pulse is 90bpm, and he is afebrile. What is the
most likely cause of his condition?

d. Focal segmental glomerulosclerosis √
Description
Focal segmental glomerulosclerosis is the most common form of idiopathic nephrotic syndrome in
HIV-positive patients.
Minimal change disease is more common in children, while membranous glomerulonephritis is

more common in adults.
Page - 1601
Question 56/96
Question #56
Which of the following is considered the most responsive to steroid therapy?

Page - 1602
Question 56/96
Question #56
Which of the following is considered the most responsive to steroid therapy?
a. Minimal change disease √

Description
Minimal change disease is the most common cause of primary Nephrotic syndrome in children.
It is characterized by eacement of podocytes foot processes seen by the electronic microscope but
no changes seen on the light microscope.
Minimal change disease is the most responsive to steroids.
Page - 1603
Question 57/96
Question #57
A 39-year-old male patient is diagnosed with adult polycystic kidney disease. However, his brother
recently died due to a brain insult. What is the most likely cause of his brother’s death?
a. Ruptured berry aneurysm

b. Subdural hematoma
c. Epidural hematoma
d. Intracerebral hemorrhage
e. Ischemic CVA
Page - 1604
Internal Medicine - Nephrology - Cystic diseases of the kidney
Question 57/96
Question #57
A 39-year-old male patient is diagnosed with adult polycystic kidney disease. However, his brother
recently died due to a brain insult. What is the most likely cause of his brother’s death?
a. Ruptured berry aneurysm √

b. Subdural hematoma
c. Epidural hematoma
d. Intracerebral hemorrhage
e. Ischemic CVA
Description
Autosomal dominant polycystic kidney disease is associated with berry aneurysms that may rupture
and lead to subarachnoid hemorrhage.
A family history of ADPKD is a sucient clue in the question to raise the suspicion of berry aneurysm
Page - 1605
Question 58/96
Question #58
A 35-year-old male patient complains of HTN, painless hematuria, flank pain, and recurrent
headache. What is the most likely diagnosis?
a. Transitional cell carcinoma of the urinary bladder

c. Hemolytic uremic syndrome
d. Adult polycystic kidney disease
e. Prostatic cancer
Page - 1606
Question 58/96
Question #58
A 35-year-old male patient complains of HTN, painless hematuria, flank pain, and recurrent
headache. What is the most likely diagnosis?
a. Transitional cell carcinoma of the urinary bladder

c. Hemolytic uremic syndrome
d. Adult polycystic kidney disease √
e. Prostatic cancer
Description
is is a typical presentation of adult-onset autosomal dominant polycystic kidney disease (ADPKD)
ADPKD results from two types of gene mutations
PKD1 (more severe and early onset) (code for polycystin1)

PKD2 (less severe and later onset) (code for polycystin2)
Recurrent headaches are due to the association between ADPKD and berry aneurysms, which may
rupture and cause SAH.
Page - 1607
Question 59/96
Question #59
A 36-year-old male patient has a history of HTN and subarachnoid hemorrhage. In addition, he
presents with recurrent hematuria and UTI. However, His physical examination demonstrates
enlarged kidneys, and his family history is positive for a grandfather with renal impairment at the
age of 40. What is the most likely diagnosis?
a. Autosomal dominant polycystic kidney disease

b. Autosomal recessive polycystic kidney disease
c. Alport syndrome
d. IgA nephropathy
e. Ascending bacterial infection of the urinary tract
Page - 1608
Question 59/96
Question #59
A 36-year-old male patient has a history of HTN and subarachnoid hemorrhage. In addition, he
presents with recurrent hematuria and UTI. However, His physical examination demonstrates
enlarged kidneys, and his family history is positive for a grandfather with renal impairment at the
age of 40. What is the most likely diagnosis?
a. Autosomal dominant polycystic kidney disease √

b. Autosomal recessive polycystic kidney disease
c. Alport syndrome
d. IgA nephropathy
e. Ascending bacterial infection of the urinary tract
Description
Description:
is is a typical presentation of adult-onset autosomal dominant polycystic kidney disease (ADPKD)
ADPKD results from two types of gene mutations
PKD1 (more severe and early onset) (code for polycystin1)

PKD2 (less severe and later onset) (code for polycystin2)
e presence of subarachnoid hemorrhage (SAH) is due to the presence of an association between

ADPKD and berry aneurysm, which may rupture and cause SAH
Page - 1609
Question 60/96
Question #60
A 43-year-old male patient was found to have an accidental finding of unilateral simple renal cyst.
Lab results and physical examination are unremarkable. What is the next step in the management
of this patient?
a. Reassurance
b. Perform renal biopsy
c. Perform nephrectomy
d. Genetic study for PKD1 and PKD2 genes
e. Perform Pan-CT scan
Page - 1610
Question 60/96
Question #60
A 43-year-old male patient was found to have an accidental finding of unilateral simple renal cyst.
Lab results and physical examination are unremarkable. What is the next step in the management
of this patient?
a. Reassurance √
b. Perform renal biopsy
c. Perform nephrectomy
d. Genetic study for PKD1 and PKD2 genes
e. Perform Pan-CT scan
Description
A simple renal cyst is a common finding encountered incidentally in an ultrasound done for another
purpose.
ere is no need to take any action in this situation, only follow-up and expectant management
Page - 1611
Question 61/96
Question #61
e following ECG changes are considered typical hyperkalemia changes except:
a. Flat P wave
b. Wide QRS complex
c. Peaked T wave
d. Sine wave
e. U wave
Page - 1612
Internal Medicine - Nephrology - Electrolytes disturbances
Question 61/96
Question #61
e following ECG changes are considered typical hyperkalemia changes except:
a. Flat P wave
b. Wide QRS complex
c. Peaked T wave
d. Sine wave
e. U wave √
Description
U wave is an ECG finding of hypokalemia, not hyperkalemia.
Hyperkalemia-related cardiac conduction abnormalities on ECG are:
Low or absent P, Prolonged PR, Wide QRS, peaked T wave

Sine wave (severe hyperkalemia)
Cardiac arrhythmias
Page - 1613
Question 62/96
Question #62
Which of the following is the main cause of osmotic demyelination?
a. Rapid correction of hypocalcemia

b. Rapid correction of hypernatremia
c. Rapid correction of hyponatremia
d. Rapid correction of hypomagnesemia
e. Rapid correction of hyperkalemia
Page - 1614
Question 62/96
Question #62
Which of the following is the main cause of osmotic demyelination?
a. Rapid correction of hypocalcemia

b. Rapid correction of hypernatremia
c. Rapid correction of hyponatremia √
d. Rapid correction of hypomagnesemia
e. Rapid correction of hyperkalemia
Description
When hyponatremia is corrected too rapidly, the brain will have no time to recapture the organic
osmolytes; this will lead to osmotic demyelination of the brain.
e accurate correction rate in hyponatremia is no more than 8 – 12 mEq/l daily (slower correction “5
– 8 mEq/l daily” is indicated in chronic hyponatremia).
Page - 1615
Question 63/96
Question #63
A patient with heart failure is on spironolactone, beta-blockers, furosemide, and ACE inhibitors. e
patient has minimal symptoms at night and on exertion. His kidney function test is normal, his
serum potassium level is 5 mEq/L, and his blood pressure is 119/79. What is the most appropriate
action at this time?
a. Increase the dose of furosemide

b. Increase the dose of spironolactone
c. Increase the dose of ACE inhibitor
d. Reduce the dose of furosemide
e. Reduce the dose of beta-blockers
Page - 1616
Question 63/96
Question #63
A patient with heart failure is on spironolactone, beta-blockers, furosemide, and ACE inhibitors. e
patient has minimal symptoms at night and on exertion. His kidney function test is normal, his
serum potassium level is 5 mEq/L, and his blood pressure is 119/79. What is the most appropriate
action at this time?
a. Increase the dose of furosemide √

b. Increase the dose of spironolactone
c. Increase the dose of ACE inhibitor
d. Reduce the dose of furosemide
e. Reduce the dose of beta-blockers
Description
In the case of heart failure, it is common to control and balance serum potassium by using
spironolactone and furosemide dose adjustments
e patient’s potassium is more than 4.5 mEq/L, so increasing the dose of furosemide will reduce the
symptoms of heart failure and reduce the serum potassium to a safer level.
Increasing ACE inhibitors or spironolactone may lead to hyperkalemia in this case.
Page - 1617
Question 64/96
Question #64
You encountered a case of elevated serum potassium (7.3 mEq/L). What is the best next step in the
a. Insulin and glucose

b. Hemodialysis
c. Calcium gluconate
d. Furosemide
e. Nebulized salbutamol
Page - 1618
Question 64/96
Question #64
You encountered a case of elevated serum potassium (7.3 mEq/L). What is the best next step in the
a. Insulin and glucose

b. Hemodialysis
c. Calcium gluconate √
d. Furosemide
e. Nebulized salbutamol
Description
e priority here is to stabilize the cell membrane and prevent arrhythmia.
e following table demonstrates the anti-hyperkalemia protocol:
Page - 1619
Question 65/96
Question #65
On routine investigations, a patient is found to have serum potassium of 5.7 mEq/L. However, the
rest of his investigations and physical examination are normal. What is the most appropriate action
to take at this time?
a. Hemodialysis
b. Provide calcium gluconate
c. Provide insulin and dextrose
d. Start nebulized salbutamol
e. Repeat the blood sample without Torniquate
Page - 1620
Question 65/96
Question #65
On routine investigations, a patient is found to have serum potassium of 5.7 mEq/L. However, the
rest of his investigations and physical examination are normal. What is the most appropriate action
to take at this time?
a. Hemodialysis
b. Provide calcium gluconate
c. Provide insulin and dextrose
d. Start nebulized salbutamol
e. Repeat the blood sample without Torniquate √
Description
is patient is found to have hyperkalemia
e first step in this scenario is to repeat the blood sample without Torniquate to exclude the
possibility of pseudohyperkalemia.
Hemodialysis is indicated in refractory hyperkalemia of more than 7 mEq/L
Anti-hyperkalemia protocol should be initiated once hyperkalemia is confirmed or once ECG

changes of hyperkalemia are noted.
Page - 1621
Question 66/96
Question #66
A patient was admitted to the medical ward with severe vomiting and dehydration. His lab
investigations show serum sodium of 155mEq/L. What is the most appropriate fluid therapy at this
time?
a. Normal saline
b. Ringer lactate
c. Dextrose 5% water
d. Dextrose 10% water
e. Water restriction
Page - 1622
Question 66/96
Question #66
A patient was admitted to the medical ward with severe vomiting and dehydration. His lab
investigations show serum sodium of 155mEq/L. What is the most appropriate fluid therapy at this
time?
a. Normal saline √
b. Ringer lactate
c. Dextrose 5% water
d. Dextrose 10% water
e. Water restriction
Description
In the case of hypovolemic hypernatremia, you should start the treatment with isotonic 0.9% NaCl
to correct the water deficit, and then you can switch to hypotonic fluid (e.g., D5%W or 0.45% NS.
Ringer lactate is not a good choice in this condition as it will aggravate the metabolic alkalosis
resulting from the vomiting.
Page - 1623
Question 67/96
Question #67
In a patient with hyperkalemia, the anti-hyperkalemia protocol fails to achieve a response despite
being repeated appropriately. Which of the following is the most appropriate treatment?
a. Exchange transfusion
b. Check for magnesium level
c. Continuous anti-hyperkalemia protocol
d. Hemodialysis
e. Check for calcium level
Page - 1624
Question 67/96
Question #67
In a patient with hyperkalemia, the anti-hyperkalemia protocol fails to achieve a response despite
being repeated appropriately. Which of the following is the most appropriate treatment?
a. Exchange transfusion
b. Check for magnesium level
c. Continuous anti-hyperkalemia protocol
d. Hemodialysis √
e. Check for calcium level
Description
Hemodialysis is the treatment of choice for refractory hyperkalemia.
Serum magnesium levels should be checked for refractory hypocalcemia and refractory
hypokalemia (not hyperkalemia).
Page - 1625
Question 68/96
Question #68
Which of the following agents doesn’t used to reduce serum potassium in hyperkalemia?
b. Insulin
c. Salbutamol
d. Calcium resonium
e. Furosemide
Page - 1626
Question 68/96
Question #68
Which of the following agents doesn’t used to reduce serum potassium in hyperkalemia?
a. Calcium gluconate √
b. Insulin
c. Salbutamol
d. Calcium resonium
e. Furosemide
Description
Calcium gluconate only stabilizes the cell membrane and prevents arrhythmia. It doesn’t reduce the
serum potassium level. Calcium gluconate is the first-line treatment for hyperkalemia.
Page - 1627
Question 69/96
Question #69
Which drug is considered the most eective in reducing serum potassium levels?
a. Furosemide
b. Calcium gluconate
c. Insulin
d. Calcium resonium
e. Sodium polystyrene sulfate
Page - 1628
Question 69/96
Question #69
Which drug is considered the most eective in reducing serum potassium levels?
a. Furosemide
b. Calcium gluconate
c. Insulin √
d. Calcium resonium
e. Sodium polystyrene sulfate
Description
Insulin is the strongest anti hyperkalemia to reduce the serum potassium level
It shis the extracellular potassium into the cells
Page - 1629
Question 70/96
Question #70
A 56-year-old woman presents to the emergency department with recurrent abdominal pain and
diarrhea. Laboratory results showed serum potassium is 2.5 mEq/L. An Electrocardiogram is
expected to be one of these:
a. Tented T wave
b. Reduced P wave amplitude
c. Prominent U wave
d. Short QT interval
e. Wide QRS complex
Page - 1630
Question 70/96
Question #70
A 56-year-old woman presents to the emergency department with recurrent abdominal pain and
diarrhea. Laboratory results showed serum potassium is 2.5 mEq/L. An Electrocardiogram is
expected to be one of these:
a. Tented T wave
b. Reduced P wave amplitude
c. Prominent U wave √
d. Short QT interval
e. Wide QRS complex
Description
is is a case of hypokalemia secondary to recurrent diarrhea. Regardeless the cause of diarrhea, the
question is focusing about the ECG changes that are related to hypokalemia.
ECG changes in hypokalemia include high P wave, Depressed ST, broad flat T wave, and prominent U
wave.
Page - 1631
Question 71/96
Question #71
Despite a high dose KCl through a central line, a 55-year-old male patient has hypokalemia that fails
to rise. What is the most appropriate action?
a. Hemodialysis
b. Continue KCl until serum potassium returns to normal
c. Check for serum magnesium level
d. Administrate combined oral and intravenous potassium
e. Check for urinary potassium loss
Page - 1632
Question 71/96
Question #71
Despite a high dose KCl through a central line, a 55-year-old male patient has hypokalemia that fails
to rise. What is the most appropriate action?
a. Hemodialysis
b. Continue KCl until serum potassium returns to normal
c. Check for serum magnesium level √
d. Administrate combined oral and intravenous potassium
e. Check for urinary potassium loss
Description
ere are magnesium-dependent potassium channels that open and spell potassium in urine in case
of hypomagnesemia.
Always check for and correct magnesium levels in the case of refractory hypokalemia.
Page - 1633
Question 72/96
Question #72
You are the doctor in charge at the emergency department, and the laboratory calls you to report
that the serum potassium level is 7.6 mEq/L. What is the most urgent step to perform at this time?
a. Urea and creatinine level

b. Repeat the sample
c. Electrocardiogram
d. Serum glucose level
e. Arterial blood gas
Page - 1634
Question 72/96
Question #72
You are the doctor in charge at the emergency department, and the laboratory calls you to report
that the serum potassium level is 7.6 mEq/L. What is the most urgent step to perform at this time?
a. Urea and creatinine level

b. Repeat the sample
c. Electrocardiogram √
d. Serum glucose level
Description
ECG is the most urgent step to take in the case of hyperkalemia. If there are ECG changes of wide
QRS, peaked T wave, flat P, or even sine wave, you should start calcium gluconate and other anti-
hyperkalemia protocol.
Repeating the sample to exclude pseudohyperkalemia, checking for kidney function, assessing ABGs
to look for associated acidosis, and serum glucose levels are all indicated, but they are not as urgent
as ECG.
Page - 1635
Question 73/96
Question #73
Which of the following is the expected electrolyte disturbance in diabetes insipidus?
a. Hypernatremia
b. Hyponatremia
c. Hypermagnesemia
d. Hyperkalemia
e. Hypocalcemia
Page - 1636
Question 73/96
Question #73
Which of the following is the expected electrolyte disturbance in diabetes insipidus?
a. Hypernatremia √
b. Hyponatremia
c. Hypermagnesemia
d. Hyperkalemia
e. Hypocalcemia
Description
In diabetes insipidus (DI), there is a decreased secretion of antidiuretic hormone (ADH) from the
pituitary (cranial DI) or an insensitivity to antidiuretic hormone (nephrogenic DI)
In this case, the kidneys are unable to concentrate urine and reabsorb water.
is will lead to water loss and hypernatremia
Hypocalcemia and hypokalemia are possible causes of DI.
Page - 1637
Question 74/96
Question #74
e rapid correction of hypernatremia will result in which of the following condition?
a. Osmotic demyelination
b. Brain edema and nerve cell swelling
c. Arrhythmia
d. Rhabdomyolysis
e. Renal impairment
Page - 1638
Question 74/96
Question #74
e rapid correction of hypernatremia will result in which of the following condition?
a. Osmotic demyelination
b. Brain edema and nerve cell swelling √
c. Arrhythmia
d. Rhabdomyolysis
e. Renal impairment
Description
Hypernatremia should be corrected at a rate not more than 0.5 mEq/l per hour.
If hypernatremia is corrected rapidly, the brain tissue will have no time to lose organic osmolytes,
leading to brain edema and cellular swelling.
Page - 1639
Question 75/96
Question #75
A patient with heart failure was admitted as a case of digoxin toxicity. His lab investigations show
serum potassium of 7.2 mEq/L. What is the first-line treatment in this situation?
b. Insulin and dextrose
c. Hemodialysis
d. Furosemide
e. Calcium resonium
Page - 1640
Question 75/96
Question #75
A patient with heart failure was admitted as a case of digoxin toxicity. His lab investigations show
serum potassium of 7.2 mEq/L. What is the first-line treatment in this situation?
b. Insulin and dextrose √
c. Hemodialysis
d. Furosemide
e. Calcium resonium
Description
In the case of digoxin toxicity, it is better to avoid calcium gluconate because it may precipitate
arrhythmias.
Insulin is the most eective drug in lowering serum potassium.
Page - 1641
Question 76/96
Question #76
A 66-year-old male patient is treated for sepsis at the intensive care unit. On his 4th day aer
admission, you found serum sodium of 127 mEq/L, serum potassium of 4 mEq/L, and normal urea
and creatinine levels. What is the most likely cause of his hyponatremia?
a. Hypotension
b. Hypertension
c. Iatrogenic
d. Liver cirrhosis
e. Acute renal impairment
Page - 1642
Question 76/96
Question #76
A 66-year-old male patient is treated for sepsis at the intensive care unit. On his 4th day aer
admission, you found serum sodium of 127 mEq/L, serum potassium of 4 mEq/L, and normal urea
and creatinine levels. What is the most likely cause of his hyponatremia?
a. Hypotension
b. Hypertension
c. Iatrogenic √
d. Liver cirrhosis
e. Acute renal impairment
Description
is is a case of iatrogenic hyponatremia resulting from overtreatment with hypotonic saline
In the case of sepsis, the preferred fluid is normal saline 0.9% or Hartmann’s solution; they will
restore the fluid volume without iatrogenic dilution.
Page - 1643
Question 77/96
Question #77
A 55-year-old male patient was investigated for polyuria. His lab results show a serum glucose level
of 580 mg/dL. His serum sodium was 130 mEq/L. However, the patient is euvolemic and has a serum
osmolarity of 300 mOsm/L. You started insulin therapy for hyperglycemia. Which of the following is
the most appropriate treatment for hyponatremia?

b. Intravenous hypertonic saline
c. Water restriction
d. Intravenous Ringer Lactate
e. No need for treatment
Page - 1644
Question 77/96
Question #77
A 55-year-old male patient was investigated for polyuria. His lab results show a serum glucose level
of 580 mg/dL. His serum sodium was 130 mEq/L. However, the patient is euvolemic and has a serum
osmolarity of 300 mOsm/L. You started insulin therapy for hyperglycemia. Which of the following is
the most appropriate treatment for hyponatremia?

b. Intravenous hypertonic saline
c. Water restriction
d. Intravenous Ringer Lactate
e. No need for treatment √
Description
is is a case of pseudohyponatremia
e corrected sodium, in this case, is 138 mEq/L.
In this scenario, there is no need to treat hyponatremia, but you should correct the hyperglycemia
and the fluid state if disturbed.
Page - 1645
Question 78/96
Question #78
A 76-year-old diabetic patient has a blood pressure of 159/94. You exclude the presence of secondary
HTN. What is the best drug to be used for this patient?
a. Valsartan
b. Amlodipine
c. Metoprolol
d. Verapamil
Page - 1646
Internal Medicine - Nephrology - Hypertension (HTN)
Question 78/96
Question #78
A 76-year-old diabetic patient has a blood pressure of 159/94. You exclude the presence of secondary
a. Valsartan √
b. Amlodipine
c. Metoprolol
d. Verapamil
Description
For patients with DM and HTN, the best initial treatment is to start ACE inhibitors or ARBs because
they can protect the kidney from diabetic nephropathy
Page - 1647
Question 79/96
Question #79
A 55-year-old Afro-Caribbean female was diagnosed with HTN. Which of the following is considered
the most successful monotherapy for her hypertension?
a. Captopril
b. Hydrochlorothiazide
c. Metoprolol
d. Diltiazem
e. Valsartan
Page - 1648
Question 79/96
Question #79
A 55-year-old Afro-Caribbean female was diagnosed with HTN. Which of the following is considered
the most successful monotherapy for her hypertension?
a. Captopril
b. Hydrochlorothiazide
c. Metoprolol
d. Diltiazem √
e. Valsartan
Description
In the black Afro-Caribbean race, calcium channel blockers are the most eective in controlling HTN
It has been suggested that hypertension in blacks is not as angiotensin II-dependent as it appears to
be in Caucasians
Page - 1649
Question 80/96
Question #80
A 66-year-old male patient with DM, first-degree AV block, asthma, impotence, and gout has been
diagnosed recently with HTN. Which of the following is the best treatment option for his
condition?
a. Metoprolol
b. Verapamil
d. Valsartan
e. Carvedilol
Page - 1650
Question 80/96
Question #80
A 66-year-old male patient with DM, first-degree AV block, asthma, impotence, and gout has been
diagnosed recently with HTN. Which of the following is the best treatment option for his
condition?
a. Metoprolol
b. Verapamil
d. Valsartan √
e. Carvedilol
Description
ARBs (Valsartan) are safe and eective in this patient to control blood pressure, and it is also
eective in protecting the kidney and delaying adverse diabetic nephropathy.
e point here in this question is to combine the benefit of the blood pressure-lowering eect and
the safety of the drugs on the patient.
Beta-blockers (metoprolol and carvedilol) should be avoided here in this patient because of the first-
degree AV block and asthma
Verapamil should be avoided here because of the first-degree AV block
Hydrochlorothiazide will exacerbate acute gouty arthritis in patients with gout, so it should be
avoided in this patient
Page - 1651
Question 81/96
Question #81
A 66-year-old male patient known to have DM, gout, and IHD presents with elevated blood pressure.
Which of the following anti-hypertensive medications should be avoided in this patient?
a. Beta-blockers
b. ACE Inhibitors
d. iazide diuretics
e. Alpha-blockers
Page - 1652
Question 81/96
Question #81
A 66-year-old male patient known to have DM, gout, and IHD presents with elevated blood pressure.
Which of the following anti-hypertensive medications should be avoided in this patient?
a. Beta-blockers
b. ACE Inhibitors
d. iazide diuretics √
e. Alpha-blockers
Description
iazide diuretics will cause an elevation in the serum uric acid.
iazide and loop diuretics increase the reabsorption of uric acid in the proximal renal tubules. is
will exacerbate acute gouty arthritis.
e anti-hypertensive medication of choice in case of gout is losartan
Page - 1653
Question 82/96
Question #82
A 35-year-old male patient with HTN was started on Enalapril 10mg for 2 weeks. On the follow-up
visit, you noted an elevated creatinine level, his serum potassium is 5.6 mEq/L, and his blood
pressure is 145/90. What is the most likely diagnosis?
a. Essential HTN
b. Renal artery stenosis
c. Primary hyperaldosteronism
d. Pheochromocytoma
e. Cushing’s syndrome
Page - 1654
Question 82/96
Question #82
A 35-year-old male patient with HTN was started on Enalapril 10mg for 2 weeks. On the follow-up
visit, you noted an elevated creatinine level, his serum potassium is 5.6 mEq/L, and his blood
pressure is 145/90. What is the most likely diagnosis?
a. Essential HTN
b. Renal artery stenosis √
c. Primary hyperaldosteronism
d. Pheochromocytoma
e. Cushing’s syndrome
Description
Any patient with HTN and an elevated creatinine level of more than 30% aer one week of
administering the ACE inhibitor should be evaluated for renal artery stenosis.
Essential HTN is unlikely in young patients
Primary hyperaldosteronism presents with HTN and hypokalemia
Cushing’s syndrome presents with hypokalemia, central obesity, stria, hirsutism, HTN, and other
specific morphological features.
Pheochromocytoma usually presents with episodic HTN, sweating, and tremor.
Page - 1655
Question 83/96
Question #83
A 55-year-old male patient was diagnosed with essential HTN 3 months ago. His blood pressure was
141/90, and he has been given Enalapril 5mg daily since then. Today he is asymptomatic, and his
blood pressure is 119/79 mmHg. What would you do next?
a. Continue same treatment

b. Switch to another anti-HTN agent
c. Stop his medications as he is now free of HTN
d. Order an echocardiography
e. Reduce the dose of Enalapril by 50%
Page - 1656
Question 83/96
Question #83
A 55-year-old male patient was diagnosed with essential HTN 3 months ago. His blood pressure was
141/90, and he has been given Enalapril 5mg daily since then. Today he is asymptomatic, and his
blood pressure is 119/79 mmHg. What would you do next?
a. Continue same treatment √

b. Switch to another anti-HTN agent
c. Stop his medications as he is now free of HTN
d. Order an echocardiography
e. Reduce the dose of Enalapril by 50%
Description
is patient has essential HTN, and his blood pressure is now controlled with ACE inhibitors with no
side eects and no new complaints. So, his medication should be kept at the same dose.
Reduction, stopping, or changing the drug may lead to an uncontrolled blood pressure
Echocardiogram is not indicated at this time
Page - 1657
Question 84/96
Question #84
A 76-year-old male patient has a blood pressure of 159/94. He is on Amlodipine 10mg daily but still
uncontrolled. What is the best drug to be used for this patient?
a. Enalapril
b. Verapamil
c. Metoprolol
d. Spironolactone
Page - 1658
Question 84/96
Question #84
A 76-year-old male patient has a blood pressure of 159/94. He is on Amlodipine 10mg daily but still
uncontrolled. What is the best drug to be used for this patient?
a. Enalapril √
b. Verapamil
c. Metoprolol
d. Spironolactone
Description
e following picture shows the treatment approach for patients with HTN:
Page - 1659
Question 85/96
Question #85
A 53-year-old male patient was diagnosed with HTN. He is a known case of DM and asthma. Which
medications are not allowed to be used in this patient?
a. Atenolol
b. Metoprolol
c. Esmolol
d. Bisoprolol
e. Labetalol
Page - 1660
Question 85/96
Question #85
A 53-year-old male patient was diagnosed with HTN. He is a known case of DM and asthma. Which
medications are not allowed to be used in this patient?
a. Atenolol
b. Metoprolol
c. Esmolol
d. Bisoprolol
e. Labetalol √
Description
Beta-blockers are divided into two types, selective beta 1 (only block the receptors on the heart) and
non-selective (block beta receptors in the heart and lungs, leading to bradycardia and
bronchospasms)
Non-selective beta-blockers are not used in asthma as they exacerbate symptoms.
Examples of selective beta-blockers are: Acebutolol, Atenolol, Betaxolol, Bisoprolol, Esmolol,

Metoprolol, and Nebivolol
Labetalol is non-selective and is contraindicated to be used in asthma patients
Page - 1661
Question 86/96
Question #86
A 56-year-old male patient has had a persistent cough for the last 4 months. His physical
examination and lab investigations are unremarkable except for a blood pressure of 150/95 mmHg.
he is taking enalapril 5mg daily. Which of the following is the most appropriate at this time?
a. Increase the dose of Enalapril

b. Add calcium channel blockers
c. Add ARB
d. Switch to ARBs
e. Switch to another ACE inhibitor
Page - 1662
Question 86/96
Question #86
A 56-year-old male patient has had a persistent cough for the last 4 months. His physical
examination and lab investigations are unremarkable except for a blood pressure of 150/95 mmHg.
he is taking enalapril 5mg daily. Which of the following is the most appropriate at this time?
a. Increase the dose of Enalapril

b. Add calcium channel blockers
c. Add ARB
d. Switch to ARBs √
e. Switch to another ACE inhibitor
Description
Because of high levels of bradykinin, cough is a common side eect of ACE inhibitors.
Patients who develop coughs due to ACE inhibitors should receive an ARB instead because ARBs
don’t cause coughs.
Page - 1663
Question 87/96
Question #87
A 76-year-old male patient has a blood pressure of 159/94. You exclude the presence of secondary
a. Enalapril
b. Amlodipine
c. Metoprolol
d. Spironolactone
Page - 1664
Question 87/96
Question #87
A 76-year-old male patient has a blood pressure of 159/94. You exclude the presence of secondary
a. Enalapril
b. Amlodipine √
c. Metoprolol
d. Spironolactone
Description
Amlodipine is the best treatment for HTN in elderly and black patients
Other drugs can be used as well, but CCBs are the best for this age group
Page - 1665
Question 88/96
Question #88
According to the last JNC guidelines, the target blood pressure for a diabetic 65-year-old patient
with essential HTN is less than:
a. 130/80 mmHg
b. 135/85 mmHg
c. 120/80 mmHg
d. 140/90 mmHg
e. 150/90 mmHg
Page - 1666
Question 88/96
Question #88
According to the last JNC guidelines, the target blood pressure for a diabetic 65-year-old patient
with essential HTN is less than:
a. 130/80 mmHg
b. 135/85 mmHg
c. 120/80 mmHg
d. 140/90 mmHg √
e. 150/90 mmHg
Description
According to the very last JNC guidelines for HTN, for any hypertensive patient who is less than 60-
year-old, the target blood pressure is less than 140/90 mmHg
For patients who are more than 60-year-old:
If the patient has DM or CKD, the target will be < 140/90
If the patient has no DM or DCD, the target is < 150/90
Page - 1667
Question 89/96
Question #89
A 76-year-old male patient has a blood pressure of 159/94. He is on Amlodipine 10mg daily, Natrilix
1.5 mg daily, and Enalapril 20mg bid but still uncontrolled. His potassium level is 4.2 mEq/L. What is
the best drug to be used for this patient?
a. Valsartan
b. Increase the dose of iazide like diuretic
c. Metoprolol
d. Spironolactone
e. Loop diuretic
Page - 1668
Question 89/96
Question #89
A 76-year-old male patient has a blood pressure of 159/94. He is on Amlodipine 10mg daily, Natrilix
1.5 mg daily, and Enalapril 20mg bid but still uncontrolled. His potassium level is 4.2 mEq/L. What is
the best drug to be used for this patient?
a. Valsartan
b. Increase the dose of iazide like diuretic
c. Metoprolol
d. Spironolactone √
e. Loop diuretic
Description
Page - 1669
Question 90/96
Question #90
A 70-year-old male patient was admitted to the hospital due to an ischemic stroke. His blood
pressure is 191/115 mmHg. What should you do regarding his blood pressure?
a. Only monitoring
b. Start nitroprusside
c. Start labetalol
d. Start nifedipine
e. Start hydralazine
Page - 1670
Question 90/96
Question #90
A 70-year-old male patient was admitted to the hospital due to an ischemic stroke. His blood
pressure is 191/115 mmHg. What should you do regarding his blood pressure?
a. Only monitoring √
b. Start nitroprusside
c. Start labetalol
d. Start nifedipine
e. Start hydralazine
Description
Systolic blood pressure of less than 200 mmHg and diastolic one of less than 120 mmHg indicates
only monitoring of the patient without intervention
High blood pressure in stroke patients is thought to be a protective mechanism that increases
cerebral perfusion.
Reduction of blood pressure, in this case, will exacerbate the damage to the brain and increase
mortality.
Page - 1671
Question 91/96
Question #91
A previously healthy 25-year-old male patient presents with a blood pressure of 160/92 on routine
examination. What would you do next?
a. Start ACE inhibitors

b. Start Calcium channel blockers
c. Investigate for secondary HTN
d. Obtain additional BP reading
e. Reassurance
Page - 1672
Question 91/96
Question #91
A previously healthy 25-year-old male patient presents with a blood pressure of 160/92 on routine
examination. What would you do next?
a. Start ACE inhibitors

b. Start Calcium channel blockers
c. Investigate for secondary HTN
d. Obtain additional BP reading √
e. Reassurance
Description
Two readings of ≥ 14/90 are required to make the diagnosis of HTN
is is a young patient who is unlikely to have chronic HTN, so you have to obtain another reading to
confirm the diagnosis
Page - 1673
Question 92/96
Question #92
A 65-year-old male patient was found to have a blood pressure ranging from 145/90 to 154/99 for
the last month. His medications include full dose valsartan, hydrochlorothiazide, and amlodipine.
e following are possible diagnoses except:
a. Noncompliance with medications

b. High sodium diet
c. Presence of secondary HTN
d. Expired medications
e. Valsartan overdose
Page - 1674
Question 92/96
Question #92
A 65-year-old male patient was found to have a blood pressure ranging from 145/90 to 154/99 for
the last month. His medications include full dose valsartan, hydrochlorothiazide, and amlodipine.
e following are possible diagnoses except:
a. Noncompliance with medications

b. High sodium diet
c. Presence of secondary HTN
d. Expired medications
e. Valsartan overdose √
Description
Resistant or refractory hypertension is defined as a blood pressure of 140/90mmHg, despite

adherence to treatment with full doses of at least three anti-hypertensive medications, including a
diuretic.
Valsartan overdose will cause hypotension, not hypertension
e other mentioned choices in the question are well-known causes of refractory HTN.
Page - 1675
Question 93/96
Question #93
A 55-year-old male patient has a history of mildly elevated blood pressure recorded several times at
home during the past month. He is asymptomatic, and his blood pressure today is 181/93 mmHg. On
examination, there is a displaced cardiac apex to the le with heaving apex beats. What would you
do next?
a. Repeat blood pressure on a separate day

b. Get lab tests for the patient
c. Perform an exercise stress test
d. Start daily oral furosemide
e. Reassurance
Page - 1676
Question 93/96
Question #93
A 55-year-old male patient has a history of mildly elevated blood pressure recorded several times at
home during the past month. He is asymptomatic, and his blood pressure today is 181/93 mmHg. On
examination, there is a displaced cardiac apex to the le with heaving apex beats. What would you
do next?
a. Repeat blood pressure on a separate day

b. Get lab tests for the patient √
c. Perform an exercise stress test
d. Start daily oral furosemide
e. Reassurance
Description
is patient is suspected of having chronic HTN
e displaced and heaving apex beat is suggestive of le ventricular hypertrophy.
Lab investigations, ECG, and echocardiogram should be ordered, and the patient should start on
lifestyle modifications and anti-hypertensive medications.
Requesting an additional reading on this patient is inappropriate because he has severe HTN and
signs of LV hypertrophy.
Page - 1677
Question 94/96
Question #94
A 76-year-old male patient has a blood pressure of 159/94. He is on Amlodipine 10mg daily, Enalapril
20mg bid but still uncontrolled. What is the best drug to be used for this patient?
a. Valsartan
b. iazide like diuretic
c. Metoprolol
d. Spironolactone
e. Loop diuretic
Page - 1678
Question 94/96
Question #94
A 76-year-old male patient has a blood pressure of 159/94. He is on Amlodipine 10mg daily, Enalapril
20mg bid but still uncontrolled. What is the best drug to be used for this patient?
a. Valsartan
b. iazide like diuretic √
c. Metoprolol
d. Spironolactone
e. Loop diuretic
Description
Page - 1679
Question 95/96
Question #95
A 66-year-old male presents with stage I HTN. He has obesity, dyslipidemia, and diabetes. What is
the best medication to prescribe for this patient?
a. iazide diuretics
b. Metoprolol
c. Enalapril
d. Methyldopa
e. Spironolactone
Page - 1680
Question 95/96
Question #95
A 66-year-old male presents with stage I HTN. He has obesity, dyslipidemia, and diabetes. What is
the best medication to prescribe for this patient?
a. iazide diuretics
b. Metoprolol
c. Enalapril √
d. Methyldopa
e. Spironolactone
Description
ACE inhibitors are the first line used in patients with HTN and DM.
ey inhibit the angiotensin-converting enzyme, which converts angiotensin I to angiotensin II.
is mechanism will reduce the pressure inside the nephron leading to a protective mechanism
against diabetic nephropathy.
Page - 1681
Question 96/96
Question #96
Which of the following recommendations is accurate for measuring blood pressure in adults?
a. Resting for at least 5 minutes will reduce the false high readings
b. A small cu can cause a false high reading
c. e patient should avoid smoking and coee drinking ½ hour before blood pressure measurement
d. Two readings in each arm should be obtained
e. All of the above
Page - 1682
Question 96/96
Question #96
Which of the following recommendations is accurate for measuring blood pressure in adults?
a. Resting for at least 5 minutes will reduce the false high readings
b. A small cu can cause a false high reading
c. e patient should avoid smoking and coee drinking ½ hour before blood pressure measurement
d. Two readings in each arm should be obtained
Description
To accurately measure blood pressure in adults:
e patient should sit on a chair for at least 5 minutes to reduce the incidence of false high
readings
Always choose an accurately sized cu (a small cu can cause false high reading, while a large
cu can cause false low reading)
e patient should not smoke or drink coee for ½ hour before blood pressure measurement
Obtain readings from both arms, two readings for each arm
Page - 1683
Neurology
Page - 1684
Neurology
1) Acute stroke => 3 Questions

2) Alcoholic Encephalopathies => 2 Questions
3) Aphasia => 1 Questions
4) Bell’s palsy => 2 Questions
5) Benign Paroxysmal Positional Vertigo (BPPV) => 2 Questions
6) CNS infections => 6 Questions
7) Cluster headache => 3 Questions
8) Dementia => 15 Questions
9) Epilepsy, Seizure, and Status epilepticus => 10 Questions
10) Essential Tremor => 2 Questions
11) Guillain-Barré syndrome (GBS) => 2 Questions
12) Headaches => 1 Questions
13) Horner syndrome => 3 Questions
14) Introduction to Neurology => 1 Questions
15) Meniere’s Disease => 2 Questions
16) Migraine Headache => 3 Questions
17) Multiple Sclerosis (MS) => 3 Questions
18) Myasthenia Gravis (MG) => 3 Questions
19) Organophosphate poisoning => 2 Questions
20) Parkinson’s Disease (PD) => 6 Questions
21) Postherpetic Neuralgia => 1 Questions
22) Pseudotumor Cerebri => 1 Questions
23) Tension-type headache => 1 Questions
24) e Cranial Nerves => 1 Questions
25) underclap headache => 3 Questions
26) Trigeminal Neuralgia => 2 Questions
27) Upper vs. Lower Neuron lesion => 1 Questions
Page - 1685
Internal Medicine - Neurology
Question 1/82
Question #1
A 68-year-old male patient presented aer 1 week of a brief attack of le-side weakness that lasted
for 1 hour. Today the patent is asymptomatic, with a normal neurological examination. His vital
signs are normal, and his ECG shows a normal sinus rhythm. What is the most important
investigation to do at this time?
a. Brain MRI
b. Echocardiogram
c. Cerebral angiography
d. Chest x-ray
e. Carotid artery ultrasound
Page - 1686
Internal Medicine - Neurology - Acute stroke
Question 1/82
Question #1
A 68-year-old male patient presented aer 1 week of a brief attack of le-side weakness that lasted
for 1 hour. Today the patent is asymptomatic, with a normal neurological examination. His vital
signs are normal, and his ECG shows a normal sinus rhythm. What is the most important
investigation to do at this time?
a. Brain MRI
b. Echocardiogram
c. Cerebral angiography
d. Chest x-ray
e. Carotid artery ultrasound √
Description
is is a case of TIA; a carotid artery stenosis should be ruled out by ultrasound
If blockage of the blood vessel is reversed while neurons are still viable (< 24 hours), this condition is
called TIA, but if the blockage is prolonged (> 24 hours), infarction and permanent damage with
resulting permanent symptoms can occur
Page - 1687
Question 2/82
Question #2
A 53-year-old male is a known case of paroxysmal atrial fibrillation. He has no history of HTN, DM,
HF, TIA, or stroke. What is the most appropriate management for this patient at this point?
a. Observation
b. Aspirin
c. Warfarin, target INR of 1.5-2.5
d. Warfarin, target INR of 2.0-3.0
e. Warfarin, target INR of 2.5-3.5
Page - 1688
Question 2/82
Question #2
A 53-year-old male is a known case of paroxysmal atrial fibrillation. He has no history of HTN, DM,
HF, TIA, or stroke. What is the most appropriate management for this patient at this point?
a. Observation √
b. Aspirin
c. Warfarin, target INR of 1.5-2.5
d. Warfarin, target INR of 2.0-3.0
e. Warfarin, target INR of 2.5-3.5
Description
CHA2DS2VAS score is the most appropriate tool to assess the risk of stroke in atrial fibrillation
patients.
Our patient’s score is zero, so he needs no anticoagulation.
e following table demonstrates the CHA2DS2VAS and its interpretation.
Page - 1689
Question 3/82
Question #3
A 55-year-old male patient with a known case of HTN and DM presented with right-side weakness in
his upper and lower limbs. His reflexes are exaggerated, and his power is 2/5 on the same side. In
addition, reduced temperature and vibratory sensation are present. What is the best next step in
managing this patient if he is conscious and has stable vital signs?
a. Start Aspirin
b. Observation
c. Get a CT scan without contrast
d. Start IV heparin
e. rombolysis
Page - 1690
Question 3/82
Question #3
A 55-year-old male patient with a known case of HTN and DM presented with right-side weakness in
his upper and lower limbs. His reflexes are exaggerated, and his power is 2/5 on the same side. In
addition, reduced temperature and vibratory sensation are present. What is the best next step in
managing this patient if he is conscious and has stable vital signs?
a. Start Aspirin
b. Observation
c. Get a CT scan without contrast √
d. Start IV heparin
e. rombolysis
Description
e first step is to get a CT scan to exclude intracranial hemorrhage.
Acute stroke:
Acute stroke is a rapid appearance of a neurological deficit of brain function due to the death
of brain tissue
Ischemic strokes are more common than hemorrhagic (85% of cases)
A brain CT scan is the most appropriate tool to quickly dierentiate ischemic from
hemorrhagic types of strokes.
Ischemic stroke less than 3 – 4.5 hours since onset is treated with thrombolysis (can increase
the risk of hemorrhagic transformation)
Page - 1691
Question 4/82
Question #4
A 46-year-old man with a long history of alcohol use presented with confusion, ophthalmoplegia,
and horizontal nystagmus. What is the initial treatment of choice for this condition?
a. Start Aspirin
b. iamin injection
c. Dextrose infusion
d. Naloxone IV
Page - 1692
Internal Medicine - Neurology - Alcoholic Encephalopathies
Question 4/82
Question #4
and horizontal nystagmus. What is the initial treatment of choice for this condition?
a. Start Aspirin
b. iamin injection √
c. Dextrose infusion
d. Naloxone IV
Description
iamin (Vitamin B1) is the initial treatment of choice for Wernicke’s encephalopathy.
Wernicke's encephalopathy:
Seen in alcoholism due to iamine (Vitamin B1) deficiency

Symptoms precipitated by glucose infusion in a patient with alcoholism (B1 is responsible for
glucose metabolism)
Symptoms include confusion, ataxia, ophthalmoplegia, memory impairment
It is treated by thiamine injection; avoid glucose infusion before thiamine
Page - 1693
Question 5/82
Question #5
and horizontal nystagmus. Which is the most likely diagnosis?
a. Alcohol intoxication
b. Delirium tremens
c. Wernicke’s encephalopathy
d. Hysterical conversion disorder
e. Cerebrovascular accident (CVA)
Page - 1694
Internal Medicine - Neurology - Alcoholic Encephalopathies
Question 5/82
Question #5
and horizontal nystagmus. Which is the most likely diagnosis?
a. Alcohol intoxication
b. Delirium tremens
c. Wernicke’s encephalopathy √
d. Hysterical conversion disorder
Description
Acute onset of confusion, nystagmus, partial ophthalmoplegia and ataxia are the main presentation
of Wernicke’s encephalopathy
Wernicke's encephalopathy:
Seen in alcoholism due to iamine (Vitamin B1) deficiency

Symptoms precipitated by glucose infusion in a patient with alcoholism (B1 is responsible for
glucose metabolism)
Symptoms include confusion, ataxia, ophthalmoplegia, memory impairment
It is treated by thiamine injection; avoid glucose infusion before thiamine
Page - 1695
Question 6/82
Question #6
A 67-year-old male patient with a known case of DM, HTN, presented with right-side weakness and
inability to speak. e patient can obey commands but can’t repeat phrases aer you. What is the
best description of his condition?
a. Receptive aphasia
b. Expressive aphasia
c. Global aphasia
d. Conductive aphasia
e. Anomic aphasia
Page - 1696
Internal Medicine - Neurology - Aphasia
Question 6/82
Question #6
A 67-year-old male patient with a known case of DM, HTN, presented with right-side weakness and
inability to speak. e patient can obey commands but can’t repeat phrases aer you. What is the
best description of his condition?
a. Receptive aphasia
b. Expressive aphasia √
c. Global aphasia
d. Conductive aphasia
e. Anomic aphasia
Description
Broca’s area is the most likely aected in this case
Types of aphasia:
Wernicke’s (receptive) aphasia: Lesions result in sentences that make no sense and word
substitution, but speech remains fluent
Broca’s (expressive) aphasia: Speech is non-fluent and labored
Conduction aphasia: Speech is fluent, but repetition is poor. Aware of the errors they are
making
Global aphasia: large lesion aecting all 3 of the above areas resulting in severe expressive and
receptive aphasia
Page - 1697
Question 7/82
Question #7
Two weeks aer a viral illness, a 30-year-old man developed a dropping of his mouth and
incomplete closure of his le eye. His smile is asymmetrical, and his examination is otherwise
normal. What is the most likely diagnosis?
a. Bell’s palsy.
b. Cerebrovascular accident (CVA)
c. Trigeminal nerve palsy
d. ird nerve palsy
e. Horner’s syndrome
Page - 1698
Internal Medicine - Neurology - Bell’s palsy
Question 7/82
Question #7
Two weeks aer a viral illness, a 30-year-old man developed a dropping of his mouth and
incomplete closure of his le eye. His smile is asymmetrical, and his examination is otherwise
normal. What is the most likely diagnosis?
a. Bell’s palsy. √
b. Cerebrovascular accident (CVA)
c. Trigeminal nerve palsy
d. ird nerve palsy
e. Horner’s syndrome
Description
e weakness aecting the face’s upper and lower parts is characteristic of Bell’s palsy.
Seventh nerve palsy (Bell’s palsy):
Most are idiopathic, but Lyme disease, viral infection, sarcoidosis, and tumors may be a cause
Clinical features include paralysis of the entire side of the face (upper and lower parts),
diculty closing eyes, absent wrinkles on the same side of the forehead, Hyperacusis, and
taste disturbances
e diagnosis is clinical, and no need for special testing but NCS and EMG are the most
accurate
e best initial therapy is prednisolone, but 60% recover fully without treatment
Eye care and physiotherapy should be considered during the recovery.
Page - 1699
Question 8/82
Question #8
A 22-year-old male patient presented with ocular irritation and a weird unilateral smile noted by his
friend. In addition, the patient cannot pu up the right cheek or frown his face. What is the most
appropriate next step?
a. Oral prednisolone, artificial tears, and follow-up.

b. Acyclovir, Vitamin B12 injections, and prednisolone
c. Brain CT scan
d. Schirmer blotting test
e. Start oral aspirin and Statin
Page - 1700
Internal Medicine - Neurology - Bell’s palsy
Question 8/82
Question #8
A 22-year-old male patient presented with ocular irritation and a weird unilateral smile noted by his
friend. In addition, the patient cannot pu up the right cheek or frown his face. What is the most
appropriate next step?
a. Oral prednisolone, artificial tears, and follow-up. √

b. Acyclovir, Vitamin B12 injections, and prednisolone
c. Brain CT scan
d. Schirmer blotting test
e. Start oral aspirin and Statin
Description
In Bell’s palsy oral prednisolone is the primary treatment. In addition, artificial tears are used to
protect the eye.
Seventh nerve palsy (Bell’s palsy):
Most are idiopathic, but Lyme disease, viral infection, sarcoidosis, and tumors may be a cause
Clinical features include paralysis of the entire side of the face (upper and lower parts),
diculty closing eyes, absent wrinkles on the same side of the forehead, Hyperacusis, and
taste disturbances
e diagnosis is clinical, and no need for special testing but NCS and EMG are the most
accurate
e best initial therapy is prednisolone, but 60% recover fully without treatment
Eye care and physiotherapy should be considered during the recovery.
Page - 1701
Question 9/82
Question #9
A previously healthy 45-year-old male came with a spinning sensation upon changes in his position.
Which one of the following is characteristic of benign positional vertigo (BPPV)?
a. Associated sensorineural hearing loss

b. Presence of tinnitus
c. Aggravated by turning the head
d. Preceded by headache
e. Vertigo lasts for hours
Page - 1702
Internal Medicine - Neurology - Benign Paroxysmal Positional Vertigo (BPPV)
Question 9/82
Question #9
A previously healthy 45-year-old male came with a spinning sensation upon changes in his position.
Which one of the following is characteristic of benign positional vertigo (BPPV)?
a. Associated sensorineural hearing loss

b. Presence of tinnitus
c. Aggravated by turning the head √
d. Preceded by headache
e. Vertigo lasts for hours
Description
In BPPV, no headache, no tinnitus, no hearing loss, and the attack lasts for 10-20 seconds only
Benign Paroxysmal Positional Vertigo (BPPV):
It is a spinning sensation upon changes in the position of the head.

Each episode lasts less than 1 minute
Vertigo (spinning dizziness) is the main feature; it is:
Paroxysmal (Sudden with a short duration)
Positional: (Induced by a change in head position
Associated with nausea and vomiting
Page - 1703
Question 10/82
Question #10
Dix–Hallpike test is used in the diagnosis of:
a. Meniere’s disease
b. Benign positional vertigo
c. Sensorineural hearing loss
d. Conductive hearing loss
e. Visual field defect
Page - 1704
Internal Medicine - Neurology - Benign Paroxysmal Positional Vertigo (BPPV)
Question 10/82
Question #10
Dix–Hallpike test is used in the diagnosis of:
b. Benign positional vertigo √
c. Sensorineural hearing loss
d. Conductive hearing loss
e. Visual field defect
Description
It is used in BPPV to assess the posterior semicircular canal
Dix–Hallpike test:
A test used to assess the posterior semicircular canal.

Lower your patient quickly to a supine position with the neck extended
Nystagmus will start if the test is positive
Benign Paroxysmal Positional Vertigo (BPPV):
It is a spinning sensation upon changes in the position of the head.

Each episode lasts less than 1 minute
Vertigo (spinning dizziness) is the main feature; it is:
Paroxysmal (Sudden with a short duration)
Positional: (Induced by a change in head position
Associated with nausea and vomiting
Page - 1705
Question 11/82
Question #11
A 23-year-old male patient presented with headache, fever, hallucinations, and bizarre behaviors
noted by his sister. e patient is confused and disoriented, his temperature is 39.3 °C, and the
meningeal signs are negative. His brain CT is normal. Which of the following is the most likely
diagnosis of this patient?
a. Brain abscess
b. Herpes encephalitis
c. Meningitis
d. Substance abuse
e. Brain hemorrhage
Page - 1706
Internal Medicine - Neurology - CNS infections
Question 11/82
Question #11
meningeal signs are negative. His brain CT is normal. Which of the following is the most likely
diagnosis of this patient?
a. Brain abscess
b. Herpes encephalitis √
c. Meningitis
d. Substance abuse
e. Brain hemorrhage
Description
Headache, fever, and confusion in the absence of meningeal signs are the classic presentation of
encephalitis.
Encephalitis:
Encephalitis is an acute inflammation of the brain due to either a viral infection or an

autoimmune process
e most common cause is a herpes infection
e patient presents with headache and fever of acute onset associated with confusion
Photophobia and a sti neck may present
It is treated by acyclovir intravenously
Page - 1707
Question 12/82
Question #12
A 22-year-old male patient presented with a decreased level of consciousness, fever, nuchal rigidity,
and petechial rash on his legs and trunk. Which of the following is not consistent with this patient’s
condition?
a. Cloudy CSF appearance

b. CSF glucose of 56 mg/dL
c. CSF protein of 65 mg/dL
d. CSF opening pressure of 28 mmH2O
e. Gram negative diplococci in CSF
Page - 1708
Question 12/82
Question #12
and petechial rash on his legs and trunk. Which of the following is not consistent with this patient’s
condition?
a. Cloudy CSF appearance

b. CSF glucose of 56 mg/dL √
c. CSF protein of 65 mg/dL
d. CSF opening pressure of 28 mmH2O
e. Gram negative diplococci in CSF
Description
is is suspected bacterial meningitis (Neisseria meningitides) because of the characteristic rash.
CSF glucose is less than 40 mg/dL in meningococcal meningitis.
Meningitis:
It is the inflammation of the meninges that presents with headache, fever, and meningism
e classic clinical features include headache, fever, and neck rigidity
Antibiotics should be started immediately, do not wait for culture results
Page - 1709
Question 13/82
Question #13
meningeal signs are negative. Which of the following is best to confirm the diagnosis of
encephalitis?
a. Brain CT scan
b. Brain MRI
d. PCR for HSV in the CSF.
e. Appearance and cytology of the CSF
Page - 1710
Question 13/82
Question #13
meningeal signs are negative. Which of the following is best to confirm the diagnosis of
encephalitis?
a. Brain CT scan
b. Brain MRI
d. PCR for HSV in the CSF. √
e. Appearance and cytology of the CSF
Description
is is a typical scenario of encephalitis. e diagnosis is confirmed by PCR for HSV in the CSF.
Encephalitis:
Encephalitis is an acute inflammation of the brain due to either a viral infection or an

autoimmune process
e most common cause is a herpes infection
e patient presents with headache and fever of acute onset associated with confusion
Photophobia and a sti neck may present
It is treated by acyclovir intravenously
Page - 1711
Question 14/82
Question #14
A 55-year-old male patient was found unconscious in the street. His temperature was 39.5 °C, and
marked nuchal rigidity was noted. LP is done and sent to the lab. Which drugs will cover the likely
oending organism and have good penetration into the CSF?
a. Ceriaxone
b. Ciprofloxacin
c. Dexamethasone
d. IV penicillin
e. Oral Rifaximin
Page - 1712
Question 14/82
Question #14
A 55-year-old male patient was found unconscious in the street. His temperature was 39.5 °C, and
marked nuchal rigidity was noted. LP is done and sent to the lab. Which drugs will cover the likely
oending organism and have good penetration into the CSF?
a. Ceriaxone √
b. Ciprofloxacin
c. Dexamethasone
d. IV penicillin
e. Oral Rifaximin
Description
Neck rigidity, fever, and decreased level of consciousness suggest meningitis (or maybe
meningoencephalitis) in this patient.
e most common cause of meningitis in this age group is streptococcus pneumonia. Making
ceriaxone “a 3rd generation cephalosporine” meet both criteria.
Meningitis:
Page - 1713
Question 15/82
Question #15
and petechial rash on his legs and trunk. In addition to treating this patient, which of the following
is recommended for prevention in his contacts?
a. TMP/SMX
b. Metronidazole
c. Isoniazid
d. Pneumococcal vaccination
e. Rifampicin
Page - 1714
Question 15/82
Question #15
and petechial rash on his legs and trunk. In addition to treating this patient, which of the following
is recommended for prevention in his contacts?
a. TMP/SMX
b. Metronidazole
c. Isoniazid
d. Pneumococcal vaccination
e. Rifampicin √
Description
Rifampicin, ciprofloxacin, or ceriaxone are indicated for prophylaxis in meningococcal meningitis
Neisseria meningitidis (meningococcal meningitis):
Look for a young patient with asplenia who present with a sudden high fever and signs of
meningitis plus characteristic rash (reddish or purplish rash)
It is a rare but serious infection.
It needs isolation, and prevention for close contact (rifampicin, ciprofloxacin, or ceriaxone)
No need to give prophylaxis to nurses who take care of a meningococcal patient, only persons
with kissing or another type of saliva-type contact need prophylaxis (e.g., who share cups,
kissing)
Page - 1715
Question 16/82
Question #16
In a patient who is present with headache, fever, and vomiting, you noted nuchal rigidity. e most
appropriate workup is to:
a. Brain CT scan
b. Start antibiotics and do LP
c. Coagulation profile
e. Fundoscopic examination
Page - 1716
Question 16/82
Question #16
In a patient who is present with headache, fever, and vomiting, you noted nuchal rigidity. e most
appropriate workup is to:
a. Brain CT scan
b. Start antibiotics and do LP √
c. Coagulation profile
e. Fundoscopic examination
Description
LP is the gold standard for diagnosing meningitis, but antibiotic administration should not be
delayed.
Meningitis:
Page - 1717
Question 17/82
Question #17
A 43-year-old male presents with recent, moderate to severe, bilateral, frontal, and non-throbbing,
recurrent headaches without aura. He has had similar episodes in the past. Based on this limited
history, which type of headaches can be eliminated from the dierential diagnosis?
a. Cluster headache
b. Headache of intracranial neoplasm
c. Migraine headache
d. Sinus headache
e. Tension-type headache
Page - 1718
Internal Medicine - Neurology - Cluster headache
Question 17/82
Question #17
A 43-year-old male presents with recent, moderate to severe, bilateral, frontal, and non-throbbing,
recurrent headaches without aura. He has had similar episodes in the past. Based on this limited
history, which type of headaches can be eliminated from the dierential diagnosis?
a. Cluster headache √
b. Headache of intracranial neoplasm
c. Migraine headache
d. Sinus headache
Description
Cluster headache is always unilateral.
Cluster headaches:
It is one of the most painful types of headaches

More common in males than females
It presents with sudden unilateral severe pain around the eye that may awaken the patient
from sleep, associated with conjunctival injection, tearing, miosis, and ptosis.
It occurs in cyclical patterns or clusters, once or twice a day, each episode lasting 15 minutes to
2 hours, and the clusters may last 4-12 weeks
e acute headaches are treated with 100% oxygen for 15 minutes, but the attacks are
prevented with prophylactic verapamil.
Page - 1719
Question 18/82
Question #18
A 35-year-old male presents with a 7-year history of episodic severe unilateral headaches. e
headaches occurred most days for 2 months during the most recent episode and lasted about 1 hour.
e most likely diagnosis is:
a. Migraine headache
b. Cluster headache
c. Temporal arteritis
d. Trigeminal neuralgia
e. Post-herpetic neuralgia
Page - 1720
Question 18/82
Question #18
A 35-year-old male presents with a 7-year history of episodic severe unilateral headaches. e
headaches occurred most days for 2 months during the most recent episode and lasted about 1 hour.
e most likely diagnosis is:
a. Migraine headache
b. Cluster headache √
c. Temporal arteritis
d. Trigeminal neuralgia
e. Post-herpetic neuralgia
Description
e nature, frequency, and duration of headaches in this patient strongly suggest cluster headaches.
Cluster headaches are common in males, occur in cycles, and are unilateral.
Cluster headaches:

Page - 1721
Question 19/82
Question #19
A 35-year-old male developed daily, severe, continuous headaches behind his le eye lasting for 1 – 2
hours and relieved by oxygen. It is associated with tearing from the le eye and a nasal discharge
from the le naris. Neurologic examination is unremarkable. What is the most appropriate at this
time?
a. Brain MRI
b. Start carbamazepine
c. Refer to neurologist
d. Only NSAIDs as needed with no additional treatment
e. Daily use of verapamil
Page - 1722
Question 19/82
Question #19
A 35-year-old male developed daily, severe, continuous headaches behind his le eye lasting for 1 – 2
hours and relieved by oxygen. It is associated with tearing from the le eye and a nasal discharge
from the le naris. Neurologic examination is unremarkable. What is the most appropriate at this
time?
a. Brain MRI
b. Start carbamazepine
c. Refer to neurologist
d. Only NSAIDs as needed with no additional treatment
e. Daily use of verapamil √
Description
Verapamil is used for the prevention of cluster headaches.
Cluster headaches:

e following table demonstrates a comparison between Cluster and Migraine headaches:
Page - 1723
Page - 1724
Question 20/82
Question #20
A 68-year-old woman presents to your oce with a decline in her recent memory over the last 8
years. is was associated with dysphasia. Which of the following is the most likely diagnosis?
a. CVA
b. Hydrocephalus
c. Alzheimer’s disease
d. Creutzfeldt Jakob disease (CJD)
e. Huntington’s disease
Page - 1725
Internal Medicine - Neurology - Dementia
Question 20/82
Question #20
A 68-year-old woman presents to your oce with a decline in her recent memory over the last 8
years. is was associated with dysphasia. Which of the following is the most likely diagnosis?
a. CVA
b. Hydrocephalus
c. Alzheimer’s disease √
d. Creutzfeldt Jakob disease (CJD)
e. Huntington’s disease
Description
Alzheimer’s disease (AD) is a slowly progressive memory loss in older patients > 65 years old; it is the
most common cause of dementia
Page - 1726
Question 21/82
Question #21
A 79-year-old female patient presented with declined memory and urinary incontinence. Her brain
MRI shows wide ventricles but no other pathologies. Which of the following would provide
additional evidence of the diagnosis of NPH?
a. Internuclear ophthalmoplegia
b. Recurrent headaches
c. Right leg weakness
d. Seventh nerve palsy
e. Gait disturbance
Page - 1727
Question 21/82
Question #21
A 79-year-old female patient presented with declined memory and urinary incontinence. Her brain
MRI shows wide ventricles but no other pathologies. Which of the following would provide
additional evidence of the diagnosis of NPH?
a. Internuclear ophthalmoplegia
b. Recurrent headaches
c. Right leg weakness
d. Seventh nerve palsy
e. Gait disturbance √
Description
Normal-pressure hydrocephalus (NPH), also known as Hakim’s syndrome. It is caused by an

abnormal accumulation of CSF in the brain’s ventricles.
A triad of dementia, urinary incontinence, and gait disturbance is a classic presentation of NPH.
CT scan and MRI to rule out mass lesions in the brain should be done, and LP will show normal
pressure. NPH is treated by ventriculoperitoneal shunt.
Page - 1728
Question 22/82
Question #22
A 66-year-old male patient presented with memory issues and is suspected of having Alzheimer’s
disease. e best initial workup is to do all the following except:
a. B12 level
b. TSH and T4
c. Brain CT scan
d. Carotid doppler U/S
e. History and physical examination
Page - 1729
Question 22/82
Question #22
A 66-year-old male patient presented with memory issues and is suspected of having Alzheimer’s
disease. e best initial workup is to do all the following except:
a. B12 level
b. TSH and T4
c. Brain CT scan
d. Carotid doppler U/S √
e. History and physical examination
Description
All patients with memory disturbances should be tested for B12 level, Brain CT scan, and yroid
function test. Occult hyper- or hypothyroidism can imitate the symptoms of Alzheimer’s disease.
Page - 1730
Question 23/82
Question #23
A 72-year-old male patient presented with slowly progressive memory loss associated with urinary
incontinence and gait disturbance. e examination is otherwise normal, and his lab investigations
are normal. Which one of the following should you do next?
a. Brain MRI
b. Start treatment with SSRIs
c. Prescribe carbidopa/levodopa
d. Refer to physiotherapist
e. Order a brainstem auditory evoked potential
Page - 1731
Question 23/82
Question #23
incontinence and gait disturbance. e examination is otherwise normal, and his lab investigations
are normal. Which one of the following should you do next?
a. Brain MRI √
b. Start treatment with SSRIs
c. Prescribe carbidopa/levodopa
d. Refer to physiotherapist
e. Order a brainstem auditory evoked potential
Description
MRI to rule out other conditions and to check NPH changes (enlargement of the ventricles with
preservation of cerebral parenchyma)

Page - 1732
Question 24/82
Question #24
A 75-year-old male patient was found wandering in the street and brought by police to the hospital.
He states that he has been having visual hallucinations, and his wife told you that he has a
deteriorating memory. In addition, his movements have been slowing over the past 6 months. On
examination, the patient has a shuing gait, and coarse resting tremor of the hands is noted
bilaterally. What is the most likely diagnosis?
a. Alzheimer’s disease
b. Frontotemporal dementia
c. Lewy body dementia
d. Normal-pressure hydrocephalus
e. Parkinson’s disease
Page - 1733
Question 24/82
Question #24
A 75-year-old male patient was found wandering in the street and brought by police to the hospital.
He states that he has been having visual hallucinations, and his wife told you that he has a
deteriorating memory. In addition, his movements have been slowing over the past 6 months. On
examination, the patient has a shuing gait, and coarse resting tremor of the hands is noted
bilaterally. What is the most likely diagnosis?
c. Lewy body dementia √
e. Parkinson’s disease
Description
Hallucinations, parkinsonism, and dementia are the characteristic presentation of Lewy body
dementia
Lewy body dementia presents with parkinsonism and dementia. Vividly detailed hallucinations may
manifest
Page - 1734
Question 25/82
Question #25
An 82-year-old female patient with progressive forgetfulness over the last 3 years, her physical
examination and laboratory workup are normal. However, a CT scan of the brain reveals diuse
atrophy. Which of the following is the most likely cause of the patient’s memory problem?
b. Depression induced dementia
d. Multiple brain infarctions dementia
e. Normal aging process
Page - 1735
Question 25/82
Question #25
An 82-year-old female patient with progressive forgetfulness over the last 3 years, her physical
examination and laboratory workup are normal. However, a CT scan of the brain reveals diuse
atrophy. Which of the following is the most likely cause of the patient’s memory problem?
a. Alzheimer’s disease √
b. Depression induced dementia
d. Multiple brain infarctions dementia
e. Normal aging process
Description
is is a classic case of Alzheimer’s disease. is patient has no depression, no infarctions, no
Parkinsonism.
most common cause of dementia
Page - 1736
Question 26/82
Question #26
e following are possible causes of dementia. Which of the following will not benefit from a
specific treatment?
b. B12 deficiency
c. Creutzfeldt Jakob disease
e. Sarcoidosis
Page - 1737
Question 26/82
Question #26
e following are possible causes of dementia. Which of the following will not benefit from a
specific treatment?
b. B12 deficiency
c. Creutzfeldt Jakob disease √
e. Sarcoidosis
Description
Dementia: is a decline in memory or other thinking skills severe enough to reduce a person’s
ability to perform everyday activities.
No cure for Creutzfeldt Jakob disease (CJD). It is usually fatal within months to a few years
Alzheimer’s disease is treated by Donepezil, Rivastigmine, Galantamine
B12 deficiency is treated by B12 replacement
Normal pressure hydrocephalus (NPH) is treated by ventriculoperitoneal shunt
Sarcoidosis will benefit from steroid therapy in certain conditions
Page - 1738
Question 27/82
Question #27
Which of the following disorders may benefit from the use of Ginkgo Biloba?
a. Benign prostatic hyperplasia

b. Dementia
c. Intermittent claudication
d. Tinnitus
e. Coronary heart disease
Page - 1739
Question 27/82
Question #27
Which of the following disorders may benefit from the use of Ginkgo Biloba?
a. Benign prostatic hyperplasia

b. Dementia √
c. Intermittent claudication
d. Tinnitus
e. Coronary heart disease
Description
Dementia is a decline in memory or other thinking skills severe enough to reduce a person’s ability
to perform everyday activities
Patients with dementia demonstrate that ginkgo is more eective than a placebo
Page - 1740
Question 28/82
Question #28
incontinence and gait disturbance. What is the gold standard diagnostic modality for this patient’s
condition?
a. e clinical presentation only

b. Brain CT scan
c. Intrathecal infusion test
d. CSF removal
e. Fundoscopy
Page - 1741
Question 28/82
Question #28
incontinence and gait disturbance. What is the gold standard diagnostic modality for this patient’s
condition?
a. e clinical presentation only

b. Brain CT scan
c. Intrathecal infusion test
d. CSF removal √
e. Fundoscopy
Description
Large volume lumbar puncture, 30 ml to 40 mL, is the gold standard diagnostic modality.

Page - 1742
Question 29/82
Question #29
A 45-year-old male patient presents with progressive mental impairment, irritability, and
involuntary dancing hand movements. His father had the same condition at the age of 42. He wants
to know if his children may eventually develop a similar situation. However, his wife has no history
or family history of the same condition. Which would be your most appropriate answer?
a. All his children will inherit this disease

b. Each child has a 25% risk of developing the condition
c. Each child has a 50% risk of developing the condition
d. His male children will be only at risk
e. Only one child will be at risk
Page - 1743
Question 29/82
Question #29
A 45-year-old male patient presents with progressive mental impairment, irritability, and
involuntary dancing hand movements. His father had the same condition at the age of 42. He wants
to know if his children may eventually develop a similar situation. However, his wife has no history
or family history of the same condition. Which would be your most appropriate answer?
a. All his children will inherit this disease

b. Each child has a 25% risk of developing the condition
c. Each child has a 50% risk of developing the condition √
d. His male children will be only at risk
e. Only one child will be at risk
Description
Huntington’s disease is an autosomal dominant condition. erefore, if one parent is aected, the
risk of inheritance will be 50%.
Huntington's disease/chorea:
Age aected: 30 – 50 years

Family history is common
CAG trinucleotide repeats on chromosome 4
Presence of dementia + chorea + psychiatric disturbance and personality changes
Diagnosis: by genetic testing
Treatment: tetrabenazine (for chorea) and antipsychotics
Page - 1744
Question 30/82
Question #30
A 53-year-old female patient came to you with her husband, who noted a memory issue with her.
For the past 6 months, she has complained of poor appetite, insomnia, lack of energy, and inability
to do routine housework. Her short-term recall seems impaired, but a more detailed examination
indicates that her memory is good. Which one of the following is the most likely diagnosis?
d. Creutzfeldt-Jakob disease
e. Pseudodementia
Page - 1745
Question 30/82
Question #30
A 53-year-old female patient came to you with her husband, who noted a memory issue with her.
For the past 6 months, she has complained of poor appetite, insomnia, lack of energy, and inability
to do routine housework. Her short-term recall seems impaired, but a more detailed examination
indicates that her memory is good. Which one of the following is the most likely diagnosis?
d. Creutzfeldt-Jakob disease
e. Pseudodementia √
Description
In pseudodementia of depression, the memory is usually intact when enough time is taken to
evaluate the patient carefully.
Page - 1746
Question 31/82
Question #31
Which one of the following is more predictive regarding the progression of Alzheimer’s disease?
a. Memory deficit reported by a family member

b. Self-reported memory deficit
c. Absence of Hippocampal atrophy on brain MRI
d. e lack of the apolipoprotein E4 gene
e. e development of abnormal body movement
Page - 1747
Question 31/82
Question #31
Which one of the following is more predictive regarding the progression of Alzheimer’s disease?
a. Memory deficit reported by a family member √

b. Self-reported memory deficit
c. Absence of Hippocampal atrophy on brain MRI
d. e lack of the apolipoprotein E4 gene
e. e development of abnormal body movement
Description
most common cause of dementia.
Indications for Parkinson’s disease progression:
Hippocampal atrophy on MRI

e presence of the E4 allele
Memory deficit reported by a family member
Page - 1748
Question 32/82
Question #32
incontinence and gait disturbance. What is the most likely diagnosis?
b. Normal-pressure hydrocephalus
c. Parkinson’s disease
d. Lewy body dementia
e. Creutzfeldt Jakob disease (CJD)
Page - 1749
Question 32/82
Question #32
incontinence and gait disturbance. What is the most likely diagnosis?
b. Normal-pressure hydrocephalus √
c. Parkinson’s disease
d. Lewy body dementia
e. Creutzfeldt Jakob disease (CJD)
Description

Page - 1750
Question 33/82
Question #33
Regarding the risk for Alzheimer’s disease, which is false?
a. Trisomy 18 has an increased risk of early Alzheimer’s disease

b. Advanced age has more risk of the disease
c. A family history of Alzheimer’s disease increases the risk
d. Head trauma is associated with a higher incidence
e. A homozygous genotype of apolipoprotein E4
Page - 1751
Question 33/82
Question #33
Regarding the risk for Alzheimer’s disease, which is false?
a. Trisomy 18 has an increased risk of early Alzheimer’s disease √

b. Advanced age has more risk of the disease
c. A family history of Alzheimer’s disease increases the risk
d. Head trauma is associated with a higher incidence
e. A homozygous genotype of apolipoprotein E4
Description
most common cause of dementia.
Trisomy 21, not 18, is associated with early Alzheimer’s disease (usually < 40 years old).
Page - 1752
Question 34/82
Question #34
A 62-year-old male presents with behavioral changes in the last year and memory disturbances. He
is suspected of having Pick’s disease. What would likely be found on an MRI of this patient’s brain?
a. Periventricular plaques
b. Atrophy of frontal and anterior temporal lobes
c. Corpus callosum lesion
d. Severe hippocampal, medial temporal lobe, and generalized atrophy
e. Peripheral micro-hemorrhages
Page - 1753
Question 34/82
Question #34
A 62-year-old male presents with behavioral changes in the last year and memory disturbances. He
is suspected of having Pick’s disease. What would likely be found on an MRI of this patient’s brain?
a. Periventricular plaques
b. Atrophy of frontal and anterior temporal lobes √
c. Corpus callosum lesion
d. Severe hippocampal, medial temporal lobe, and generalized atrophy
e. Peripheral micro-hemorrhages
Description
Frontal and temporal lobe atrophy in brain imaging is characteristic of Pick’s disease.
Picks disease (frontotemporal dementia):
Abnormal behavior and personality changes precede other symptoms

Memory loss
No movement disorders
Frontal and temporal lobe atrophy in brain imaging
Treatment is the same as Alzheimer’s disease
Page - 1754
Question 35/82
Question #35
A 23-year-old male patient presents with recurrent loss of consciousness and tonic-clonic muscular
contractions. His tongue fell back into the throat, and he choked. What is the most likely diagnosis?
a. Petit mal seizure

b. Grand mal seizure
c. Myoclonic seizure
d. Atonic seizure
e. Focal to generalized seizure
Page - 1755
Internal Medicine - Neurology - Epilepsy, Seizure, and Status epilepticus
Question 35/82
Question #35
A 23-year-old male patient presents with recurrent loss of consciousness and tonic-clonic muscular
contractions. His tongue fell back into the throat, and he choked. What is the most likely diagnosis?
a. Petit mal seizure

b. Grand mal seizure √
c. Myoclonic seizure
d. Atonic seizure
e. Focal to generalized seizure
Description
Grand mal seizure (tonic-clonic seizure) is characterized by a sudden loss of consciousness followed
by tonic and clonic muscular contractions.
Types of seizures:
Focal seizures: (no loss of consciousness)
Simple sensory: e.g., déjà vu

Simple motor: e.g., Jacksonian march
Complex: e.g., Automatism
Generalized seizure: (associated with loss of consciousness)
Tonic-clonic (grand mal)

Absence (petit mal)
Tonic, Clonic, Myoclonic, and Atonic types.
Focal to generalized seizure: (starts as focal, then becomes generalized)
Page - 1756
Question 36/82
Question #36
A 23-year-old male patient came to you because of recurrent loss of consciousness and tonic-clonic
muscular contractions. During the events, his tongue fell back into his throat, and he choked. What
is the drug of choice for this patient?
a. Carbamazepine
b. Phenobarbital
c. Phenytoin
d. Tiagabine
e. Valproic acid
Page - 1757
Question 36/82
Question #36
is the drug of choice for this patient?
a. Carbamazepine
b. Phenobarbital
c. Phenytoin
d. Tiagabine
e. Valproic acid √
Description
Grand mal seizure (tonic-clonic) is characterized by a sudden loss of consciousness followed by tonic
and clonic muscular contractions.
Valproic acid is the first-choice agent for treating grand-mal (tonic-clonic) seizures.
Page - 1758
Question 37/82
Question #37
A 28-year-old male patent presented with recurrent true seizure attacks for the last 15 minutes
without returning consciousness between attacks. What is the best initial treatment for his
condition?
a. Lorazepam
b. Phenytoin
c. Phenobarbital
d. Carbamazepine
e. Valproic acid
Page - 1759
Question 37/82
Question #37
A 28-year-old male patent presented with recurrent true seizure attacks for the last 15 minutes
without returning consciousness between attacks. What is the best initial treatment for his
condition?
a. Lorazepam √
b. Phenytoin
c. Phenobarbital
d. Carbamazepine
e. Valproic acid
Description
Lorazepam is the preferred agent in the treatment of Status epilepticus.
Approach to treat status epilepticus:
1st line: Lorazepam/ Diazepam

2nd line: Phenytoin/ Fosphenytoin
3rd line: Phenobarbital
4th line: ICU transfer, intubation, ventilation with general anesthesia
Page - 1760
Question 38/82
Question #38
Which of the following is the treatment of choice for absent seizures?
a. Valproic acid
b. Lamotrigine
c. Ethosuximide
d. Phenytoin
e. Levetiracetam
Page - 1761
Question 38/82
Question #38
Which of the following is the treatment of choice for absent seizures?
a. Valproic acid
b. Lamotrigine
c. Ethosuximide √
d. Phenytoin
e. Levetiracetam
Description
Ethosuximide is the drug of choice for absent (Petit mal) seizures.
e treatment of epilepsy is summarized in the following table:
Page - 1762
Question 39/82
Question #39
A 25-year-old male patient with epilepsy is on treatment with carbamazepine. In the last 2 weeks, he
had 3 episodes of convulsions. His carbamazepine level in his blood is within the therapeutic range.
a. Add another agent

b. Brain CT scan and EEG
c. Check carbamazepine level in 2 weeks
d. Observation
e. Order CBC, KFT, U&Es, T4, TSH
Page - 1763
Question 39/82
Question #39
A 25-year-old male patient with epilepsy is on treatment with carbamazepine. In the last 2 weeks, he
had 3 episodes of convulsions. His carbamazepine level in his blood is within the therapeutic range.
a. Add another agent √

b. Brain CT scan and EEG
c. Check carbamazepine level in 2 weeks
d. Observation
e. Order CBC, KFT, U&Es, T4, TSH
Description
Seizure is a clinical syndrome caused by an abnormal electrical discharge in the brain, while epilepsy
is a tendency to have a seizure; a single seizure is not epilepsy, But an indication for investigations.
e patient has uncontrolled epilepsy despite normal blood carbamazepine level. So, another agent
should be added.
Page - 1764
Question 40/82
Question #40
is the best diagnostic test to do for this patient?
a. Chest x-ray
b. Brain CT scan
c. EEG
d. Reassurance
e. Brain MRI
Page - 1765
Question 40/82
Question #40
is the best diagnostic test to do for this patient?
a. Chest x-ray
b. Brain CT scan
c. EEG √
d. Reassurance
e. Brain MRI
Description
Grand mal seizure (tonic-clonic) is characterized by a sudden loss of consciousness followed by tonic
and clonic muscular contractions.
EEG is the appropriate diagnostic test to be done for the identification and assessment of grand mal
seizures.
Page - 1766
Question 41/82
Question #41
A 23-year-old male patient experienced an episode of jerky movements and loss of consciousness.
Which of the following would make a true seizure more likely than pseudoseizures?
a. Eyes closed during the attack

b. Post-event confusion
c. History of chronic pain or fibromyalgia
d. Rapid breathing and tachycardia with carpopedal spasm
e. Carpal spasms
Page - 1767
Question 41/82
Question #41
A 23-year-old male patient experienced an episode of jerky movements and loss of consciousness.
Which of the following would make a true seizure more likely than pseudoseizures?
a. Eyes closed during the attack

b. Post-event confusion √
c. History of chronic pain or fibromyalgia
d. Rapid breathing and tachycardia with carpopedal spasm
e. Carpal spasms
Description
Eye closure is uncommon in true seizures. In comparison, carpal and carpopedal spasms may present
with hyperventilation syndrome.
Features suggestive of seizure activity include:
Tongue biting
Pre-ictal aura
Post-ictal confusion
Focal neurologic signs.
Page - 1768
Question 42/82
Question #42
What is the most frequent cause of seizures in elderly patients?
a. Alcohol withdrawal
b. Stroke
c. Head trauma
d. Hypoglycemia
e. Primary epilepsy
Page - 1769
Question 42/82
Question #42
What is the most frequent cause of seizures in elderly patients?
a. Alcohol withdrawal
b. Stroke √
c. Head trauma
d. Hypoglycemia
e. Primary epilepsy
Description
CVA’s are the most common cause of seizures in geriatric patients.
Secondary causes of seizures include:
Metabolic (Hypoglycemia, hypernatremia, hyponatremia, hypocalcemia, hypomagnesemia,

Uremia)
CNS infection (Meningitis, encephalitis, abscess)
Brain tumors, trauma, hypoxia, CVA, hemorrhage
Toxic substances (alcohol, cocaine)
Page - 1770
Question 43/82
Question #43
A 28-year-old male patent presented with recurrent true seizure attacks for the last 15 minutes.
ere is no returning consciousness between attacks. e patient is suering from which of the
following?
a. Tonic clonic convulsion

b. Absent seizure
c. Jitteriness
d. Status epilepticus
e. Hysterical conversion disorder
Page - 1771
Question 43/82
Question #43
A 28-year-old male patent presented with recurrent true seizure attacks for the last 15 minutes.
ere is no returning consciousness between attacks. e patient is suering from which of the
following?
a. Tonic clonic convulsion

b. Absent seizure
c. Jitteriness
d. Status epilepticus √
e. Hysterical conversion disorder
Description
Status epilepticus is a seizure not resolving spontaneously or recurrent convulsions without

recovery of consciousness for > 5 minutes. It can be due to a sub-therapeutic level of anti-epileptic
drugs in a patient known to have epilepsy or may be precipitated by secondary causes like metabolic
infection, tumor, etc.
Page - 1772
Question 44/82
Question #44
A 24-year-old male patient with a known case of epilepsy presented with an attack of convulsion for
the last 15 minutes without a return of consciousness. Aer maintaining adequate ventilation and
perfusion, what is the first-line pharmacological treatment you will start?
a. Phenytoin
b. Fosphenytoin
c. Naloxone
d. Lorazepam
e. Valproate sodium
Page - 1773
Question 44/82
Question #44
A 24-year-old male patient with a known case of epilepsy presented with an attack of convulsion for
the last 15 minutes without a return of consciousness. Aer maintaining adequate ventilation and
perfusion, what is the first-line pharmacological treatment you will start?
a. Phenytoin
b. Fosphenytoin
c. Naloxone
d. Lorazepam √
e. Valproate sodium
Description
Status epilepticus is a seizure not resolving spontaneously or recurrent convulsions without

recovery of consciousness for > 5 minutes
Lorazepam is the preferred agent in the treatment of Status epilepticus.
Approach to treat status epilepticus:
1st line: Lorazepam/ Diazepam

2nd line: Phenytoin/ Fosphenytoin
3rd line: Phenobarbital
4th line: ICU transfer, intubation, ventilation with general anesthesia
Page - 1774
Question 45/82
Question #45
A 66-year-old female has developed a slowly progressive right-hand tremor for 6 months. It
worsens when she holds them up against gravity but is relieved by resting them. Her mother has the
same problem, and her physical examination and lab investigations appear unremarkable. What
would you prescribe to relieve her tremor?
a. Bromocriptine
b. Carbamazepine
c. Carbidopa/levodopa
d. Escitalopram
e. Propranolol
Page - 1775
Internal Medicine - Neurology - Essential Tremor
Question 45/82
Question #45
A 66-year-old female has developed a slowly progressive right-hand tremor for 6 months. It
worsens when she holds them up against gravity but is relieved by resting them. Her mother has the
same problem, and her physical examination and lab investigations appear unremarkable. What
would you prescribe to relieve her tremor?
a. Bromocriptine
b. Carbamazepine
c. Carbidopa/levodopa
d. Escitalopram
e. Propranolol √
Description
Essential tremor occurs in both rest and intention

More common in the hands, but the head may be aected
It may aect some skills like handwriting
Caeine makes it worse, and alcohol makes it better
Primidone and propranolol are the best maintenance medical therapy
Page - 1776
Question 46/82
Question #46
Which of the following is the best to be used in treating essential tremor?
a. Isoniazid
b. Diazepam
c. Propranolol
d. Gabapentin
e. Pregabalin
Page - 1777
Internal Medicine - Neurology - Essential Tremor
Question 46/82
Question #46
Which of the following is the best to be used in treating essential tremor?
a. Isoniazid
b. Diazepam
c. Propranolol √
d. Gabapentin
e. Pregabalin
Description
Essential tremor occurs in both rest and intention

More common in the hands, but the head may be aected
It may aect some skills like handwriting
Caeine makes it worse, and alcohol makes it better
Primidone and propranolol are the best maintenance medical therapy
Page - 1778
Question 47/82
Question #47
A 46-year-old male patent presented to you with bilateral lower limb weakness and decreased ankle
jerks. 2 weeks ago, he was diagnosed with C. jejuni diarrhea. All the following are characteristic of
Guillain-Barré syndrome except:
a. Hyporeflexia or Areflexia
b. Sensory deficit
c. Infection with C. jejuni
d. Muscle weakness
e. Steroids used in the treatment
Page - 1779
Internal Medicine - Neurology - Guillain-Barré syndrome (GBS)
Question 47/82
Question #47
jerks. 2 weeks ago, he was diagnosed with C. jejuni diarrhea. All the following are characteristic of
Guillain-Barré syndrome except:
a. Hyporeflexia or Areflexia
b. Sensory deficit
c. Infection with C. jejuni
d. Muscle weakness
e. Steroids used in the treatment √
Description
ere is no benefit of steroid use in Guillain-Barre Syndrome (GBS). It is treated with IVIG or plasma
exchange
Guillain-Barre Syndrome (GBS):
Immune-mediated demyelination of the peripheral nervous system

Oen triggered by an infection (classically Campylobacter jejuni)
e clinical features include paresthesia with pain precedes weakness in ascending pattern
e most common cause of death is a respiratory failure (intubation may be needed)
Treatment is achieved by IVIG or plasmapheresis
Page - 1780
Question 48/82
Question #48
jerks. 2 weeks ago, he was diagnosed with C. jejuni diarrhea. What is the most likely diagnosis?
a. Guillain-Barré syndrome
c. Myasthenia gravis disease
d. Systemic Lupus Erythematosus (SLE)
Page - 1781
Internal Medicine - Neurology - Guillain-Barré syndrome (GBS)
Question 48/82
Question #48
jerks. 2 weeks ago, he was diagnosed with C. jejuni diarrhea. What is the most likely diagnosis?
a. Guillain-Barré syndrome √
c. Myasthenia gravis disease
d. Systemic Lupus Erythematosus (SLE)
Description
Ascending paralysis aer infectious diarrhea is the classic presentation of Guillain-Barre Syndrome
(GBS)
Guillain-Barre Syndrome (GBS):
Immune-mediated demyelination of the peripheral nervous system

Oen triggered by an infection (classically Campylobacter jejuni)
e clinical features include paresthesia with pain precedes weakness in ascending pattern
e most common cause of death is a respiratory failure (intubation may be needed)
Treatment is achieved by IVIG or plasmapheresis
Page - 1782
Question 49/82
Question #49
A 39-year-old female patient presented with 6 months of recurrent morning headaches and
vomiting. On examination, she has nystagmus. What is the next step in your investigation?
a. Referral to ophthalmologist
b. Brain CT scan
c. EEG
d. Temporal artery biopsy
e. rombolytic therapy
Page - 1783
Internal Medicine - Neurology - Headaches
Question 49/82
Question #49
A 39-year-old female patient presented with 6 months of recurrent morning headaches and
vomiting. On examination, she has nystagmus. What is the next step in your investigation?
a. Referral to ophthalmologist
b. Brain CT scan √
c. EEG
d. Temporal artery biopsy
e. rombolytic therapy
Description
If an intracranial mass is suspected, a CT or MRI of the head/brain should be done
Page - 1784
Question 50/82
Question #50
A 49-year-old patient with a known case of diabetes came with constricted pupils, a drooping upper
lid, and dry skin on the le side of his face. Which nerve is the most likely aected?
a. Oculomotor
b. Sympathetic
c. Trochlear
d. Facial
e. Abducent
Page - 1785
Internal Medicine - Neurology - Horner syndrome
Question 50/82
Question #50
A 49-year-old patient with a known case of diabetes came with constricted pupils, a drooping upper
lid, and dry skin on the le side of his face. Which nerve is the most likely aected?
a. Oculomotor
b. Sympathetic √
c. Trochlear
d. Facial
e. Abducent
Description
Ptosis, myosis, and anhidrosis are classic features of Horner syndrome. It is caused by sympathetic
nerve fibers interruption
Horner's syndrome:
Classically, presented with Ptosis, Miosis, anhidrosis, and Enophthalmos

Cased by interruption of sympathetic nerve supply to the eye
Maybe due to an apical (Pancoast) tumor of the lung
Page - 1786
Question 51/82
Question #51
A 65-year-old male patient presented with ptosis, myosis, and anhidrosis on the right side of his
face. What is the most likely cause?
a. Tumor-induced exophthalmos
b. Oculomotor nerve palsy
c. Apical pulmonary carcinoma (Pancoast)
d. yroid goiter
e. Vagus nerve palsy
Page - 1787
Question 51/82
Question #51
face. What is the most likely cause?
a. Tumor-induced exophthalmos
b. Oculomotor nerve palsy
c. Apical pulmonary carcinoma (Pancoast) √
d. yroid goiter
e. Vagus nerve palsy
Description
Ptosis, myosis, and anhidrosis are classic features of Horner syndrome. Pancoast tumor is the most
likely cause.
Horner's syndrome:

Page - 1788
Question 52/82
Question #52
face. In addition to a complete history and physical examination. Which of the following would be
most appropriate at this point?
a. A chest X-Ray.
b. Brain and orbital MRI
d. Fasting glucose level and A1C
e. An acetylcholine receptor antibody level
Page - 1789
Question 52/82
Question #52
face. In addition to a complete history and physical examination. Which of the following would be
most appropriate at this point?
a. A chest X-Ray. √
b. Brain and orbital MRI
d. Fasting glucose level and A1C
e. An acetylcholine receptor antibody level
Description
Ptosis, myosis, and anhidrosis are classic features of Horner syndrome. Pancoast tumor is the most
likely cause.
Horner's syndrome:

Page - 1790
Question 53/82
Question #53
About the nervous system in the human, all the following are true except:
a. e spinal cord is a part of the central nervous system

b. e Corpus callosum is a highly vascular area connecting the right and le hemispheres
c. e white matter is the inner part of the spinal cord.
d. e cranial nerves V, VI, and VII have their nuclei in the pones
e. e cerebellum function is to maintain coordination, voluntary motor activity, and equilibrium
Page - 1791
Internal Medicine - Neurology - Introduction to Neurology
Question 53/82
Question #53
About the nervous system in the human, all the following are true except:
a. e spinal cord is a part of the central nervous system

b. e Corpus callosum is a highly vascular area connecting the right and le hemispheres
c. e white matter is the inner part of the spinal cord. √
d. e cranial nerves V, VI, and VII have their nuclei in the pones
e. e cerebellum function is to maintain coordination, voluntary motor activity, and equilibrium
Description
e white matter occupies the inner part of the brain and the outer part of the spinal cord.
Nervous system:
e central nervous system (CNS) is formed of two main parts:

Intracranial part (Cerebrum, brain stem, cerebellum)
Spinal part (spinal cord, cauda equina)
e Cerebrum is formed of two hemispheres connected via the corpus callosum and the upper
part of the brain stem
e Brain stem is formed of the midbrain, pons, and medulla
Page - 1792
Question 54/82
Question #54
A 40-year-old female patient presented with episodes of vertigo every 4 months. She is complaining
of tinnitus and hearing loss in both ears. Vitals and physical examination are normal. What is the
b. Migraine’s headache
d. Alport syndrome
e. 3rd nerve palsy
Page - 1793
Internal Medicine - Neurology - Meniere’s Disease
Question 54/82
Question #54
of tinnitus and hearing loss in both ears. Vitals and physical examination are normal. What is the
a. Meniere’s disease √
b. Migraine’s headache
d. Alport syndrome
e. 3rd nerve palsy
Description
Meniere’s disease is characterized by a triad of vertigo, fluctuating sensorineural hearing loss, and
tinnitus.
Meniere’s disease
It is an episodic attack of tinnitus, hearing loss, and vertigo lasting for minutes to hours
Due to endolymphatic overaccumulation (Endolymphatic hydrops)
Page - 1794
Question 55/82
Question #55
of tinnitus and hearing loss in both ears. All the following about Meniere’s disease are accurate
except?
a. Endolymphatic overaccumulation is the primary pathology

b. Tinnitus, hearing loss, vertigo, and aural fullness are the main symptoms
c. ere is no diagnostic test for this condition
d. Diuretics and a low-salt diet may decrease the frequency and severity of episodes
e. Surgery never has a rule in the treatment
Page - 1795
Internal Medicine - Neurology - Meniere’s Disease
Question 55/82
Question #55
of tinnitus and hearing loss in both ears. All the following about Meniere’s disease are accurate
except?
a. Endolymphatic overaccumulation is the primary pathology

b. Tinnitus, hearing loss, vertigo, and aural fullness are the main symptoms
c. ere is no diagnostic test for this condition
d. Diuretics and a low-salt diet may decrease the frequency and severity of episodes
e. Surgery never has a rule in the treatment √
Description
Meniere’s disease is characterized by a triad of vertigo, fluctuating sensorineural hearing loss, and
tinnitus.
Meniere’s disease
It is an episodic attack of tinnitus, hearing loss, and vertigo lasting for minutes to hours
Due to endolymphatic overaccumulation (Endolymphatic hydrops)
Medical treatment includes bed rest, antiemetics, antivertiginous drugs (betahistine,
meclizine, diphenhydramine), and anticholinergics (e.g., scopolamine)
Surgical treatment may be beneficial; the vestibular system can be ablated with topical
gentamicin or surgery
Page - 1796
Question 56/82
Question #56
Which of the following agents is helpful for prophylactic use for migraine headaches?
a. Dihydroergotamine
b. Amitriptyline
c. Sumatriptan
d. Aspirin
e. Acetaminophen
Page - 1797
Internal Medicine - Neurology - Migraine Headache
Question 56/82
Question #56
Which of the following agents is helpful for prophylactic use for migraine headaches?
a. Dihydroergotamine
b. Amitriptyline √
c. Sumatriptan
d. Aspirin
e. Acetaminophen
Description
Beta-blockers, antidepressants, anticonvulsants, calcium channel blockers, and serotonin

antagonists are the major classes of drugs used for preventive migraine therapy
Migraine headaches:
Migraine headache is a type of headache that is more common in females.

It can be precipitated by emotional stress, noises, alcohol, caeine, and oral contraceptive pills
It is a recurrent, severe headache that fulfills the POUND criteria: (Disabling, Pulsatile, One-day
duration, Unilateral, and associated with nausea and vomiting).
Patients with more than 3 of the POUND criteria can be diagnosed with migraine without
additional testing
Migraine with aura strongly contributes to stroke when combined with DM, HTN, and obesity.
e episodes of headaches are treated by analgesia (aspirin, paracetamol) and Triptans
Migraine headaches are controlled by prophylactic administration of beta-blockers, valproic
acid, or topiramate.
Page - 1798
Question 57/82
Question #57
Which of the following is not used as a prophylactic treatment for a migraine headache in adults?
a. Gabapentin
b. Propranolol
c. Amitriptyline
d. Verapamil
e. Naproxen
Page - 1799
Question 57/82
Question #57
Which of the following is not used as a prophylactic treatment for a migraine headache in adults?
a. Gabapentin
b. Propranolol
c. Amitriptyline
d. Verapamil
e. Naproxen √
Description
Naproxen is used to relieve, not to prevent, migraine headaches
Migraine headaches:

additional testing
Page - 1800
Question 58/82
Question #58
A 32-year-old female complains of unilateral frontotemporal throbbing headaches for 4 – 6 hours

every 2 – 3 weeks. However, the headache is associated with nausea and occasional vomiting and is
relieved with simple analgesia, sleeping, and massage. Based on history alone, what is the most
likely diagnosis?
a. Acute sinusitis
b. Cluster headache
c. Intracranial mass
d. Migraine headache
Page - 1801
Question 58/82
Question #58
A 32-year-old female complains of unilateral frontotemporal throbbing headaches for 4 – 6 hours

every 2 – 3 weeks. However, the headache is associated with nausea and occasional vomiting and is
relieved with simple analgesia, sleeping, and massage. Based on history alone, what is the most
likely diagnosis?
a. Acute sinusitis
b. Cluster headache
c. Intracranial mass
d. Migraine headache √
Description
Migraine headache is the most likely if young and female. e headaches are unilateral, infrequent,
and throbbing; the headaches are associated with nausea and vomiting, and sleep oers relief.
Migraine headaches:

additional testing
Page - 1802
Question 59/82
Question #59
A 24-year-old female presents with le-side weakness, blurry vision, and ataxia. 2 years ago, she had
a history of ataxic gait, right-side numbness, and urinary incontinence. What is the most likely
diagnosis?
a. Multiple sclerosis
b. Systemic lupus erythematosus (SLE)
c. Stroke
d. Fibromyalgia
e. Guillain-Barré syndrome
Page - 1803
Internal Medicine - Neurology - Multiple Sclerosis (MS)
Question 59/82
Question #59
A 24-year-old female presents with le-side weakness, blurry vision, and ataxia. 2 years ago, she had
a history of ataxic gait, right-side numbness, and urinary incontinence. What is the most likely
diagnosis?
a. Multiple sclerosis √
b. Systemic lupus erythematosus (SLE)
c. Stroke
d. Fibromyalgia
e. Guillain-Barré syndrome
Description
MS is diagnosed based on McDonald’s criteria: at least two attacks disseminated in time,

disseminated in place, and typical radiological features.
Multiple sclerosis is defined as a demyelinating autoimmune disease of the CNS
Cell-mediated autoimmune attack of myelin-producing Oligodendrocyte of the CNS
Relapsing-remitting course (80%) – Most common type
Page - 1804
Question 60/82
Question #60
A 26-year-old female with a history of multiple sclerosis presented with a sudden vision loss in the
right eye. External ocular movements are normal, but funduscopic examination shows pallor of the
optic disk. is patient’s condition is most likely due to demyelination of which of the following?
a. Corpus callosum
b. Oculomotor nerve
c. Trigeminal nerve
d. Optic nerve
e. Visual cortex
Page - 1805
Question 60/82
Question #60
A 26-year-old female with a history of multiple sclerosis presented with a sudden vision loss in the
right eye. External ocular movements are normal, but funduscopic examination shows pallor of the
optic disk. is patient’s condition is most likely due to demyelination of which of the following?
a. Corpus callosum
b. Oculomotor nerve
c. Trigeminal nerve
d. Optic nerve √
e. Visual cortex
Description
Localization of the lesion is determined by history and physical examination.

Page - 1806
Question 61/82
Question #61
A 26-year-old female patient presented with facial numbness, a painful le eye, weak right upper
limb; she intermittently has urine incontinence, and the symptoms are associated with hot weather.
Physical examination shows hyperreflexia. Which of the following will most likely confirm the
diagnosis?
a. EMG
b. EEG
c. Cervical and Brain MRI with contrast
d. Brain CT scan with contrast
e. CSF examination
Page - 1807
Question 61/82
Question #61
A 26-year-old female patient presented with facial numbness, a painful le eye, weak right upper
limb; she intermittently has urine incontinence, and the symptoms are associated with hot weather.
Physical examination shows hyperreflexia. Which of the following will most likely confirm the
diagnosis?
a. EMG
b. EEG
c. Cervical and Brain MRI with contrast √
d. Brain CT scan with contrast
e. CSF examination
Description
MRI is the diagnostic modality of choice for multiple sclerosis to ascertain the presence of the
characteristic demyelinating lesions.
Page - 1808
Question 62/82
Question #62
A 29-year-old female patient presented with diplopia, dysphagia, with choking. You examined her
and noted ptosis, weak facial muscles, and normal tendon reflexes. You suspected a diagnosis of
myasthenia gravis. Which is true regarding this condition?
a. More common in men

b. Anti-acetylcholinesterase antibodies are characteristic
c. ymic hypoplasia is characteristic
d. It may be associated with autoimmune thyroiditis
e. Diagnosed by chest CT or MRI
Page - 1809
Internal Medicine - Neurology - Myasthenia Gravis (MG)
Question 62/82
Question #62
and noted ptosis, weak facial muscles, and normal tendon reflexes. You suspected a diagnosis of
myasthenia gravis. Which is true regarding this condition?
a. More common in men

b. Anti-acetylcholinesterase antibodies are characteristic
c. ymic hypoplasia is characteristic
d. It may be associated with autoimmune thyroiditis √
e. Diagnosed by chest CT or MRI
Description
Autoimmune diseases are usually associated with other autoimmune diseases.
Myasthenia gravis (MG):
It is an immune-mediated disease in which autoantibodies to acetylcholine receptors in the

neuromuscular junction develop
15% of patients have a thymoma, and many others have thymus hyperplasia
Clinical features include fatigue and weakness, especially the ocular and facial muscles, but all
the body muscles can be aected
e most common cause of death in this disease is respiratory muscle involvement, respiratory
failure, and respiratory infections secondary to aspiration
It is diagnosed by the combination of tensilon test, EMG, and anti-acetylcholine receptor
antibodies > 80% of cases
Chest CT scan should be done for all cases to rule out thymoma, thymus hyperplasia
Pyridostigmine is the treatment of choice for this condition
Page - 1810
Question 63/82
Question #63
and noted ptosis, weak facial muscles, and normal tendon reflexes. What is the most likely
diagnosis?
b. Myasthenia gravis disease
c. Multiple sclerosis
d. Dermatomyositis
e. Fibromyalgia
Page - 1811
Question 63/82
Question #63
and noted ptosis, weak facial muscles, and normal tendon reflexes. What is the most likely
diagnosis?
b. Myasthenia gravis disease √
d. Dermatomyositis
e. Fibromyalgia
Description
e eye muscles are aected first in 40% of people with myasthenia gravis.

Page - 1812
Question 64/82
Question #64
A 30-year-old female patient with progressive ptosis throughout the day and dysphagia, which of
the following is the most appropriate diagnostic test to confirm the diagnosis of myasthenia gravis?
a. C reactive protein
b. Tensilon test
c. Spinal MRI
d. Chest CT scan
e. Acetylcholine receptor antibody test
Page - 1813
Question 64/82
Question #64
A 30-year-old female patient with progressive ptosis throughout the day and dysphagia, which of
the following is the most appropriate diagnostic test to confirm the diagnosis of myasthenia gravis?
a. C reactive protein
b. Tensilon test
c. Spinal MRI
d. Chest CT scan
e. Acetylcholine receptor antibody test √
Description
e anti-acetylcholine receptor antibody test is 100% specific.
It has a sensitivity of 90% in generalized MG but only 50-70% in ocular MG.

Page - 1814
Question 65/82
Question #65
A 22-year-old depressed lady committed suicide by ingestion of organophosphate insecticide. What

is the primary mechanism of action in organophosphate poisoning?
a. Acetylcholine inhibition
b. Catecholamine activation
c. Cholinesterase activation
d. Cholinesterase inhibition
e. Respiratory center depression
Page - 1815
Internal Medicine - Neurology - Organophosphate poisoning
Question 65/82
Question #65

is the primary mechanism of action in organophosphate poisoning?
a. Acetylcholine inhibition
b. Catecholamine activation
c. Cholinesterase activation
d. Cholinesterase inhibition √
e. Respiratory center depression
Description
Inhibition of the cholinesterase enzyme will lead to enhance in the amount of acetylcholine in the
body and a wide variety of reactions
Organophosphate poisoning:
Organophosphate is a substance that is used widely in insecticides; most of the war gases are
organophosphates as well
e time from exposure to the onset of symptoms is 30 – 120 minutes
Patients should be treated by gastric lavage, washing skin, atropine, Pralidoxime, and other
supportive measures
Page - 1816
Question 66/82
Question #66

is the drug of choice to reverse the condition?
a. Adrenalin
b. Deferoxamine
c. Atropine
d. Acetylcholine
e. Diltiazem
Page - 1817
Internal Medicine - Neurology - Organophosphate poisoning
Question 66/82
Question #66

is the drug of choice to reverse the condition?
a. Adrenalin
b. Deferoxamine
c. Atropine √
d. Acetylcholine
e. Diltiazem
Description
Atropine is the drug of choice to reverse the action of acetylcholine in organophosphate poisoning
Organophosphate poisoning:
Organophosphate is a substance that is used widely in insecticides; most of the war gases are
organophosphates as well
e time from exposure to the onset of symptoms is 30 – 120 minutes
Patients should be treated by gastric lavage, washing skin, atropine, Pralidoxime, and other
supportive measures
Page - 1818
Question 67/82
Question #67
e correct initial treatment for a patient with Parkinson’s disease is:
a. Sinemet (carbidopa/levodopa) 25mg/100mg tablet three times a day

b. Ginkgo biloba tablets 2 times a day
c. Donepezil
d. Propranolol oral tablets
e. Deep electrical brain stimulation
Page - 1819
Internal Medicine - Neurology - Parkinson’s Disease (PD)
Question 67/82
Question #67
e correct initial treatment for a patient with Parkinson’s disease is:
a. Sinemet (carbidopa/levodopa) 25mg/100mg tablet three times a day √

b. Ginkgo biloba tablets 2 times a day
c. Donepezil
d. Propranolol oral tablets
e. Deep electrical brain stimulation
Description
Parkinson’s disease (PD) results from the loss of cells in the substantia nigra resulting in decreased
dopamine secretion. It is a clinical syndrome of Bradykinesia, rigidity, tremor, and loss of postural
reflexes.
Sinemet (carbidopa/levodopa) 25mg/100mg tablet three times a day is the best initial treatment for
Parkinson’s disease.
Page - 1820
Question 68/82
Question #68
Which of the following is the most helpful for confirming the diagnosis of Parkinson’s disease?
a. Brain CT scan
b. Brain MRI
c. Positive response to levodopa
d. Presence of intention tremor
e. Symmetrical bilateral tremor
Page - 1821
Question 68/82
Question #68
Which of the following is the most helpful for confirming the diagnosis of Parkinson’s disease?
a. Brain CT scan
b. Brain MRI
c. Positive response to levodopa √
d. Presence of intention tremor
e. Symmetrical bilateral tremor
Description
Patients with Parkinson’s disease should respond to dopamine agonists and levodopa.
reflexes.
Page - 1822
Question 69/82
Question #69
A 67-year-old male patent has been a known case of DM and severe Parkinson’s disease for 7 years,
and he is now on Levodopa- Carbidopa. He came to you with constipation, early satiety, GI reflux,
and bloating. Which of the following treatments is contraindicated?
a. Erythromycin
b. Metoclopramide
c. Domperidone
d. Nifedipine
e. Lactulose
Page - 1823
Question 69/82
Question #69
A 67-year-old male patent has been a known case of DM and severe Parkinson’s disease for 7 years,
and he is now on Levodopa- Carbidopa. He came to you with constipation, early satiety, GI reflux,
and bloating. Which of the following treatments is contraindicated?
a. Erythromycin
b. Metoclopramide √
c. Domperidone
d. Nifedipine
e. Lactulose
Description
Metoclopramide is a dopamine antagonist and can be used to treat gastroparesis, but it is

contraindicated in patients with severe Parkinson’s disease.
reflexes.
Page - 1824
Question 70/82
Question #70
Which of the following diseases is associated with rigidity, tremor, depigmentation of substantia
nigra, and loss of dopaminergic input to basal ganglia?
a. Epilepsy
b. Parkinson disease
c. Bipolar disorder
d. Alzheimer’s disease
e. Huntington disease
Page - 1825
Question 70/82
Question #70
Which of the following diseases is associated with rigidity, tremor, depigmentation of substantia
nigra, and loss of dopaminergic input to basal ganglia?
a. Epilepsy
b. Parkinson disease √
c. Bipolar disorder
d. Alzheimer’s disease
e. Huntington disease
Description
reflexes.
Page - 1826
Question 71/82
Question #71
A 73-year-old male patient presented with smaller, shuing footsteps and a tendency to fall; all the
following may be found in this patient except:
a. Intention tremor of the hands

b. Loss of facial expressions
c. Rolling resting tremor of the hands
d. Micrographia
e. Bradykinesia
Page - 1827
Question 71/82
Question #71
A 73-year-old male patient presented with smaller, shuing footsteps and a tendency to fall; all the
following may be found in this patient except:
a. Intention tremor of the hands √

b. Loss of facial expressions
c. Rolling resting tremor of the hands
d. Micrographia
e. Bradykinesia
Description
Intention tremor is a tremor that gets worse when a person is moving or reaching for an object. It
results from dysfunction of the cerebellum, not Parkinson’s disease.
reflexes.
Page - 1828
Question 72/82
Question #72
Which of the following is more likely to manifest in early Parkinson’s disease rather than drug-
induced parkinsonism?
a. Resting tremor
b. Micrographia
c. Shuing gait
d. Bradykinesia
e. Loss of facial expression
Page - 1829
Question 72/82
Question #72
Which of the following is more likely to manifest in early Parkinson’s disease rather than drug-
induced parkinsonism?
a. Resting tremor √
b. Micrographia
c. Shuing gait
d. Bradykinesia
e. Loss of facial expression
Description
Resting tremor is more likely to present in Parkinson’s disease than variants such as progressive
supranuclear palsy, multiple system atrophy, and drug-induced parkinsonism
reflexes.
Page - 1830
Question 73/82
Question #73
Which one of the following would be the most appropriate treatment to minimize the chance of
post-herpetic neuralgia?
a. Famciclovir
b. Prednisone
c. Capsaicin
d. Carbamazepine
e. Paracetamol
Page - 1831
Internal Medicine - Neurology - Postherpetic Neuralgia
Question 73/82
Question #73
Which one of the following would be the most appropriate treatment to minimize the chance of
post-herpetic neuralgia?
a. Famciclovir √
b. Prednisone
c. Capsaicin
d. Carbamazepine
e. Paracetamol
Description
Studies show that patients who present for treatment of herpes zoster within 72 hours will benefit
from antiviral therapy such as famciclovir to reduce the pain and decrease the risk of post-herpetic
neuralgia
Tricyclic antidepressants, Pregabalin, Gabapentin, Carbamazepine, and Phenytoin, can be used in

the treatment of post-herpetic neuralgia
Page - 1832
Question 74/82
Question #74
A 19-year-old obese female comes with bilateral frontal non-throbbing, worsening headaches for 5
months, aggravated by lying flat and relieved by getting up and walking around. Fundus
examination shows mild optic disk blurring, and her brain MRI is normal. e most appropriate next
step is to:
a. Obtain an EEG
b. Neurosurgical consult
c. Perform a lumbar puncture
d. Repeat Brain MRI
e. Start propranolol
Page - 1833
Internal Medicine - Neurology - Pseudotumor Cerebri
Question 74/82
Question #74
A 19-year-old obese female comes with bilateral frontal non-throbbing, worsening headaches for 5
months, aggravated by lying flat and relieved by getting up and walking around. Fundus
examination shows mild optic disk blurring, and her brain MRI is normal. e most appropriate next
step is to:
a. Obtain an EEG
b. Neurosurgical consult
c. Perform a lumbar puncture √
d. Repeat Brain MRI
e. Start propranolol
Description
For Pseudotumor cerebri, LP will show an elevated opening pressure and normal CSF analysis.
Benign intracranial HTN (BIH):
Also known as Pseudotumor cerebri, or idiopathic intracranial HTN (IIH)

ere is an increase in intracranial pressure without identifiable structural pathology
90% of aected patients are female
Associated with obesity, venous sinus thrombosis, OCP use, and vitamin A toxicity
Page - 1834
Question 75/82
Question #75
A 22-year-old college student presented with tightening, band-like headaches more frequently in
the morning. What is the most likely diagnosis?
a. Cluster headache
b. Migraine headache
c. Premenstrual headache
d. Sinus headache
e. Tension headache
Page - 1835
Internal Medicine - Neurology - Tension-type headache
Question 75/82
Question #75
A 22-year-old college student presented with tightening, band-like headaches more frequently in
the morning. What is the most likely diagnosis?
a. Cluster headache
b. Migraine headache
c. Premenstrual headache
d. Sinus headache
e. Tension headache √
Description
A classic presentation of tension-type headache.
Tension-type headache:
It is the most common type of headache

It presents as mild to moderate bilateral squeezing, dull, like pressure in nature, and non-
throbbing. However, it usually radiates forward from the occipital region and is precipitated by
a stressful event.
Treatment is achieved by rest, painkillers (like paracetamol and NSAIDs), and antidepressants.
Page - 1836
Question 76/82
Question #76
All the following cranial nerves are matched correctly with their type except:
a. Abducent nerve → Motor

b. Facial nerve → Mixed
c. Vagus nerve → Motor.
d. Olfactory nerve → Sensory
e. Optic nerve → Sensory
Page - 1837
Internal Medicine - Neurology - e Cranial Nerves
Question 76/82
Question #76
All the following cranial nerves are matched correctly with their type except:
a. Abducent nerve → Motor

b. Facial nerve → Mixed
c. Vagus nerve → Motor. √
d. Olfactory nerve → Sensory
e. Optic nerve → Sensory
Description
e Vagus nerve contains parasympathetic nerve fibers (Autonomic).
e Vagus nerve (CN X):
Name: Vagus nerve (autonomic)

Function: Parasympathetic control of the heart, lungs, and digestive tract.
e longest nerve of the autonomic nervous system in the human body
Page - 1838
Question 77/82
Question #77
A 35-year-old man is a known case of polycystic kidney disease. He came to the emergency
department with a sudden severe headache and neck stiness. However, his brain CT scan is shown
in the picture below. What is the most likely diagnosis?
a. Tension-type headache
c. Subdural hemorrhage
d. Epidural hemorrhage
e. Interventricular hemorrhage
Page - 1839
Internal Medicine - Neurology - underclap headache
Question 77/82
Question #77
A 35-year-old man is a known case of polycystic kidney disease. He came to the emergency
department with a sudden severe headache and neck stiness. However, his brain CT scan is shown
in the picture below. What is the most likely diagnosis?
a. Tension-type headache
b. Subarachnoid hemorrhage √
c. Subdural hemorrhage
d. Epidural hemorrhage
e. Interventricular hemorrhage
Description
Berry aneurysm is associated with polycystic kidney disease and carries a risk of rupture and
subarachnoid hemorrhage.
Page - 1840
Subarachnoid hemorrhage (SAH):
It is the most common cause of thunderclap headache
85% are caused by a ruptured saccular berry aneurysm

Clinical features include thunderclap headache, neck rigidity, photophobia, and vomiting.
Because CT scans may be negative in SAH, cerebral angiography is the best investigation.
Lumbar puncture (LP) showing xanthochromia, high protein, high pressure, and high RBC
count is typical, especially 12 hours aer the bleeding onset.
Page - 1841
Question 78/82
Question #78
A 53-year-old female presents with a sudden thunderclap headache, nausea, and photophobia
associated with a progressively reduced level of consciousness. Which one of the following would be
the best next step?
a. Brain CT angiography
c. Brain CT scan without contrast
d. Brain MRI
e. LP and CSF analysis
Page - 1842
Question 78/82
Question #78
A 53-year-old female presents with a sudden thunderclap headache, nausea, and photophobia
associated with a progressively reduced level of consciousness. Which one of the following would be
the best next step?
a. Brain CT angiography
c. Brain CT scan without contrast √
d. Brain MRI
e. LP and CSF analysis
Description
In a patient with suspected subarachnoid hemorrhage, the first study to do is a CT scan without
contrast

Page - 1843
Question 79/82
Question #79
A 35-year-old female presents with a 14-hour history of headaches described as the “Worst headache
in her life” her BP is 140/90, and the rest of her vital signs are normal. ere are no focal neurologic
findings, but neck stiness is present. Unenhanced CT of the head is negative. Which one of the
following findings in the bloody spinal fluid would indicate a diagnosis of subarachnoid
hemorrhage?
a. Yellowish discoloration of the fluid

b. A WBC:RBC ratio of 1/1000
c. A protein to RBC of 1/1000
d. A glucose level below 2.2 mmol/L
e. A CSF pressure of 17 cmH2O
Page - 1844
Question 79/82
Question #79
A 35-year-old female presents with a 14-hour history of headaches described as the “Worst headache
in her life” her BP is 140/90, and the rest of her vital signs are normal. ere are no focal neurologic
findings, but neck stiness is present. Unenhanced CT of the head is negative. Which one of the
following findings in the bloody spinal fluid would indicate a diagnosis of subarachnoid
hemorrhage?
a. Yellowish discoloration of the fluid √

b. A WBC:RBC ratio of 1/1000
c. A protein to RBC of 1/1000
d. A glucose level below 2.2 mmol/L
e. A CSF pressure of 17 cmH2O
Description
Xanthochromia is caused by the lysis of RBCs leading to a yellow-orange color of the CSF
e WBC:RBC ratio is more helpful in diagnosing meningitis.

Page - 1845
Question 80/82
Question #80
A 43-year-old man complains of severe, sharp, lancinating pain in his face that is aggravated by
touching a specific area. Neuro-examination is normal. Brain MRI with contrast shows no
abnormalities of the trigeminal nerve. Which is the most appropriate initial treatment?
a. Anticonvulsants
b. Aspirin
c. Nimodipine
d. NSAIDs
e. Vasodilators
Page - 1846
Internal Medicine - Neurology - Trigeminal Neuralgia
Question 80/82
Question #80
A 43-year-old man complains of severe, sharp, lancinating pain in his face that is aggravated by
touching a specific area. Neuro-examination is normal. Brain MRI with contrast shows no
abnormalities of the trigeminal nerve. Which is the most appropriate initial treatment?
a. Anticonvulsants √
b. Aspirin
c. Nimodipine
d. NSAIDs
e. Vasodilators
Description
In trigeminal neuralgia, carbamazepine is usually the first choice, but phenytoin has also been used.
Trigeminal neuralgia:
A disease of unknown cause but may be due to compression at the fih cranial nerve root.
Presents with a unilateral lancinating facial pain in the 2nd and 3rd division of trigeminal
nerve territories, which may remit and relapse over a year
e pain may be precipitated by touching the face, mastication, or even pronouncing certain
words.
It is treated by Carbamazepine (First line)
Pregabalin, Gabapentin, and Steroids are used if the patient can’t tolerate carbamazepine)
Surgical treatment is the last resort: Decompression of the trigeminal nerve root
Page - 1847
Question 81/82
Question #81
A man has shooting pain when he touches his face. You suspect trigeminal neuralgia. What is the
treatment of choice for this condition?
a. SSRI’s
b. Oral Prednisolone
c. Acyclovir
d. Carbamazepine
e. NSAIDs
Page - 1848
Internal Medicine - Neurology - Trigeminal Neuralgia
Question 81/82
Question #81
A man has shooting pain when he touches his face. You suspect trigeminal neuralgia. What is the
a. SSRI’s
b. Oral Prednisolone
c. Acyclovir
d. Carbamazepine √
e. NSAIDs
Description
carbamazepine or gabapentin can be used in the treatment of trigeminal neuralgia
Trigeminal neuralgia:
A disease of unknown cause but may be due to compression at the fih cranial nerve root.
Presents with a unilateral lancinating facial pain in the 2nd and 3rd division of trigeminal
nerve territories, which may remit and relapse over a year
e pain may be precipitated by touching the face, mastication, or even pronouncing certain
words.
It is treated by Carbamazepine (First line)
Pregabalin, Gabapentin, and Steroids are used if the patient can’t tolerate carbamazepine)
Surgical treatment is the last resort: Decompression of the trigeminal nerve root
Page - 1849
Question 82/82
Question #82
A 60-year-old-male patient came with right lower limb twitching and weakness. On examination,
he has fasciculations, decreased reflexes, and a down-going plantar reflex in the same leg. is
lesion should be suspected in:
a. A Lower Motor Neuron (LMN)

b. Both upper and lower motor neurons
c. An Upper Motor Neuron (UMN)
d. An Extrapyramidal Neuron
e. e tibiofemoral joint space
Page - 1850
Internal Medicine - Neurology - Upper vs. Lower Neuron lesion
Question 82/82
Question #82
A 60-year-old-male patient came with right lower limb twitching and weakness. On examination,
he has fasciculations, decreased reflexes, and a down-going plantar reflex in the same leg. is
lesion should be suspected in:
a. A Lower Motor Neuron (LMN) √

b. Both upper and lower motor neurons
c. An Upper Motor Neuron (UMN)
d. An Extrapyramidal Neuron
e. e tibiofemoral joint space
Description
Fasciculations, hyporeflexia, and down-growing plantar reflexes are features of lower motor neuron
lesions.
e following table demonstrates the dierence between upper and lower motor neuron lesions
according to symptoms and physical examination.
Page - 1851
Pulmonology
Page - 1852
Pulmonology
1) A-a Gradient => 1 Questions

2) Adult Respiratory Distress Syndrome (ARDS) => 1 Questions
3) Asbestosis => 3 Questions
4) Chronic Obstructive Pulmonary disease (COPD) => 20 Questions
5) Drug-induced lung fibrosis => 1 Questions
6) Eosinophilic lung disease => 1 Questions
7) Extrinsic Allergic Alveolitis (EAA) => 2 Questions
8) Idiopathic Pulmonary Fibrosis (IPF) => 2 Questions
9) Lung Abscess => 3 Questions
10) Pleural Eusion 1 => 7 Questions
11) Pulmonary Function Test (PFT) => 9 Questions
12) Pulmonary Hypertension => 2 Questions
13) Respiratory Alkalosis => 5 Questions
14) Respiratory neoplasms => 3 Questions
15) Sarcoidosis => 12 Questions
16) Silicosis => 1 Questions
17) Tuberculosis (TB) => 8 Questions
18) Asthma => 36 Questions
19) Bronchiectasis => 8 Questions
20) Pneumonia => 13 Questions
21) Sleep apnea syndrome => 6 Questions
Page - 1853
Internal Medicine - Pulmonology
Question 1/144
Question #1
e dierence between Alveolar-arterial PO2 may occur in which one of the following?
a. COPD
b. Hypoventilation
c. Stroke
d. High altitude
e. Anemia
Page - 1854
Internal Medicine - Pulmonology - A-a Gradient
Question 1/144
Question #1
e dierence between Alveolar-arterial PO2 may occur in which one of the following?
a. COPD √
b. Hypoventilation
c. Stroke
d. High altitude
e. Anemia
Description
A-a gradient measures the ecacy of gas exchange between alveoli (A) and the artery (a)
How to calculate:
A – a gradient = PAO2 – PaO2

PaO2 is measured by ABGs
PAO2 = FiO2 * (760 – 47) – (1.25 * PaCO2)
e normal A-a gradient = 0.3 * age in years
Interpretation:
An abnormal A-a gradient suggests the lungs as a possible cause of hypoxemia

e normal A-a gradient suggests causes external to the lung as a cause for hypoxemia
Page - 1855
Question 2/144
Question #2
A 32-year-old male patient was admitted to the surgical ICU aer sustaining a road trac accident.
e patient developed shortness of breath and tachypnea. His respiratory rate was 39 cycles per
minute, and he was distressed. ABG’s show PH of 7.47, PaO2 of 44 mmHg, PaO2/FiO2 ratio is 140. you
intubated the patient and started mechanical ventilation with high PEEP, but hypoxia is not
improving. What is the most likely diagnosis?
a. Respiratory depression due to brain stem injury

b. Pulmonary edema due to heart failure
c. Adult respiratory distress syndrome
d. Adrenal crisis
e. Tension pneumothorax
Page - 1856
Internal Medicine - Pulmonology - Adult Respiratory Distress Syndrome (ARDS)
Question 2/144
Question #2
A 32-year-old male patient was admitted to the surgical ICU aer sustaining a road trac accident.
e patient developed shortness of breath and tachypnea. His respiratory rate was 39 cycles per
minute, and he was distressed. ABG’s show PH of 7.47, PaO2 of 44 mmHg, PaO2/FiO2 ratio is 140. you
intubated the patient and started mechanical ventilation with high PEEP, but hypoxia is not
improving. What is the most likely diagnosis?
a. Respiratory depression due to brain stem injury

b. Pulmonary edema due to heart failure
c. Adult respiratory distress syndrome √
d. Adrenal crisis
e. Tension pneumothorax
Description
Respiratory distress and hypoxia aer a road trac accident or any extensive injury along with low
PaO2/FiO2 will raise the suspicion of ARDS, and the patient will need intubation and mechanical
ventilation with high PEEP and low Tidal volume
Adult respiratory distress syndrome:
ARDS: is a respiratory failure from lung injury or due to systemic disease

Presented with Secondary hypoxia + distress + non-cardiogenic pulmonary edema
Prognosis is Poor, Mortality 30-40%
It is induced by damage to the lung (e.g., sepsis, aspiration, PE, etc.)
It is treated by intubation, high PEEP and low Tidal volume, and supportive therapy.
Page - 1857
Question 3/144
Question #3
A 60-year-old male patient with a long history of asbestos exposure presents for follow-up. Which
of the following conditions are not caused by asbestos exposure?
a. High risk of lung cancer

b. Benign pleural plaques
c. Malignant pleural involvement
d. Pleural thickening
e. An obstructive pattern on PFT
Page - 1858
Internal Medicine - Pulmonology - Asbestosis
Question 3/144
Question #3
A 60-year-old male patient with a long history of asbestos exposure presents for follow-up. Which
of the following conditions are not caused by asbestos exposure?
a. High risk of lung cancer

b. Benign pleural plaques
c. Malignant pleural involvement
d. Pleural thickening
e. An obstructive pattern on PFT √
Description
Asbestos exposure is known to cause lower-zone lung fibrosis. erefore, the pulmonary function
test will show a restrictive pattern, not an obstructive one.
e following are the diseases that are possible to be found in asbestos exposure:
Pleural plaques are the most common asbestos-related lung disease (Benign with no malignant
transformation)
Asbestos may cause pleural thickening

Asbestosis (lower lobe fibrosis)
Lung cancer: Asbestosis and smoking together increase the risk 50 times
Mesothelioma is a malignant asbestos-related disease of the pleura
Page - 1859
Question 4/144
Question #4
A 50-year-old male patient presents with shortness of breath, dry cough, and Velcro-like crepitation
on both lower zones. He previously worked in a factory that manufactures helmets “using asbestos”
for 30 years before retiring 5 years ago. What is the best next step in the management of this
patient?
a. Lung biopsy for asbestos bodies

b. Look for pleural plaques by chest x-ray
c. Look for an obstructive pattern on PFT
d. Order ANA titer
e. Chest CT scan
Page - 1860
Question 4/144
Question #4
A 50-year-old male patient presents with shortness of breath, dry cough, and Velcro-like crepitation
on both lower zones. He previously worked in a factory that manufactures helmets “using asbestos”
for 30 years before retiring 5 years ago. What is the best next step in the management of this
patient?
a. Lung biopsy for asbestos bodies

b. Look for pleural plaques by chest x-ray √
c. Look for an obstructive pattern on PFT
d. Order ANA titer
e. Chest CT scan
Description
is patient is suspected of having asbestoses. e chest x-ray is the best initial test for this
condition.
In patients with asbestosis, pulmonary function studies reveal restrictive lung disease, and pleural
plaques in the diaphragmatic pleura on X-ray are considered a reliable indicator of asbestos
exposure
Page - 1861
Question 5/144
Question #5
A 61-year-old male patient is found to have bilateral pleural plaques incidentally during a routine
examination. You suspect occupational exposure. What is the most likely cause of this condition?
a. Silica dust
b. Smoking
c. Asbestos
d. Fungal spores
e. Coal dust
Page - 1862
Question 5/144
Question #5
A 61-year-old male patient is found to have bilateral pleural plaques incidentally during a routine
examination. You suspect occupational exposure. What is the most likely cause of this condition?
a. Silica dust
b. Smoking
c. Asbestos √
d. Fungal spores
e. Coal dust
Description
Pleural plaques are the most common asbestos-related lung disease.
is condition is a benign condition with no malignant transformation
Other diseases caused by asbestos exposure are pleural thickening, asbestosis (fibrosis), lung cancer,
and mesothelioma.
Page - 1863
Question 6/144
Question #6
A 65-year-old male patient has had his spirometer that confirms the presence of fixed obstruction.
However, he is a heavy smoker. e following treatments are associated with a decreased mortality
rate in this patient except:
a. Salmeterol
b. Smoking cessation
c. Lung volume reduction surgery
d. Long-term oxygen therapy
e. Pneumococcal vaccination
Page - 1864
Internal Medicine - Pulmonology - Chronic Obstructive Pulmonary disease (COPD)
Question 6/144
Question #6
A 65-year-old male patient has had his spirometer that confirms the presence of fixed obstruction.
However, he is a heavy smoker. e following treatments are associated with a decreased mortality
rate in this patient except:
a. Salmeterol √
b. Smoking cessation
c. Lung volume reduction surgery
d. Long-term oxygen therapy
e. Pneumococcal vaccination
Description
Salmeterol is a long-acting beta 2 agonist used for the symptomatic treatment of COPD patients,
but it doesn’t reduce the mortality rate.
Treatment of COPD:
Measures to reduce mortality:

Smoking cessation (the most important)
H. Influenza and pneumococcal vaccine
Long-Term Oxygen erapy (LTOT).
Measure to reduce symptoms:
SABA (More rapid onset)
SAMA (Most eective in COPD but slower than SABA)
LABA (More sustained eect)
ICS + LABA (ICS is not used as monotherapy in COPD)
Surgical measures (both morality and symptomatic benefits):
Volume reduction
Lung transplant
Page - 1865
Question 7/144
Question #7
A 66-year-old presents to the ER with COPD exacerbation. He recently developed an increasing

amount of purulent sputum. All the following are indicated in the treatment except:
a. Supplemental Oxygen
b. Ipratropium nebulizer
c. Intravenous methylprednisolone
d. TMP/SMX
e. Inhaled corticosteroids
Page - 1866
Question 7/144
Question #7
A 66-year-old presents to the ER with COPD exacerbation. He recently developed an increasing

amount of purulent sputum. All the following are indicated in the treatment except:
a. Supplemental Oxygen
b. Ipratropium nebulizer
c. Intravenous methylprednisolone
d. TMP/SMX
e. Inhaled corticosteroids √
Description
Inhaled corticosteroids are not indicated in acute COPD exacerbation.
Treatment of COPD exacerbation:
O2 therapy:
O2 saturation target is 88 – 92% until ABGs available
If there is no CO2 retention, make the target 94 – 98%
Bronchodilator (SABA+SAMA) with a back-to-back nebulizer
Give prednisolone 40 mg daily for 5 days
Oral antibiotics (Amoxicillin, Tetracycline, or clarithromycin) only if there are purulent sputum
Page - 1867
Question 8/144
Question #8
A 32-year-old male patient who was previously healthy presented to you with recurrent shortness of
breath for 6 months duration. Aer a pulmonary function test was performed, a diagnosis of COPD
was made. Of the following, what is the most accurate test to diagnose this disease?
a. Chest x-ray
b. Alpha 1 antitrypsin level
c. Bronchoscopy biopsy
d. Positron emission tomography scan
e. Chest CT scan
Page - 1868
Question 8/144
Question #8
A 32-year-old male patient who was previously healthy presented to you with recurrent shortness of
breath for 6 months duration. Aer a pulmonary function test was performed, a diagnosis of COPD
was made. Of the following, what is the most accurate test to diagnose this disease?
a. Chest x-ray
b. Alpha 1 antitrypsin level √
c. Bronchoscopy biopsy
d. Positron emission tomography scan
e. Chest CT scan
Description
Any young patient with COPD should be tested for alpha 1 antitrypsin level. A1AT deficiency is the
most common cause of COPD in young patients.
Alpha-1-antitrypsin deficiency:
Deficiency of alpha-1-antitrypsin due to a genetic problem

Autosomal recessive condition (located on chromosome 14)
Normally, PiMM
Homozygous PiSS (50% normal A1AT levels)
Homozygous PiZZ (10% normal A1AT levels)
Alpha-1-antitrypsin is a protease inhibitor protein synthesized by the liver
A1AT deficiency presents with a combination of COPD and liver cirrhosis
COPD (usually Emphysema) in young (< 40 years) and non-smoker patients is considered A1AT
deficiency until proven otherwise
Page - 1869
Question 9/144
Question #9
A 70-year-old heavy smoker presents with 6 months history of shortness of breath and productive
cough most days. His FEV1 is 43% of predicted, FEV1/FVC ratio is < 70%, and the total lung capacity
(TLC) is elevated. Which of the following is most likely to positively aect his survival?
a. Inhaled corticosteroids
b. Inhaled salmeterol
c. Prophylactic antibiotics
d. Oxygen supplementation
e. Short-acting muscarinic antagonists
Page - 1870
Question 9/144
Question #9
A 70-year-old heavy smoker presents with 6 months history of shortness of breath and productive
cough most days. His FEV1 is 43% of predicted, FEV1/FVC ratio is < 70%, and the total lung capacity
(TLC) is elevated. Which of the following is most likely to positively aect his survival?
c. Prophylactic antibiotics
d. Oxygen supplementation √
e. Short-acting muscarinic antagonists
Description
LTOT is used for those whose PaO2 is less than 55 mmHg
24 hours use is more eective than 12 hours of nocturnal use
It is eective to:
Reduce the mortality rate

Reduces the hemoglobin level
Facilitate sleeping
Increases the exercise tolerance
Indications for LTOT:
PaO2 < 55 mmHg (resting or exercise)

O2 saturation < 88% (resting or exercise)
PaO2 < 60 mmHg with heart disease or polycythemia
O2 saturation < 90% with heart disease or polycythemia
Instructions for LTOT usage:
Maintain O2 saturation > 90% and PaO2 > 60 mmHg

Devices used: Nasal cannula or venturi mask
Duration: at least 15 hours per day
Page - 1871
Page - 1872
Question 10/144
Question #10
A known case of COPD 50-year-old male presents with purulent sputum and shortness of breath for
the last 3 days. On examination, widespread wheezes and coarse crackles are heard on the right lung
base. e patient is not distressed and has stable vital signs. Which of the following is used to treat
his acute COPD exacerbation?
a. Long-acting beta agonists (LABA)

b. Oral prednisolone
c. Metronidazole
d. 100% oxygen
e. Tiotropium
Page - 1873
Question 10/144
Question #10
A known case of COPD 50-year-old male presents with purulent sputum and shortness of breath for
the last 3 days. On examination, widespread wheezes and coarse crackles are heard on the right lung
base. e patient is not distressed and has stable vital signs. Which of the following is used to treat
his acute COPD exacerbation?
a. Long-acting beta agonists (LABA)

b. Oral prednisolone √
c. Metronidazole
d. 100% oxygen
e. Tiotropium
Description
Systemic steroids (oral or IV) shorten hospital stays and decreases treatment failures
LABA and Tiotropium (LAMA) are not used in acute COPD exacerbation but are used to control
the disease and reduce exacerbation recurrence
100% O2 is contraindicated in acute COPD exacerbation as it can cause respiratory failure
Metronidazole is not used in acute COPD exacerbation.
e antibiotic that is used in COPD exacerbation should cover the most likely organisms to
cause this exacerbation (S pneumonia, H influenza, and Moraxella catarrhalis
O2 therapy:
Page - 1874
Question 11/144
Question #11
Which of the following does not indicate admission in a patient with COPD exacerbation?
a. Type 2 respiratory failure

b. ABGs showing PH of 7.31
c. Decreased level of consciousness
d. Coughs and Wheezy chest
e. Accessory muscle use
Page - 1875
Question 11/144
Question #11
Which of the following does not indicate admission in a patient with COPD exacerbation?
a. Type 2 respiratory failure

b. ABGs showing PH of 7.31
c. Decreased level of consciousness
d. Coughs and Wheezy chest √
e. Accessory muscle use
Description
In COPD exacerbations, coughs and wheezy chest are expected regardless of the severity of the
exacerbation.
Type 2 respiratory failure and respiratory acidosis require ventilator or NIV support
e use of accessory muscles indicates impending respiratory failure and life-threatening attacks.
Decreased level of consciousness indicates life-threatening COPD exacerbation.
Page - 1876
Question 12/144
Question #12
A 75-year-old male patient with longstanding COPD presents with slowly progressive shortness of
breath over the past year. His medications include a salbutamol inhaler (as required), an ipratropium
bromide inhaler (as required), and a salmeterol inhaler (twice daily). His oxygen saturation is 89%.
Which of the following is considered an indication for long-term oxygen therapy in this patient?
a. PaO2 of 58 mmHg
b. Recurrent infective exacerbations
c. Low exercise tolerance
d. Decreased level of consciousness
e. Presence of polycythemia
Page - 1877
Question 12/144
Question #12
A 75-year-old male patient with longstanding COPD presents with slowly progressive shortness of
breath over the past year. His medications include a salbutamol inhaler (as required), an ipratropium
bromide inhaler (as required), and a salmeterol inhaler (twice daily). His oxygen saturation is 89%.
Which of the following is considered an indication for long-term oxygen therapy in this patient?
a. PaO2 of 58 mmHg
b. Recurrent infective exacerbations
c. Low exercise tolerance
d. Decreased level of consciousness
e. Presence of polycythemia √
Description
LTOT has a mortality benefit in COPD patients
Indications for LTOT:
PaO2 < 55 mmHg (resting or exercise)

O2 saturation < 88% (resting or exercise)
PaO2 < 60 mmHg with heart disease or polycythemia
O2 saturation < 90% with heart disease or polycythemia
Instructions for LTOT usage:
Maintain O2 saturation > 90% and PaO2 > 60 mmHg

Devices used: Nasal cannula or venturi mask
Duration: at least 15 hours per day
Page - 1878
Question 13/144
Question #13
A 70-year-old male who is known case of COPD presents to the ER with COPD exacerbation; all the
following treatments are indicated except:
a. Salbutamol
b. Ipratropium bromide
c. A 100% oxygen flow
d. Prednisolone
e. Intravenous hydrocortisone
Page - 1879
Question 13/144
Question #13
A 70-year-old male who is known case of COPD presents to the ER with COPD exacerbation; all the
following treatments are indicated except:
a. Salbutamol
b. Ipratropium bromide
c. A 100% oxygen flow √
d. Prednisolone
e. Intravenous hydrocortisone
Description
100% oxygen is contraindicated in CO2 retainers patients (COPD and type 2 respiratory failure)
because it can suppress the respiratory center and lead to respiratory failure.
O2 therapy:
Page - 1880
Question 14/144
Question #14
A 65-year-old male patient was recently diagnosed with COPD. His pulmonary function test shows
an FEV1 of 33% of predicted and an FEV1/FVC ratio of 60%. e pulmonary function test of this
patient will categorize him as:
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4
e. No enough information
Page - 1881
Question 14/144
Question #14
A 65-year-old male patient was recently diagnosed with COPD. His pulmonary function test shows
an FEV1 of 33% of predicted and an FEV1/FVC ratio of 60%. e pulmonary function test of this
patient will categorize him as:
a. Stage 1
b. Stage 2
c. Stage 3 √
d. Stage 4
e. No enough information
Description
All COPD stages have an FEV1/FVC ratio of < 0.7, but the staging depends on FEV1.
FEV1 of 33% predicted is typical for stage 3 COPD.
Stages of COPD:
Stage 1: FEV1 is ≥ 80%

Stage 2: FEV1 is 50 – 79%
Stage 3: FEV1 is 30 – 49%
Stage 4: FEV1 is < 30%
Page - 1882
Question 15/144
Question #15
A 72-year-old male patient has 2 years history of progressive wheezes and shortness of breath and
was diagnosed with COPD secondary to heavy smoking. All the following are correct about this
condition except:
a. Smoking-related Emphysema usually aects the upper zones

b. Inhaled corticosteroid is not used as monotherapy
c. e most eective to stop COPD progression is smoking cessation
d. LTOT is used for symptomatic relief without any mortality benefit
e. DLco is reduced in Emphysema but not aected in chronic bronchitis
Page - 1883
Question 15/144
Question #15
A 72-year-old male patient has 2 years history of progressive wheezes and shortness of breath and
was diagnosed with COPD secondary to heavy smoking. All the following are correct about this
condition except:
a. Smoking-related Emphysema usually aects the upper zones

b. Inhaled corticosteroid is not used as monotherapy
c. e most eective to stop COPD progression is smoking cessation
d. LTOT is used for symptomatic relief without any mortality benefit √
e. DLco is reduced in Emphysema but not aected in chronic bronchitis
Description
Page - 1884
Question 16/144
Question #16
A 66-year-old heavy-smoker male is diagnosed with COPD, and you decided to start Inhaled
corticosteroids as a part of the treatment. In a COPD patient, ICS is shown to do one of the following:
a. Increases the rate of exacerbations

b. Increases the risk of pneumonia
c. Reduce the mortality rate
d. Prevents the progression of COPD
e. Increase the rate of bone fractures
Page - 1885
Question 16/144
Question #16
A 66-year-old heavy-smoker male is diagnosed with COPD, and you decided to start Inhaled
corticosteroids as a part of the treatment. In a COPD patient, ICS is shown to do one of the following:
a. Increases the rate of exacerbations

b. Increases the risk of pneumonia √
c. Reduce the mortality rate
d. Prevents the progression of COPD
e. Increase the rate of bone fractures
Description
ICS increases the risk of candidiasis of the oropharynx and pneumonia, but it does not increase the
risk of bone fractures like systemic steroids.
ICS reduces the risk of exacerbations but does not prevent COPD progression nor reduce mortality.
Page - 1886
Question 17/144
Question #17
A 66-year-old male patient presents with infective COPD exacerbation. He is treated at the
emergency room with 28% oxygen by venturi mask, nebulized SABA and SAMA, and intravenous
hydrocortisone. However, the patient is still symptomatic, and his Arterial blood gases are PH 7.31,
PaCO2 56 mmHg, and PaO2 78 mmHg. What is the most appropriate next step in the management
of this patient?
a. Invasive ventilation
b. Long-acting beta2 agonist
c. Start antibiotics
d. Non-invasive ventilation
e. Continue same treatment
Page - 1887
Question 17/144
Question #17
A 66-year-old male patient presents with infective COPD exacerbation. He is treated at the
emergency room with 28% oxygen by venturi mask, nebulized SABA and SAMA, and intravenous
hydrocortisone. However, the patient is still symptomatic, and his Arterial blood gases are PH 7.31,
PaCO2 56 mmHg, and PaO2 78 mmHg. What is the most appropriate next step in the management
of this patient?
a. Invasive ventilation
b. Long-acting beta2 agonist
c. Start antibiotics
d. Non-invasive ventilation √
e. Continue same treatment
Description
A PH of 7.25 – 7.35 in COPD exacerbation indicates the user of non-invasive ventilation.
O2 therapy:
e O2 saturation target is 88 – 92% until ABGs available
Indications for non-invasive ventilation:
COPD with respiratory acidosis pH 7.25-7.35

Type II respiratory failure secondary to:
Chest wall deformity
Neuromuscular disease
Obstructive sleep apnea
Cardiogenic pulmonary edema
Page - 1888
Weaning from tracheal intubation
Page - 1889
Question 18/144
Question #18
A 29-year-old male patient presented with recurrent shortness of breath for 3 months. However, the
pulmonary function test shows a fixed obstructive pattern. Which of the following is the most
appropriate test?
a. Alpha 1 antitrypsin level

b. Chest x-ray
c. Bronchoscopy and biopsy
d. High-resolution chest CT scan
e. PET scan
Page - 1890
Question 18/144
Question #18
A 29-year-old male patient presented with recurrent shortness of breath for 3 months. However, the
pulmonary function test shows a fixed obstructive pattern. Which of the following is the most
appropriate test?
a. Alpha 1 antitrypsin level √

b. Chest x-ray
c. Bronchoscopy and biopsy
d. High-resolution chest CT scan
e. PET scan
Description
Any young patient with COPD should be tested for alpha 1 antitrypsin level. A1AT deficiency is the
most common cause of COPD in young patients.
Alpha-1-antitrypsin deficiency:
Deficiency of alpha-1-antitrypsin due to a genetic problem

Autosomal recessive condition (located on chromosome 14)
Normally, PiMM
Homozygous PiSS (50% normal A1AT levels)
Homozygous PiZZ (10% normal A1AT levels)
Alpha-1-antitrypsin is a protease inhibitor protein synthesized by the liver
A1AT deficiency presents with a combination of COPD and liver cirrhosis
COPD (usually Emphysema) in young (< 40 years) and non-smoker patients is considered A1AT
deficiency until proven otherwise
Page - 1891
Question 19/144
Question #19
A 60-year-old male was diagnosed with COPD 8 years ago. Which of the following measures would
most improve the survival of the patient?
a. LAMA and SAMA

b. SAMA and SABA
c. Corticosteroid treatment
d. Oxygen and smoking cessation
e. Oxygen and Steroids
Page - 1892
Question 19/144
Question #19
A 60-year-old male was diagnosed with COPD 8 years ago. Which of the following measures would
most improve the survival of the patient?
a. LAMA and SAMA

b. SAMA and SABA
c. Corticosteroid treatment
d. Oxygen and smoking cessation √
e. Oxygen and Steroids
Description
Long-term oxygen therapy and smoking cessation are indicated to reduce the mortality rate in
patients with COPD
LAMA, LABA, SAMA, SABA, and Steroids are used to treat or prevent exacerbations but not improve
the mortality rate.
Treatment of COPD:

Volume reduction
Lung transplant
Page - 1893
Question 20/144
Question #20
Which of the following is most essential to prevent the worsening of COPD in a 55-year-old male
patient?
c. Inhaled beclomethasone
d. Prophylactic antibiotics
e. Stop smoking
a. eophylline
Page - 1894
Question 20/144
Question #20
Which of the following is most essential to prevent the worsening of COPD in a 55-year-old male
patient?
c. Inhaled beclomethasone
d. Prophylactic antibiotics
e. Stop smoking √
a. eophylline
Description
Smoking cessation is the most crucial step to attenuate the progression of COPD. It may improve
lung function as well.
Treatment of COPD:

Volume reduction
Lung transplant
Page - 1895
Question 21/144
Question #21
A heavy smoker 55-year-old male patient has chronic productive cough and wheezes. In addition, he
has hyperinflation on his chest x-ray and polycythemia. What is the most likely diagnosis?
a. Interstitial lung disease

b. Granulomatosis with polyangiitis
c. Lung cancer
d. COPD
e. Tuberculosis
Page - 1896
Question 21/144
Question #21
A heavy smoker 55-year-old male patient has chronic productive cough and wheezes. In addition, he
has hyperinflation on his chest x-ray and polycythemia. What is the most likely diagnosis?
a. Interstitial lung disease

b. Granulomatosis with polyangiitis
c. Lung cancer
d. COPD √
e. Tuberculosis
Description
History of heavy smoking, hyperinflated chest x-ray, and polycythemia suggest COPD.
In COPD patients, chronic hypoxia will increase the level of erythropoietin hormone leading to
polycythemia.
A fixed obstructive pattern in PFT is expected in this patient, and smoking cessation is the most
eective step in reducing mortality.
Page - 1897
Question 22/144
Question #22
A 66-year-old male with a history of heavy smoking and COPD presents with a 1-week history of
increasing purulent sputum and shortness of breath. Which of the following is false regarding the
a. Antibiotic reduces the risk of treatment failure or death

b. A short course of systemic corticosteroids shortens hospital stays and decreases treatment
failures
c. Oral and IV steroids are equivalent in the treatment of this patient
d. ICS should be used in the treatment of acute COPD exacerbation
e. BiPAP is reserved for severe cases only
Page - 1898
Question 22/144
Question #22
A 66-year-old male with a history of heavy smoking and COPD presents with a 1-week history of
increasing purulent sputum and shortness of breath. Which of the following is false regarding the
a. Antibiotic reduces the risk of treatment failure or death

b. A short course of systemic corticosteroids shortens hospital stays and decreases treatment
failures
c. Oral and IV steroids are equivalent in the treatment of this patient
d. ICS should be used in the treatment of acute COPD exacerbation √
e. BiPAP is reserved for severe cases only
Description
Inhaled corticosteroids are not indicated in acute COPD exacerbation.
O2 therapy:
Page - 1899
Question 23/144
Question #23
A 49-year-old male patient with dyspnea and productive cough for the past 2 years presents for
evaluation. His DLco is normal, and his FEV1/FVC is 2.4/3.7. He was given inhaled salbutamol then
spirometry was repeated. e new results show FEV1/FVC of 2.5/3.8. What is the most likely
diagnosis?
a. Chronic bronchitis
b. Emphysema
c. Asthma
d. Interstitial lung disease
e. Kyphosis
Page - 1900
Question 23/144
Question #23
A 49-year-old male patient with dyspnea and productive cough for the past 2 years presents for
evaluation. His DLco is normal, and his FEV1/FVC is 2.4/3.7. He was given inhaled salbutamol then
spirometry was repeated. e new results show FEV1/FVC of 2.5/3.8. What is the most likely
diagnosis?
a. Chronic bronchitis √
b. Emphysema
c. Asthma
d. Interstitial lung disease
e. Kyphosis
Description
FEV1/FVC ratio of less than 0.7 indicates obstructive lung disease.
e bronchodilator challenge test shows less than 12% improvement in FEV1, making COPD the most
likely diagnosis.
Chronic bronchitis has a normal DLco, but Emphysema will manifest with a low DLco level.
In summary, the spirometry that shows a fixed (irreversible) obstructive pattern, and the normal
DLco suggest chronic bronchitis.
Asthma will manifest as a reversible obstructive pattern, while Emphysema will show low DLco.
Interstitial lung disease and Kyphosis will show a restrictive pattern on spirometry.
Page - 1901
Question 24/144
Question #24
A patient with COPD will exhibit hyperinflation of the lungs. All the following are features of a
hyperinflated lung on chest x-ray except:
a. Horizontal wide-spaced ribs

b. Cardiomegaly
c. Hyperlucent lung field
d. Depressed diaphragm
e. Air trapping
Page - 1902
Question 24/144
Question #24
A patient with COPD will exhibit hyperinflation of the lungs. All the following are features of a
hyperinflated lung on chest x-ray except:
a. Horizontal wide-spaced ribs

b. Cardiomegaly √
c. Hyperlucent lung field
d. Depressed diaphragm
e. Air trapping
Description
A slim vertical heart is a feature of hyperinflation on chest x-ray, not cardiomegaly.
Features of hyperinflated chest on chest x-ray:
Horizontal ribs
Wide spaces between ribs
Low set, flat diaphragm
Vertical heart
Hyperlucent lung field
Page - 1903
Question 25/144
Question #25
A 60-year-old male patient with COPD presents for a Pulmonary function test. His spirometry shows
an FEV1 of 45% of the predicted. Which other findings can also be observed in a patient with COPD
on spirometry?
a. Increased tidal volume

b. Decreased total lung capacity
c. Increased residual volume
d. Reduced functional residual capacity
e. Elevated FEV1/FVC ratio
Page - 1904
Question 25/144
Question #25
A 60-year-old male patient with COPD presents for a Pulmonary function test. His spirometry shows
an FEV1 of 45% of the predicted. Which other findings can also be observed in a patient with COPD
on spirometry?
a. Increased tidal volume

b. Decreased total lung capacity
c. Increased residual volume √
d. Reduced functional residual capacity
e. Elevated FEV1/FVC ratio
Description
e following findings are expected to be found in COPD patients.
FEV1 less than 80% of predicted

FEV1/FVC ratio of less than 70%
Increased Total lung capacity (TLC), Functional residual capacity (FRC), Residual volume (RV),
and Vital capacity (VC).
DLco is expected to be low in Emphysema but normal in chronic bronchitis patients
Note: in COPD patients, spirometry should only be tested when the patient’s condition is stable,
ideally six weeks aer the last exacerbation.
Page - 1905
Question 26/144
Question #26
A known case of HTN, migraine headache, and Hodgkin’s lymphoma, a 54-year-old female presents
with fatigue, dry cough, and shortness of breath for a 6-month duration. Her chest examination is
consistent with fine basal crepitations bilaterally. Her PFT is done and shows FEV1 55%, FEV1/FVC
ratio 90% of predicted. You suspect a drug-induced condition. Which of the following is the most
likely cause?
a. Captopril 50mg daily

b. Propranolol 40 mg bid
c. Bleomycin SC 1 unit daily
d. Indapamide 1.5 mg daily
e. Amlodipine 5mg daily
Page - 1906
Internal Medicine - Pulmonology - Drug-induced lung fibrosis
Question 26/144
Question #26
A known case of HTN, migraine headache, and Hodgkin’s lymphoma, a 54-year-old female presents
with fatigue, dry cough, and shortness of breath for a 6-month duration. Her chest examination is
consistent with fine basal crepitations bilaterally. Her PFT is done and shows FEV1 55%, FEV1/FVC
ratio 90% of predicted. You suspect a drug-induced condition. Which of the following is the most
likely cause?
a. Captopril 50mg daily

b. Propranolol 40 mg bid
c. Bleomycin SC 1 unit daily √
d. Indapamide 1.5 mg daily
e. Amlodipine 5mg daily
Description
Bleomycin is a chemotherapy agent that is a recognized cause of pulmonary fibrosis
Drugs that possibly cause lung fibrosis:
- Bleomycin
- Cyclophosphamide
- Amiodarone
- Procainamide
- Illicit drugs (heroin, methadone)
- Antibiotics: nitrofurantoin, penicillin, sulfonamide
- Anti-Inflammatory Agents: methotrexate, penicillamine
- Gold salts
- Rituximab, anti-TNF agents (Infliximab, Etanercept, Adalimumab)
Page - 1907
Question 27/144
Question #27
All the following are considered eosinophilic lung diseases except:
a. Loer’s syndrome
b. Aspergillosis
c. Churg-Strauss syndrome
d. Cocaine-induced pneumonitis
e. Sarcoidosis
Page - 1908
Internal Medicine - Pulmonology - Eosinophilic lung disease
Question 27/144
Question #27
All the following are considered eosinophilic lung diseases except:
a. Loer’s syndrome
b. Aspergillosis
c. Churg-Strauss syndrome
d. Cocaine-induced pneumonitis
e. Sarcoidosis √
Description
Sarcoidosis and extrinsic allergic alveolitis are not eosinophilic lung diseases.
Eosinophilic lung diseases:
Diseases that are associated with increased eosinophils in bronchoalveolar lavage and lung
biopsy
Causes:
Loer’s syndrome: pulmonary eosinophilia in response to parasitic infection (e.g., Ascaris,

Strongyloides, Dirofilaria)
Allergic Bronchopulmonary Aspergillosis (ABPA)
Eosinophilic pneumonia (can be viral or bacterial)
Churg-Strauss syndrome (vasculitis)
Drug-induced (cocaine, Phenytoin, some antibiotics, etc.)
Page - 1909
Question 28/144
Question #28
A 45-year-old farmer presents with a dry cough, chest tightness, and shortness of breath for a few
hours; his temperature is 39 °C, respiratory rate is 28 per minute, and blood pressure is normal.
What is the most appropriate diagnosis?
a. Extrinsic allergic alveolitis

c. Granulomatosis with polyangiitis
d. cardiogenic pulmonary edema
e. progressive massive fibrosis
Page - 1910
Internal Medicine - Pulmonology - Extrinsic Allergic Alveolitis (EAA)
Question 28/144
Question #28
A 45-year-old farmer presents with a dry cough, chest tightness, and shortness of breath for a few
hours; his temperature is 39 °C, respiratory rate is 28 per minute, and blood pressure is normal.
What is the most appropriate diagnosis?
a. Extrinsic allergic alveolitis √

d. cardiogenic pulmonary edema
e. progressive massive fibrosis
Description
e occupation of the patient, “Farmer,” and the other signs and symptoms of the patient indicate
acute (type 3) EAA as the most likely diagnosis.
Extrensic allergic alveolitis (EAA)
- Also known as (hypersensitivity pneumonitis)
- Inhalation of organic substance → destruction of alveoli → fibrosis
- Involves type 3 or type 4 hypersensitivity reaction (Type 3 more prominent)
Page - 1911
Question 29/144
Question #29
A 46-year-old patient is suspected of having extrinsic allergic alveolitis. is condition is most likely
acquired from inhalation of which one of the following?
a. Silica dust
b. Organophosphate compounds
c. Chlorine gas
d. Fungal spores
e. Smoking
Page - 1912
Internal Medicine - Pulmonology - Extrinsic Allergic Alveolitis (EAA)
Question 29/144
Question #29
A 46-year-old patient is suspected of having extrinsic allergic alveolitis. is condition is most likely
acquired from inhalation of which one of the following?
a. Silica dust
b. Organophosphate compounds
c. Chlorine gas
d. Fungal spores √
e. Smoking
Description
EAA is caused by an allergic reaction to inhaled organic substances
Extrensic allergic alveolitis (EAA)
Also known as (hypersensitivity pneumonitis)

Inhalation of organic substance → destruction of alveoli → fibrosis
Involves type 3 or type 4 hypersensitivity reaction (Type 3 more prominent)
Page - 1913
Question 30/144
Question #30
A 56-year-old male presents with Exertional dyspnea, Non-productive cough, Late expiratory
crackles, and clubbing. What is the best investigation to make the diagnosis of this condition?
a. Eosinophilia in the complete blood picture

b. Ground-glass appearance on high-resolution CT scan
c. Increased vascular markings on chest x-ray
d. An obstructive pattern on spirometry
e. Respiratory alkalosis without hypoxia on ABGs
Page - 1914
Internal Medicine - Pulmonology - Idiopathic Pulmonary Fibrosis (IPF)
Question 30/144
Question #30
A 56-year-old male presents with Exertional dyspnea, Non-productive cough, Late expiratory
crackles, and clubbing. What is the best investigation to make the diagnosis of this condition?
a. Eosinophilia in the complete blood picture

b. Ground-glass appearance on high-resolution CT scan √
c. Increased vascular markings on chest x-ray
d. An obstructive pattern on spirometry
e. Respiratory alkalosis without hypoxia on ABGs
Description
A High-resolution CT scan is the best for the diagnosis of IPF. It will show a ground-glass appearance
A chest x-ray will show a reticulonodular pattern (early stage), or honeycombing (late stage)
Spirometry will show a restrictive pattern
Idiopathic pulmonary fibrosis:
It is an idiopathic progressive disease of an Irreversible process

Clinical features include exertional dyspnea, non-productive cough, late expiratory crackles
(Velcro-like crepitations), and clubbing.
It is diagnosed by a workup of chest x-ray, PFT, and high-resolution CT scan
Biopsy is the most accurate test, but it is usually not indicated
Page - 1915
Question 31/144
Question #31
Digital clubbing and bibasilar inspiratory (Velcro-like) crackles in a 54-year-old previously healthy
male patient indicate one of the following?
a. Asthma
b. GERD
c. Chronic bronchitis
d. Emphysema
e. Idiopathic pulmonary fibrosis (IPF)
Page - 1916
Internal Medicine - Pulmonology - Idiopathic Pulmonary Fibrosis (IPF)
Question 31/144
Question #31
Digital clubbing and bibasilar inspiratory (Velcro-like) crackles in a 54-year-old previously healthy
male patient indicate one of the following?
a. Asthma
b. GERD
d. Emphysema
e. Idiopathic pulmonary fibrosis (IPF) √
Description
Description:
Exertional dyspnea, Non-productive cough, late expiratory crackles (Velcro-like crepitations), and
clubbing are indicative of IPF
Idiopathic pulmonary fibrosis:
It is an idiopathic progressive disease of an Irreversible process

Clinical features include exertional dyspnea, non-productive cough, late expiratory crackles
(Velcro-like crepitations), and clubbing.
It is diagnosed by a workup of chest x-ray, PFT, and high-resolution CT scan
Biopsy is the most accurate test, but it is usually not indicated
Page - 1917
Question 32/144
Question #32
A 65-year-old male patient who is bedridden due to a Stroke presents with coughs productive of
purulent sputum, hemoptysis, and fever. Chest x-ray shows a cavity lesion with an air-fluid level. A
sputum culture is positive for anaerobic bacteria. What is the treatment of choice for this patient’s
condition?
a. Penicillin
b. Clarithromycin
c. Azithromycin
d. Clindamycin
e. Amoxicillin
Page - 1918
Internal Medicine - Pulmonology - Lung Abscess
Question 32/144
Question #32
A 65-year-old male patient who is bedridden due to a Stroke presents with coughs productive of
purulent sputum, hemoptysis, and fever. Chest x-ray shows a cavity lesion with an air-fluid level. A
sputum culture is positive for anaerobic bacteria. What is the treatment of choice for this patient’s
condition?
a. Penicillin
b. Clarithromycin
c. Azithromycin
d. Clindamycin √
e. Amoxicillin
Description
is is a case of lung abscess; the leading risk factor here is aspiration which is common in stroke
patients
anaerobic bacteria cause most lung abscesses; clindamycin will be the most eective in most cases.
Page - 1919
Question 33/144
Question #33
For the last 2 weeks, a 34-year-old male patient with epilepsy has presented to you with fever,
anorexia, and persistent cough with smelly sputum. His temperature is 38.9 °C, and his chest
examination reveals rales in the right lower zone. In addition, he has poor dental hygiene. Of the
following, what is the most likely to be expected on a chest x-ray?
a. Bilateral hilar lymphadenopathy

b. Miliary Tuberculosis
c. Pleural eusion
d. Hyperinflated chest
e. Lung abscess
Page - 1920
Question 33/144
Question #33
For the last 2 weeks, a 34-year-old male patient with epilepsy has presented to you with fever,
anorexia, and persistent cough with smelly sputum. His temperature is 38.9 °C, and his chest
examination reveals rales in the right lower zone. In addition, he has poor dental hygiene. Of the
following, what is the most likely to be expected on a chest x-ray?
a. Bilateral hilar lymphadenopathy

b. Miliary Tuberculosis
c. Pleural eusion
d. Hyperinflated chest
e. Lung abscess √
Description
Lung abscess is found in patients at risk of aspiration. Physical examination usually reveals poor
dental hygiene, a foul odor of the breath and sputum, rales, and consolidation.
Page - 1921
Question 34/144
Question #34
A 43-year-old male underwent surgery 3 weeks ago. He presents with cough, sputum, fever, and
right lower zone cavity lesion on chest x-ray. Examination reveals rales and consolidation. Which is
the most likely eective treatment for this patient’s condition?
a. Ceriaxone
b. Clindamycin
c. Metronidazole
d. TMP/SMX
e. Vancomycin
Page - 1922
Question 34/144
Question #34
A 43-year-old male underwent surgery 3 weeks ago. He presents with cough, sputum, fever, and
right lower zone cavity lesion on chest x-ray. Examination reveals rales and consolidation. Which is
the most likely eective treatment for this patient’s condition?
a. Ceriaxone
b. Clindamycin √
c. Metronidazole
d. TMP/SMX
e. Vancomycin
Description
is is a lung abscess; the leading risk factor here is an aspiration common in postoperative patients.
Anaerobic bacteria cause most lung abscesses; clindamycin will be the most eective in most cases.
Page - 1923
Question 35/144
Question #35
A 48-year-old male patient presents with fever, cough, and hemoptysis for the last week. On
examination, there is a decreased breathing sound, dullness to percussion, and reduced TVF on the
right side. e trachea is shied toward the le side. What is the most likely diagnosis of this
patient?
a. Right-side Pneumothorax
b. Right-side Pleural eusion
c. Le-side Pneumothorax
d. Le-side Pleural eusion
e. Right-side lung collapse
Page - 1924
Internal Medicine - Pulmonology - Pleural Eusion 1
Question 35/144
Question #35
right side. e trachea is shied toward the le side. What is the most likely diagnosis of this
patient?
a. Right-side Pneumothorax
b. Right-side Pleural eusion √
c. Le-side Pneumothorax
d. Le-side Pleural eusion
e. Right-side lung collapse
Description
ere will be an ipsilateral stony dullness in pleural eusion, decreased breathing sound, and
decreased Tactile vocal fremitus (TVF). e trachea will be shied to the opposite side as well.
In the case of pneumothorax, there will be an ipsilateral Hyperresonant chest, decreased breath
sound, and increased TVF. e trachea will be shied to the opposite side as well.
In case of lung collapse, the trachea will be shied to the same side.
Page - 1925
Question 36/144
Question #36
A 37-year-old male patient was diagnosed with pneumonia which is now complicated by empyema.
What is the essential step in the management of this patient?
a. Oxygen therapy
b. Intubation and ventilation
c. Chest tube insertion
d. Pleural biopsy
e. Antibiotics use
Page - 1926
Question 36/144
Question #36
A 37-year-old male patient was diagnosed with pneumonia which is now complicated by empyema.
What is the essential step in the management of this patient?
a. Oxygen therapy
b. Intubation and ventilation
c. Chest tube insertion √
d. Pleural biopsy
e. Antibiotics use
Description
Chest tube insertion is the most important step in the management of empyema.
Antibiotics, intubation, oxygen therapy, and biopsies may be needed to manage, but the patient will
not improve without chest tube insertion.
Page - 1927
Question 37/144
Question #37
right side. e trachea is shied toward the le side. What is the best initial step to take in
managing this patient?
a. Chest x-ray
b. Pleural biopsy
c. oracentesis
d. Chest CT scan
e. Start antibiotics
Page - 1928
Question 37/144
Question #37
right side. e trachea is shied toward the le side. What is the best initial step to take in
managing this patient?
a. Chest x-ray √
b. Pleural biopsy
c. oracentesis
d. Chest CT scan
e. Start antibiotics
Description
A chest x-ray is the best initial test for any patient suspected of pleural eusion.
Chest Ct scan, thoracentesis, pleural biopsy, and antibiotics may be needed later on according to the
underlying condition.
Pleural eusion:
Pleural eusion is an abnormal collection of fluids within the pleural space

Pleural fluids can be Transudates or exudates
Chest X-ray (best initial test) but CT scan (more informative than chest x-ray)
oracentesis (most accurate test): dierentiate exudates from Transudates
Treatment of pleural eusion:
Small eusion needs no treatment

Cardiogenic pleural eusion is highly responsive to diuretics
oracentesis can be therapeutic and diagnostic
For refractory and recurrent pleural eusion, pleurodesis (intrapleural bleomycin or talcum
powder)
For empyema, a chest tube, antibiotics, and surgical drainage may be needed
Page - 1929
Question 38/144
Question #38
A 62-year-old male with a known case of DM and HTN presents with right-side chest pain and
shortness of breath. His chest x-ray is shown below. oracentesis shows a protein concentration of
18 g/L. What is the most likely diagnosis of his condition?
a. Rheumatoid arthritis
b. Hypothyroidism
c. Nephrotic syndrome
d. Congestive heart failure
e. Liver cirrhosis
Page - 1930
‫‪Page - 1931‬‬
Question 38/144
Question #38
A 62-year-old male with a known case of DM and HTN presents with right-side chest pain and
shortness of breath. His chest x-ray is shown below. oracentesis shows a protein concentration of
18 g/L. What is the most likely diagnosis of his condition?
b. Hypothyroidism
c. Nephrotic syndrome
d. Congestive heart failure √
e. Liver cirrhosis
Page - 1932
Description
is patient is complaining of right-side pleural eusion. e history and the results of paracentesis
suggest heart failure as the most likely cause.
Rheumatoid arthritis is a possible cause of exudative eusion (not transudates)
e history of HTN, DM, and cardiomegaly on chest x-ray makes CHF more likely than the other
conditions mentioned.
Pleural eusion:


powder)
Page - 1933
Question 39/144
Question #39
right side. e trachea is shied toward the le side. What is the most accurate test to diagnose the
patient’s underlying condition?
a. Chest x-ray
b. Chest CT scan
c. oracentesis
d. Bronchoscopy
e. CT pulmonary angiography
Page - 1934
Question 39/144
Question #39
right side. e trachea is shied toward the le side. What is the most accurate test to diagnose the
patient’s underlying condition?
a. Chest x-ray
b. Chest CT scan
c. oracentesis √
d. Bronchoscopy
e. CT pulmonary angiography
Description
oracentesis is the most accurate test to confirm the presence of pleural eusion and dierentiate
exudates from transudates.
Pleural eusion:

oracentesis analysis:
Check for pleural fluid protein:

If > 30 g/l, consider exudates
If < 20 g/l, consider transudates
If 20 – 30 g/l and one of the light’s criteria are found, consider exudates
Modified light’s criteria:
Pleural/serum protein ratio > 0.5
Pleural/serum LDH ratio > 0.6
Pleural fluid LDH > two-thirds the upper limit of normal serum
Page - 1935

powder)
Page - 1936
Question 40/144
Question #40
A 63-year-old male presents with right-side pleural eusion; the pleural fluid analysis reveals
protein of 24 g/L, LDH level of 35 U/L, Serum total protein is 60 g/L (normally 60 – 83), Serum LDH of
140 U/L (normally 100-105). which of the following is the most likely diagnosis?
b. Liver cirrhosis
c. Tuberculous pleurisy
d. Lung cancer
e. Para-pneumonic eusion
Page - 1937
Question 40/144
Question #40
A 63-year-old male presents with right-side pleural eusion; the pleural fluid analysis reveals
protein of 24 g/L, LDH level of 35 U/L, Serum total protein is 60 g/L (normally 60 – 83), Serum LDH of
140 U/L (normally 100-105). which of the following is the most likely diagnosis?
b. Liver cirrhosis √
c. Tuberculous pleurisy
d. Lung cancer
e. Para-pneumonic eusion
Description
When the pleural protein level is between 20 – 30 g/L (2 – 3 g/dL), you should apply light’s criteria to
know the nature of the eusion (exudate vs. transudate)
e fluid analysis:
e fluid protein is less than 30 g/L
Here the pleural/serum protein ratio = 24/60 = 0.4
e pleural/serum LDH ratio = 70/140 = 0.5
e pleural LDH is less than 0.45 of the normal upper limit of the serum LDH.
So, the pleural fluid analysis is going with transudates
e only cause of transudates among the choices is liver cirrhosis.
Pleural eusion:

Page - 1938
oracentesis analysis:
Check for pleural fluid protein:

If > 30 g/l, consider exudates
If < 20 g/l, consider transudates
If 20 – 30 g/l and one of the light’s criteria are found, consider exudates
Modified light’s criteria:
Pleural/serum protein ratio > 0.5
Pleural/serum LDH ratio > 0.6
Pleural fluid LDH > two-thirds the upper limit of normal serum

powder)
Page - 1939
Question 41/144
Question #41
e following choices are correctly matching with each other except:
a. Pleural eusion → fluid collection in the pleura

b. Empyema → pus collection in the pleura
c. Chylothorax → blood collection in the pleura
d. Ascites → fluid collection in the abdominal cavity
e. Pericardial eusion → fluid collection in the pericardium
Page - 1940
Question 41/144
Question #41
e following choices are correctly matching with each other except:
a. Pleural eusion → fluid collection in the pleura

b. Empyema → pus collection in the pleura
c. Chylothorax → blood collection in the pleura √
d. Ascites → fluid collection in the abdominal cavity
e. Pericardial eusion → fluid collection in the pericardium
Description
Chylothorax is a lymphatic fluid collection in the pleural space.
Note that the blood collection in the pleural space is called Hemothorax.
Pleural space collections:
Pneumothorax: air in the pleural space

Hemothorax: blood in pleural space
Chylothorax: lymphatic fluid in pleural space
Empyema: Pus in the pleural space
Page - 1941
Question 42/144
Question #42
A 45-year-old male patient has pulmonary hemorrhage and hemoptysis. Aer an appropriate
workup, he was diagnosed with Goodpasture syndrome. Which of the following pulmonary function
tests findings is expected to be found?
a. High residual volume

b. Increased TLC
c. Increased tidal volume
d. High DLco
e. Reduced FEV1
Page - 1942
Internal Medicine - Pulmonology - Pulmonary Function Test (PFT)
Question 42/144
Question #42
A 45-year-old male patient has pulmonary hemorrhage and hemoptysis. Aer an appropriate
workup, he was diagnosed with Goodpasture syndrome. Which of the following pulmonary function
tests findings is expected to be found?
a. High residual volume

b. Increased TLC
c. Increased tidal volume
d. High DLco √
e. Reduced FEV1
Description
is patient is suering from pulmonary hemorrhage.
Regardless of the cause, he is expected to have a high DLco.
e other choices mentioned above are not explicitly related to pulmonary hemorrhage
Page - 1943
Question 43/144
Question #43
A 66-year-old smoker presents with recurrent shortness of breath and a fixed obstructive pattern on
spirometry. Which of the following would most likely dierentiate chronic bronchitis from
Emphysema?
a. Total lung capacity

b. Residual volume
c. Expiratory reserve volume
d. Diusing ling capacity of carbon monoxide
e. e arterial blood gases
Page - 1944
Question 43/144
Question #43
A 66-year-old smoker presents with recurrent shortness of breath and a fixed obstructive pattern on
spirometry. Which of the following would most likely dierentiate chronic bronchitis from
Emphysema?
a. Total lung capacity

b. Residual volume
c. Expiratory reserve volume
d. Diusing ling capacity of carbon monoxide √
e. e arterial blood gases
Description
DLco is the central part of lung function that is used to dierentiate COPD vs. Emphysema; it will be
decreased in Emphysema and will not be aected in chronic bronchitis
Page - 1945
Question 44/144
Question #44
A 16-year-old female patient has two episodes of acute cough and wheezes. ese symptoms
respond quickly to bronchodilators, but she is now asymptomatic. In addition, she has a history of
eczema and a strong family history of asthma. Which of the following is the most appropriate
investigation?
a. Chest x-ray
b. Peak flow diary
c. Spirometry
d. Arterial blood gas
e. Chest CT scan
Page - 1946
Question 44/144
Question #44
A 16-year-old female patient has two episodes of acute cough and wheezes. ese symptoms
respond quickly to bronchodilators, but she is now asymptomatic. In addition, she has a history of
eczema and a strong family history of asthma. Which of the following is the most appropriate
investigation?
a. Chest x-ray
b. Peak flow diary
c. Spirometry √
d. Arterial blood gas
e. Chest CT scan
Description
Spirometry is done here to assess for an obstructive pattern in this patient who is suspected of
having asthma.
Note that peak flow diary and arterial blood gases are used in acute asthma exacerbations to assess
the severity of asthma, but here there is no acute exacerbation as the patient is asymptomatic at
this moment
Chest x-ray and chest CT scan are not diagnostic in asthma, but chest x-ray can be used to rule out
pneumonia or pneumothorax in case of acute asthma exacerbation, and again, there is no acute
exacerbation at this time in this patient
Page - 1947
Question 45/144
Question #45
About DLco, the following statements are factual except:
a. It is used to dierentiate chronic bronchitis from Emphysema

b. It can distinguish intrinsic vs. Extrinsic restrictive lung disease
c. It is usually increased in case of polycythemia, and male individuals
d. In patients with Emphysema, is it usually elevated
e. In anemia, it is expected to be reduced
Page - 1948
Question 45/144
Question #45
About DLco, the following statements are factual except:
a. It is used to dierentiate chronic bronchitis from Emphysema

b. It can distinguish intrinsic vs. Extrinsic restrictive lung disease
c. It is usually increased in case of polycythemia, and male individuals
d. In patients with Emphysema, is it usually elevated √
e. In anemia, it is expected to be reduced
Description
DLco is the diusing capacity or transfer factor of the lung for CO gas
It describes the rate of gas diusion from alveoli to blood.
In COPD, DLco dierentiates Emphysema from chronic bronchitis
In restrictive lung diseases, DLco determines intrinsic vs. extrinsic restrictive lung diseases.
DLco is expected to be low in Emphysema
Page - 1949
Question 46/144
Question #46
A 65-year-old male patient presented with shortness of breath. He is a heavy smoker and drinks
alcohol on occasion. His spirometry shows reduced FEV1 and normal FVC. Of the following, what is
a. COPD
b. Asthma
c. Bronchiectasis
d. Kyphosis
e. Asthma COPD overlap syndrome
Page - 1950
Question 46/144
Question #46
A 65-year-old male patient presented with shortness of breath. He is a heavy smoker and drinks
alcohol on occasion. His spirometry shows reduced FEV1 and normal FVC. Of the following, what is
a. COPD
b. Asthma
c. Bronchiectasis
d. Kyphosis √
e. Asthma COPD overlap syndrome
Description
is is an obstructive pattern in spirometry. e only restrictive disease of the mentioned choices is
Kyphosis.
Obstructive lung disease presents with a reduced FEV1/FVC ratio along with increased TLC
Page - 1951
Question 47/144
Question #47
An 80-year-old male patient presents to you for evaluation due to shortness of breath. Which
changes would typically occur with age?
a. Decreased FVC, FEV1, and PEFR

b. Increased Residual volume
c. TLC remains constant
d. A collapse of the small airways
e. All of the above
Page - 1952
Question 47/144
Question #47
An 80-year-old male patient presents to you for evaluation due to shortness of breath. Which
changes would typically occur with age?
a. Decreased FVC, FEV1, and PEFR

b. Increased Residual volume
c. TLC remains constant
d. A collapse of the small airways
Description
e following results are typical changes to occur with age:
Vital capacity declines with age

Total lung capacity remains constant.
e reduction in vital capacity (VC) results from an increase in residual volume
Residual volume increases nearly 50% between early adulthood and age 70
FEV1, PEFR, and maximal expiratory flow volume have been shown to decline
Arterial oxygen tension also slowly decreases with age
A Collapse of small airways
Page - 1953
Question 48/144
Question #48
A 65-year-old male patient known to be a heavy smoker for 40 years presented to you to evaluate
his progressively increasing shortness of breath for 6 months. He was a known case of Tuberculosis
20 years ago. His spirometry shows an FVC of 59%, FEV1 of 80%, and FEV1/FVC ratio was 0.81. what is
the most appropriate next step in the management?
a. Order diusion capacity of the lung

b. Methacholine challenge test
c. Order Mantoux test
d. Start short-acting beta-agonists
e. Order a high-resolution CT scan
Page - 1954
Question 48/144
Question #48
A 65-year-old male patient known to be a heavy smoker for 40 years presented to you to evaluate
his progressively increasing shortness of breath for 6 months. He was a known case of Tuberculosis
20 years ago. His spirometry shows an FVC of 59%, FEV1 of 80%, and FEV1/FVC ratio was 0.81. what is
the most appropriate next step in the management?
a. Order diusion capacity of the lung √

b. Methacholine challenge test
c. Order Mantoux test
d. Start short-acting beta-agonists
e. Order a high-resolution CT scan
Description
is is a case of restrictive pattern on spirometry, and DLco is the best next step to dierentiate
intrinsic vs. extrinsic restrictive disorders
Page - 1955
Question 49/144
Question #49
A 55-year-old female presents with shortness of breath on exertion for six months; she has been a
heavy smoker for the past 32 years. What is the best diagnostic test to diagnose this patient?
a. Arterial blood gases

b. Chest x-ray
c. Chest CT scan
d. Brain natriuretic peptide
e. Spirometry
Page - 1956
Question 49/144
Question #49
A 55-year-old female presents with shortness of breath on exertion for six months; she has been a
heavy smoker for the past 32 years. What is the best diagnostic test to diagnose this patient?
a. Arterial blood gases

b. Chest x-ray
c. Chest CT scan
d. Brain natriuretic peptide
e. Spirometry √
Description
e most likely diagnosis is COPD because she is a heavy smoker and old with chronic dyspnea.
Spirometry is the best tool for the diagnosis of COPD, which will show a fixed obstructive pattern
Page - 1957
Question 50/144
Question #50
A 46-year-old male patient presented with chronic shortness of breath. Aer doing a pulmonary
function test, you find FEV1 and FEV1/FVC ratio to be reduced, and the total lung capacity was
increased. What is the least likely diagnosis?
a. Asthma
b. COPD
c. Bronchiectasis
d. Sarcoidosis
e. cystic fibrosis
Page - 1958
Question 50/144
Question #50
A 46-year-old male patient presented with chronic shortness of breath. Aer doing a pulmonary
function test, you find FEV1 and FEV1/FVC ratio to be reduced, and the total lung capacity was
increased. What is the least likely diagnosis?
a. Asthma
b. COPD
c. Bronchiectasis
d. Sarcoidosis √
e. cystic fibrosis
Description
Obstructive lung disease presents with a reduced FEV1/FVC ratio along with increased TLC. e only
restrictive disease from the mentioned choices is sarcoidosis
Page - 1959
Question 51/144
Question #51
A 59-year-old heavy smoker was found to have fixed obstruction on PFT, and the diagnosis of COPD
was made 10 years ago. Despite treatment, he presents with persistent shortness of breath, his O2
saturation is 87%, and his PaO2 is 53 mmHg. e echocardiogram confirms the presence of moderate
pulmonary HTN and the Ejection fraction to be normal. What is the most appropriate treatment at
this time?

b. Start long-term oxygen therapy
c. Start sildenafil (Viagra)
d. Start Nifedipine
e. Low dose steroid
Page - 1960
Internal Medicine - Pulmonology - Pulmonary Hypertension
Question 51/144
Question #51
A 59-year-old heavy smoker was found to have fixed obstruction on PFT, and the diagnosis of COPD
was made 10 years ago. Despite treatment, he presents with persistent shortness of breath, his O2
saturation is 87%, and his PaO2 is 53 mmHg. e echocardiogram confirms the presence of moderate
pulmonary HTN and the Ejection fraction to be normal. What is the most appropriate treatment at
this time?

b. Start long-term oxygen therapy √
c. Start sildenafil (Viagra)
d. Start Nifedipine
e. Low dose steroid
Description
e criteria to use LTOT here are met, and it is the best treatment for this patient’s pulmonary HTN.
Sildenafil and CCBs are used in treating pulmonary HTN not related to COPD or hypoxia.
Page - 1961
Question 52/144
Question #52
A 49-year-old male with a known case of interstitial lung disease presents with shortness of breath
and exertional dyspnea. What is the best way to confirm the presence of pulmonary HTN in this
patient?
a. Chest X-ray
b. Echocardiogram
c. Swan-Ganz catheterization
d. ECG
e. CTPA
Page - 1962
Internal Medicine - Pulmonology - Pulmonary Hypertension
Question 52/144
Question #52
A 49-year-old male with a known case of interstitial lung disease presents with shortness of breath
and exertional dyspnea. What is the best way to confirm the presence of pulmonary HTN in this
patient?
a. Chest X-ray
b. Echocardiogram
c. Swan-Ganz catheterization √
d. ECG
e. CTPA
Description
Swan-Ganz catheterization is the most accurate test to diagnose pulmonary HTN. It accurately
measures the pulmonary artery pressure
Chest X-ray can point to the possible cause of pulmonary HTN
e echocardiogram will estimate the pulmonary pressure, but the Swan-Ganz catheter is more
accurate
ECG is not specific, but it will show features of RVH, RAH, and cor pulmonale
CTPA is used when recurrent PE is suspected as a cause for pulmonary HTN, but it doesn’t diagnose
the presence of high pulmonary arterial pressure
Page - 1963
Question 53/144
Question #53
Aer the breakup with her boyfriend, a 19-year-old female presents to the ER with lightheadedness,
shortness of breath, headaches, and tingling around her mouth and on her tongue. e patient
appears anxious, and the life-threatening conditions have been ruled out. What would you do next?
a. Order urine and blood toxicology screen

b. Explanation and reassurance
c. Give diazepam intravenously
d. Give Oxygen supplementation
e. Start intravenous fluids
Page - 1964
Internal Medicine - Pulmonology - Respiratory Alkalosis
Question 53/144
Question #53
Aer the breakup with her boyfriend, a 19-year-old female presents to the ER with lightheadedness,
shortness of breath, headaches, and tingling around her mouth and on her tongue. e patient
appears anxious, and the life-threatening conditions have been ruled out. What would you do next?
a. Order urine and blood toxicology screen

b. Explanation and reassurance √
c. Give diazepam intravenously
d. Give Oxygen supplementation
e. Start intravenous fluids
Description
In young patients with normal physical examination and absence of hypoxemia, hyperventilation is
most likely due to hyperventilation syndrome.
Hyperventilation syndrome needs no treatment other than explanation and reassurance. If it is

recurrent, refer the patient to a psychiatrist.
Hyperventilation syndrome: when a patient is exposed to stress, he starts to hyperventilate, feeling

unwell, then more hyperventilation develops.
Respiratory alkalosis is a feature

A patient may develop symptoms like chest pain, numbness, and weakness
Treat the patients by making them breathe into a bag to reduce the CO2 wash
Page - 1965
Question 54/144
Question #54
A 32-year-old male patient presented with tachypnea and chest tightness. His ABGs show PH 7.56,
PaO2 100 mmHg, and PaCO2 24. What is the most likely diagnosis?
b. Anxiety induced Hyperventilation syndrome
c. Alpha 1 antitrypsin deficiency
d. Tension pneumothorax
e. Acute myocardial infarction
Page - 1966
Question 54/144
Question #54
A 32-year-old male patient presented with tachypnea and chest tightness. His ABGs show PH 7.56,
PaO2 100 mmHg, and PaCO2 24. What is the most likely diagnosis?
b. Anxiety induced Hyperventilation syndrome √
d. Tension pneumothorax
e. Acute myocardial infarction
Description
is patient has respiratory alkalosis without hypoxia.
Anxiety hyperventilation presents with respiratory alkalosis without hypoxia, but PE presents with
hypoxia.


Page - 1967
Question 55/144
Question #55
A 21-year-old female presents to you with recurrent shortness of breath, palpitations, and a tingling
sensation in her hands. is condition usually starts when she is in a crowded area, lasts for about 30
minutes, and then goes away. e patient has no medical history of note, and her vital signs are
normal during the episodes. Which ABGs finding is expected to be encountered in this patient
during the attack?
a. PH: 7.55, PaO2: 60 mmHg, PaCO2: 19 mmHg, HCO3: 26 mmol/l

b. PH: 7.56, PaO2: 99 mmHg, PaCO2: 18 mmHg, HCO3: 13 mmol/l
c. PH: 7.57, PaO2: 99 mmHg, PaCO2: 20 mmHg, HCO3: 25 mmol/l
d. PH: 7.28, PaO2: 105 mmHg, PaCO2: 48 mmHg, HCO3: 24 mmol/l
e. PH: 7.27, PaO2: 62 mmHg, PaCO2: 51 mmHg, HCO3: 24 mmol/l
Page - 1968
Question 55/144
Question #55
A 21-year-old female presents to you with recurrent shortness of breath, palpitations, and a tingling
sensation in her hands. is condition usually starts when she is in a crowded area, lasts for about 30
minutes, and then goes away. e patient has no medical history of note, and her vital signs are
normal during the episodes. Which ABGs finding is expected to be encountered in this patient
during the attack?
a. PH: 7.55, PaO2: 60 mmHg, PaCO2: 19 mmHg, HCO3: 26 mmol/l

b. PH: 7.56, PaO2: 99 mmHg, PaCO2: 18 mmHg, HCO3: 13 mmol/l
c. PH: 7.57, PaO2: 99 mmHg, PaCO2: 20 mmHg, HCO3: 25 mmol/l √
d. PH: 7.28, PaO2: 105 mmHg, PaCO2: 48 mmHg, HCO3: 24 mmol/l
e. PH: 7.27, PaO2: 62 mmHg, PaCO2: 51 mmHg, HCO3: 24 mmol/l
Description
Description:
is patient is most likely to have acute respiratory alkalosis secondary to hyperventilation
syndrome and agoraphobia.
Hyperventilation will lead to reduced CO2 and elevated PH but no hypoxia.
HCO3 needs time to start changing, so in the case of acute respiratory alkalosis, it is expected to be
normal.
In hyperventilation syndrome (high PH, normal O2, normal HCO3, and low CO2)
Page - 1969
Question 56/144
Question #56
A 56-year-old male patient presents with shortness of breath and chest pain. His ABGs show PH 7.58,
PaCO2 23 mmHg, PaO2 80 mmHg. What is the acid-base balance in this patient?
a. Metabolic alkalosis
b. Respiratory alkalosis
d. Respiratory acidosis
e. Information is not enough
Page - 1970
Question 56/144
Question #56
A 56-year-old male patient presents with shortness of breath and chest pain. His ABGs show PH 7.58,
PaCO2 23 mmHg, PaO2 80 mmHg. What is the acid-base balance in this patient?
a. Metabolic alkalosis
b. Respiratory alkalosis √
d. Respiratory acidosis
e. Information is not enough
Description
e high PH indicates alkalosis, and the CO2 wash indicates a respiratory cause.
Reduced CO2 due to hyperventilation resulted in elevated PH (Alkalosis)
Page - 1971
Question 57/144
Question #57
A 17-year-old female presents with tachypnea, tachycardia, carpal spasms, and numbness.
Regarding hyperventilation syndrome, all the following statements are true except:
a. CO2 retention is a feature

b. It is common aer stressful condition
c. Respiratory alkalosis is a feature
d. e patient may develop chest pain, numbness, and weakness
e. Explanation and reassurance are the main treatment
Page - 1972
Question 57/144
Question #57
A 17-year-old female presents with tachypnea, tachycardia, carpal spasms, and numbness.
Regarding hyperventilation syndrome, all the following statements are true except:
a. CO2 retention is a feature √

b. It is common aer stressful condition
c. Respiratory alkalosis is a feature
d. e patient may develop chest pain, numbness, and weakness
e. Explanation and reassurance are the main treatment
Description
In hyperventilation syndrome, CO2 wash, not CO2 retention, is the main ABG finding.


Page - 1973
Question 58/144
Question #58
A 70-year-old male patient who has been a heavy smoker for the last 40 years presents with night
sweats, weight loss, continuous cough, and hoarseness of voice for the previous 6 months. Recently
he got more fatigue and has been confused at times. His lab investigations show serum sodium of
125 mEq/L, serum calcium of 9.2 mg/dL, serum glucose of 90 mg/dL, and serum potassium of 4
mEq/L. His kidney function test and liver function test are normal. What is the most likely diagnosis?
a. Sarcoidosis
b. Squamous cell lung cancer
c. Small cell lung cancer
d. Adenocarcinoma of the lung
e. Large cell lung cancer
Page - 1974
Internal Medicine - Pulmonology - Respiratory neoplasms
Question 58/144
Question #58
A 70-year-old male patient who has been a heavy smoker for the last 40 years presents with night
sweats, weight loss, continuous cough, and hoarseness of voice for the previous 6 months. Recently
he got more fatigue and has been confused at times. His lab investigations show serum sodium of
125 mEq/L, serum calcium of 9.2 mg/dL, serum glucose of 90 mg/dL, and serum potassium of 4
mEq/L. His kidney function test and liver function test are normal. What is the most likely diagnosis?
a. Sarcoidosis
b. Squamous cell lung cancer
c. Small cell lung cancer √
d. Adenocarcinoma of the lung
e. Large cell lung cancer
Description
e presence of chronic cough, weight loss, night sweating, and a history of heavy smoking will raise
the suspicion of lung cancer.
e type of lung cancer that is associated with hyponatremia as a paraneoplastic feature due to ADH
release is small-cell lung cancer
Page - 1975
Question 59/144
Question #59
A man presents for routine evaluation and is found to have cavitary lesions on a chest x-ray. All the
following are possible causes except:
a. Squamous cell lung cancer

b. Klebsiella pneumonia
c. Lung abscess
d. COVID-19
e. Tuberculosis
Page - 1976
Question 59/144
Question #59
A man presents for routine evaluation and is found to have cavitary lesions on a chest x-ray. All the
following are possible causes except:
a. Squamous cell lung cancer

b. Klebsiella pneumonia
c. Lung abscess
d. COVID-19 √
e. Tuberculosis
Description
Causes of cavitating lesions on chest X-Ray are:
Lung abscess (Staph aureus, Klebsiella, and Pseudomonas)

Squamous cell lung cancer
Pulmonary Tuberculosis
Wegener’s granulomatosis
Pulmonary embolism
Rheumatoid arthritis
Sarcoidosis
Aspergillosis
Histoplasmosis
Coccidioidomycosis
Page - 1977
Question 60/144
Question #60
A patient was diagnosed with squamous cell lung cancer and now develops hypercalcemia. What is
the primary mechanism of the development of hypercalcemia in this patient?
a. Vitamin D activation by the macrophages

b. Parathyroid hormone-related peptide release
c. Antidiuretic hormone release
d. Increased osteoblastic activation
e. Iatrogenic due to treatment
Page - 1978
Question 60/144
Question #60
A patient was diagnosed with squamous cell lung cancer and now develops hypercalcemia. What is
the primary mechanism of the development of hypercalcemia in this patient?
a. Vitamin D activation by the macrophages

b. Parathyroid hormone-related peptide release √
c. Antidiuretic hormone release
d. Increased osteoblastic activation
e. Iatrogenic due to treatment
Description
PTHrP is released by squamous cell lung cancer leading to hypercalcemia as a paraneoplastic

syndrome.
Note that ADH release is a feature of small-cell lung cancer
Vitamin D activation by the macrophages occurs in sarcoidosis
Chemotherapy may cause hypercalcemia, but it is not the primary mechanism in squamous cell lung
cancer.
Page - 1979
Question 61/144
Question #61
A 27-year-old female presents with shortness of breath for 2 months, painful reddish lesions on both
legs, and intermittent joint stiness. Her physical examination is unremarkable, and her chest x-ray
shows bilateral hilar lymphadenopathy and diuse interstitial infiltrations. All the following are true
about her condition except:
a. Hypercalcemia may be a feature

b. A chest x-ray is used for staging in this patient
c. A biopsy is the most accurate test to do
d. Facial palsy may manifest
e. e ACE level is essential in the diagnosis
Page - 1980
Internal Medicine - Pulmonology - Sarcoidosis
Question 61/144
Question #61
A 27-year-old female presents with shortness of breath for 2 months, painful reddish lesions on both
legs, and intermittent joint stiness. Her physical examination is unremarkable, and her chest x-ray
shows bilateral hilar lymphadenopathy and diuse interstitial infiltrations. All the following are true
about her condition except:
a. Hypercalcemia may be a feature

b. A chest x-ray is used for staging in this patient
c. A biopsy is the most accurate test to do
d. Facial palsy may manifest
e. e ACE level is essential in the diagnosis √
Description
e ACE level may be high (it is not specific, not sensitive, but can be used for the monitoring of the
disease activity →a negligible role in the diagnosis)
Sarcoidosis:
It is a multi-system disease characterized by non-caseating granuloma

It has an unknown etiology but usually occurs in young and black patients, and it is more
common in non-smokers.
e clinical presentation consists of shortness of breath, erythema nodosum, bilateral hilar
lymphadenopathy on chest x-ray, hypercalcemia, and neurological manifestations
Lofgren’s syndrome is an acute sarcoidosis characterized by bilateral hilar lymphadenopathy
(BHL), erythema nodosum, fever, and polyarthralgia. It usually carries an excellent prognosis
Heerfordt’s syndrome (uveoparotid fever), there is parotid enlargement, fever, uveitis, and
facial palsy secondary to sarcoidosis
e most accurate test is a biopsy that shows non-caseating granuloma
e staging system depends on the chest x-ray findings
Page - 1981
Question 62/144
Question #62
A 32-year-old female with shortness of breath and cervical lymphadenopathy presents for
evaluation, she has painful erythematous nodules on her shins, and her chest x-ray shows bilateral
hilar lymphadenopathies. All of the following are considered poor prognostic factors for this patient
except:
a. Elderly patient
b. Presence of erythema nodosum
c. Presence of facial palsy
d. Presence of lupus pernio
e. Stage IV on chest X-ray
Page - 1982
Question 62/144
Question #62
hilar lymphadenopathies. All of the following are considered poor prognostic factors for this patient
except:
a. Elderly patient
b. Presence of erythema nodosum √
c. Presence of facial palsy
d. Presence of lupus pernio
e. Stage IV on chest X-ray
Description
is is a typical presentation of sarcoidosis.
Poor prognostic factors in sarcoidosis:
An absence of erythema nodosum

Black people and Older ages
Chest X-Ray: stage III-IV
Extra-pulmonary manifestations: e.g., lupus pernio, splenomegaly
Insidious onset, symptoms > 6 months
Sarcoidosis:

Page - 1983
Page - 1984
Question 63/144
Question #63
hilar lymphadenopathies. What is the most likely diagnosis?
a. Idiopathic pulmonary fibrosis

b. Sarcoidosis
d. Lymphoma
e. Metastatic thyroid cancer
Page - 1985
Question 63/144
Question #63
hilar lymphadenopathies. What is the most likely diagnosis?

b. Sarcoidosis √
d. Lymphoma
e. Metastatic thyroid cancer
Description
Erythema nodosum, bilateral hilar lymphadenopathy, and cervical lymphadenopathy are suggestive
of sarcoidosis
Sarcoidosis:

Page - 1986
Question 64/144
Question #64
hilar lymphadenopathies. Which of the following is expected to be found in this patient?
a. Hypocalcemia
b. Hypercalcemia
c. Hypokalemia
d. Hyperkalemia
e. Hypomagnesemia
Page - 1987
Question 64/144
Question #64
hilar lymphadenopathies. Which of the following is expected to be found in this patient?
a. Hypocalcemia
c. Hypokalemia
d. Hyperkalemia
e. Hypomagnesemia
Description
Macrophages inside the granulomas cause an increased conversion of vitamin D to its active form
(1,25-dihydroxycholecalciferol), leading to hypercalcemia.
Sarcoidosis:

Page - 1988
Question 65/144
Question #65
A 29-year-old male patient complained of progressive shortness of breath and dry cough over the
past six weeks. His chest x-ray shows bilateral hilar lymphadenopathy, and his shins show nodular
cherry-sized lumps. What is the most likely diagnosis?
d. Cystic fibrosis
e. Pneumonia
a. Bronchial asthma
b. Sarcoidosis
Page - 1989
Question 65/144
Question #65
A 29-year-old male patient complained of progressive shortness of breath and dry cough over the
past six weeks. His chest x-ray shows bilateral hilar lymphadenopathy, and his shins show nodular
cherry-sized lumps. What is the most likely diagnosis?
d. Cystic fibrosis
e. Pneumonia
a. Bronchial asthma
b. Sarcoidosis √
Description
Any questions in the exam mention shin lesions and bilateral hilar lymphadenopathy, you should
think about sarcoidosis. is lesion is most likely to be erythema nodosum.
Sarcoidosis:

Page - 1990
Question 66/144
Question #66
You confirmed a diagnosis of sarcoidosis in a 32-year-old male patient. Which of the following tests
should be done next?
a. Electroencephalogram (EEG)
b. Genetic testing
c. Liver biopsy
d. Renal biopsy
e. Slit-lamp examination
Page - 1991
Question 66/144
Question #66
You confirmed a diagnosis of sarcoidosis in a 32-year-old male patient. Which of the following tests
should be done next?
a. Electroencephalogram (EEG)
b. Genetic testing
c. Liver biopsy
d. Renal biopsy
e. Slit-lamp examination √
Description
e necessary tests to be done in a patient with sarcoidosis aer the diagnosis are:
Serum calcium level (to rule out hypercalcemia)

Pulmonary function testing
Slit-lamp examination (to rule out uveitis)
ECG
Serum ACE level
Sarcoidosis:

Treatment of sarcoidosis:
Page - 1992
Stages 1&2: spontaneous resolution
Steroids may be needed If:
Stages > 2 with progressive symptoms
Hypercalcemia
Eye-heart or CNS involvement
Page - 1993
Question 67/144
Question #67
hilar lymphadenopathies. What is the most accurate test to confirm the diagnosis?
a. Chest CT scan
b. Lymph node biopsy
c. ESR level
d. ACE level
e. Spirometry
Page - 1994
Question 67/144
Question #67
hilar lymphadenopathies. What is the most accurate test to confirm the diagnosis?
a. Chest CT scan
b. Lymph node biopsy √
c. ESR level
d. ACE level
e. Spirometry
Description
is is a typical scenario of sarcoidosis. erefore, the most accurate test is a biopsy (from the lung or
the lymph nodes) that shows non-caseating granuloma
Sarcoidosis:

Page - 1995
Question 68/144
Question #68
hilar lymphadenopathies. Her lab investigation and the rest of the physical examination are normal,
Slit-lamp test and ECG are normal. What is the treatment indicated for this patient?
b. No treatment is indicated at this stage
c. Provide short-acting beta-agonist
d. Refer to a hematologist for evaluation
e. Start systemic steroid therapy
Page - 1996
Question 68/144
Question #68
hilar lymphadenopathies. Her lab investigation and the rest of the physical examination are normal,
Slit-lamp test and ECG are normal. What is the treatment indicated for this patient?
b. No treatment is indicated at this stage √
c. Provide short-acting beta-agonist
d. Refer to a hematologist for evaluation
e. Start systemic steroid therapy
Description
is is stage 1 of sarcoidosis, with no hypocalcemia, eye, heart, or CNS involvement. So, a
spontaneous resolution will occur mostly, and no steroid therapy is indicated in this case.
Sarcoidosis:

Treatment of sarcoidosis:
Stages 1&2: spontaneous resolution

Steroids may be needed If:
Page - 1997
Stages > 2 with progressive symptoms
Hypercalcemia
Eye-heart or CNS involvement
Page - 1998
Question 69/144
Question #69
A 34-year-old black female presents for routine checkups. Her physical examination shows enlarged,
non-tender supraclavicular lymph nodes. Her chest x-ray is shown below. She has no cough,
shortness of breath, night sweats, weight loss, or fever. e rest of the physical examination is
normal, her PPD test is negative, and her septic workup is negative. Her PFT and ECG are normal.
What is the next step in the management of this patient?
a. Periodic chest x-ray, PFT without any treatment

b. Hospital admission and start IVIG
c. Start INH and do sputum culture again
d. Start systemic steroids and monitor the lymph node size
e. Start methotrexate and order lymph node biopsy
Page - 1999
Question 69/144
Question #69
A 34-year-old black female presents for routine checkups. Her physical examination shows enlarged,
non-tender supraclavicular lymph nodes. Her chest x-ray is shown below. She has no cough,
shortness of breath, night sweats, weight loss, or fever. e rest of the physical examination is
normal, her PPD test is negative, and her septic workup is negative. Her PFT and ECG are normal.
What is the next step in the management of this patient?
a. Periodic chest x-ray, PFT without any treatment √

b. Hospital admission and start IVIG
c. Start INH and do sputum culture again
d. Start systemic steroids and monitor the lymph node size
e. Start methotrexate and order lymph node biopsy
Description
is is an asymptomatic patient with sarcoidosis. It is stage 1, which is usually spontaneously

resolved and has no indication of steroid use or hospital admission
e chest x-ray shows (Garland’s triad) Bilateral hilar lymphadenopathy and paratracheal
Page - 2000
lymphadenopathy (see the following image!).
Page - 2001
Question 70/144
Question #70
evaluation. She has painful erythematous nodules on her shins. Her chest x-ray shows bilateral hilar
lymphadenopathies without infiltration. Which stage of sarcoidosis does this patient have if she is
confirmed by biopsy to have the disease?
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4
e. e information is not enough
Page - 2002
Question 70/144
Question #70
evaluation. She has painful erythematous nodules on her shins. Her chest x-ray shows bilateral hilar
lymphadenopathies without infiltration. Which stage of sarcoidosis does this patient have if she is
confirmed by biopsy to have the disease?
a. Stage 1 √
b. Stage 2
c. Stage 3
d. Stage 4
e. e information is not enough
Description
is is a typical scenario of sarcoidosis, and Her chest x-ray shows bilateral hilar lymphadenopathies
without infiltration. erefore, her Sarcoidosis stage is 1.
e staging system depends on the chest x-ray findings as the following:
Stage 1 = Bilateral Hilar Lymphadenopathy (BHL)

Stage 2 = BHL + interstitial infiltrates
Stage 3 = diuse interstitial infiltrates only
Stage 4 = diuse fibrosis
Sarcoidosis:

Page - 2003
Page - 2004
Question 71/144
Question #71
A 35-year-old female is complaining of breathlessness. Her chest x-ray shows bilateral hilar
lymphadenopathy. In addition, there are red tender lesions on her shins. What is the most likely
diagnosis?
a. Asthma
b. Cystic fibrosis
c. Sarcoidosis
d. Silicosis
e. Bronchiectasis
Page - 2005
Question 71/144
Question #71
A 35-year-old female is complaining of breathlessness. Her chest x-ray shows bilateral hilar
lymphadenopathy. In addition, there are red tender lesions on her shins. What is the most likely
diagnosis?
a. Asthma
b. Cystic fibrosis
c. Sarcoidosis √
d. Silicosis
e. Bronchiectasis
Description
In any questions in the exam, if shin lesions and bilateral hilar lymphadenopathy are present, you
should think about sarcoidosis. is lesion is most likely to be erythema nodosum
Sarcoidosis:

Page - 2006
Question 72/144
Question #72
A 25-year-old male has had dyspnea, cough, and fatigue for 3 months. On examination, a bilateral
facial nerve palsy is present, and his chest x-ray shows bilateral hilar lymphadenopathy. What is the
a. Lymphoma
b. Sarcoidosis
c. Polyarteritis nodosa
d. Benign pulmonary nodules
e. Extrinsic allergic alveolitis
Page - 2007
Question 72/144
Question #72
A 25-year-old male has had dyspnea, cough, and fatigue for 3 months. On examination, a bilateral
facial nerve palsy is present, and his chest x-ray shows bilateral hilar lymphadenopathy. What is the
a. Lymphoma
b. Sarcoidosis √
c. Polyarteritis nodosa
d. Benign pulmonary nodules
e. Extrinsic allergic alveolitis
Description
is is a case of sarcoidosis with neurological involvement; steroids are indicated for the treatment
Sarcoidosis:

Page - 2008
Question 73/144
Question #73
A 52-year-old man presents with shortness of breath, fatigue, and progressive dry cough. His chest
x-ray shows multiple coin-like lesions on the upper lobe of the right lung. He recently retired from a
cement manufacturing company in Al-Zarqa’a, Jordan. His Tuberculosis test is negative. What is the
a. Sarcoidosis
b. Silicosis
c. Tuberculosis
d. Aspergillosis
e. Atypical mycobacteria
Page - 2009
Internal Medicine - Pulmonology - Silicosis
Question 73/144
Question #73
A 52-year-old man presents with shortness of breath, fatigue, and progressive dry cough. His chest
x-ray shows multiple coin-like lesions on the upper lobe of the right lung. He recently retired from a
cement manufacturing company in Al-Zarqa’a, Jordan. His Tuberculosis test is negative. What is the
a. Sarcoidosis
b. Silicosis √
c. Tuberculosis
d. Aspergillosis
e. Atypical mycobacteria
Description
is patient has occupational exposure to cement, which is rich in silicon.
Silicosis due to inhalation of silica dust is usually a well-known case of upper zone fibrosis. Diagnosis
is by clinical history and chest x-ray, and no specific treatment is available
Page - 2010
Question 74/144
Question #74
A 33-year-old male patient presents with fever, dyspnea, and hemoptysis; he was started on INH,
Rifampicin, and Ethambutol aer being diagnosed with TB. Aer 2 months, he developed a pins and
needles sensation in his hands and feet, and neurological examination is otherwise normal. What is
the best next step in management?
a. Start vitamin B12 supplementation

b. Start gabapentin orally
c. Start pyridoxine supplementation
d. Start vitamin D supplementation
e. Start thiamin (B1) supplementation
Page - 2011
Internal Medicine - Pulmonology - Tuberculosis (TB)
Question 74/144
Question #74
the best next step in management?
a. Start vitamin B12 supplementation

b. Start gabapentin orally
c. Start pyridoxine supplementation √
d. Start vitamin D supplementation
e. Start thiamin (B1) supplementation
Description
Isoniazid interferes with the metabolism of vitamin B6, leading to neuropathy. is condition may
result in coma and seizures and is reversed by vitamin B6 (pyridoxine)
Page - 2012
Question 75/144
Question #75
A 55-year-old male previously worked at a silica mine, and he is known to have silicosis. He presents
today with 6 months history of cough and weight loss; his chest x-ray shows upper zone infiltration
and fibrosis, Sputum culture is sent, and results are pending. What is the most likely diagnosis?
a. COPD
b. Mesothelioma
c. Pneumonia
d. Rapidly progressive silicosis
e. Tuberculosis
Page - 2013
Question 75/144
Question #75
A 55-year-old male previously worked at a silica mine, and he is known to have silicosis. He presents
today with 6 months history of cough and weight loss; his chest x-ray shows upper zone infiltration
and fibrosis, Sputum culture is sent, and results are pending. What is the most likely diagnosis?
a. COPD
b. Mesothelioma
c. Pneumonia
d. Rapidly progressive silicosis
e. Tuberculosis √
Description
Since silica is toxic to macrophages, Tuberculosis is associated with silica exposure.
Tuberculosis (TB):
It is an infection caused by Mycobacterium Tuberculosis (an Acid-fast bacilli bacterium that

can cause caseating granuloma)
It can be latent in 95% and primary active disease in 5%, or secondary active disease (activation
of latent infection)
It can be pulmonary, extrapulmonary, or both.
Tuberculosis has an airborne mode of transmission. en, the bacteria invade the immunity,
survive and replicate in the macrophages
Clinical features are: pneumonia resistant to antibiotics, constitutional symptoms, upper zone
infiltration on the chest x-ray
Page - 2014
Question 76/144
Question #76
e threshold for diagnosing a patient with Tuberculosis aer PPD screening in an HIV patient is an
induration of more than which of the following?
a. 3 mm
b. 5 mm
c. 7 mm
d. 10 mm
e. 15 mm
Page - 2015
Question 76/144
Question #76
e threshold for diagnosing a patient with Tuberculosis aer PPD screening in an HIV patient is an
induration of more than which of the following?
a. 3 mm
b. 5 mm √
c. 7 mm
d. 10 mm
e. 15 mm
Description
Induration ≥ 5 mm induration in an HIV patient is considered a positive PPD test
e following table demonstrates the Mantoux test interpretations:
Mantoux test is considered positive in the following conditions:
Induration ≥ 15 mm induration (for any patient)

Induration ≥ 10 mm induration and one of the following:
A recent arrival from a high prevalent country
IV drug user
Child < 4 years
Induration ≥ 5 mm induration and one of the following:
HIV positive
Recent contact with TB patient
Typical TB changes on chest x-ray
Organ transplant
Page - 2016
Question 77/144
Question #77
A 22-year-old male has had recent contact with a TB patient; his tuberculin test was negative 6
months ago but now shows a 12 mm induration. Which of the following is essential to check before
starting latent TB treatment with INH?
a. Vitamin B6 level
b. Presence of neuropathy
c. Active Tuberculosis
d. History of Hepatitis A
Page - 2017
Question 77/144
Question #77
A 22-year-old male has had recent contact with a TB patient; his tuberculin test was negative 6
months ago but now shows a 12 mm induration. Which of the following is essential to check before
starting latent TB treatment with INH?
a. Vitamin B6 level
b. Presence of neuropathy
c. Active Tuberculosis √
d. History of Hepatitis A
Description
Starting INH alone in latent TB for 9 months is eective, but it carries a high risk of drug resistance if
started alone in active TB patients. A chest x-ray should be done to exclude active Tuberculosis
should be done first before starting INH for latent TB
Page - 2018
Question 78/144
Question #78
A 34-year-old male patient was diagnosed with TB and is now on treatment. Which of the following
drugs is the most active against mycobacterium tuberculosis?
a. Isoniazid
b. Rifampicin
c. Ethambutol
d. Pyrazinamide
e. Streptomycin
Page - 2019
Question 78/144
Question #78
A 34-year-old male patient was diagnosed with TB and is now on treatment. Which of the following
drugs is the most active against mycobacterium tuberculosis?
a. Isoniazid √
b. Rifampicin
c. Ethambutol
d. Pyrazinamide
e. Streptomycin
Description
Isoniazid (INH) is the most active drug against Mycobacterium tuberculosis. It penetrates most body
fluids and accumulates in caseated lesions.
INH is used alone for 9 months in latent TB. In addition, it should be administrated with other anti-
TB drugs in active TB to avoid the development of drug resistance.
Page - 2020
Question 79/144
Question #79
the most likely cause of his symptoms?
a. Isoniazid
b. Rifampicin
c. Ethambutol
d. B12 deficiency
e. Cerebrovascular accident
Page - 2021
Question 79/144
Question #79
the most likely cause of his symptoms?
a. Isoniazid √
b. Rifampicin
c. Ethambutol
d. B12 deficiency
e. Cerebrovascular accident
Description
Isoniazid interferes with the metabolism of vitamin B6, leading to neuropathy. is condition may
result in coma and seizures and is reversed by vitamin B6 (pyridoxine).
e following table demonstrates the adverse eects of anti-TB medications and their treatments:
Page - 2022
Question 80/144
Question #80
A 32-year-old male who returns from south Africa presents with several months of hemoptysis and
weight loss. Physical examination, including vital signs, chest, heart, and abdomen, are all
unremarkable. His chest x-ray shows right upper zone cavitation, the tuberculin test is positive, the
sputum smear is negative for AFB, and cultures are pending. Which is the best initial treatment for
his condition?
a. Wait for culture results, then start treatment

b. INH for 9 months duration
c. Rifampicin and pyrazinamide for 9 months
d. Rifampicin for 6 weeks
e. INH, Rifampicin, Ethambutol, and pyrazinamide for 6 months
Page - 2023
Question 80/144
Question #80
A 32-year-old male who returns from south Africa presents with several months of hemoptysis and
weight loss. Physical examination, including vital signs, chest, heart, and abdomen, are all
unremarkable. His chest x-ray shows right upper zone cavitation, the tuberculin test is positive, the
sputum smear is negative for AFB, and cultures are pending. Which is the best initial treatment for
his condition?
a. Wait for culture results, then start treatment

b. INH for 9 months duration
c. Rifampicin and pyrazinamide for 9 months
d. Rifampicin for 6 weeks
e. INH, Rifampicin, Ethambutol, and pyrazinamide for 6 months √
Description
South Africa is known to have a high prevalence of Tuberculosis. Treatment shouldn’t be delayed for
those with high clinical suspicion, as in this case.
INH alone has a high risk of resistance, so 4 drugs should be started for 2 months, and then 2 drugs
for 4 months are the best regimen.
Page - 2024
Question 81/144
Question #81
An alcoholic 49-year-old male patient presents with general weakness, weight loss, and cough. His
temperature is 39 °C, hepatomegaly is noted, but his alpha-fetoprotein is normal. e chest x-ray is
a. Reactivation pulmonary Tuberculosis

b. Lobar pneumonia
c. Bronchiectasis
d. Miliary TB
e. Hepatic cell carcinoma
Page - 2025
Question 81/144
Question #81
An alcoholic 49-year-old male patient presents with general weakness, weight loss, and cough. His
temperature is 39 °C, hepatomegaly is noted, but his alpha-fetoprotein is normal. e chest x-ray is
a. Reactivation pulmonary Tuberculosis

b. Lobar pneumonia
c. Bronchiectasis
d. Miliary TB √
e. Hepatic cell carcinoma
Description
e chest x-ray shows diuse, well-defined nodules less than 5 mm in diameter, characteristic of
Miliary Tuberculosis. e negative alpha-fetoprotein excludes hepatic cancer. Page - 2026
Features of Miliary TB:
Widespread hematogenous dissemination of TB to the lung, abdominal organs, CNS, etc.

e lesions are usually yellowish granulomas of 1 – 2 mm in diameter
Fever, night sweats, anorexia, weakness, and weight loss are presenting symptoms in the
majority of cases
Page - 2027
Question 82/144
Question #82
A 15-year-old male has presented with recurrent shortness of breath for the last 6 months. His
dyspnea occurs more at night. His little brother has a history of eczema. Which of the following is
most likely to present in the Pulmonary function test?
a. Normal FEV1, high FEV1/FVC ratio, High TLC

b. Low FEV1, Low FEV1/FVC ratio, Low TLC
c. Low FEV1, Normal FEV1/FVC ratio, High TLC
d. Low FEV1, Low FEV1/FVC ratio, High TLC
e. Normal FEV1, Normal FEV1/FVC ratio, Normal TLC
Page - 2028
Internal Medicine - Pulmonology - Asthma
Question 82/144
Question #82
dyspnea occurs more at night. His little brother has a history of eczema. Which of the following is
most likely to present in the Pulmonary function test?
a. Normal FEV1, high FEV1/FVC ratio, High TLC

b. Low FEV1, Low FEV1/FVC ratio, Low TLC
c. Low FEV1, Normal FEV1/FVC ratio, High TLC
d. Low FEV1, Low FEV1/FVC ratio, High TLC √
e. Normal FEV1, Normal FEV1/FVC ratio, Normal TLC
Description
is patient complains of recurrent shortness of breath, night symptoms, and a family history of an
IgE-related disease (eczema in her brother). erefore, asthma is the most likely diagnosis.
Asthma is known to manifest as an obstructive lung disease on the pulmonary function test
In pure obstructive lung disease, FEV1/FVC ratio will be low, and the TLC will be high.
Asthma:
Asthma is a chronic disease that causes inflammation with reversible & variable narrowing of
the airways (e main dierence between asthma and COPD is reversibility and variability)
Asthma is usually associated with a history or family history of other IgE-related diseases like
atopic dermatitis (eczema) and atopic rhinitis (hay fever)
Triggers are: dust, smoking, air pollution, Drugs – NSAID, Beta-blockers, exercise, emotions,
sudden changes in air temperature
Page - 2029
Question 83/144
Question #83
A 30-year-old male patient presents with 6 months history of shortness of breath. His symptoms get
better at weekends but get worse on workdays. What is the most likely diagnosis?
a. Atopic asthma
b. Occupational asthma
d. Alpha 1 antitrypsin deficiency
e. Cough variant asthma
Page - 2030
Question 83/144
Question #83
A 30-year-old male patient presents with 6 months history of shortness of breath. His symptoms get
better at weekends but get worse on workdays. What is the most likely diagnosis?
a. Atopic asthma
b. Occupational asthma √
d. Alpha 1 antitrypsin deficiency
Description
is patient complains of variable asthmatic symptoms that are worse on workdays and better at
weekends. erefore, Occupational asthma is the most likely diagnosis.
To diagnose occupational asthma, perform pulmonary function tests on work days and weekends to
compare the results.
Note: in occupational asthma, chemicals at work worsen symptoms, and the patient is better at
weekends.
Page - 2031
Question 84/144
Question #84
A 22-year-old male is a known case of asthma. He presents with acute asthma exacerbation for 2
hours. He is not improving despite the use of SABA and SAMA. On examination, the patient is using
accessory muscles in respiration. His blood pressure is 100/60. Chest auscultation shows loud
expiratory wheezing, ABGs show PH 7.45, PaCO2 39 mmHg, and HCO3 was 26. What is the next step
in the management of this patient?
a. Admission to the hospital and provide Oxygen by mask

b. Inhaled high dose beclomethasone
c. Repeat O2, SABA, SAMA, and prednisolone
d. Intubation, 100% oxygen, and IV steroids
e. Reassurance
Page - 2032
Question 84/144
Question #84
A 22-year-old male is a known case of asthma. He presents with acute asthma exacerbation for 2
hours. He is not improving despite the use of SABA and SAMA. On examination, the patient is using
accessory muscles in respiration. His blood pressure is 100/60. Chest auscultation shows loud
expiratory wheezing, ABGs show PH 7.45, PaCO2 39 mmHg, and HCO3 was 26. What is the next step
in the management of this patient?
a. Admission to the hospital and provide Oxygen by mask

b. Inhaled high dose beclomethasone
c. Repeat O2, SABA, SAMA, and prednisolone
d. Intubation, 100% oxygen, and IV steroids √
e. Reassurance
Description
Normal PaCO2 in acute asthma exacerbation is a sign of life-threatening asthma. erefore,

intubation is warranted at this point.
Based on PEFR, ABGs, and clinical features, asthma exacerbations are classified as moderate, severe,
and life-threatening.
e following table demonstrates the features of acute asthma classes:
Page - 2033
Question 85/144
Question #85
dyspnea occurs more at night. In addition, his little brother has a history of eczema. Which of the
following is the best to establish a diagnosis of his condition?
a. Chest X-ray
b. Chest CT scan
c. Symptomatic control on bronchodilators
d. Bronchoscopy
e. DLco
Page - 2034
Question 85/144
Question #85
dyspnea occurs more at night. In addition, his little brother has a history of eczema. Which of the
following is the best to establish a diagnosis of his condition?
a. Chest X-ray
b. Chest CT scan
c. Symptomatic control on bronchodilators √
d. Bronchoscopy
e. DLco
Description
An improvement of the dyspnea aer administration of SABA is indicative of reversibility and is

diagnostic of asthma in this patient.
Asthma:
Page - 2035
Question 86/144
Question #86
A 24-year-old male patient presents with acute asthma exacerbation. He has received nebulized
SABA, 200 mg hydrocortisone IV, and 100% oxygen for the last 20 minutes. Unfortunately, he is still
symptomatic. His chest is wheezy, and his oxygen saturation is 90%. What is the best next step in
a. Prednisolone 40 mg PO
b. Nebulized Ipratropium bromide 0.5 mg
c. Intramuscular adrenalin
d. Stop oxygen administration
e. Magnesium sulfate intravenously
Page - 2036
Question 86/144
Question #86
A 24-year-old male patient presents with acute asthma exacerbation. He has received nebulized
SABA, 200 mg hydrocortisone IV, and 100% oxygen for the last 20 minutes. Unfortunately, he is still
symptomatic. His chest is wheezy, and his oxygen saturation is 90%. What is the best next step in
a. Prednisolone 40 mg PO
b. Nebulized Ipratropium bromide 0.5 mg √
c. Intramuscular adrenalin
d. Stop oxygen administration
e. Magnesium sulfate intravenously
Description
Ipratropium bromide is a short-acting muscarinic antagonist used as an asthma reliever for patients
who do not respond to SAMA and early steroid administration.
Treatment of asthma exacerbation:
e first step:
Oxygen: For all hypoxic patients, given by venturi mask
SABA: 5 – 10 pus by MDI and spacer (SABA nebulizer is indicated in severe cases)- can be
repeated up to 3 doses in 1 hour.
Early administration of systemic steroid (40 – 50 mg oral prednisolone)
e second step: Nebulized SAMA (Short-acting muscarinic antagonists, e.g., Ipratropium)
e third step: Magnesium sulfate IV (1.2 – 2 g over 30 minutes)
Not routinely used
Only if the previous measures fail to improve the patient
Intubation and mechanical ventilation should be done in any patient with life-threatening or
near-fatal asthma.
Page - 2037
Question 87/144
Question #87
An 18-year-old male patient with asthma developed sudden chest pain and shortness of breath
while running for a bus. His breath sounds are reduced on the right side. His oxygen saturation is
95% on room air. What is the single most appropriate investigation at this moment?
a. ECG
b. Chest x-ray
c. Chest CT scan
d. D Dimer
Page - 2038
Question 87/144
Question #87
An 18-year-old male patient with asthma developed sudden chest pain and shortness of breath
while running for a bus. His breath sounds are reduced on the right side. His oxygen saturation is
95% on room air. What is the single most appropriate investigation at this moment?
a. ECG
b. Chest x-ray √
c. Chest CT scan
d. D Dimer
Description
is patient is most likely to have acute asthma exacerbation secondary to pneumothorax.
Primary spontaneous pneumothorax here in this patient is likely because of the presence of
unilaterally reduced breathing sound and the history of running
A standard erect chest x-ray is recommended as an initial diagnostic investigation for this patient.
Page - 2039
Question 88/144
Question #88
A 22-year-old male patient presents with acute asthma exacerbation. He is treated with 100%
oxygen, nebulized salbutamol, oral prednisolone, and nebulized ipratropium bromide.
Unfortunately, the patient is still symptomatic and tachypneic. What is the best next step in the
a. Intravenous aminophylline
b. Intravenous MgSO4
c. Intravenous salbutamol
d. Intravenous adrenalin
e. Intramuscular adrenalin
Page - 2040
Question 88/144
Question #88
A 22-year-old male patient presents with acute asthma exacerbation. He is treated with 100%
oxygen, nebulized salbutamol, oral prednisolone, and nebulized ipratropium bromide.
Unfortunately, the patient is still symptomatic and tachypneic. What is the best next step in the
a. Intravenous aminophylline
b. Intravenous MgSO4 √
c. Intravenous salbutamol
d. Intravenous adrenalin
Description
is patient with acute asthma exacerbation didn’t respond to SABA, steroids, and SAMA. erefore,
you should provide Magnesium sulfate intravenously at this step.
e first step:
Not routinely used
near-fatal asthma.
Page - 2041
Question 89/144
Question #89
A 33-year-old female with a long history of asthma uses a salbutamol inhaler as needed. She needs it
3 times per week in the daytime and 3 times monthly at night as the symptoms awaken her from
sleep. What would you do next?
a. Add LABA
b. Add LTRA
c. Add low-dose ICS
d. Continue same treatment
e. Increase the dose of salbutamol
Page - 2042
Question 89/144
Question #89
A 33-year-old female with a long history of asthma uses a salbutamol inhaler as needed. She needs it
3 times per week in the daytime and 3 times monthly at night as the symptoms awaken her from
sleep. What would you do next?
a. Add LABA
b. Add LTRA
c. Add low-dose ICS √
d. Continue same treatment
e. Increase the dose of salbutamol
Description
e patient is still uncontrolled because she uses her inhaler more than 2 times weekly.
You should add a low-dose ICS to her regimen to control her asthma.
e following diagram demonstrates the recent guidelines in asthma management:
Page - 2043
Question 90/144
Question #90
A 25-year-old male patient known case of asthma complains of daily symptoms of shortness of
breath and wheezing. He occasionally wakes up from sleeping due to chest tightness and dyspnea.
He is on a salbutamol inhaler as required. e next step in the management of this patient is:
a. Increase the dose of salbutamol

b. Give oral prednisolone
c. Add ipratropium bromide in two pus 4 times a day
d. Add low dose beclomethasone two pus BID
e. Stop salbutamol and start long-acting beta-agonist
Page - 2044
Question 90/144
Question #90
A 25-year-old male patient known case of asthma complains of daily symptoms of shortness of
breath and wheezing. He occasionally wakes up from sleeping due to chest tightness and dyspnea.
He is on a salbutamol inhaler as required. e next step in the management of this patient is:
a. Increase the dose of salbutamol

b. Give oral prednisolone
c. Add ipratropium bromide in two pus 4 times a day
d. Add low dose beclomethasone two pus BID √
e. Stop salbutamol and start long-acting beta-agonist
Description
is patent is in the first step of his treatment, and he is not responsive. erefore, a step up of his
treatment by adding a low dose of ICS is recommended.
You should add a low-dose inhaled steroid (fluticasone, beclomethasone) to the patient’s treatment.
Page - 2045
Question 91/144
Question #91
A 29-year-old dentist presents to you with coughs, wheezing, and shortness of breath. He exercises
regularly and experiences his symptoms about 5 minutes aer starting his exercises. His physical
examination and lab investigations are all normal. What is the most likely diagnosis?
a. Occupational asthma
b. Atopic asthma
c. Drug-induced asthma
d. Exercise-induced asthma
Page - 2046
Question 91/144
Question #91
A 29-year-old dentist presents to you with coughs, wheezing, and shortness of breath. He exercises
regularly and experiences his symptoms about 5 minutes aer starting his exercises. His physical
examination and lab investigations are all normal. What is the most likely diagnosis?
a. Occupational asthma
b. Atopic asthma
c. Drug-induced asthma
d. Exercise-induced asthma √
Description
is patient has bronchospasms that are induced by exercise. Bronchodilators should be provided as
needed for this patient
Page - 2047
Question 92/144
Question #92
A 30-year-old male patient presents with a 6-month history of shortness of breath. His symptoms
get better at weekends but get worse on workdays. What is the best tool to establish the most likely
diagnosis?
a. Chest X-ray
b. Lung volume study
c. DLco
d. Spirometry at workdays and weekends
e. Methacholine challenge test
Page - 2048
Question 92/144
Question #92
A 30-year-old male patient presents with a 6-month history of shortness of breath. His symptoms
get better at weekends but get worse on workdays. What is the best tool to establish the most likely
diagnosis?
a. Chest X-ray
b. Lung volume study
c. DLco
d. Spirometry at workdays and weekends √
Description
is patient complains of variable asthmatic symptoms that are worse on workdays and better at
weekends. erefore, Occupational asthma is the most likely diagnosis.
To diagnose occupational asthma, perform pulmonary function tests on work days and weekends to
compare the results.
Note: in occupational asthma, chemicals at work worsen symptoms, and the patient is better at
weekends.
Note: Spirometry showing obstructive pattern at workdays which improves at weekends, is

suggestive of occupational asthma
Page - 2049
Question 93/144
Question #93
A 22-year-old female patient suers from wheezing and chest tightness, which is more frequent at
night and when exposed to cold weather. What is the most likely diagnosis?
a. COPD
b. Pneumonia
c. Asthma
d. Bronchiectasis
e. Interstitial lung disease
Page - 2050
Question 93/144
Question #93
A 22-year-old female patient suers from wheezing and chest tightness, which is more frequent at
night and when exposed to cold weather. What is the most likely diagnosis?
a. COPD
b. Pneumonia
c. Asthma √
d. Bronchiectasis
e. Interstitial lung disease
Description
is patient is suering from symptoms of asthma aer she exposed to a precipitant
Asthma is a chronic disease that causes inflammation with reversible & variable narrowing of the
airways (e main dierence between asthma and COPD is reversibility and variability)
Asthma:
Page - 2051
Question 94/144
Question #94
What is the best test to dierentiate between asthma and COPD in a patient with recurrent
shortness of breath?

b. Bronchodilation challenge test
c. 6-Minute walk test
d. DLco
e. Chest x-ray
Page - 2052
Question 94/144
Question #94
What is the best test to dierentiate between asthma and COPD in a patient with recurrent
shortness of breath?

b. Bronchodilation challenge test √
c. 6-Minute walk test
d. DLco
e. Chest x-ray
Description
Asthma:
Asthma is a chronic disease that causes inflammation with reversible & variable narrowing of the
airways (e main dierence between asthma and COPD is reversibility and variability)
Reversibility of more than 12% and 200 mL in FEV1 aer the administration of SABA is the main test
to identify reversibility.
Page - 2053
Question 95/144
Question #95
A 25-year-old male patient with acute asthma exacerbation is treated at the ER initially with 100%
oxygen and salbutamol nebulizers. e patient’s respiratory rate is 21 per minute, O2 saturation is
93%, and his heart rate is 90 bpm. What would you do next in the management of this patient?
a. No additional treatment
b. Administrate oral prednisolone 40 mg
c. Administrate MgSO4 1.5 grams intravenously
d. Intubation and mechanical ventilation
Page - 2054
Question 95/144
Question #95
A 25-year-old male patient with acute asthma exacerbation is treated at the ER initially with 100%
oxygen and salbutamol nebulizers. e patient’s respiratory rate is 21 per minute, O2 saturation is
93%, and his heart rate is 90 bpm. What would you do next in the management of this patient?
a. No additional treatment
b. Administrate oral prednisolone 40 mg √
c. Administrate MgSO4 1.5 grams intravenously
d. Intubation and mechanical ventilation
Description
Here the patient has mild acute asthma exacerbation. However, early administration of steroids is
vital in acute asthma exacerbation
e first step:
Not routinely used
near-fatal asthma.
Page - 2055
Question 96/144
Question #96
Compared to the regular nebulizer, the use of a metered-dose inhaler (MDI) in asthma attack
treatment in the emergency department will result in all of the following except:
a. Reduces the required salbutamol dose

b. Shorter duration in the ER
c. Better improvement in PEFR
d. Better improvement on ABGs
e. Increases the recurrence of exacerbations
Page - 2056
Question 96/144
Question #96
Compared to the regular nebulizer, the use of a metered-dose inhaler (MDI) in asthma attack
treatment in the emergency department will result in all of the following except:
a. Reduces the required salbutamol dose

b. Shorter duration in the ER
c. Better improvement in PEFR
d. Better improvement on ABGs
e. Increases the recurrence of exacerbations √
Description
Compared to nebulizers, MDIs with spacers have been shown to reduce the recurrence of
exacerbations.
e first step:
Not routinely used
near-fatal asthma.
Page - 2057
Question 97/144
Question #97
An asthmatic 21-year-old male patient presents to the ER with shortness of breath that is not
improving on his inhaled salbutamol. However, physical examination shows a dyspneic conscious,
and alert person. His vital signs are normal. What is the next step best to be done at this point?
a. Start inhaled corticosteroids

b. IV methylprednisolone
c. Oxygen with bag and mask ventilation
d. Start oral corticosteroids
Page - 2058
Question 97/144
Question #97
An asthmatic 21-year-old male patient presents to the ER with shortness of breath that is not
improving on his inhaled salbutamol. However, physical examination shows a dyspneic conscious,
and alert person. His vital signs are normal. What is the next step best to be done at this point?
a. Start inhaled corticosteroids

b. IV methylprednisolone
c. Oxygen with bag and mask ventilation
d. Start oral corticosteroids √
Description
Early administration of steroids is vital in acute asthma exacerbation
Bag-mask ventilation is not indicated in stable patients.
IV steroids are equivalent to oral steroids in the treatment of asthma
e first step:
Not routinely used
near-fatal asthma.
Page - 2059
Question 98/144
Question #98
A 19-year-old male patient is a known case of asthma. He presented with frequent night coughs and
exercise-induced shortness of breath. He is on inhaled salbutamol as needed and twice daily inhaled
corticosteroids. His inhaler technique is good. What would you do next in the management of this
patient?
a. Add Salmeterol inhaler

b. Add oral theophylline
c. Add nebulized albuterol
d. Add regular oral corticosteroids
e. Increase the dose of ICS
Page - 2060
Question 98/144
Question #98
A 19-year-old male patient is a known case of asthma. He presented with frequent night coughs and
exercise-induced shortness of breath. He is on inhaled salbutamol as needed and twice daily inhaled
corticosteroids. His inhaler technique is good. What would you do next in the management of this
patient?
a. Add Salmeterol inhaler √

b. Add oral theophylline
c. Add nebulized albuterol
d. Add regular oral corticosteroids
Description
is patient is taking SABA and Low dose ICS. erefore, the best next step is to step up his
treatment and start LABA (salmeterol) inhaler in his regimen.
Page - 2061
Question 99/144
Question #99
A 21-year-old male patient with a history of eczema presents with fever, shortness of breath, and
wheezes. Pulmonary function test shows FEV1/FCV of 55%. is ratio became 72% aer the
administration of bronchodilators. What is the most likely diagnosis?
a. Asthma exacerbation
b. COPD
c. Tuberculosis
d. Bronchiectasis
e. Chronic bronchitis
Page - 2062
Question 99/144
Question #99
A 21-year-old male patient with a history of eczema presents with fever, shortness of breath, and
wheezes. Pulmonary function test shows FEV1/FCV of 55%. is ratio became 72% aer the
administration of bronchodilators. What is the most likely diagnosis?
a. Asthma exacerbation √
b. COPD
c. Tuberculosis
d. Bronchiectasis
e. Chronic bronchitis
Description
e history of eczema, SOB, and Wheezes are typical asthma presentations.
e most likely diagnosis is an infective exacerbation of asthma (fever, SOB, and Wheezes).
e most accurate test to confirm asthma is to perform a Pulmonary function test that is expected
to show a reversible obstruction pattern in the asthma patients, i.e., reduced FEV1 and FEV1/FVC
ratio; this will improve by more than 200 ml and 12% aer the administration of SABA.
Asthma:
Page - 2063
Question 100/144
Question #100
A 22-year-old male with mild persistent asthma is on inhaled corticosteroids. Which of the following
is true regarding this drug?
a. ey are used as needed (to relieve attack)

b. ey are ineective in a patient who takes beta-blockers
c. ey are less eective than SABA in controlling asthma
d. ey are acting by causing bronchodilatation
e. ey are eective within 5 minutes for 6 hours duration
Page - 2064
Question 100/144
Question #100
A 22-year-old male with mild persistent asthma is on inhaled corticosteroids. Which of the following
is true regarding this drug?
a. ey are used as needed (to relieve attack)

b. ey are ineective in a patient who takes beta-blockers
c. ey are less eective than SABA in controlling asthma
d. ey are acting by causing bronchodilatation
e. ey are eective within 5 minutes for 6 hours duration √
Description
e eect of ICS starts within 5 minutes and lasts up to 4 – 6 hours.
It is used regularly, twice daily (not as needed)
SABA is not used to control asthma. It is used to relieve it
ICS acts by anti-inflammatory eect (Not a bronchodilator)
Page - 2065
Question 101/144
Question #101
A 22-year-old male patient with a known case of asthma presents with palpitations and tachycardia.
His heart rate is 115 bpm and regular. His peak expiratory flow rate is normal. What is the most
appropriate management of this patient?
a. Lifestyle changes
b. Holter 24-hour monitoring
c. Admission to the CCU for more investigations
d. Do Chest x-ray
e. Review his medications
Page - 2066
Question 101/144
Question #101
A 22-year-old male patient with a known case of asthma presents with palpitations and tachycardia.
His heart rate is 115 bpm and regular. His peak expiratory flow rate is normal. What is the most
appropriate management of this patient?
a. Lifestyle changes
b. Holter 24-hour monitoring
c. Admission to the CCU for more investigations
d. Do Chest x-ray
e. Review his medications √
Description
e patient most likely suers from a common side eect due to beta-agonist use.
SABA: Short-acting beta 2 agonists:
Used as reliever, not controller (cause bronchodilation)

Example: salbutamol, albuterol, levalbuterol
Side eects: hypokalemia, tachycardia, and tremor
SABA alone has more risk of exacerbation compared to SABA + ICS use. erefore, according to
the recent guidelines, ensure the patient will adhere to ICS therapy before prescribing SABA.
Page - 2067
Question 102/144
Question #102
A patient with a known case of asthma who has acute shortness of breath daily and night-time
symptoms once weekly, which of the following asthma classes does he have?
a. Mild intermittent asthma

b. Mild persistent asthma
c. Moderate persistent asthma
d. Severe persistent asthma
e. Moderate intermittent asthma
Page - 2068
Question 102/144
Question #102
A patient with a known case of asthma who has acute shortness of breath daily and night-time
symptoms once weekly, which of the following asthma classes does he have?
a. Mild intermittent asthma

b. Mild persistent asthma
c. Moderate persistent asthma √
d. Severe persistent asthma
e. Moderate intermittent asthma
Description
Daily daytime and weekly night-time symptoms of asthma are typical for moderate persistent
asthma
e following table shows the classification of asthma according to the frequency of symptoms and
the FEV1.
Page - 2069
Question 103/144
Question #103
Which is the most appropriate first-line treatment for a 22-year-old male patient with acute asthma
exacerbation?
a. Oxygen
b. Salbutamol intravenously
c. Salbutamol nebulizer
d. Salmeterol nebulizer
e. Intravenous MgSO4
Page - 2070
Question 103/144
Question #103
Which is the most appropriate first-line treatment for a 22-year-old male patient with acute asthma
exacerbation?
a. Oxygen
b. Salbutamol intravenously
c. Salbutamol nebulizer √
d. Salmeterol nebulizer
e. Intravenous MgSO4
Description
It is essential to know that Oxygen is beneficial for acute asthma exacerbation patients, but the
first-line treatment is SABA (Salbutamol, Albuterol, Levalbuterol).
e first step:
Not routinely used
near-fatal asthma.
Page - 2071
Question 104/144
Question #104
A 55-year-old male patient with a history of HTN and Asthma developed wheezes and chest
tightness 2 days aer changing his medications, which his GP prescribed. What is the most likely
cause of his symptoms?
a. Bisoprolol
b. Enalapril
c. Verapamil
d. Carvedilol
e. Aldactone
Page - 2072
Question 104/144
Question #104
A 55-year-old male patient with a history of HTN and Asthma developed wheezes and chest
tightness 2 days aer changing his medications, which his GP prescribed. What is the most likely
cause of his symptoms?
a. Bisoprolol
b. Enalapril
c. Verapamil
d. Carvedilol √
e. Aldactone
Description
Patients with asthma should avoid using aspirin, NSAIDs, and non-selective Beta-blockers because
they can exacerbate their symptoms.
Bisoprolol is a selective beta 1 blocker and will not cause bronchospasm if used wisely.
Note: Even the selective beta-blockers in high doses will lose their selectivity, so do not use selective
beta-blockers in high doses for asthma patients
Page - 2073
Question 105/144
Question #105
Which of the following asthmatic patient would be preferred to be treated with low-dose inhaled
corticosteroids alone?
a. A 19-year-old male with once-weekly symptoms

b. A 20-year-old female with symptoms of 3 times weekly but less than once daily
c. A 20-year-old male with exercise-induced asthma
d. A 21-year-old female with asthma symptoms several times a day
e. A18-year-old male with daily asthmatic symptoms
Page - 2074
Question 105/144
Question #105
Which of the following asthmatic patient would be preferred to be treated with low-dose inhaled
corticosteroids alone?
a. A 19-year-old male with once-weekly symptoms

b. A 20-year-old female with symptoms of 3 times weekly but less than once daily √
c. A 20-year-old male with exercise-induced asthma
d. A 21-year-old female with asthma symptoms several times a day
e. A18-year-old male with daily asthmatic symptoms
Description
According to recent guidelines, the initial asthma management depends on the class of asthma as
the following:
Mild intermittent: No maintenance therapy required.

Mild persistent: Low dose ICS alone
Moderate persistent: Low dose ICS + LABA
Severe persistent: high dose ICS + LABA
Very severe persistent: high dose ICS + LABA + oral steroids
e second patient (Choice B) complains of 3 times weekly symptoms but less than once daily.
erefore, he has mild persistent asthma. He needs maintenance treatment with ICS alone. Which
makes this the correct answer
Page - 2075
Page - 2076
Question 106/144
Question #106
dyspnea occurs more at night. His little brother has a history of eczema. e following drugs are not
safe to use in this patient except:
a. Propranolol
b. Naproxen
c. Aspirin
d. Celecoxib
e. Prednisolone
Page - 2077
Question 106/144
Question #106
dyspnea occurs more at night. His little brother has a history of eczema. e following drugs are not
safe to use in this patient except:
a. Propranolol
b. Naproxen
c. Aspirin
d. Celecoxib
e. Prednisolone √
Description
Prednisolone is safe to use in the treatment of asthma.
e rest of the drugs mentioned can cause bronchospasm and should be avoided in asthmatic
patients.
Page - 2078
Question 107/144
Question #107
All the following patients with acute status asthmaticus should be admitted to the hospital except:
a. A patient with a history of life-threatening asthma

b. A pregnant lady with a moderate asthma attack
c. A patient on oral steroids presents with a moderate asthma attack
d. A patient with normal PaCO2 on ABGs during the event
Page - 2079
Question 107/144
Question #107
All the following patients with acute status asthmaticus should be admitted to the hospital except:
a. A patient with a history of life-threatening asthma

b. A pregnant lady with a moderate asthma attack
c. A patient on oral steroids presents with a moderate asthma attack
d. A patient with normal PaCO2 on ABGs during the event
e. None of the above √
Description
All of the mentioned patients should be admitted to the hospital.
Indications for admission in acute asthma attacks are:
All patients with life-threatening asthma

Severe asthma attack not responding to the initial treatment
Previous near-fatal asthma attack
Pregnant women
An attack despite the use of oral steroids
Page - 2080
Question 108/144
Question #108
A 29-year-old male patient presents to your clinic because he has had uncontrolled asthma over the
past month. He experiences asthmatic symptoms more than 5 times weekly and recurrent night-
time exacerbations. However, his current medications include salbutamol with ICS as required,
regular low-dose ICS, and a regular Salmeterol inhaler. What is the best next step in the
a. Keep the same treatment

b. Add oral steroid
c. Add ipratropium bromide inhaler PRN
d. Add theophylline
Page - 2081
Question 108/144
Question #108
A 29-year-old male patient presents to your clinic because he has had uncontrolled asthma over the
past month. He experiences asthmatic symptoms more than 5 times weekly and recurrent night-
time exacerbations. However, his current medications include salbutamol with ICS as required,
regular low-dose ICS, and a regular Salmeterol inhaler. What is the best next step in the
a. Keep the same treatment

b. Add oral steroid
c. Add ipratropium bromide inhaler PRN
d. Add theophylline
e. Increase the dose of ICS √
Description
is patient takes low-dose ICS + LABA for asthma maintenance and still has uncontrolled
symptoms. erefore, high-dose ICS should be used instead of low doses.
Page - 2082
Question 109/144
Question #109
A 22-year-old gentleman with a known case of asthma presents with acute exacerbation. Which of
the following is the first line to use in acute exacerbation of his asthma?
a. Oxygen
b. Salbutamol nebulizer
c. Prednisolone
d. Ipratropium bromide
e. Sodium cromolyn
Page - 2083
Question 109/144
Question #109
the following is the first line to use in acute exacerbation of his asthma?
a. Oxygen
b. Salbutamol nebulizer √
c. Prednisolone
e. Sodium cromolyn
Description
e first-line treatment for acute attacks of asthma is short-acting beta-agonists
e first step:
Not routinely used
near-fatal asthma.
Page - 2084
Question 110/144
Question #110
A 29-year-old female is a known case of asthma and is on a salbutamol inhaler as needed. She uses
her inhaler 4 – 5 times weekly with a good response. What is the next step in management?
a. Keep the patient on the same treatment

b. Add Long-acting beta 2 agonist
c. Add a low dose of beclomethasone
d. Add a high-dose beclomethasone
e. Add ipratropium bromide as needed
Page - 2085
Question 110/144
Question #110
A 29-year-old female is a known case of asthma and is on a salbutamol inhaler as needed. She uses
her inhaler 4 – 5 times weekly with a good response. What is the next step in management?
a. Keep the patient on the same treatment

b. Add Long-acting beta 2 agonist
c. Add a low dose of beclomethasone √
d. Add a high-dose beclomethasone
e. Add ipratropium bromide as needed
Description
e patient is still uncontrolled because she uses her inhaler more than 2 times weekly.
You should add a low-dose ICS to her regimen to control her asthma.
Page - 2086
Question 111/144
Question #111
the following is not used in treating acute asthmatic attacks?
a. Short-acting beta-agonist
b. Inhaled corticosteroids
c. Oral Prednisolone
e. Adrenalin
Page - 2087
Question 111/144
Question #111
the following is not used in treating acute asthmatic attacks?
a. Short-acting beta-agonist
b. Inhaled corticosteroids √
c. Oral Prednisolone
e. Adrenalin
Description
Inhaled corticosteroids are used in preventing asthmatic attacks, not as a reliever
e first step:
Not routinely used
near-fatal asthma.
Page - 2088
Question 112/144
Question #112
dyspnea occurs more at night, and his little brother has a history of eczema. What is the most likely
diagnosis?
a. COPD
b. Sarcoidosis
c. Asthma
d. Allergic rhinitis
e. Cystic fibrosis
Page - 2089
Question 112/144
Question #112
dyspnea occurs more at night, and his little brother has a history of eczema. What is the most likely
diagnosis?
a. COPD
b. Sarcoidosis
c. Asthma √
d. Allergic rhinitis
e. Cystic fibrosis
Description
Recurrent dyspnea and a family history of an IgE-related disease (Eczema) strongly suggest asthma
in this patient.
Asthma:
Page - 2090
Question 113/144
Question #113
A 19-year-old male patient was brought to the emergency department aer falling on his knee. e
patient is in pain, and you decided to give him analgesia. However, his medications include only
salbutamol for asthma as needed. What is the most appropriate analgesia to administer?
a. Aspirin
b. Diclofenac
c. Ibuprofen
d. Paracetamol
e. Celecoxib
Page - 2091
Question 113/144
Question #113
A 19-year-old male patient was brought to the emergency department aer falling on his knee. e
patient is in pain, and you decided to give him analgesia. However, his medications include only
salbutamol for asthma as needed. What is the most appropriate analgesia to administer?
a. Aspirin
b. Diclofenac
c. Ibuprofen
d. Paracetamol √
e. Celecoxib
Description
Aspirin, NSAIDs, and beta-blockers may exacerbate asthma. ese drugs should be avoided here
e safest drug to give here is paracetamol
Triggers of asthma: dust, smoking, air pollution, Drugs – NSAID, Beta-blockers, exercise, emotions,
Page - 2092
Question 114/144
Question #114
A 22-year-old male patient who is known case of asthma presents with acute asthma exacerbation;
the following features indicate a life-threatening asthma attack except:
a. PEFR < 33%

b. Normal or high CO2
c. Respiratory acidosis
d. Wheezy chest
e. Bradycardia and Hypotension
Page - 2093
Question 114/144
Question #114
A 22-year-old male patient who is known case of asthma presents with acute asthma exacerbation;
the following features indicate a life-threatening asthma attack except:
a. PEFR < 33%

b. Normal or high CO2
c. Respiratory acidosis
d. Wheezy chest √
e. Bradycardia and Hypotension
Description
A silent chest, not a wheezy chest, is a feature of life-threatening asthma.
Page - 2094
Question 115/144
Question #115
A 25-year-old male patient presented with acute asthma exacerbation. His respiratory rate is 25
breaths per minute. His pulse rate is 110 bpm, the patient has a wheezy chest, and he looks drowsy.
Which of the following is a criterion for life-threatening asthma?
a. Respiratory rate > 24 breaths per minute

b. PEFR 33 – 50% of predicted
c. Heart rate of more than 90 bpm
d. Bilateral severe wheezes
e. Altered mental status and drowsiness
Page - 2095
Question 115/144
Question #115
A 25-year-old male patient presented with acute asthma exacerbation. His respiratory rate is 25
breaths per minute. His pulse rate is 110 bpm, the patient has a wheezy chest, and he looks drowsy.
Which of the following is a criterion for life-threatening asthma?
a. Respiratory rate > 24 breaths per minute

b. PEFR 33 – 50% of predicted
c. Heart rate of more than 90 bpm
d. Bilateral severe wheezes
e. Altered mental status and drowsiness √
Description
Page - 2096
Question 116/144
Question #116
A 36-year-old patient with a known case of asthma presents to the ER with a status asthmaticus. All
of the following may be included in the therapy except:
a. Inhaled beta 2 agonist

b. IV hydration
c. Ipratropium bromide
d. Intubation and ventilation
e. Inhaled corticosteroids
Page - 2097
Question 116/144
Question #116
A 36-year-old patient with a known case of asthma presents to the ER with a status asthmaticus. All
of the following may be included in the therapy except:
a. Inhaled beta 2 agonist

b. IV hydration
c. Ipratropium bromide
d. Intubation and ventilation
e. Inhaled corticosteroids √
Description
Inhaled steroids are not used in acute asthma exacerbation.
Oral or IV steroids are equivalent to each other in acute asthma management.
e first step:
Not routinely used
near-fatal asthma.
Page - 2098
Question 117/144
Question #117
A 24-year-old male presents with a cough, shortness of breath, and wheezes. e symptoms start 10
minutes aer jogging. What test would you do next for your patient?
a. Chest x-ray
b. Allergy skin test
c. Spirometry
d. Peak flow rate
Page - 2099
Question 117/144
Question #117
A 24-year-old male presents with a cough, shortness of breath, and wheezes. e symptoms start 10
minutes aer jogging. What test would you do next for your patient?
a. Chest x-ray
b. Allergy skin test
c. Spirometry √
d. Peak flow rate
Description
Description:
is is a suspected case of exercise-induced asthma; spirometry showing a reversible obstructive

pattern is diagnostic in this condition.
Note that if the patient improves on the salbutamol inhaler, this will be diagnostic for asthma
Page - 2100
Question 118/144
Question #118
A patient with recurrent chest infections presents with persistent coughs productive of a copious
amount of purulent sputum. Physical examination shows inspiratory crepitation and finger
clubbing. His chest x-ray shows a tram track appearance. What is the most likely diagnosis?
a. Sarcoidosis
b. Bronchiectasis
c. Asthma
d. COPD
e. Pulmonary fibrosis
Page - 2101
Internal Medicine - Pulmonology - Bronchiectasis
Question 118/144
Question #118
A patient with recurrent chest infections presents with persistent coughs productive of a copious
amount of purulent sputum. Physical examination shows inspiratory crepitation and finger
clubbing. His chest x-ray shows a tram track appearance. What is the most likely diagnosis?
a. Sarcoidosis
b. Bronchiectasis √
c. Asthma
d. COPD
Description
Several points in the question point to bronchiectasis as the most likely diagnosis.
e presence of recurrent chest infection, copious amount of purulent sputum, clubbing, and tram
track appearance on chest x-ray
Bronchiectasis is an irreversible abnormal dilatation of small and medium-sized bronchi with

chronic airway inflammation. It is associated with regular sputum production, chronic cough,
recurrent acute chest infections, and airflow obstruction.
Page - 2102
Question 119/144
Question #119
A young adult who has had recurrent chest infections since childhood presents with excessive
purulent sputum and drumstick-shaped fingers. What is the most likely diagnosis?
a. Sarcoidosis
b. Bronchiectasis
c. Asthma
d. COPD
Page - 2103
Question 119/144
Question #119
A young adult who has had recurrent chest infections since childhood presents with excessive
purulent sputum and drumstick-shaped fingers. What is the most likely diagnosis?
a. Sarcoidosis
c. Asthma
d. COPD
Description

Asthma and COPD have not been known to cause figure clubbing
Pulmonary fibrosis manifests with dry cough
Page - 2104
Question 120/144
Question #120
A 29-year-old male has had recurrent chest infections and chronic coughs since childhood. His cough
is exacerbated by lying flat and is associated with bloody, foul-smelling sputum. Examination shows
clubbing fingers, and coarse crepitations are heard over the lung bases. Which is the most likely
diagnosis?
a. Emphysema
b. Chronic bronchitis
c. Lung cancer
d. Bronchiectasis
e. Atopic asthma
Page - 2105
Question 120/144
Question #120
A 29-year-old male has had recurrent chest infections and chronic coughs since childhood. His cough
is exacerbated by lying flat and is associated with bloody, foul-smelling sputum. Examination shows
clubbing fingers, and coarse crepitations are heard over the lung bases. Which is the most likely
diagnosis?
a. Emphysema
c. Lung cancer
d. Bronchiectasis √
e. Atopic asthma
Description
History of chronic or recurrent chest infection, Cough with foul-smelling sputum that changes with
body position, and Presence of coarse crepitations are all indicating bronchiectasis
Bronchiectasis:
It is a dilatation of the airways due to chronic lung infection in childhood (anatomic defect)
It usually aects medium-sized airways
Cystic fibrosis is the most common cause of bronchiectasis
Page - 2106
Question 121/144
Question #121
A 34-year-old male patient has been known to have a history of cystic fibrosis and recurrent chest
infections since childhood. In addition, he presents with chronic coughs; his chest x-ray is shown in
the picture below. What is the most likely diagnosis?
a. Emphysema
c. Bronchiectasis
d. Asthma
e. Acute lobar pneumonia

Page - 2107
Question 121/144
Question #121
infections since childhood. In addition, he presents with chronic coughs; his chest x-ray is shown in
the picture below. What is the most likely diagnosis?
a. Emphysema
c. Bronchiectasis √
d. Asthma
e. Acute lobar pneumonia
Description
Page - 2108
Tram tack appearance on chest X-ray, History of chronic or recurrent chest infection, Cough with
foul-smelling sputum that changes with body position, and Presence of coarse crepitations are all
indicating bronchiectasis
Bronchiectasis:
Page - 2109
Question 122/144
Question #122
A 42-year-old male patient with 3 years history of daily cough and malodourous sputum was treated
with antibiotics for a recurrent chest infection and hemoptysis. His FEV1/FVC ratio is 0.60. His CT
scan shows bronchial wall thickening and dilatation of the bronchi. What is the most likely
diagnosis?

b. Sarcoidosis
c. Bronchiectasis
d. Bronchitis
e. Emphysema
Page - 2110
Question 122/144
Question #122
A 42-year-old male patient with 3 years history of daily cough and malodourous sputum was treated
with antibiotics for a recurrent chest infection and hemoptysis. His FEV1/FVC ratio is 0.60. His CT
scan shows bronchial wall thickening and dilatation of the bronchi. What is the most likely
diagnosis?

b. Sarcoidosis
c. Bronchiectasis √
d. Bronchitis
e. Emphysema
Description
History of recurrent lung infection, foul-smelling (malodourous) sputum, the CT scan findings, and
Spirometry findings are suggestive of bronchiectasis
Bronchiectasis:
Page - 2111
Question 123/144
Question #123
A 60-year-old male patient has a productive cough, foul-smelling sputum, clubbing, coarse
crepitations, and peri-bronchial thickening on chest X-ray. What is the next step in managing this
patient?
a. Bronchoscopy
b. High-resolution CT scan
c. Sputum culture
d. Lung biopsy
e. Electrocardiogram
Page - 2112
Question 123/144
Question #123
A 60-year-old male patient has a productive cough, foul-smelling sputum, clubbing, coarse
crepitations, and peri-bronchial thickening on chest X-ray. What is the next step in managing this
patient?
a. Bronchoscopy
b. High-resolution CT scan √
c. Sputum culture
d. Lung biopsy
e. Electrocardiogram
Description
Description:
is is a typical scenario for bronchiectasis. However, a High-resolution CT scan of the lung is the
diagnostic modality of choice for bronchiectasis
Bronchiectasis:
Page - 2113
Question 124/144
Question #124
An HIV-positive, 32-year-old male patient presents with persistent productive coughs with a large
amount of purulent sputum. His chest examination shows inspiratory crepitations. However, His
chest x-ray shows a tram track appearance. What is the most likely diagnosis?
a. Sarcoidosis
b. Bronchiectasis
c. Asthma
d. COPD
Page - 2114
Question 124/144
Question #124
An HIV-positive, 32-year-old male patient presents with persistent productive coughs with a large
amount of purulent sputum. His chest examination shows inspiratory crepitations. However, His
chest x-ray shows a tram track appearance. What is the most likely diagnosis?
a. Sarcoidosis
c. Asthma
d. COPD
Description
Several points in the question point to bronchiectasis as the most likely diagnosis.
e possible presence of recurrent chest infection secondary to HIV, copious amount of purulent
sputum, and tram track appearance on chest x-ray

Page - 2115
Question 125/144
Question #125
infections since childhood. He presents with chronic coughs; his chest CT scan is shown in the
picture below. What is the name of this sign?
a. Tram track appearance

b. Meniscus sign
c. Signet-ring sign
d. Peri-bronchial edema
e. Ground glass appearance
Page - 2116
Question 125/144
Question #125
infections since childhood. He presents with chronic coughs; his chest CT scan is shown in the
picture below. What is the name of this sign?
a. Tram track appearance

b. Meniscus sign
c. Signet-ring sign √
d. Peri-bronchial edema
e. Ground glass appearance
Description
Signet-ring sign on chest CT scan, history of chronic or recurrent chest infection, Cough with foul-
Page - 2117
smelling sputum that changes with body position, and Presence of coarse crepitations are all
indicating bronchiectasis
Bronchiectasis:
Page - 2118
Question 126/144
Question #126
A 20-year-old male patient presents with a dry cough, headache, fatigue, and low-grade fever for
one week. He is in good general condition. His chest x-ray shows bilateral pneumonia without
pleural eusion. Which is the most likely cause of this patient’s condition?
a. H. influenzas type B
b. Streptococcus pneumonia
c. Staphylococci
d. Klebsiella
e. Mycoplasma
Page - 2119
Internal Medicine - Pulmonology - Pneumonia
Question 126/144
Question #126
A 20-year-old male patient presents with a dry cough, headache, fatigue, and low-grade fever for
one week. He is in good general condition. His chest x-ray shows bilateral pneumonia without
pleural eusion. Which is the most likely cause of this patient’s condition?
a. H. influenzas type B
c. Staphylococci
d. Klebsiella
e. Mycoplasma √
Description
is is atypical pneumonia (dry cough and looking well patient). e most common cause of atypical
pneumonia is mycoplasma pneumonia.
Pneumonia:
Pneumonia is defined as an infection of the lung, which can be bacterial, viral, or fungal
Low immunity, reduced protective mechanisms, and low ciliary movement are risk factors for
pneumonia
It is classified into community-acquired (CAP) or Hospital-acquired (HAP)
CAP is further classified into typical and atypical pneumonia.
Causes of pneumonia:
Pneumococcal pneumonia is the most common Typical CAP

Mycoplasma pneumonia is the most common atypical CAP
Staph aureus is the most common cause of HAP
PCP is the most common in HIV and immunosuppressed patients
Legionella is common in air conditioning system workers
Klebsiella pneumonia is common in alcoholics and DM patients
Aerobics are common in those with aspiration or poor dentation
Page - 2120
Question 127/144
Question #127
An alcoholic 49-year-old male presents with shortness of breath, cough, fever, and bloody sputum.
His chest x-ray shows an early cavitary lesion. What is the most common cause of his condition?
a. Pneumococcal pneumonia
b. Legionella pneumonia
c. Mycoplasma pneumonia
d. PCP
e. Klebsiella pneumonia
Page - 2121
Question 127/144
Question #127
An alcoholic 49-year-old male presents with shortness of breath, cough, fever, and bloody sputum.
His chest x-ray shows an early cavitary lesion. What is the most common cause of his condition?
d. PCP
e. Klebsiella pneumonia √
Description
Klebsiella pneumonia is common in alcoholic patients and is a known cause of cavitary lesions on
chest x-ray. e presence of Red-Current jelly will support the diagnosis.
Klebsiella pneumonia:
It is classically in alcoholics and DM patients

Presented with Red-Current jelly sputum (hemoptysis from necrotizing disease)
Present with aspiration pneumonia
A common cause of Lung Abscess and cavitating lesions on chest x-ray
Page - 2122
Question 128/144
Question #128
Which of the following CD4 count are the HIV patients at increased risk of pneumocystis carinii
pneumonia (PCP)?
a. Above 500 cells/mm

b. 200 – 500 cells/mm
c. 100 – 200 cells/mm
d. 50 – 100 cells/mm
e. Less than 50 cells/mm
Page - 2123
Question 128/144
Question #128
Which of the following CD4 count are the HIV patients at increased risk of pneumocystis carinii
pneumonia (PCP)?
a. Above 500 cells/mm

b. 200 – 500 cells/mm
c. 100 – 200 cells/mm √
d. 50 – 100 cells/mm
e. Less than 50 cells/mm
Description
PCP is the most common type of pneumonia that occurs in HIV patients.
Pneumocystis Carinii Pneumonia (PCP):
It is caused by yeast-like fungus pneumocystis jiroveci

Usually seen in patients with cancer, chemotherapy, HIV, and drug abusers
It is the most common cause of pneumonia in HIV patients (with CD4 of 100 – 200/mm3)
Pneumothorax is a common complication
e following table demonstrates the most common diseases aecting the HIV
Patients and the CD4 count at which the diseases most commonly occur:
Page - 2124
Page - 2125
Question 129/144
Question #129
A 48-year-old male patient presents with a fever of 39.2 °C, rigors, chills, and cough productive of
yellow sputum. He is previously healthy and never experienced a similar condition before. Chest x-
ray shows le lower lobe consolidation. e most likely cause of his pneumonia is:
a. Staphylococcus aureus
b. Klebsiella
c. Streptococcus pneumonia
d. Legionella pneumonia
Page - 2126
Question 129/144
Question #129
A 48-year-old male patient presents with a fever of 39.2 °C, rigors, chills, and cough productive of
yellow sputum. He is previously healthy and never experienced a similar condition before. Chest x-
ray shows le lower lobe consolidation. e most likely cause of his pneumonia is:
b. Klebsiella
c. Streptococcus pneumonia √
d. Legionella pneumonia
Description
is is typical pneumonia; the most common cause of typical pneumonia is streptococcus
pneumonia.
Pneumonia:
pneumonia

Page - 2127
Question 130/144
Question #130
A 24-year-old female presents with 2 days history of fever, shortness of breath, cough, and sputum.
Chest x-ray reveals pneumonia. 2 months ago, she was treated for sinusitis with amoxicillin. Which
of the following is the best choice for antibiotic treatment?
a. Amoxicillin
b. Azithromycin
c. Ceriaxone
d. Levofloxacin
e. Ciprofloxacin
Page - 2128
Question 130/144
Question #130
A 24-year-old female presents with 2 days history of fever, shortness of breath, cough, and sputum.
Chest x-ray reveals pneumonia. 2 months ago, she was treated for sinusitis with amoxicillin. Which
of the following is the best choice for antibiotic treatment?
a. Amoxicillin
b. Azithromycin
c. Ceriaxone
d. Levofloxacin √
e. Ciprofloxacin
Description
Because the patient was using antibiotics in the last 3 months, respiratory fluoroquinolones are
indicated.
If the patient wasn’t using antibiotics in the last 3 months, macrolides are the first-line treatment.
e choice of antibiotic in typical pneumonia treatment:
Outpatient cases:
If previously healthy with no antibiotic use in the past 3 months, use macrolides
(azithromycin or clarithromycin) or Doxycycline
If there are comorbidities or use of antibiotics in the past 3 months, use respiratory
fluoroquinolones (Levofloxacin or Moxifloxacin)
Inpatient cases:
Respiratory fluoroquinolone (Levofloxacin or Moxifloxacin) or
Ceriaxone with Azithromycin
Page - 2129
Question 131/144
Question #131
A 15-year-old patient was injured during a road trac accident; he had a resection of his lacerated
spleen at that time. Today aer 1 year, he presents with pneumonia. Which of the following is the
most likely cause of pneumonia?
c. E. coli
d. Klebsiella pneumonia
e. Neisseria meningitidis
Page - 2130
Question 131/144
Question #131
A 15-year-old patient was injured during a road trac accident; he had a resection of his lacerated
spleen at that time. Today aer 1 year, he presents with pneumonia. Which of the following is the
most likely cause of pneumonia?
b. Streptococcus pneumonia √
c. E. coli
d. Klebsiella pneumonia
e. Neisseria meningitidis
Description
Streptococcus pneumonia is the most important pathogen in asplenic patients
Pneumonia:
pneumonia

Page - 2131
Question 132/144
Question #132
A 29-year-old male patient presents with coughs and shortness of breath and is diagnosed with
pneumonia. On physical examination, you find a rash of Kaposi’s sarcoma. What is the most likely
cause of his pneumonia?
a. Streptococcal pneumonia
b. Staphylococcus aureus
c. Pneumocystis carinii
d. Mycobacterium avium intercellulare
Page - 2132
Question 132/144
Question #132
A 29-year-old male patient presents with coughs and shortness of breath and is diagnosed with
pneumonia. On physical examination, you find a rash of Kaposi’s sarcoma. What is the most likely
cause of his pneumonia?
a. Streptococcal pneumonia
c. Pneumocystis carinii √
d. Mycobacterium avium intercellulare
Description
Kaposi’s sarcoma is usually found in Immunocompromised patients (e.g., AIDS); the most common
pneumonia in HIV patients is PCP.
Pneumonia:
pneumonia

Page - 2133
Question 133/144
Question #133
A 58-year-old male patient with a known COPD case presents with shortness of breath and cough
and an increasing amount of purulent sputum for 4 days. Chest examination is consistent with
crackles, dullness to percussion, and bronchial breathing. His temperature is 38.1 °C, BP is 130/80,
and pulse is 82 bpm. You diagnosed him with community-acquired pneumonia. What is the true
statement about this condition?
a. Amoxicillin is the preferred agent

b. A chest x-ray is indicated
c. A sputum sample is the most accurate test
d. Supportive treatment is only indicated
e. Wait until culture results are available before starting antibiotics
Page - 2134
Question 133/144
Question #133
A 58-year-old male patient with a known COPD case presents with shortness of breath and cough
and an increasing amount of purulent sputum for 4 days. Chest examination is consistent with
crackles, dullness to percussion, and bronchial breathing. His temperature is 38.1 °C, BP is 130/80,
and pulse is 82 bpm. You diagnosed him with community-acquired pneumonia. What is the true
statement about this condition?
a. Amoxicillin is the preferred agent

b. A chest x-ray is indicated √
c. A sputum sample is the most accurate test
d. Supportive treatment is only indicated
e. Wait until culture results are available before starting antibiotics
Description
A chest x-ray is the best initial test; the patient is suspected of having pneumonia complicated by
pleural eusion. Treatment should include bronchodilators, steroids, antibiotics, and supportive
care.
Pneumonia:
pneumonia

Page - 2135
Page - 2136
Question 134/144
Question #134
A 22-year-old previously healthy male presents with low-grade fever, dry cough, and bilateral basal
infiltration on a chest x-ray. He is clinically well. You suspect mycoplasma pneumonia. What is the
a. Amoxicillin
b. Azithromycin
c. Ceriaxone
d. Vancomycin
e. Paracetamol
Page - 2137
Question 134/144
Question #134
A 22-year-old previously healthy male presents with low-grade fever, dry cough, and bilateral basal
infiltration on a chest x-ray. He is clinically well. You suspect mycoplasma pneumonia. What is the
a. Amoxicillin
b. Azithromycin √
c. Ceriaxone
d. Vancomycin
e. Paracetamol
Description
Macrolides are the drugs of choice to treat mycoplasma pneumonia. Mycoplasma doesn’t have a cell
wall, so it will not be aected by antibiotics that inhibit cell wall synthesis.
Pneumonia:
pneumonia

Page - 2138
Question 135/144
Question #135
A 22-year-old male presents with community-acquired pneumonia. He is conscious-oriented and

alert and doesn’t use any medication. His temperature is 39.9 °C, his blood pressure is 91/62, and his
respiratory rate is 23 per minute. His lab investigations show hemoglobin of 14 g/dL, WBC of 25,000,
and normal kidney and liver function tests. Which of the following is the best action to take?
a. Discharge home on azithromycin and follow up aer 24 hours

b. Discharge home on Levofloxacin and follow up aer 24 hours
c. Admission to the hospital and start intravenous ceriaxone
d. Admission to the ICU and start intravenous antibiotics
e. Discharge home on paracetamol without antibiotics
Page - 2139
Question 135/144
Question #135
A 22-year-old male presents with community-acquired pneumonia. He is conscious-oriented and

alert and doesn’t use any medication. His temperature is 39.9 °C, his blood pressure is 91/62, and his
respiratory rate is 23 per minute. His lab investigations show hemoglobin of 14 g/dL, WBC of 25,000,
and normal kidney and liver function tests. Which of the following is the best action to take?
a. Discharge home on azithromycin and follow up aer 24 hours √

b. Discharge home on Levofloxacin and follow up aer 24 hours
c. Admission to the hospital and start intravenous ceriaxone
d. Admission to the ICU and start intravenous antibiotics
e. Discharge home on paracetamol without antibiotics
Description
According to the CURB 65 score, this patient is not indicated to be admitted to the hospital.
Because the patient wasn’t using antibiotics in the last 3 months, macrolides are the first-line
treatment
Respiratory fluoroquinolones are indicated if the patient was using antibiotics in the last 3 months.
e choice of antibiotic in typical pneumonia treatment:
Outpatient cases:
If previously healthy with no antibiotic use in the past 3 months, use macrolides
(azithromycin or clarithromycin) or Doxycycline
If there are comorbidities or use of antibiotics in the past 3 months, use respiratory
fluoroquinolones (Levofloxacin or Moxifloxacin)
Inpatient cases:
Respiratory fluoroquinolone (Levofloxacin or Moxifloxacin) or
Ceriaxone with Azithromycin
e following table shows the CURB65 criteria for pneumonia:
Page - 2140
Page - 2141
Question 136/144
Question #136
Aer returning from a holiday, a 48-year-old patient developed shortness of breath, diarrhea, cough,
and chest pain. His chest x-ray shows bilateral infiltration, and his labs show serum sodium of 125
mEq/L, Potassium of 3.2 mEq/L, but otherwise normal. What is the most likely diagnosis?
d. PCP
e. E. coli infection
Page - 2142
Question 136/144
Question #136
Aer returning from a holiday, a 48-year-old patient developed shortness of breath, diarrhea, cough,
and chest pain. His chest x-ray shows bilateral infiltration, and his labs show serum sodium of 125
mEq/L, Potassium of 3.2 mEq/L, but otherwise normal. What is the most likely diagnosis?
b. Legionella pneumonia √
d. PCP
e. E. coli infection
Description
Diarrhea, hyponatremia, and a history of travel suggest legionella infection.
Legionella pneumonia:
Commonly in air-conditioning systems, workers

Associated with:
GI symptoms (abdominal pain and diarrhea)
CNS symptoms (e.g., headache and confusion)
Hyponatremia
Lymphopenia is a feature
Diagnosis by Urine antigen test
Treatment: Macrolides (e.g., Erythromycin)
Page - 2143
Question 137/144
Question #137
A 30-year-old man presents with shortness of breath, cough, and pleuritic chest pain for a 1-week
duration. Physical examination reveals a temperature of 38.4 °C, generalized lymphadenopathy,
bibasilar rales, and multiple perianal contusions suggestive of homosexuality. Which of the
following is the best action at this time?
a. Admission and administration of TMP/SMX intravenously

b. Admission and starting Intravenous ceriaxone
c. Start Anti-TB treatment
d. Erythromycin orally and follow up in 24 hours
e. Start acetaminophen and bed rest at home
Page - 2144
Question 137/144
Question #137
A 30-year-old man presents with shortness of breath, cough, and pleuritic chest pain for a 1-week
duration. Physical examination reveals a temperature of 38.4 °C, generalized lymphadenopathy,
bibasilar rales, and multiple perianal contusions suggestive of homosexuality. Which of the
following is the best action at this time?
a. Admission and administration of TMP/SMX intravenously √

b. Admission and starting Intravenous ceriaxone
c. Start Anti-TB treatment
d. Erythromycin orally and follow up in 24 hours
e. Start acetaminophen and bed rest at home
Description
e perianal contusions are suggestive of homosexuality and will raise the suspicion of HIV
infection. e most common cause of Pneumonia in HIV patients is PCP which is treated with
TMP/SMX
Pneumonia:
pneumonia

Page - 2145
Page - 2146
Question 138/144
Question #138
A 28-year-old healthy male presents with a fever of 38.9˚C, dry cough and shortness of breath,
bronchial breathing, and crepitations that are auscultated in the middle lung zone. What is the best
next step for this patient?
a. Start empiric antibiotic treatment

b. Give antibiotics only if the chest x-ray is abnormal
c. Give antibiotics if cultures are positive
d. Supportive treatment only
e. Give bronchodilators and antibiotics if PFT is abnormal
Page - 2147
Question 138/144
Question #138
A 28-year-old healthy male presents with a fever of 38.9˚C, dry cough and shortness of breath,
bronchial breathing, and crepitations that are auscultated in the middle lung zone. What is the best
next step for this patient?
a. Start empiric antibiotic treatment √

b. Give antibiotics only if the chest x-ray is abnormal
c. Give antibiotics if cultures are positive
d. Supportive treatment only
e. Give bronchodilators and antibiotics if PFT is abnormal
Description
is is a case of atypical bacterial pneumonia. Antibiotics (macrolides are the first line) are indicated
regardless of the chest x-ray. e chest x-ray may be normal in the early stages.
Pneumonia:
pneumonia

Page - 2148
Question 139/144
Question #139
An obese 52-yar-old male presents with excessive daytime sleepiness, choking, and snoring at night.
His vital signs are normal except for stage 1 HTN. Which of the following is the first-line treatment
for his condition?
a. Weight loss
b. CPAP
c. BiPAP
d. Uvulopalatopharyngoplasty
e. Long-term Oxygen therapy (LTOT)
Page - 2149
Internal Medicine - Pulmonology - Sleep apnea syndrome
Question 139/144
Question #139
An obese 52-yar-old male presents with excessive daytime sleepiness, choking, and snoring at night.
His vital signs are normal except for stage 1 HTN. Which of the following is the first-line treatment
for his condition?
a. Weight loss
b. CPAP √
c. BiPAP
d. Uvulopalatopharyngoplasty
e. Long-term Oxygen therapy (LTOT)
Description
is patient’s most likely diagnosis is Obstructive sleep apnea.
e first-line treatment for his condition is CPAP.
Sleep apnea syndrome:
It is defined as a repetitive period of apnea during sleep leading to distorted sleeping, snoring,
daytime sleepiness, and hypertension
A period of more than 10 seconds without breathing is considered an apneic episode
Obesity is the most common cause of obstructive sleep apnea
e clinical features include Daytime somnolence, headache, impaired memory, and Loud
snoring (usually noted by a sleep partner).
Polysomnography (Sleep study) is the most accurate test: a pulse oximeter, EEG, airflow, and
thoracoabdominal movements may be monitored during sleep.
C-PAP (continuous positive airway pressure) is the first line treatment of obstructive sleep
apnea
Page - 2150
Question 140/144
Question #140
A 59-year-old male patient was diagnosed with obstructive sleep apnea (OSA). Which of the
following is most commonly expected to manifest in this disease?
a. Snoring
b. Headache
c. Esophageal reflux
d. Daytime fatigue and sleepiness
e. Choking
Page - 2151
Question 140/144
Question #140
A 59-year-old male patient was diagnosed with obstructive sleep apnea (OSA). Which of the
following is most commonly expected to manifest in this disease?
a. Snoring
b. Headache
c. Esophageal reflux
d. Daytime fatigue and sleepiness √
e. Choking
Description
e most common presenting symptom of obstructive sleep apnea is excessive daytime sleepiness.
apnea
Page - 2152
Question 141/144
Question #141
A 45-year-old male presents with general fatigue and poor concentration for the last year, his wife
state that he snores loudly, and at times he looks like he is choking and stops breathing during sleep.
Which of the following is associated with this patient’s condition?
a. Carpel tunnel syndrome

b. COPD
c. Hypercalcemia
d. Hypertension
e. Vitiligo
Page - 2153
Question 141/144
Question #141
Which of the following is associated with this patient’s condition?
a. Carpel tunnel syndrome

b. COPD
c. Hypercalcemia
d. Hypertension √
e. Vitiligo
Description
Obstructive sleep apnea is associated with HTN and may be caused by HTN. Many patients with OSA
improve when their blood pressure is controlled.
apnea
Page - 2154
Question 142/144
Question #142
A 54-year-old male patient is treated with CPAP for obstructive sleep apnea. What is the major
problem encountered in the use of CPAP?
a. Recurrent coughing
b. Excessive daytime sleeping
c. Recurrent sneezing
d. Non-compliance
e. Dry mucous membranes
Page - 2155
Question 142/144
Question #142
A 54-year-old male patient is treated with CPAP for obstructive sleep apnea. What is the major
problem encountered in the use of CPAP?
a. Recurrent coughing
b. Excessive daytime sleeping
c. Recurrent sneezing
d. Non-compliance √
e. Dry mucous membranes
Description
Sneezing, rhinorrhea, and dry mucous membranes are common results of CPAP, but non-compliance
is the major problem in its use.
e patients usually complain of discomfort, claustrophobia, panic attacks, and noise from the
machine.
apnea
Page - 2156
Question 143/144
Question #143
What is the diagnostic procedure of choice for his condition?
a. Chest x-ray
b. Chest CT scan
c. Pulmonary function test
d. Polysomnography
e. Bronchoscopy
Page - 2157
Question 143/144
Question #143
What is the diagnostic procedure of choice for his condition?
a. Chest x-ray
b. Chest CT scan
c. Pulmonary function test
d. Polysomnography √
e. Bronchoscopy
Description
is patient’s most likely diagnosis is Obstructive sleep apnea.
Polysomnography is the diagnostic test of choice for OSA.
apnea
Page - 2158
Question 144/144
Question #144
What is the most eective treatment for OSA in a 50-year-old patient?
a. Sildenafil (Viagra)
b. CPAP
c. Weight reduction
d. Bronchodilators
e. Inhaled steroid
Page - 2159
Question 144/144
Question #144
What is the most eective treatment for OSA in a 50-year-old patient?
a. Sildenafil (Viagra)
b. CPAP √
c. Weight reduction
d. Bronchodilators
e. Inhaled steroid
Description
e first-line and the most eective treatment for his condition is CPAP
apnea
Page - 2160
Rheumatology
Page - 2161
Rheumatology
1) Behçet’s Syndrome => 2 Questions

2) Dermatomyositis => 3 Questions
3) Fibromyalgia => 3 Questions
4) Giant cell arteritis (temporal arteritis) => 6 Questions
5) Gout (podagra) => 9 Questions
6) Infective arthritis => 6 Questions
7) Polymyalgia Rheumatica (PMR) => 4 Questions
8) Polymyositis => 2 Questions
9) Pseudogout => 4 Questions
10) Rheumatoid Arthritis (RA) => 10 Questions
11) Sjögren's syndrome => 5 Questions
12) Spondyloarthropathies => 6 Questions
13) Systemic Lupus Erythematosus (SLE) => 9 Questions
14) Systemic sclerosis (SS) => 2 Questions
Page - 2162
Internal Medicine - Rheumatology
Question 1/71
Question #1
A 30-year-old female patient presents with painful ulcers in her mouth and vagina. She denies
sexual activity, and her Tzanck test is negative for herpes simplex virus. You performed a blood
laboratory workup and asked her to visit you again within 48 hours. However, she came to you on
the second visit with a new pustule at the venipuncture site. What is the most likely diagnosis?
a. Reactive arthritis
b. Syphilis infection
c. Behçet’s syndrome
d. HIV infection
e. Kawasaki’s disease
Page - 2163
Internal Medicine - Rheumatology - Behçet’s Syndrome
Question 1/71
Question #1
A 30-year-old female patient presents with painful ulcers in her mouth and vagina. She denies
sexual activity, and her Tzanck test is negative for herpes simplex virus. You performed a blood
laboratory workup and asked her to visit you again within 48 hours. However, she came to you on
the second visit with a new pustule at the venipuncture site. What is the most likely diagnosis?
a. Reactive arthritis
b. Syphilis infection
c. Behçet’s syndrome √
d. HIV infection
e. Kawasaki’s disease
Description
Oral ulcers, genital ulcers, and the positive pathergy test strongly suggest the disease.
Behçet’s syndrome is a vasculitis of an unknown cause that involves venules. It is associated with
HLA B5
e clinical features of Behçet’s syndrome may include:
Oral ulcers, Genital ulcers, inflammatory arthritis

Skin: Erythema nodosum, acne
Eye: Anterior uveitis, retinal Vasculitis, iritis
Neurological: aseptic meningitis
Superior vena cava obstruction may occur (venous involvement)
Positive pathergy test is suggestive (puncture site following needle prick becomes inflamed with
small pustule forming)
Page - 2164
Question 2/71
Question #2
e following signs and symptoms are associated with Behçet’s syndrome except:
a. Mouth ulcers
b. Genital ulcers
c. Positive pathergy test
d. Erythema nodosum
e. Viral meningitis
Page - 2165
Internal Medicine - Rheumatology - Behçet’s Syndrome
Question 2/71
Question #2
e following signs and symptoms are associated with Behçet’s syndrome except:
a. Mouth ulcers
b. Genital ulcers
c. Positive pathergy test
d. Erythema nodosum
e. Viral meningitis √
Description
Aseptic meningitis is the manifestation here, not viral meningitis.
Behçet’s syndrome is a vasculitis of an unknown cause that involves venules. It is associated with
HLA B5
e clinical features of Behçet’s syndrome may include:
Oral ulcers, Genital ulcers, inflammatory arthritis

Skin: Erythema nodosum, acne
Eye: Anterior uveitis, retinal Vasculitis, iritis
Neurological: aseptic meningitis
Superior vena cava obstruction may occur (venous involvement)
Positive pathergy test is suggestive (puncture site following needle prick becomes inflamed with
small pustule forming)
Page - 2166
Question 3/71
Question #3
A 22-year-old female presents with muscle weakness. Physical examination demonstrates the
finding shown in the picture below. What is the most likely diagnosis?
a. Scleroderma
b. Dermatomyositis
c. Polymyalgia rheumatica
d. Fibromyalgia
e. Fungal infection
Page - 2167
‫‪Page - 2168‬‬
Internal Medicine - Rheumatology - Dermatomyositis
Question 3/71
Question #3
A 22-year-old female presents with muscle weakness. Physical examination demonstrates the
finding shown in the picture below. What is the most likely diagnosis?
a. Scleroderma
b. Dermatomyositis √
c. Polymyalgia rheumatica
d. Fibromyalgia
e. Fungal infection
Page - 2169
Description
is picture shows Gottron’s papule. e presence of this skin finding and muscle weakness is typical
for dermatomyositis.
Dermatomyositis is an inflammatory disorder causing symmetrical, proximal muscle weakness and

characteristic skin lesions.
Clinical findings include:
Symmetrical proximal muscle weakness

Photosensitivity (Malar involvement)
Photo distributed poikiloderma:
Shawl sign: erythema of the back and shoulders
V sign: neck and back or the neck and upper chest
Holser sign: along the lateral thigh
Heliotrope rash: edematous and purplish eyelids
Mechanic’s hand: palmer fishering and hyperkeratosis
Gottron’s papules: scaly patches at PIP and MCP joints
Lab investigations will show high CPK, positive ANA (60%), and positive Anti-Mi-2 (25%). Muscle
biopsy is the most accurate test.
Page - 2170
Question 4/71
Question #4
Which of the following is mostly associated with dermatomyositis?
a. Anti-Ro
b. Anti-La
c. Anti-Mi-2
d. Anti-Jo-1
e. Anti-sm
Page - 2171
Question 4/71
Question #4
Which of the following is mostly associated with dermatomyositis?
a. Anti-Ro
b. Anti-La
c. Anti-Mi-2 √
d. Anti-Jo-1
e. Anti-sm
Description
e anti-Mi-2 antibody is the most specific for dermatomyositis


Lab investigations will show high CPK, positive ANA (60%), and positive Anti-Mi-2 (25%)
Muscle biopsy is the most accurate test.
Page - 2172
Question 5/71
Question #5
A 55-year-old male patient presents with muscle weakness. On physical examination, you found an
erythematous scaly rash on his knuckles and an edematous right upper eyelid. In addition, his
creatine phosphokinase is elevated. What is the most likely diagnosis?
a. Psoriasis
b. Dermatomyositis
c. Polymyositis
d. Fibromyalgia
e. Atopic dermatitis
Page - 2173
Question 5/71
Question #5
A 55-year-old male patient presents with muscle weakness. On physical examination, you found an
erythematous scaly rash on his knuckles and an edematous right upper eyelid. In addition, his
creatine phosphokinase is elevated. What is the most likely diagnosis?
a. Psoriasis
b. Dermatomyositis √
c. Polymyositis
d. Fibromyalgia
e. Atopic dermatitis
Description
Gottron’s papules, Heliotrope rash, high CPK, and muscle weakness strongly suggest the diagnosis
of dermatomyositis.


Lab investigations will show high CPK, positive ANA (60%), and positive Anti-Mi-2 (25%)
Muscle biopsy is the most accurate test.
Page - 2174
Question 6/71
Question #6
A 29-year-old female presents with generalized pain and is suspected of having fibromyalgia. Which
of the following is associated with this condition?
a. Elevated ESR and CRP

b. Positive muscle biopsy
c. Sleep disturbances
d. Convulsions
e. Anemia
Page - 2175
Internal Medicine - Rheumatology - Fibromyalgia
Question 6/71
Question #6
A 29-year-old female presents with generalized pain and is suspected of having fibromyalgia. Which
of the following is associated with this condition?
a. Elevated ESR and CRP

b. Positive muscle biopsy
c. Sleep disturbances √
d. Convulsions
e. Anemia
Description
Fibromyalgia is a disease of unknown cause characterized by chronic generalized pain and

tenderness in multiple sites of the body, stiness, and sleeping disorders.
Fibromyalgia usually aects females (the females-to-males ratio is 9:1)
Treatment of this condition is achieved by the following:
Aerobic exercise (the best for functional improvement)

Cognitive therapy
Medications:
Anticonvulsant (Pregabalin)
Dual serotonin-norepinephrine reuptake inhibitor (Duloxetine, Milnacipran)
SSRI and TCA may be used
Page - 2176
Question 7/71
Question #7
A 25-year-old female patient has complained of fatigue, shoulder and back pain, and insomnia for
several months. Physical examination is unremarkable except for tenderness over the costochondral
junctions, the medial aspect of the knee joint, and the trapezius muscle. Lab investigations,
including CBC, ESR, and CRP, are unremarkable. What is the most likely diagnosis?
a. Dermatomyositis
b. Polymyositis
c. Fibromyalgia
d. Polymyalgia rheumatica
e. Duchenne muscular dystrophy
Page - 2177
Question 7/71
Question #7
A 25-year-old female patient has complained of fatigue, shoulder and back pain, and insomnia for
several months. Physical examination is unremarkable except for tenderness over the costochondral
junctions, the medial aspect of the knee joint, and the trapezius muscle. Lab investigations,
including CBC, ESR, and CRP, are unremarkable. What is the most likely diagnosis?
a. Dermatomyositis
b. Polymyositis
c. Fibromyalgia √
d. Polymyalgia rheumatica
e. Duchenne muscular dystrophy
Description


Cognitive therapy
Medications:
Page - 2178
Question 8/71
Question #8
A 28-year-old female presents with 6 months history of neck, back, and shoulder pains associated
with fatigue and insomnia. Her physical examination shows ten dierent tender points in her body
but otherwise normal. Her lab investigations are unremarkable. What is the most appropriate
treatment for this patient’s condition?
a. NSAIDs
b. Opioids
c. Steroids
d. Cognitive therapy
e. Massage therapy
Page - 2179
Question 8/71
Question #8
A 28-year-old female presents with 6 months history of neck, back, and shoulder pains associated
with fatigue and insomnia. Her physical examination shows ten dierent tender points in her body
but otherwise normal. Her lab investigations are unremarkable. What is the most appropriate
treatment for this patient’s condition?
a. NSAIDs
b. Opioids
c. Steroids
d. Cognitive therapy √
e. Massage therapy
Description
Cognitive therapy is the most eective in the treatment of fibromyalgia.


Cognitive therapy
Medications:
Page - 2180
Question 9/71
Question #9
A 69-year-old female patient complains of shoulder stiness and pain and le-sided facial pain
aggravated by mastication. In addition, the show recently complained of weight loss, fever, and
fatigue. Her lab investigations show CPK of 80 mcg/L and ESR of 120 mm/h. Which one of the
following is the greatest immediate risk for this patient?
a. Hemiparesis
b. Convulsions
c. Unilateral loss of vision
d. Pulmonary embolism
e. Sudden death
Page - 2181
Internal Medicine - Rheumatology - Giant cell arteritis (temporal arteritis)
Question 9/71
Question #9
A 69-year-old female patient complains of shoulder stiness and pain and le-sided facial pain
aggravated by mastication. In addition, the show recently complained of weight loss, fever, and
fatigue. Her lab investigations show CPK of 80 mcg/L and ESR of 120 mm/h. Which one of the
following is the greatest immediate risk for this patient?
a. Hemiparesis
b. Convulsions
c. Unilateral loss of vision √
d. Pulmonary embolism
e. Sudden death
Description
e patient complains of jaw claudication, shoulder stiness and pain, and markedly elevated ESR.
is is a case of temporal arteritis as a spectrum of polymyalgia rheumatica (PMR).
Patients with temporal arteritis are at considerable risk of vision loss and should receive steroids as
soon as possible.
Polymyalgia Rheumatica (PMR) usually occurs in those over 50 years of age
It may present with systemic features of fever, malaise, and weight loss.
Severe pain and stiness in the shoulder, neck, and pelvic girdle muscles are characteristic.
In PMR, ESR is typically extremely high (as high as 100 mm/h), but CPK is not elevated (no muscle
destruction).
Because temporal arteritis is strongly associated with PMR, temporal artery biopsy is important in
the workup.
Treatment: Steroid (there will be a rapid response even at low dose)
Page - 2182
Question 10/71
Question #10
A 52-year-old female with a severe headache and jaw pain when she chews food. Bilateral shoulder
pain and wrist weakness. Her ESR is 82 mm/h. What is the most likely diagnosis?
a. Rheumatoid Arthritis
b. Temporal Arteritis
c. Polymyositis
d. Sarcoidosis
e. Otitis media
Page - 2183
Question 10/71
Question #10
A 52-year-old female with a severe headache and jaw pain when she chews food. Bilateral shoulder
pain and wrist weakness. Her ESR is 82 mm/h. What is the most likely diagnosis?
a. Rheumatoid Arthritis
b. Temporal Arteritis √
c. Polymyositis
d. Sarcoidosis
e. Otitis media
Description
Headache, jaw claudication, and high ESR point toward Temporal arteritis, shoulder pain, and
muscle weakness are due to Simultaneous polymyalgia rheumatica
Page - 2184
Question 11/71
Question #11
A 70-year-old woman could not brush her teeth because of arm pain and weakness. e pain is
improved with NSAIDs, and physical examination shows le-side tenderness at the scalp. Which of
the following is the most appropriate next step?
a. Increase the dose of the NSAIDs

b. Order ESR level
c. Check for RA antibody
d. Cervical spine x-ray
e. Refer her for psychiatric counseling
Page - 2185
Question 11/71
Question #11
A 70-year-old woman could not brush her teeth because of arm pain and weakness. e pain is
improved with NSAIDs, and physical examination shows le-side tenderness at the scalp. Which of
the following is the most appropriate next step?
a. Increase the dose of the NSAIDs

b. Order ESR level √
c. Check for RA antibody
d. Cervical spine x-ray
e. Refer her for psychiatric counseling
Description
Temporal arteritis is suspected, high ESR level is sensitive to temporal arteritis
Temporal artery biopsy is the most accurate test
Page - 2186
Question 12/71
Question #12
A 50-year-old female recently became unable to comb her hair due to severe shoulder pain and
stiness. She presents to you with severe unilateral headache and facial pain. On examination,
severe pain was elicited by touching her temporal area. Her labs show an ESR level of 115 mm/h.
a. Temporal artery biopsy

b. Administrate high-dose steroids
c. Administrate intravenous opiate
d. Give paracetamol
e. Order brain MRI
Page - 2187
Question 12/71
Question #12
A 50-year-old female recently became unable to comb her hair due to severe shoulder pain and
stiness. She presents to you with severe unilateral headache and facial pain. On examination,
severe pain was elicited by touching her temporal area. Her labs show an ESR level of 115 mm/h.
a. Temporal artery biopsy

b. Administrate high-dose steroids √
c. Administrate intravenous opiate
d. Give paracetamol
e. Order brain MRI
Description
Although temporal artery biopsy is the most accurate test, steroids should not be delayed, and they
are the most appropriate next step.
Prednisolone should be started when you suspect temporal arteritis if ESR is elevated. However, do
not wait till you get a temporal artery biopsy.
Giant cell arteritis (temporal arteritis) is a disease that is on a spectrum of PMR.
It is characterized by severe headache, scalp tenderness, and jaw claudication
is condition may present with sudden painless vision loss (permanent or temporary)
Investigations will show an extremely high ESR and high CRP. However, the most accurate test is
temporal artery biopsy.
Temporal artery biopsy will be false negative aer 36 hours of steroid therapy. However, high-dose
steroids should not be delayed waiting for a biopsy.
Page - 2188
Question 13/71
Question #13
A 60-year-old male patient complains of headache, blurry vision, and jaw pain associated with
chewing. What is the most accurate investigation?
a. ESR
b. Brain CT scan
c. Fundoscopic examination
d. Visual evoked potential
e. Temporal artery biopsy
Page - 2189
Question 13/71
Question #13
A 60-year-old male patient complains of headache, blurry vision, and jaw pain associated with
chewing. What is the most accurate investigation?
a. ESR
b. Brain CT scan
c. Fundoscopic examination
d. Visual evoked potential
e. Temporal artery biopsy √
Description
Giant cell arteritis (temporal arteritis) is a disease that is on a spectrum of PMR.
It is characterized by severe headache, scalp tenderness, and jaw claudication
is condition may present with sudden painless vision loss (permanent or temporary)
Investigations will show an extremely high ESR and high CRP. However, the most accurate test is
temporal artery biopsy.
Temporal artery biopsy will be false negative aer 36 hours of steroid therapy. However, high-dose
steroids should not be delayed waiting for a biopsy.
Page - 2190
Question 14/71
Question #14
A 59-year-old female patient presented with headaches, and a tender cordlike structure is palpable
just anterior to her ear and extending up to her lateral scalp. Her labs show an ESR of 102mm/h.
Which one of the following would be most appropriate at this point?
a. Clopidogrel
b. High-dose corticosteroids
c. NSAIDs
d. Aspirin
e. Paracetamol
Page - 2191
Question 14/71
Question #14
A 59-year-old female patient presented with headaches, and a tender cordlike structure is palpable
just anterior to her ear and extending up to her lateral scalp. Her labs show an ESR of 102mm/h.
Which one of the following would be most appropriate at this point?
a. Clopidogrel
b. High-dose corticosteroids √
c. NSAIDs
d. Aspirin
e. Paracetamol
Description
is is a typical scenario of temporal arteritis.
High-dose steroids are indicated in temporal arteritis to prevent vision loss.
Page - 2192
Question 15/71
Question #15
Aer a night of binge alcohol drinking, a 40-year-old male patient presented with sudden, painful
swelling of the big toe associated with hotness and tenderness. Joint aspiration reveals
monosodium Urate crystals (needle shape). What is the most likely diagnosis?
a. Septic arthritis
b. Rheumatoid arthritis
c. Gout
d. Pseudogout
e. Osteoarthritis
Page - 2193
Internal Medicine - Rheumatology - Gout (podagra)
Question 15/71
Question #15
Aer a night of binge alcohol drinking, a 40-year-old male patient presented with sudden, painful
swelling of the big toe associated with hotness and tenderness. Joint aspiration reveals
monosodium Urate crystals (needle shape). What is the most likely diagnosis?
a. Septic arthritis
c. Gout √
d. Pseudogout
e. Osteoarthritis
Description
Gout is a disease of uric acid metabolism which leads to the accumulation of sodium Urate crystals
in (Joints, So tissues, and urinary tract stones)
e presence of negative birefringent needle-shaped sodium urate crystals in the joint aspiration is
the most accurate test to confirm the disease.
Page - 2194
Question 16/71
Question #16
A 66-year-old male patient develops sudden onset pain, redness, and swelling of his right knee joint.
His medical history is significant for heart failure, for which he has received treatment for the past 2
years. What is the most appropriate method for confirming the diagnosis of his painful knee?
a. Joint aspiration for microscopy

b. Joint aspiration for culture and sensitivity
c. Serum urate level
d. ESR and CRP
e. Knee x-ray
Page - 2195
Question 16/71
Question #16
His medical history is significant for heart failure, for which he has received treatment for the past 2
years. What is the most appropriate method for confirming the diagnosis of his painful knee?
a. Joint aspiration for microscopy √

b. Joint aspiration for culture and sensitivity
c. Serum urate level
d. ESR and CRP
e. Knee x-ray
Description
e presence of heart failure for which the patient should receive furosemide) will raise the
suspicion of acute gouty arthritis due to the side eect of loop diuretics.
Joint aspiration is the best diagnostic test; it will show urate crystals under the microscope.
Synovial fluid culture is better when suspected infective arthritis
Serum uric acid level is not always elevated in acute gouty arthritis
Despite high sensitivity, ESR and CRP are not specific for gouty arthritis
Page - 2196
Question 17/71
Question #17
A 39-year-old alcoholic male patient develops right first toe pain and swelling for 5 days. On
examination, hotness, redness, and tenderness are present. What is the most appropriate
investigation at this time?
a. Joint x-ray
b. Joint aspiration
c. ESR and CRP
d. Kidney function test
e. Joint CT scan
Page - 2197
Question 17/71
Question #17
examination, hotness, redness, and tenderness are present. What is the most appropriate
investigation at this time?
a. Joint x-ray
b. Joint aspiration √
c. ESR and CRP
d. Kidney function test
e. Joint CT scan
Description
is patient has gout.
Page - 2198
Question 18/71
Question #18
His medical history is significant for heart failure, HTN, DM, and dyslipidemia, for which he has
received treatment for the past 2 years. You performed joint aspiration and found urate crystals.
Which of the following is the most likely cause of his acute gouty arthritis?
a. Simvastatin
b. Metformin
c. Aspirin
d. Furosemide
e. Losartan
Page - 2199
Question 18/71
Question #18
His medical history is significant for heart failure, HTN, DM, and dyslipidemia, for which he has
received treatment for the past 2 years. You performed joint aspiration and found urate crystals.
Which of the following is the most likely cause of his acute gouty arthritis?
a. Simvastatin
b. Metformin
c. Aspirin
d. Furosemide √
e. Losartan
Description
Furosemide may raise uric acid levels and precipitate gout
Among the mentioned medications, it is the most likely cause of this patient’s condition.
Page - 2200
Question 19/71
Question #19
A 72-year-old male patient with a history of HTN, DM, and gout presents to you for follow-up and
evaluation. Which medication is the most appropriate to use in his scenario?
a. Enalapril
b. Losartan
c. Valsartan
d. Amlodipine
Page - 2201
Question 19/71
Question #19
A 72-year-old male patient with a history of HTN, DM, and gout presents to you for follow-up and
evaluation. Which medication is the most appropriate to use in his scenario?
a. Enalapril
b. Losartan √
c. Valsartan
d. Amlodipine
Description
ACE inhibitors or ARBs are the most appropriate antihypertensive medication in the presence of DM.
Among ARBs, Losartan is the first-line treatment of HTN in patients with gout.
Losartan will be beneficial as a nephroprotective agent and control HTN without exacerbating gout.
iazide diuretics will increase uric acid and worsen Gout symptoms.
Page - 2202
Question 20/71
Question #20
A 41-year-old male patient presents with le metatarsophalangeal joint pain and tenderness. e x-
ray is shown below. What is the most appropriate treatment?
a. Allopurinol
b. Febuxostat
c. Colchicine
d. Prednisolone
e. Naproxen
Page - 2203
Question 20/71
Question #20
A 41-year-old male patient presents with le metatarsophalangeal joint pain and tenderness. e x-
ray is shown below. What is the most appropriate treatment?
a. Allopurinol
b. Febuxostat
c. Colchicine
d. Prednisolone
e. Naproxen √
Description
e clinical scenario and the imaging are typical for acute gouty arthritis.
e image above shows punched-out erosion.
NSAIDs are the first-line treatment of acute gouty arthritis
In the critical presentation of gout, the treatment is as the following:
NSAIDs (better than colchicine) – the first line

Colchicine (if NSAIDs or steroids cannot be used)
Corticosteroids (if no NSAIDs are ineective or contraindicated)
If the patient is taking allopurinol, do not stop it.
Page - 2204
Question 21/71
Question #21
examination, hotness, redness, and tenderness are present. What is the first-line treatment for this
a. Allopurinol
b. Febuxostat
c. Aspirin
d. Naproxen
e. Corticosteroids
Page - 2205
Question 21/71
Question #21
examination, hotness, redness, and tenderness are present. What is the first-line treatment for this
a. Allopurinol
b. Febuxostat
c. Aspirin
d. Naproxen √
e. Corticosteroids
Description
is patient has gout.
Page - 2206
Question 22/71
Question #22
A 54-year-old male patient has a history of gout and recurrent acute gouty arthritis and is on
allopurinol. He told you that he is not compliant with his medications because of severe diarrhea
caused by this drug. What is the most appropriate treatment to lower his uric acid level?
a. Colchicine
b. Prednisolone
c. Febuxostat
d. Naproxen
Page - 2207
Question 22/71
Question #22
A 54-year-old male patient has a history of gout and recurrent acute gouty arthritis and is on
allopurinol. He told you that he is not compliant with his medications because of severe diarrhea
caused by this drug. What is the most appropriate treatment to lower his uric acid level?
a. Colchicine
b. Prednisolone
c. Febuxostat √
d. Naproxen
Description
Drug treatments for gout:
Allopurinol (inhibits the formation of Uric acid)

Febuxostat (used when the patient cannot tolerate allopurinol)
Colchicine
Always stop thiazide because it exacerbates the condition.
Page - 2208
Question 23/71
Question #23
A 66-year-old male patient complains of sudden, painful ankle joint swelling. Joint aspiration
demonstrates monosodium urate crystals. What is the most likely diagnosis?
a. Septic arthritis
c. Gout
d. Pseudogout
e. Osteoarthritis
Page - 2209
Question 23/71
Question #23
A 66-year-old male patient complains of sudden, painful ankle joint swelling. Joint aspiration
demonstrates monosodium urate crystals. What is the most likely diagnosis?
a. Septic arthritis
c. Gout √
d. Pseudogout
e. Osteoarthritis
Description
Page - 2210
Question 24/71
Question #24
A 28-year-old male patient complains of knee pain and fever. Which of the following, if negative, has
the highest negative predictive value of septic arthritis?
a. Blood culture
b. ESR and CRP
c. Synovial fluid culture
d. Synovial fluid gram staining
e. Synovial fluid WBC
Page - 2211
Internal Medicine - Rheumatology - Infective arthritis
Question 24/71
Question #24
A 28-year-old male patient complains of knee pain and fever. Which of the following, if negative, has
the highest negative predictive value of septic arthritis?
a. Blood culture
b. ESR and CRP √
c. Synovial fluid culture
d. Synovial fluid gram staining
e. Synovial fluid WBC
Description
e negative predictive value of both CRP and ESR together is almost 90%.
e negative predictive value means the percentage of the cases giving non-false negative test
results.
Negative predictive value = true negative / (total negative results)
See the following table:
Page - 2212
Question 25/71
Question #25
A 20-year-old sexually active female develops right-side knee, ankle, and le wrist swellings.
Physical examination demonstrates petechial rashes on both her legs. On x-ray, knee joint eusion
is noted. However, her RA antibody test is negative. What is the most likely diagnosis?
a. Psoriatic arthritis
c. Reactive arthritis
d. Gonococcal arthritis
Page - 2213
Question 25/71
Question #25
A 20-year-old sexually active female develops right-side knee, ankle, and le wrist swellings.
Physical examination demonstrates petechial rashes on both her legs. On x-ray, knee joint eusion
is noted. However, her RA antibody test is negative. What is the most likely diagnosis?
d. Gonococcal arthritis √
Description
Gonococcal arthritis is one of the common causes of septic arthritis in a previously sexually active
patient
Blood cultures are 40% positive; culture may be positive from genitalia, throat, and rectum
e dierence in presentation from septic arthritis; Gonococcal arthritis will have polyarticular
involvement, tenosynovitis, and petechial rash.
Treatment is achieved by ceriaxone 1g IV for 2 days, then ciprofloxacin 500mg PO BID for 7 days
Page - 2214
Question 26/71
Question #26
A 43-year-old female patient has complained of acute hot, red, swollen right knee associated with
fever and general weakness. In addition, there is a reduced active and passive range of motion in
that joint. What is the most appropriate investigation at this time?
a. Knee two-view x-ray

b. Joint aspirate with culture and sensitivity
c. Knee ultrasound
d. Knee MRI
e. ESR and CRP
Page - 2215
Question 26/71
Question #26
A 43-year-old female patient has complained of acute hot, red, swollen right knee associated with
fever and general weakness. In addition, there is a reduced active and passive range of motion in
that joint. What is the most appropriate investigation at this time?
a. Knee two-view x-ray

b. Joint aspirate with culture and sensitivity √
c. Knee ultrasound
d. Knee MRI
e. ESR and CRP
Description
is patient most likely suers from septic arthritis.
Joint aspiration with cytology and culture is the most accurate test to confirm the diagnosis,
determine the infective organism, and determine the appropriate antibiotics that can be used
eectively.
Page - 2216
Question 27/71
Question #27
A 42-year-old male patient presents with a painful Knee joint. In addition, the patient mentioned a
history of trauma at the same joint 2 weeks ago. On examination, the joint is swollen, hot, red, and
tender, and his temperature is 38.9 °C. You perform arthrocentesis, and the results are pending.
Which of the following is most likely to appear in the synovial fluid culture?
a. E. coli
d. Pseudomonas
e. Klebsiella
Page - 2217
Question 27/71
Question #27
tender, and his temperature is 38.9 °C. You perform arthrocentesis, and the results are pending.
Which of the following is most likely to appear in the synovial fluid culture?
a. E. coli
b. Staphylococcus aureus √
d. Pseudomonas
e. Klebsiella
Description
e causes of septic arthritis are as the following:
e most common organism is Staphylococcus aureus (40%)

Others: (streptococci, E. coli, Pseudomonas)
e most common cause of septic arthritis in a recently placed artificial joint is Staphylococcus
epidermidis.
Page - 2218
Question 28/71
Question #28
A 42-year-old male patient presents with a painful elbow joint. In addition, the patient mentioned a
tender, and his temperature is 38.9 °C. Which of the following is the most accurate test in this
scenario?
a. Blood culture
b. Arthrocentesis
c. CT scan of the aected joint
d. X-ray of the aected joint
e. ESR and CRP
Page - 2219
Question 28/71
Question #28
A 42-year-old male patient presents with a painful elbow joint. In addition, the patient mentioned a
tender, and his temperature is 38.9 °C. Which of the following is the most accurate test in this
scenario?
a. Blood culture
b. Arthrocentesis √
c. CT scan of the aected joint
d. X-ray of the aected joint
e. ESR and CRP
Description
is patient most likely suers from septic arthritis.
Joint aspiration with cytology and culture is the most accurate test to confirm the diagnosis,
determine the infective organism, and determine the appropriate antibiotics that can be used
eectively.
Page - 2220
Question 29/71
Question #29
tender, and his temperature is 38.9 °C. What are the most appropriate empirical antibiotics to use
for this patient?
a. Flucloxacillin
b. Amoxicillin
c. Azithromycin
d. Ampicillin
e. Rifampicin
Page - 2221
Question 29/71
Question #29
tender, and his temperature is 38.9 °C. What are the most appropriate empirical antibiotics to use
for this patient?
a. Flucloxacillin √
b. Amoxicillin
c. Azithromycin
d. Ampicillin
e. Rifampicin
Description
Antibiotics treatment in septic arthritis:
Flucloxacillin for 4 to 6 weeks

If penicillin-allergic patients: use clindamycin
If gonococcal arthritis: use cefotaxime or ceriaxone
If the infection is not responding to antibiotics: perform repeated percutaneous aspiration
In general, intravenous antibiotics are used for 7 days until the swelling subsides and the blood
cultures become negative. is is followed by a 4-week course of oral antibiotics.
Page - 2222
Question 30/71
Question #30
A 53-year-old male patient complains of fever, malaise, and weight loss. In addition, he was recently
complaining of sti, painful shoulders and neck. His lab investigations show hemoglobin of 11g/dL,
MCV of 85 fl, and ESR of 102 mm/h. what is the most likely diagnosis?
a. Polyarteritis nodosa
b. Polymyalgia rheumatica
d. Churg Strauss syndrome
e. Behçet’s syndrome
Page - 2223
Internal Medicine - Rheumatology - Polymyalgia Rheumatica (PMR)
Question 30/71
Question #30
A 53-year-old male patient complains of fever, malaise, and weight loss. In addition, he was recently
complaining of sti, painful shoulders and neck. His lab investigations show hemoglobin of 11g/dL,
MCV of 85 fl, and ESR of 102 mm/h. what is the most likely diagnosis?
b. Polymyalgia rheumatica √
Description
Severe pain and stiness in the shoulder, neck and pelvic girdle muscles are characteristic.
destruction).
the workup.
Page - 2224
Question 31/71
Question #31
A 66-year-old male patient complains of diculty getting out of a chair because of pain and
morning stiness in his shoulders and proximal arms. His ESR is extremely high. What is the most
likely diagnosis?
Page - 2225
Question 31/71
Question #31
A 66-year-old male patient complains of diculty getting out of a chair because of pain and
morning stiness in his shoulders and proximal arms. His ESR is extremely high. What is the most
likely diagnosis?
b. Polymyalgia rheumatica √
Description
Severe pain and stiness in the shoulders, neck, and pelvic girdle muscles are characteristic.
destruction).
the workup.
Page - 2226
Question 32/71
Question #32
Which of the following condition is associated with polymyalgia rheumatica?
a. Temporal arteritis
b. Takayasu’s arteritis
c. Behçet’s disease
d. Polyarteritis nodosa
e. Fibromyalgia
Page - 2227
Question 32/71
Question #32
Which of the following condition is associated with polymyalgia rheumatica?
a. Temporal arteritis √
b. Takayasu’s arteritis
d. Polyarteritis nodosa
e. Fibromyalgia
Description
Giant cell arteritis (temporal arteritis) is on a spectrum of polymyalgia rheumatica (PMR).
It is characterized by severe headache and tenderness and may be complicated by blindness
Page - 2228
Question 33/71
Question #33
A 66-year-old male patient is suspected of having polymyalgia rheumatica (PMR). Which of the
following is necessary to make this diagnosis?
a. Joint swelling and redness

b. Early morning stiness
c. Positive response to the NSAIDs
d. Extremely high ESR
e. Bilateral shoulder pain and stiness
Page - 2229
Question 33/71
Question #33
A 66-year-old male patient is suspected of having polymyalgia rheumatica (PMR). Which of the
following is necessary to make this diagnosis?
a. Joint swelling and redness

b. Early morning stiness
c. Positive response to the NSAIDs
d. Extremely high ESR
e. Bilateral shoulder pain and stiness √
Description
To diagnose PMR, at least one 1-month of shoulder or hip stiness and pain should present.
Severe pain and stiness in the shoulders, neck, and pelvic girdle muscles are characteristic.
destruction).
the workup.
Page - 2230
Question 34/71
Question #34
A 40-year-old male patient is unable to get up from a chair due to proximal muscle weakness. He
denies visual symptoms and informs you his symptoms improved aer using steroids. However, lab
investigations demonstrate elevated creatine kinase and high CRP. What is the most likely
diagnosis?
a. Myasthenia gravis disease

b. Amyotrophic lateral sclerosis
d. Cerebrovascular accident
e. Polymyositis
Page - 2231
Internal Medicine - Rheumatology - Polymyositis
Question 34/71
Question #34
A 40-year-old male patient is unable to get up from a chair due to proximal muscle weakness. He
denies visual symptoms and informs you his symptoms improved aer using steroids. However, lab
investigations demonstrate elevated creatine kinase and high CRP. What is the most likely
diagnosis?
a. Myasthenia gravis disease

b. Amyotrophic lateral sclerosis
d. Cerebrovascular accident
e. Polymyositis √
Description
Polymyositis is an inflammatory disorder with symmetrical muscle weakness. However, there is no

skin involvement like dermatomyositis.
Usually aects middle-aged females; the females-to-males ratio is 3:1
Clinical and laboratory manifestations may include the following:
Weak and tender proximal muscles

Dysphagia
Respiratory muscle involvement
Elevated muscle enzymes (CPK, AST, LDH)
Anti-synthetase antibodies (anti-Jo-1 antibodies) are positive
No skin involvement
Page - 2232
Question 35/71
Question #35
A 60-year-old male patient complains of dysphagia, muscle weakness, and inability to climb stairs.
His lab investigations demonstrate high CPK, AST, and LDH but normal alkaline phosphatase; the
Anti-Jo-1 antibody is positive. What is the most likely diagnosis?
a. Polymyositis
c. Duchenne muscle dystrophy
d. Osteoarthritis
e. Liver disease
Page - 2233
Internal Medicine - Rheumatology - Polymyositis
Question 35/71
Question #35
A 60-year-old male patient complains of dysphagia, muscle weakness, and inability to climb stairs.
His lab investigations demonstrate high CPK, AST, and LDH but normal alkaline phosphatase; the
Anti-Jo-1 antibody is positive. What is the most likely diagnosis?
a. Polymyositis √
c. Duchenne muscle dystrophy
d. Osteoarthritis
e. Liver disease
Description
Polymyositis is an inflammatory disorder with symmetrical muscle weakness but no skin

involvement, like dermatomyositis.
Usually aects middle-aged females; the females-to-males ratio is 3:1
Clinical and laboratory manifestations may include the following:
Weak and tender proximal muscles

Dysphagia
Respiratory muscle involvement
Elevated muscle enzymes (CPK, AST, LDH)
Anti-synthetase antibodies (anti-Jo-1 antibodies) are positive
No skin involvement
Page - 2234
Question 36/71
Question #36
A 54-year-old male patient complains of a red and inflamed right knee. His arthrocentesis result
shows rhomboid positively birefringent crystals. What is the most appropriate treatment for his
condition?
a. Indomethacin
b. Colchicine
c. Prednisolone
d. Allopurinol
e. Febuxostat
Page - 2235
Internal Medicine - Rheumatology - Pseudogout
Question 36/71
Question #36
shows rhomboid positively birefringent crystals. What is the most appropriate treatment for his
condition?
a. Indomethacin √
b. Colchicine
c. Prednisolone
d. Allopurinol
e. Febuxostat
Description
NSAIDs are the first-line treatment of Pseudogout.
Pseudogout, also known as calcium pyruvate deposition disease, is a disease of unknown cause
(despite the association with hemochromatosis, hyperparathyroidism, hypothyroidism, and true
gout in some patients)
Synovial fluid aspiration will show positive birefringent cuboidal calcium pyrophosphate crystals
and bloodstained or turbid aspirated fluid.
Joint X-Ray usually shows chondrocalcinosis due to calcium deposition in the cartilage.
Treatment is achieved by the following measures:
NSAIDs (best initial treatment)

Intraarticular steroid (if NSAID’s resistant)
Joint aspiration to relieve swelling and pain
Colchicine for prophylaxis
Page - 2236
Question 37/71
Question #37
Chondrocalcinosis is a typical feature of which of the following?
a. Gout
b. Pseudogout
c. Osteomalacia
d. Osteoporosis
e. Ankylosing spondylitis
Page - 2237
Question 37/71
Question #37
Chondrocalcinosis is a typical feature of which of the following?
a. Gout
b. Pseudogout √
c. Osteomalacia
d. Osteoporosis
e. Ankylosing spondylitis
Description
Chondrocalcinosis is a linear calcification of the articular cartilage in the joints, especially the knee
joint. It is associated with pseudogout.
e following picture shows Chondrocalcinosis:
Page - 2238
Question 38/71
Question #38
shows rhomboid positively birefringent crystals. What is the most likely diagnosis?
a. Gout
b. Pseudogout
c. Rheumatoid arthritis
d. Septic arthritis
e. Reactive arthritis
Page - 2239
Question 38/71
Question #38
shows rhomboid positively birefringent crystals. What is the most likely diagnosis?
a. Gout
b. Pseudogout √
d. Septic arthritis
e. Reactive arthritis
Description

Page - 2240
Question 39/71
Question #39
A patient complains of knee pain, redness, and hotness. His knee x-ray is shown below. What is the
a. Gout
b. Infective arthritis
c. Osteoarthritis
d. Pseudogout
e. Rheumatoid arthritis
Page - 2241
Question 39/71
Question #39
A patient complains of knee pain, redness, and hotness. His knee x-ray is shown below. What is the
a. Gout
b. Infective arthritis
c. Osteoarthritis
d. Pseudogout √
Description
is picture shows a typical finding of Chondrocalcinosis.
Chondrocalcinosis is a typical fining of Pseudogout in which calcium pyrophosphate crystals deposit

in the joints.
Page - 2242

Page - 2243
Question 40/71
Question #40
You suspect a diagnosis of rheumatoid arthritis in a 55-year-old male patient. Which of the following
is the most distinctive with the diagnosis?
a. Large joint involvement

b. Unilateral joint involvement
c. Hepatosplenomegaly
d. Morning joint stiness
e. Maculopapular rash
Page - 2244
Internal Medicine - Rheumatology - Rheumatoid Arthritis (RA)
Question 40/71
Question #40
You suspect a diagnosis of rheumatoid arthritis in a 55-year-old male patient. Which of the following
is the most distinctive with the diagnosis?
a. Large joint involvement

b. Unilateral joint involvement
c. Hepatosplenomegaly
d. Morning joint stiness √
e. Maculopapular rash
Description
Rheumatoid arthritis is an inflammatory deforming arthritis that usually aects the small joints,
typically symmetrically bilateral, more prominent in the hands, and associated with morning joint
stiness for more than 1 hour.
Page - 2245
Question 41/71
Question #41
A 66-year-old male patient is treated for Rheumatoid arthritis. Which drug is hepatotoxic and needs
follow-up with a complete blood count and pulmonary function test?
a. Methotrexate
b. Prednisone
c. Rituximab
d. Sulfasalazine
e. Hydroxychloroquine
Page - 2246
Question 41/71
Question #41
A 66-year-old male patient is treated for Rheumatoid arthritis. Which drug is hepatotoxic and needs
follow-up with a complete blood count and pulmonary function test?
a. Methotrexate √
b. Prednisone
c. Rituximab
d. Sulfasalazine
e. Hydroxychloroquine
Description
While preparing for your medical exam, you should identify the common adverse eects of the
drugs used to treat rheumatoid arthritis.
Methotrexate is a hepatotoxic drug that causes bone marrow suppression and pulmonary fibrosis.
So, a patient on methotrexate should be followed with regular CBC, LFT, and PFT.
e following table shows the common drugs used in rheumatoid arthritis and their possible side
eects:
Page - 2247
Question 42/71
Question #42
A 60-year-old male patient with a background of rheumatoid arthritis was started on NSAIDs and
methotrexate. However, his routine follow-up laboratory results are as follows:
Hemoglobin: 10.5 g/dL
Platelet count: 95 * 10^9
WBC: 2.9 * 10^9
What is the most appropriate management?
a. Start ferrous sulfate

b. Start folic acid
c. Blood transfusion
e. Start Folinic acid
Page - 2248
Question 42/71
Question #42
methotrexate. However, his routine follow-up laboratory results are as follows:
Hemoglobin: 10.5 g/dL
Platelet count: 95 * 10^9
WBC: 2.9 * 10^9
What is the most appropriate management?
a. Start ferrous sulfate

b. Start folic acid
c. Blood transfusion
e. Start Folinic acid √
Description
e patient suers from myelosuppression secondary to her methotrexate therapy.
Folic acid is used to prevent methotrexate-associated side eects, but Folinic acid is the
recommended treatment of myelosuppression due to methotrexate therapy.
Page - 2249
Question 43/71
Question #43
A heavy smoker 55-year-old female complains of a bilaterally limited range of motion in her wrists
and hands, and you suspect rheumatoid arthritis (RA). What is the most specific test for the
diagnosis of RA?
a. Antinuclear antibody titer (ANA)

b. Erythrocyte sedimentation rate (ESR)
c. Rheumatoid factor (RA)
d. Anti-smith antibody (Anti-sm)
e. Anti-cyclic citrullinated peptide (anti-CCP) antibody
Page - 2250
Question 43/71
Question #43
A heavy smoker 55-year-old female complains of a bilaterally limited range of motion in her wrists
and hands, and you suspect rheumatoid arthritis (RA). What is the most specific test for the
diagnosis of RA?
a. Antinuclear antibody titer (ANA)

b. Erythrocyte sedimentation rate (ESR)
c. Rheumatoid factor (RA)
d. Anti-smith antibody (Anti-sm)
e. Anti-cyclic citrullinated peptide (anti-CCP) antibody √
Description
Anti-CCP is the most specific antibody in Rheumatoid arthritis
It has 95% specificity and 70% sensitivity.
RA and Anti-CCP antibodies are neither sucient nor mandatory to diagnose rheumatoid arthritis.
Page - 2251
Question 44/71
Question #44
A 65-year-old male patient is a known case of rheumatoid arthritis. However, his medications
include Ibuprofen and methotrexate. Which of the following vitamins and minerals should the
patient receive in addition to his medications?
a. Vitamin b12
b. Iron supplement
c. Folic acid supplement
d. Zinc supplement
e. Selenium
Page - 2252
Question 44/71
Question #44
A 65-year-old male patient is a known case of rheumatoid arthritis. However, his medications
include Ibuprofen and methotrexate. Which of the following vitamins and minerals should the
patient receive in addition to his medications?
a. Vitamin b12
b. Iron supplement
c. Folic acid supplement √
d. Zinc supplement
e. Selenium
Description
Methotrexate is well known to cause folic acid deficiency. erefore, all patients who receive
methotrexate for more than 3 weeks should receive a folic acid supplement to prevent hematologic
and neurologic adverse outcomes.
Vitamin B12 should be received in patients who have pernicious anemia, gastrectomy, terminal ilium
resection, or those who are vegans.
Iron supplements should be received for dietary insuciency, malabsorption, high demands, or
chronic blood loss.
Selenium is beneficial in the case of Hashimoto’s thyroiditis; it helps to enhance thyroid function.
Page - 2253
Question 45/71
Question #45
Which test should be done for a patient with Rheumatoid arthritis before starting on TNF inhibitors?
a. Blood film
c. Mantoux test
d. Serum albumin level
Page - 2254
Question 45/71
Question #45
Which test should be done for a patient with Rheumatoid arthritis before starting on TNF inhibitors?
a. Blood film
c. Mantoux test √
d. Serum albumin level
Description
TNF inhibitors (e.g., etanercept) are known to cause reactivation of latent TB, so the Mantoux test
should be performed before starting these drugs.
e following table shows the common drugs used in rheumatoid arthritis and their possible side
eects:
Page - 2255
Question 46/71
Question #46
A 39-year-old male patient complains of 8 months history of painful tender wrists and hands.
However, he has more than 1 hour of morning stiness but no rash, fever, or skin changes. On
examination, you noted symmetrical swelling and redness in the proximal interphalangeal and
metacarpophalangeal joints. His blood tests are negative for ANA and RA antibodies, and his ESR is
b. Systemic lupus erythematosus
c. Infective arthritis
d. Osteoarthritis
e. Acute gouty arthritis
Page - 2256
Question 46/71
Question #46
A 39-year-old male patient complains of 8 months history of painful tender wrists and hands.
However, he has more than 1 hour of morning stiness but no rash, fever, or skin changes. On
examination, you noted symmetrical swelling and redness in the proximal interphalangeal and
metacarpophalangeal joints. His blood tests are negative for ANA and RA antibodies, and his ESR is
a. Rheumatoid arthritis √
c. Infective arthritis
d. Osteoarthritis
e. Acute gouty arthritis
Description
is patient most likely has rheumatoid arthritis.
e history of more than 6 weeks, the presence of symmetrical bilateral small joint involvement that
does not aect the distal interphalangeal joint, the presence of morning stiness of more than 1
hour, and the presence of high ESR are strongly aected, suggestive of the disease.
e following table demonstrates the criteria for the diagnosis of rheumatoid arthritis:
Page - 2257
Page - 2258
Question 47/71
Question #47
A 55-year-old female is diagnosed with Rheumatoid arthritis. Which of the following is known to
delay the progression of the disease?
a. Ibuprofen
b. Intraarticular corticosteroids
c. Indomethacin
d. Hydroxychloroquine
e. Aspirin
Page - 2259
Question 47/71
Question #47
A 55-year-old female is diagnosed with Rheumatoid arthritis. Which of the following is known to
delay the progression of the disease?
a. Ibuprofen
b. Intraarticular corticosteroids
c. Indomethacin
d. Hydroxychloroquine √
e. Aspirin
Description
Aspirin and Ibuprofen are known to reduce pain and the mortality rate but do not aect the
progression of the disease.
Hydroxychloroquine is a disease-modifying anti-Rheumatic agent (DMARD) that delays the

progression of rheumatoid arthritis.
Page - 2260
Question 48/71
Question #48
methotrexate. However, he came to you with a clinical feature of UTI. Which of the following is
contraindicated in this patient?
a. Amoxicillin
b. Ciprofloxacin
c. Nitrofurantoin
d. Trimethoprim/sulfamethoxazole
e. Ceriaxone
Page - 2261
Question 48/71
Question #48
methotrexate. However, he came to you with a clinical feature of UTI. Which of the following is
contraindicated in this patient?
a. Amoxicillin
b. Ciprofloxacin
c. Nitrofurantoin
d. Trimethoprim/sulfamethoxazole √
e. Ceriaxone
Description
e concomitant use of Trimethoprim and methotrexate is dangerous because of the risk of severe
myelosuppression and cytopenia that could be fatal.
Page - 2262
Question 49/71
Question #49
A 66-year-old male patient with rheumatoid arthritis complains of severe joint pains in his hands
and feet. His medical history is otherwise unremarkable. What is the most appropriate drug to
control his pain?
a. Methotrexate
b. Hydroxychloroquine
c. Paracetamol
d. Ibuprofen
e. Morphine
Page - 2263
Question 49/71
Question #49
A 66-year-old male patient with rheumatoid arthritis complains of severe joint pains in his hands
and feet. His medical history is otherwise unremarkable. What is the most appropriate drug to
control his pain?
a. Methotrexate
b. Hydroxychloroquine
c. Paracetamol
d. Ibuprofen √
e. Morphine
Description
e most appropriate drugs used in treating pain in Rheumatoid arthritis are NSAIDs (e.g.,
Ibuprofen), but they should never be used as a monotherapy.
Page - 2264
Question 50/71
Question #50
Schirmer’s test is used in which of the following disorders?
a. Ankylosing spondylitis
b. Pernicious anemia
c. Sjögren’s syndrome
d. Myasthenia graves
Page - 2265
Internal Medicine - Rheumatology - Sjögren's syndrome
Question 50/71
Question #50
Schirmer’s test is used in which of the following disorders?
b. Pernicious anemia
c. Sjögren’s syndrome √
d. Myasthenia graves
Description
In Schirmer’s test, a filter paper is placed to measure tear formation. It is used in Sjögren’s syndrome
and is considered positive if reduced teat formation is present.
e test used in ankylosing spondylitis is called Schöber’s test
e test used in pernicious anemia is called schilling test
e test used in Behçet’s syndrome is called pathergy test
e test used in myasthenia graves is called tensilon test
Page - 2266
Question 51/71
Question #51
A 50-year-old female patient presents with a burning sensation in her eyes. She has a long history of
dry eyes and mouth, altered taste sensation, and dysphagia. In addition, she develops hoarseness of
voice when she talks for a long time. What is the most likely diagnosis?
a. Sjögren’s syndrome
c. Hypothyroidism
d. Graves disease
e. Scleroderma
Page - 2267
Question 51/71
Question #51
A 50-year-old female patient presents with a burning sensation in her eyes. She has a long history of
dry eyes and mouth, altered taste sensation, and dysphagia. In addition, she develops hoarseness of
voice when she talks for a long time. What is the most likely diagnosis?
a. Sjögren’s syndrome √
c. Hypothyroidism
d. Graves disease
e. Scleroderma
Description
Sjögren’s syndrome is an autoimmune disorder of unknown cause resulting from autoantibodies

against lacrimal and salivary glands.
is will result in dry eyes, dry mouth, pancreatic dysfunction, and other exocrine dysfunctions
Page - 2268
Question 52/71
Question #52
A 45-year-old female complains of blurry vision and dry eyes that ate now getting worse. In addition,
she mentioned diculty in swallowing and the need for water drinking to swallow food. Lab
investigations demonstrate positive SSA and SSB antibodies. e following are appropriate for the
treatment except:
a. Artificial tears
b. Pancreatic enzyme replacement
c. Pilocarpine administration
d. Artificial saliva
e. Antihistamines
Page - 2269
Question 52/71
Question #52
A 45-year-old female complains of blurry vision and dry eyes that ate now getting worse. In addition,
she mentioned diculty in swallowing and the need for water drinking to swallow food. Lab
investigations demonstrate positive SSA and SSB antibodies. e following are appropriate for the
treatment except:
a. Artificial tears
b. Pancreatic enzyme replacement
c. Pilocarpine administration
d. Artificial saliva
e. Antihistamines √
Description
Antihistamines will cause more dryness and worsen the condition.
is is a typical scenario of Sjögren’s syndrome

is will result in dry eyes, dry mouth, pancreatic dysfunction, and other exocrine dysfunctions
Treatment of Sjögren’s syndrome is as the following:
Artificial Tears
Artificial saliva
Pilocarpine may stimulate saliva production
Pancreatic enzyme replacement
Page - 2270
Question 53/71
Question #53
A 50-year-old male patient is known to have rheumatoid arthritis. He complains of dry eye and
dysphagia. In addition, his Schirmer test shows reduced tear formation. What is the most likely
diagnosis?
c. Hypothyroidism
d. Medication side eects
e. Systemic sclerosis
Page - 2271
Question 53/71
Question #53
A 50-year-old male patient is known to have rheumatoid arthritis. He complains of dry eye and
dysphagia. In addition, his Schirmer test shows reduced tear formation. What is the most likely
diagnosis?
c. Hypothyroidism
Description

is will result in dry eyes and mouth, pancreatic dysfunction, and other exocrine dysfunctions.
Page - 2272
Question 54/71
Question #54
A 45-year-old male patient complains of reduced tear and saliva production and extensive dental
caries. However, he denies taking any medication. What is the most likely diagnosis?
c. Hypothyroidism
Page - 2273
Question 54/71
Question #54
A 45-year-old male patient complains of reduced tear and saliva production and extensive dental
caries. However, he denies taking any medication. What is the most likely diagnosis?
c. Hypothyroidism
Description

is will result in dry eye and mouth, pancreatic dysfunction, and other exocrine dysfunctions.
Page - 2274
Question 55/71
Question #55
e following disorders are seronegative Spondyloarthropathies except:
b. Reactive arthritis
c. Enteropathic arthritis
d. Psoriatic arthritis
Page - 2275
Internal Medicine - Rheumatology - Spondyloarthropathies
Question 55/71
Question #55
e following disorders are seronegative Spondyloarthropathies except:
c. Enteropathic arthritis
e. Rheumatoid arthritis √
Description
Spondyloarthropathies (seronegative arthritis):
e gene most strongly associated with Spondyloarthropathies is HLA B27

Usually involves men under the age of 40 years
is group includes:
Ankylosing spondylitis
Reactive arthritis (Reiter’s syndrome)
Psoriatic arthritis
Enteropathic arthritis (associated with IBD)
Page - 2276
Question 56/71
Question #56
A 33-year-old female has had sudden onset arthritis aer a febrile illness. On examination, a
maculopapular rash is noted on her soles of feet, she has conjunctivitis, and red, painful, and
swollen joints of her feet and knees are noted. What is the most likely diagnosis?
d. Septic arthritis
Page - 2277
Question 56/71
Question #56
A 33-year-old female has had sudden onset arthritis aer a febrile illness. On examination, a
maculopapular rash is noted on her soles of feet, she has conjunctivitis, and red, painful, and
swollen joints of her feet and knees are noted. What is the most likely diagnosis?
b. Reactive arthritis √
d. Septic arthritis
Description
Reactive arthritis is caused when a joint reacts to an infection elsewhere in the body.
May develop days or weeks aer GI or GU infection with Salmonella, Shigella, Campylobacter,
Chlamydia, or Ureaplasma urealyticum
Male to female ratio is 20:1
Associated with HLD B27 (70%)
Symptoms include:
Conjunctivitis 50%
Urethritis
Arthritis (Knee and ankle is the most commonest sites)
Keratoderma blennorrhagica 10% (psoriasiform rash on sole and feet)
Circinate balanitis (psoriasiform rash on the penis)
Systemic features: Fever, weight loss, Carditis, Aortic regurgitation
Page - 2278
Question 57/71
Question #57
When compared with rheumatoid arthritis, all are correct about Spondyloarthropathies except:
a. ey aect the axial skeleton more than the small joints
b. ey cause asymmetrical arthritis
c. Rheumatoid factor is negative
d. More common in males than females
e. Steroids are the best treatment option for Spondyloarthropathies
Page - 2279
Question 57/71
Question #57
When compared with rheumatoid arthritis, all are correct about Spondyloarthropathies except:
a. ey aect the axial skeleton more than the small joints
b. ey cause asymmetrical arthritis
c. Rheumatoid factor is negative
d. More common in males than females
e. Steroids are the best treatment option for Spondyloarthropathies √
Description
Spondyloarthropathies (seronegative arthritis):
e gene most strongly associated with Spondyloarthropathies is HLA B27

Usually involves men under the age of 40 years
is group includes:
Ankylosing spondylitis
Reactive arthritis (Reiter’s syndrome)
Psoriatic arthritis
Enteropathic arthritis (associated with IBD)
e following table demonstrates the dierences between seropositive and seronegative arthritis:
Page - 2280
Question 58/71
Question #58
You suspect ankylosing spondylitis in a 25-year-old male patient. Which of the following is correct
about this condition?
a. More in women than men

b. Most commonly aects the small joints of the hands
c. Morning stiness that improves with activity
d. Schirmer test is used in the diagnosis
e. Peak incidence at the age of 70s
Page - 2281
Question 58/71
Question #58
You suspect ankylosing spondylitis in a 25-year-old male patient. Which of the following is correct
about this condition?
a. More in women than men

b. Most commonly aects the small joints of the hands
c. Morning stiness that improves with activity √
d. Schirmer test is used in the diagnosis
e. Peak incidence at the age of 70s
Description
Ankylosing spondylitis:
Chronic inflammation aects the sacroiliac joint and spine

Most cases begin in late adolescence or early adulthood
It involves the SI joint and progress cranially without skipping any region
Associated with progressive stiening and fusion of axial skeleton
Male to female ratio is 3: 1
Associated with HLA B27 (70%)
Low Back pain worse at rest (early morning and inactivity) is the main feature
Page - 2282
Question 59/71
Question #59
A 25-year-old male presents with chronic lower back pain and stiness. On further questioning, he
mentioned that his symptoms worsen in the morning or at rest. His Schober test is positive. What is
the most appropriate investigation to perform?
a. HLA B27
b. Sacroiliac x-ray
c. oracic spine x-ray
d. ESR
e. RA antibody titer
Page - 2283
Question 59/71
Question #59
A 25-year-old male presents with chronic lower back pain and stiness. On further questioning, he
mentioned that his symptoms worsen in the morning or at rest. His Schober test is positive. What is
the most appropriate investigation to perform?
a. HLA B27
b. Sacroiliac x-ray √
c. oracic spine x-ray
d. ESR
e. RA antibody titer
Description
is is a typical presentation of ankylosing spondylitis; a sacroiliac x-ray is the best next step in the
management of this patient
ESR is not specific
HLA B27 test is not recommended nor sucient to diagnose spondyloarthropathies
Diagnosis of Ankylosing spondylitis:
ESR – high, RF - absent

Lumber X-Ray:
Maybe normal early in the disease
Sacroiliitis: subchondral erosions and sclerosis.
Square vertebrae with tramline appearance
Bamboo spine: a late finding with a fusion of vertebrae
Lumbar MRI (most accurate)
Page - 2284
Question 60/71
Question #60
A 22-year-old male patient presents with urethral discharge, knee pain, le second toe pain, oral
ulcers, and intermittent diarrhea. On further questioning, the patient admits that he is bisexual. You
performed a physical examination and found conjunctival edema and erythema. What is the most
likely diagnosis?
e. Psoriatic arthritis
Page - 2285
Question 60/71
Question #60
A 22-year-old male patient presents with urethral discharge, knee pain, le second toe pain, oral
ulcers, and intermittent diarrhea. On further questioning, the patient admits that he is bisexual. You
performed a physical examination and found conjunctival edema and erythema. What is the most
likely diagnosis?
b. Reactive arthritis √
e. Psoriatic arthritis
Description
Reactive arthritis is caused when a joint reacts to an infection elsewhere in the body.
May develop days or weeks aer GI or GU infection with Salmonella, Shigella, Campylobacter,
Chlamydia, or Ureaplasma urealyticum
Male to female ratio is 20:1
Associated with HLD B27 (70%)
Symptoms include:
Conjunctivitis 50%
Urethritis
Arthritis (Knee and ankle are the most common sites)
Keratoderma blennorrhagica 10% (psoriasiform rash on sole and feet)
Circinate balanitis (psoriasiform rash on the penis)
Systemic features: Fever, weight loss, Carditis, Aortic regurgitation
Page - 2286
Question 61/71
Question #61
A young lady was recently diagnosed with systemic lupus erythematosus. e following findings
indicate active disease except:
a. High ESR
b. High CRP
c. high Anti-DsDNA titer
d. low C3
e. low C4
Page - 2287
Internal Medicine - Rheumatology - Systemic Lupus Erythematosus (SLE)
Question 61/71
Question #61
A young lady was recently diagnosed with systemic lupus erythematosus. e following findings
indicate active disease except:
a. High ESR
b. High CRP √
c. high Anti-DsDNA titer
d. low C3
e. low C4
Description
CRP is reduced in the case of active SLE (not elevated).
Signs of active SLE are as the following:
Elevated ESR and Anti-DsDNA
Reduced CRP, C3, and C4
Page - 2288
Question 62/71
Question #62
A 50-year-old female complains of arthritis, fever, serositis, and proteinuria. In addition, her medical
history is significant for atrial fibrillation, for which she takes procainamide. Which of the following
antibodies is the most specific for the suspected disease?
a. Anti-sm antibody
b. Anti-DsDNA antibody
c. Anti-Histone antibody
d. Antinuclear antibody
e. Ant-La (SSB)
Page - 2289
Question 62/71
Question #62
A 50-year-old female complains of arthritis, fever, serositis, and proteinuria. In addition, her medical
history is significant for atrial fibrillation, for which she takes procainamide. Which of the following
antibodies is the most specific for the suspected disease?
a. Anti-sm antibody √
e. Ant-La (SSB)
Description
Although procainamide can cause drug-induced lupus, drugs can not cause renal involvement in
SLE.
In drug-induced lupus, the symptoms are limited to arthritis, fever, and serositis (do not order Anti-
histone antibodies in a patient with renal involvement of SLE).
Page - 2290
Question 63/71
Question #63
A young female is found to have a positive antinuclear antibody. Her history is significant for
arthralgia, malar rash, ankle edema, and proteinuria. What is the most likely diagnosis?
a. Systemic lupus erythematosus

c. Isolated Reynaud’s disease
d. Systemic sclerosis
e. Multiple sclerosis
Page - 2291
Question 63/71
Question #63
A young female is found to have a positive antinuclear antibody. Her history is significant for
arthralgia, malar rash, ankle edema, and proteinuria. What is the most likely diagnosis?
a. Systemic lupus erythematosus √

c. Isolated Reynaud’s disease
d. Systemic sclerosis
e. Multiple sclerosis
Description
Antinuclear antibody (ANA) is the most sensitive test in SLE, but it is not specific.
e presence of arthralgia, malar rash, and renal involvement strongly suggest SLE.
Page - 2292
Question 64/71
Question #64
A 30-year-old female presents with a malar rash and arthralgia. You suspect SLE. Which of the
following is the best initial test to perform now?
a. ANA
b. Anti-DsDNA
c. Anti-sm
d. Anti-Histone
e. Complement level
Page - 2293
Question 64/71
Question #64
following is the best initial test to perform now?
a. ANA √
b. Anti-DsDNA
c. Anti-sm
d. Anti-Histone
e. Complement level
Description
ANA is the best initial and the most sensitive test in SLE
It is 99% sensitive but only 70% specific
e following are the antibodies associated with SLE and their key details:
Antinuclear antibody (ANA): Highly Sensitive (99%) but not specific
RF: 20% sensitive, not specific
Anti-Smith: Most specific (> 99%), sensitivity (30%)
Anti-Double stranded DNA (Anti-dsDNA): Specific (99%) but only 70% sensitive (Indicates active
disease)
Anti-Ro (SSA)
Anti-La (SSB)
Anti-Histone antibody (for drug-induced SLE)
SLE can be associated with antiphospholipid antibodies
Page - 2294
Question 65/71
Question #65
following is the most specific test to perform?
a. ANA
b. Anti-DsDNA
c. Anti-sm
d. Anti-Histone
e. Complement level
Page - 2295
Question 65/71
Question #65
following is the most specific test to perform?
a. ANA
b. Anti-DsDNA
c. Anti-sm √
d. Anti-Histone
e. Complement level
Description
Anti-sm is the most specific (>99%) for SLE while Anti-DsDNA is 99% specific; so, Anti-sm is slightly
more specific than Anti-DsDNA.
ANA is the best initial and the most sensitive test in SLE
It is 99% sensitive but only 70% specific
e following are the antibodies associated with SLE and their key details:
Antinuclear antibody (ANA): Highly Sensitive (99%) but not specific
RF: 20% sensitive, not specific
Anti-Smith: Most specific (> 99%), sensitivity (30%)
Anti-Double stranded DNA (Anti-dsDNA): Specific (99%) but only 70% sensitive (Indicates active
disease)
Anti-Ro (SSA)
Anti-La (SSB)
Anti-Histone antibody (for drug-induced SLE)
SLE can be associated with antiphospholipid antibodies
Page - 2296
Question 66/71
Question #66
A 52-year-old female patient is known to have HTN, for which she receives hydrochlorothiazide,
hydralazine, and enalapril. She presents with a 1-month history of symmetrical arthralgia of hands
and arms and knee pain. On further evaluation, you found a pleural friction rub, elevated ANA titer,
and negative rheumatoid factor. What is the most appropriate initial management?
a. Stop enalapril
b. Stop hydrochlorothiazide
c. Stop hydralazine
d. Start on steroid therapy
e. Order Anti-sm antibody titer
Page - 2297
Question 66/71
Question #66
A 52-year-old female patient is known to have HTN, for which she receives hydrochlorothiazide,
hydralazine, and enalapril. She presents with a 1-month history of symmetrical arthralgia of hands
and arms and knee pain. On further evaluation, you found a pleural friction rub, elevated ANA titer,
and negative rheumatoid factor. What is the most appropriate initial management?
a. Stop enalapril
b. Stop hydrochlorothiazide
c. Stop hydralazine √
d. Start on steroid therapy
e. Order Anti-sm antibody titer
Description
is is a case of drug-induced lupus.
e most common drugs that can cause drug-induced lupus are:
Procainamide (the most common oender)

Hydralazine (the second most common oender)
Isoniazid
Tumor necrosis factor (TNF) alpha inhibitors (such as etanercept, infliximab, and adalimumab)
Minocycline
Quinidine
Page - 2298
Question 67/71
Question #67
A 30-year-old lady complains of symmetrical arthritis, facial rash at the sun exposure distribution,
and mouth ulcer. Which of the following is the most likely diagnosis?
a. Gonococcal arthritis
b. Psoriatic arthritis
d. Systemic lupus erythematosus
Page - 2299
Question 67/71
Question #67
A 30-year-old lady complains of symmetrical arthritis, facial rash at the sun exposure distribution,
and mouth ulcer. Which of the following is the most likely diagnosis?
a. Gonococcal arthritis
b. Psoriatic arthritis
d. Systemic lupus erythematosus √
Description
SLE is an autoimmune disorder with several autoantibodies that are Associated with HLA B8, DR2,
DR3
e females are more aected than males (F: M ratio is 9:1)
ere are several Autoantibodies associated with this condition (the most specific one is an anti-
smith antibody (Anti-sm)
Page - 2300
Question 68/71
Question #68
A 24-year-old female presents with fever, malaise, malar rash, and arthralgia. Anti-sm antibody is
positive. Which of the following is the most likely diagnosis?

e. Polymyalgia
Page - 2301
Question 68/71
Question #68
A 24-year-old female presents with fever, malaise, malar rash, and arthralgia. Anti-sm antibody is
positive. Which of the following is the most likely diagnosis?

b. Systemic lupus erythematosus √
e. Polymyalgia
Description
SLE is an autoimmune disorder with several autoantibodies that are Associated with HLA B8, DR2,
DR3
e females are more aected than males (F: M ratio is 9:1)
ere are several Autoantibodies associated with this condition (the most specific one is an anti-
smith antibody (Anti-sm)
Page - 2302
Question 69/71
Question #69
A 50-year-old female complains of arthritis, fever, and serositis. Her medical history is significant for
atrial fibrillation, for which she takes procainamide. Which of the following antibodies would mostly
help reach the suspected diagnosis?
a. Anti-sm antibody
e. Ant-La (SSB)
Page - 2303
Question 69/71
Question #69
A 50-year-old female complains of arthritis, fever, and serositis. Her medical history is significant for
atrial fibrillation, for which she takes procainamide. Which of the following antibodies would mostly
help reach the suspected diagnosis?
a. Anti-sm antibody
c. Anti-Histone antibody √
e. Ant-La (SSB)
Description
is is a case of drug-induced lupus. Procainamide is the most common drug to cause lupus.
e most common drugs that can cause drug-induced lupus are:
Procainamide (the most common oender)

Hydralazine (the second most common oender)
Isoniazid
Tumor necrosis factor (TNF) alpha inhibitors (such as etanercept, infliximab, and adalimumab)
Minocycline
Quinidine
Page - 2304
Question 70/71
Question #70
A 50-year-old female complains of both hands pain related to cold exposure. In addition, she has
dysphagia and exertional shortness of breath. What is the most likely diagnosis?
a. Esophageal carcinoma
b. Systemic sclerosis
c. Nasopharyngeal carcinoma
d. Benign esophageal stricture
e. Lupus erythematosus
Page - 2305
Internal Medicine - Rheumatology - Systemic sclerosis (SS)
Question 70/71
Question #70
A 50-year-old female complains of both hands pain related to cold exposure. In addition, she has
dysphagia and exertional shortness of breath. What is the most likely diagnosis?
a. Esophageal carcinoma
b. Systemic sclerosis √
c. Nasopharyngeal carcinoma
d. Benign esophageal stricture
e. Lupus erythematosus
Description
e hand’s pain on cold exposure is typical for Raynaud’s phenomena.
e presence of exertional shortness of breath may indicate pulmonary fibrosis or cardiac

involvement, while dysphagia results from esophageal involvement.
is clinical scenario is typical for systemic sclerosis (SS).
SS is a generalized disorder of connective tissue of unknown cause characterized by skin fibrosis and
blood vessels and visceral involvement
e lungs, heart, or GI tract may be involved in the disease.
Page - 2306
Question 71/71
Question #71
A 45-year-old female complains of symmetrical arthritis, pallor, and cyanosis of her fingers aer
exposure to cold weather. On examination, you noted telangiectasia on her lips and figures. Which
b. Systemic sclerosis
d. Reactive arthritis
e. Antiphospholipid antibody syndrome
Page - 2307
Internal Medicine - Rheumatology - Systemic sclerosis (SS)
Question 71/71
Question #71
A 45-year-old female complains of symmetrical arthritis, pallor, and cyanosis of her fingers aer
exposure to cold weather. On examination, you noted telangiectasia on her lips and figures. Which
b. Systemic sclerosis √
d. Reactive arthritis
e. Antiphospholipid antibody syndrome
Description
Systemic sclerosis (SS) is a generalized disorder of connective tissue of unknown cause characterized
by skin fibrosis and blood vessels and visceral involvement
e lungs, heart, or GI tract may be involved in the disease.
In this scenario, the patient only has skin manifestations of SS, making limited type SS the most
likely diagnosis.
Page - 2308
Page - 2309

Internal Medicine - 1081 ﺔﻠﺌﺳﻷا دﺪﻋ 08-04-2023 ﺔﻠﺌﺳﻷا ﺚﻳﺪﺤﺗ ﺦﻳرﺎﺗ ﻒﻴﻔﻋ ﺪﺠﻣأ .د ﻖﻴﺒﻄﺗ ﰲ ةدﻮﺟﻮﳌا ﺔﻠﺌﺳﻷا ﻊﻴﻤﺟ ﲆﻋ يﻮﺘﺤﻳ ﻊﻴﻤﺠﺘﻟا اﺬﻫ

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Internal Medicine - 1081 ﺔﻠﺌﺳﻷا دﺪﻋ 08-04-2023 ﺔﻠﺌﺳﻷا ﺚﻳﺪﺤﺗ ﺦﻳرﺎﺗ ﻒﻴﻔﻋ ﺪﺠﻣأ .د ﻖﻴﺒﻄﺗ ﰲ ةدﻮﺟﻮﳌا ﺔﻠﺌﺳﻷا ﻊﻴﻤﺟ ﲆﻋ يﻮﺘﺤﻳ ﻊﻴﻤﺠﺘﻟا اﺬﻫ

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‫ﺑﻨﻚ أﺳﺌﻠﺔ اﻟﺪﻛﺘﻮر أﻣﺠﺪ ﻋﻔﻴﻒ‬

‫‪Internal Medicine -‬‬

‫ﻋﺪد اﻷﺳﺌﻠﺔ ‪1081‬‬

‫ﺗﺎرﻳﺦ ﺗﺤﺪﻳﺚ اﻷﺳﺌﻠﺔ ‪08-04-2023‬‬

‫ﻫﺬا اﻟﺘﺠﻤﻴﻊ ﻳﺤﺘﻮي ﻋﲆ ﺟﻤﻴﻊ اﻷﺳﺌﻠﺔ اﳌﻮﺟﻮدة ﰲ ﺗﻄﺒﻴﻖ د‪ .‬أﻣﺠﺪ ﻋﻔﻴﻒ‬

1) Cardiology => 155 Questions

‫ﻣﻮاﺿﻴﻊ اﻷﺳﺌﻠﺔ وأﻋﺪادﻫﺎ‬

1) Acute and decompensated heart failure (DHF) => 5 Questions

a. Acute refractory pulmonary edema

‫اﻹﺟﺎﺑﺔ ﻋﲆ اﻟﺼﻔﺤﺔ اﻟﺘﺎﻟﻴﺔ‬

a. Acute refractory pulmonary edema

‫اﻹﺟﺎﺑﺔ ﻋﲆ اﻟﺼﻔﺤﺔ اﻟﺘﺎﻟﻴﺔ‬

Diuretics (intravenous furosemide)

‫اﻹﺟﺎﺑﺔ ﻋﲆ اﻟﺼﻔﺤﺔ اﻟﺘﺎﻟﻴﺔ‬

Diuretics (intravenous furosemide)

‫اﻹﺟﺎﺑﺔ ﻋﲆ اﻟﺼﻔﺤﺔ اﻟﺘﺎﻟﻴﺔ‬

If the BNP level is high (> 500 pg/ml) à cardiac cause

Causes of high BNP:

‫اﻹﺟﺎﺑﺔ ﻋﲆ اﻟﺼﻔﺤﺔ اﻟﺘﺎﻟﻴﺔ‬

‫اﻹﺟﺎﺑﺔ ﻋﲆ اﻟﺼﻔﺤﺔ اﻟﺘﺎﻟﻴﺔ‬

is ECG indicates posterior MI.

a. Le circumﬂex artery

‫اﻹﺟﺎﺑﺔ ﻋﲆ اﻟﺼﻔﺤﺔ اﻟﺘﺎﻟﻴﺔ‬

a. Le circumﬂex artery

Anatomy of the coronary artery:

‫اﻹﺟﺎﺑﺔ ﻋﲆ اﻟﺼﻔﺤﺔ اﻟﺘﺎﻟﻴﺔ‬

a. Aspirin, Clopidogrel, Heparin, metoprolol, Oxygen, Nitrates

‫اﻹﺟﺎﺑﺔ ﻋﲆ اﻟﺼﻔﺤﺔ اﻟﺘﺎﻟﻴﺔ‬

a. Aspirin, Clopidogrel, Heparin, metoprolol, Oxygen, Nitrates

Dual antiplatelet agents are indicated in all cases of ACS.

‫اﻹﺟﺎﺑﺔ ﻋﲆ اﻟﺼﻔﺤﺔ اﻟﺘﺎﻟﻴﺔ‬

If ventricular arrhythmia develops, early DC cardioversion is indicated to control the patient’s

a. A 42-year-old male with new ST-segment depression

‫اﻹﺟﺎﺑﺔ ﻋﲆ اﻟﺼﻔﺤﺔ اﻟﺘﺎﻟﻴﺔ‬

a. A 42-year-old male with new ST-segment depression

rombolytic therapy is contraindicated in patients with a brain hemorrhage

a. Reassurance and explanation that this is a panic attack

‫اﻹﺟﺎﺑﺔ ﻋﲆ اﻟﺼﻔﺤﺔ اﻟﺘﺎﻟﻴﺔ‬

a. Reassurance and explanation that this is a panic attack

a. Admission and adjustment of the treatment

‫اﻹﺟﺎﺑﺔ ﻋﲆ اﻟﺼﻔﺤﺔ اﻟﺘﺎﻟﻴﺔ‬

a. Admission and adjustment of the treatment √

CABG is not indicated at this point.

Indications for CABG:

ree vessels disease

a. Right coronary artery

‫اﻹﺟﺎﺑﺔ ﻋﲆ اﻟﺼﻔﺤﺔ اﻟﺘﺎﻟﻴﺔ‬

a. Right coronary artery

e ECG shows ST elevation on V2 – V4

is indicates anterior wall myocardial infarction

e most common artery aected in this case is LAD

a. Right coronary artery

‫اﻹﺟﺎﺑﺔ ﻋﲆ اﻟﺼﻔﺤﺔ اﻟﺘﺎﻟﻴﺔ‬

a. Right coronary artery √

e ECG shows ST elevation on II, III, and aVF

is indicates Inferior wall myocardial infarction

e most common artery aected in this case is RCA

‫اﻹﺟﺎﺑﺔ ﻋﲆ اﻟﺼﻔﺤﺔ اﻟﺘﺎﻟﻴﺔ‬

‫اﻹﺟﺎﺑﺔ ﻋﲆ اﻟﺼﻔﺤﺔ اﻟﺘﺎﻟﻴﺔ‬

is is a case of anaphylactic shock.

e treatment of choice for anaphylactic shock is adrenaline intramuscularly.

Subcutaneous administration of drugs in hypotensive patients is inappropriate because of the