Q Bank MSQs PDF

Questions bank It contains all the files that Dr. Shoeb attached in the Drive. It’s already solved by Dr. Shoeb, So I didn’t add or change anything. 1. A 15-year-old girl presents with her parents complaining of a discrete mobile fluctuant midline swelling of the anterior neck at the level of the hyoid bone. On examination this mass was moving on swallowing and protrusion of the tongue. What is the probable diagnosis in her case? A. Thyroglossal Cyst B. Dermoid cyst C. Multinodular Goiter D. Branchial cleft cyst 2. 45-year-old woman presents to your office for evaluation. She reports that over the last few weeks, she’s noted an enlarging mass in the front of her neck. She feels well, has had no changes in her health, and denies symptoms of hyper- or hypothyroidism. She also denies recent viral illness. On examination, you note a diffusely enlarged thyroid that is tender to touch. What is her most likely diagnosis? A. Hashimoto’s thyroiditis B. Non-toxic multinodular goiter C. Toxic multinodular goiter D. Graves’ disease 3. A 16-year-old girl presents to her GP complaining of a swelling in her neck which she has noticed in the last 2 weeks. She has felt more irritable although this is often transient and only when she is stressed out.On examination, a diffuse swelling is palpated with no bruit on auscultation. The most likely diagnosis is: A. Hyperthyroidism B. Simple goitre C. Thyroid carcinoma D. Thyroid cyst 4. A 25-year al patient presents with an asymptomatic doughy soft, fluctuant swelling on lateral neck which was present for month but recently enlarged following an upper respiratory tract infection. Most likely diagnosis of the swelling is: A. Scrofula B. Lymphoma C. Cervicofacial actinomycosis D. Cervical lymphoepithelial cyst 5. An 11-year-old child presents to your clinic complaining of a neck swelling in his left anterior neck, pain and sever fever. He says the pain is getting worsen. Which of the following is the most likely diagnosis? A. Reactive viral lymphadenopathy B. Grave's disease C. Thyroid adenoma D. Lymphoma 6. Which of the following groups of lymph nodes is first to exhibit lymphadenopathy in cases of infection monocucleous? A. Axillary B. Cervical C. Inguinal D. Mediastinal 7. A 72-year-old woman complains of shortness of breath on exertion as well as cough. She states that she also becomes short of breath at night unless she uses three pillows (orthopnea). Physical examination reveals mild obesity, bilateral pitting leg edema, and fine crackling sounds on inspiration (rales). A chest X-ray shows cardiomegaly. What are the most likely diagnoses in this patient? A. Asthma B. Emphysema C. Left-sided heart failure. D. Myocardial infarction 8. A 40-year-old woman with a history of rheumatic fever presents with shortness of breath, cough, weight loss, fatigue, and abdominal distension. Physical examination shows rales in the lungs, hepatosplenomegaly, and 2+ pitting edema of the legs. A chest X-ray reveals only left atrial enlargement and pulmonary edema. What is the most likely cause of pulmonary edema in this patient? A. Aortic stenosis B. Tricuspid insufficiency C. Mitral stenosis D. Pulmonic stenosis 9. A 39-year-old man comes to the physician because of a 6-month history of progressive shortness of breath. He has had a cough productive of white sputum for 2 years. He smoked 1 pack of cigarettes daily for 16 years but quit 10 years ago. He is in mild respiratory distress with pursed lips and a barrel chest; he is using the accessory muscles of respiration. Breath sounds are distant and crackles are present in the lower lung fields bilaterally. Pulmonary function tests show a decreased FEV1:FVC ratio, increased residual volume, and decreased diffusion capacity. An x-ray of the chest shows hyperinflation and hypertranslucency of the lower lobes of both lungs. Which of the following is the most likely diagnosis? A. Asthma B. Chronic pulmonary fibrosis C. Cystic fibrosis D. Emphysema 10. A 48-year-old woman has been diagnosed with essential hypertension and was commenced on treatment three months ago. She presents you with a dry cough which has not been getting better despite taking cough linctus and antibiotics. You assess the patient’s medication history. Which of the following antihypertensive medications is responsible for the patient’s symptoms? A. Amlodipine B. Lisinopril C. Bendroflumethiazide D. Brofen 11. A 56-year-old man attends your clinic with a three-month history of a productive cough with blood-tinged sputum, following his return from India. Associated symptoms include lethargy, night sweats and decreased appetite. He is normally fit and healthy with no past medical history. On examination, the patient's chest has good air entry bilaterally with no added sounds and his temperature is 37.3°C. A sputum sample sent from the patient's general physician reveals a growth of acid fast bacilli. From the list below, which is the most likely diagnosis? A. Pulmonary embolism B. Tuberculosis C. Bronchitis D. Pneumonia 12. A 45-year-old male is evaluated in the clinic for asthma. His symptoms began 2 years ago and are characterized by an episodic cough and wheezing that responded initially to inhaled bronchodilators and inhaled corticosteroids but now require nearly constant prednisone tapers. He notes that the symptoms are worst on weekdays but cannot pinpoint specific triggers. The patient has no habits and works as a textile worker. Physical examination is notable for mild diffuse polyphonic expiratory wheezing but no other abnormality. Which of the following is the most appropriate next step? A. Exercise physiology testing B. Measurement of FEV, before and after work C. Methacholine challenge testing D. Skin testing for allergies 13. A 54-year-old woman presents complaining of a chronic cough that has worsened over a period of 6-12 months. She reports the cough to be present day and night, and productive of a thick green sputum. Over the course of the day, she estimates that she produces as much as 100 mL of sputum daily. Bilateral coarse crackles are heard in the lower lung zones. Pulmonary function tests demonstrate an FEV, of 1.68 L (53.3% predicted), FVC of 3.00 L (75% predicted), and FEV /FVC ratio of 56%. A chest radiograph is unre-markable. What would you recommend as the next step in the evaluation of this patient? A. Bronchoscopy with bronchoalveolar lavage B. Chest CT with intravenous contrast C. High-resolution chest CT D. Serum immunoglobulin levels 14. A 35-year-old male presents with cough, breathlessness, wheeze and tightness in his chest. He states that all this has started after 15 minutes of his jogging. What is the most likely diagnosis of his condition? A. Emphysema B. Allergies C. Bronichial Asthma D. Bronchitis 15. A 55-year-old man and his wife complain that for a year he has been constantly clearing his throat and frequently coughs just as he is falling off to sleep or on occasion while asleep. He has never smoked and is on no prescription medications, and he has not seen other doctors for the cough. Which of the following is the LEAST likely cause of this problem? A. Post-nasal drip. B. Gastro-esophageal reflux (GERD). C. Viral infection. D. Asthma 16. A 50 year old patient who is known to have had myocardial infarction. He just arrive from pilgrim 5 days ago. He presented to your clinic with cough, SOB, blood tongued sputum. On chest examination: dullness over the lower lobe with bronchial breathing. Which of the following is expected finding on Chest X-Ray? A. Lobar pneumonia B. Segmental atelectasis C. Multiple canon ball D. Reticular interstitial opacities 17. A 50-year-old Afro-Caribbean man, with no past medical history, presents with a four-month history of dry cough and shortness of breath on exertion. The patient’s GP referred him to the chest clinic after performing blood tests which revealed a raised erythrocyte sedimentation rate (ESR) and serum angiotensin-converting enzyme (ACE) level. You review the patient’s chest x-ray which reveals bilateral hilar lyphadenopathy. From the list below, select the most likely diagnosis: A. Rheumatoid arthritis B. Systemic lupus erythematosus (SLE) C. Sarcoidosis D. Idiopathic pulmonary fibrosis 18. You see a 68-year-old man in clinic, with a 40 (cigarette) pack year history, who has been experiencing breathlessness on exertion and a productive cough of white sputum over the last four months. You assess his spirometry results which reveal an FEV1/FVC of 51 per cent with minimal reversibility after a 2-week trial of oral steroids. Cardiological investigations are normal. Which of the following is the most likely diagnosis? A. Asthma B. Chronic obstructive pulmonary disease (COPD) C. Left ventricular failure D. Chronic bronchitis 19. A 55-year-old alcoholic man presents with fever and shortness of breath. The patient was in his usual state of health until 10 days ago, when he developed intermittent fever; a productive, foul-smelling cough; and anorexia. He has been a heavy drinker for many years and admits to recent binges. He denies having urinary, abdominal, or gastrointestinal symptoms. On physical examination, the patient’s temperature is 99.9° F (37.7° C). He has exceptionally poor dentition, and dullness to percussion is noted at the right pulmonary base. Chest x-ray reveals an air-space infiltrate in the right lower lobe, with an associated moderate pleural effusion. Thoracentesis reveals an exudative effusion of pH 6.95. Gram stain of the pleural fluid reveals gram- negative rods. Which of the following statements regarding the diagnosis and treatment of empyema is true? A. Staphylococcus aureus, various species of Streptococcus, and gram- negative bacilli are the most common causes of empyema B. Bacteria typically reach the pleural space by hematogenous spread C. Gross purulence is diagnostic of empyema, and the absence of frank pus rules out infection D. Video-assisted thoracoscopic surgery (VATS) is the traditional method for draining empyemas 20. A 68-year-old man comes to the physician because of worsening nonproductive cough and progressive shortness of breath during the past 2 months. Three months ago, he was able to walk an unlimited distance without difficulty; now, he becomes short of breath after walking one block. He has had no fever, chest pain, or leg swelling. He has atrial fibrillation and hypertension treated with medications. His temperature is 37.7°C (99.8°F), pulse is 90/min, and respirations are 22/min. Pulse oximetry on room air shows an oxygen saturation of 92%. Diffuse inspiratory crackles are heard bilaterally. The remainder of the examination shows no abnormalities. His plasma brain natriuretic peptide concentration is within the reference range. A chest x-ray shows bilateral interstitial infiltrates. Which of the following medications is the most likely cause of these findings? A. Amiodarone B. Digoxin C. Lisinopril D. Metoprolol 21. A 25-year-old woman comes to the physician because of a 4-month history of cough and unintentional weight loss. Rhonchi are heard posteriorly over the right upper thorax. A chest x-ray shows an 8-cm cavity in the right upper lobe and hilar lymphadenopathy. Ziehl-Neelsen staining of an induced sputum specimen shows acid- fast bacilli. The patient begins treatment with four antimycobacterial drugs, including rifampin. Synthesis of which of the following components of the suspected pathogen is most likely directly inhibited by the rifampin in this patient's medication regimen? A. Folic acid B. Peptidoglycan C. Protein D. RNA 22. A 56-year-old male patient presented with a history of fever, malaise, and shortness of breath. His medical history was significant for hypertension and smoking. Upon physical examination, there was an audible murmur in the heart. Laboratory tests showed an elevated white blood cell count and C-reactive protein. The chest X-ray was normal, and an echocardiogram revealed vegetation on the mitral valve. What is the most likely diagnosis for this patient? A. Myocardial infarction B. Endocarditis C. Pericarditis D. Cardiomyopathy 23. An 85-year-old man comes to the emergency department because of chest discomfort and shortness of breath that started two hours ago while watching television. Past medical history includes hypertension and hyperlipidemia. During the past 10 years, the patient has had similar episodes of chest pain, which resolved with rest. The patient's pulse is 94/min, respirations are 22/min, and blood pressure is 134/86 mmHg. The patient appears to be in distress and is diaphoretic. Physical examination shows normal heart sounds with no murmurs or gallops on auscultation. An ECG shows Inferior wall myocardial infarction. Treatment is administered, and the patient suddenly reports feeling faint and loses consciousness. Which of the following medications is most likely the cause of the patient's worsened condition? A. Nitrates B. Clopidogrel C. Warfarin D. Aspirin 24. A 65-year-old man presents to accident and emergency with right-sided chest pain and some shortness of breath. Examination reveals a pleural effusion which is confirmed on chest X-ray. Aspiration of the fluid identifies more than 30g of protein. Which of the following would not be consistent with the above picture? A. Nephrotic syndrome. B. Pneumonia. C. Hypothyroidism. D. Liver cirrhosis. 25. A 55-year-old man has just arrived in accident and emergency complaining of 20 minutes of central crushing chest pain. Which feature is most indicative of myocardial infarction at this moment in time? A. Inverted T waves B. ST depression C. ST elevation D. Raised troponin 26. A 60-year-old man presents to accident and emergency with a 3-day history of increasingly severe chest pain. The patient describes the pain as a sharp, tearing pain starting in the center of his chest and radiating straight through to his back between his shoulder blades. The patient looks in pain but there is no pallor, heart rate is 95, respiratory rate is 20, temperature 37°C and blood pressure is 155/95 mmHg. The most likely diagnosis is: A. Myocardial infarction B. Myocardial ischemia C. Aortic dissection D. Pulmonary embolism 27. What is the most sensitive and specific marker for a myocardial infarction (MI)? A. AST B. LDH C. Troponin I D. CK-MB 28. 14.80 y/o Old patient with SOB,pink frothy sputum and cyanosis, on exam chest bilateral crackles at the base.What is the Most likely diagnosis: A. Pneumonia B. Pulmonary edema C. Plural effusion D. Pneumothorax 29. An elderly man traveled to north america from Australia. After 5 days he delelops dyspnea, chest pain, tachycardia and is rushed to the hospital.What is the most likely diagnosis ? A. Pulmonary embolism B. Pneumonia C. Myocardial infarction D. Aortic dissection 30. Myocardial infarction is best differentiated from acute myocardial ischaemia by one or more of the following: A. Duration of chest pain B. The electrocardiogram C. Troponin and cardiac enzyme levels D. The electrocardiogram combined with troponin and enzyme levels 31. A 50-year-old man with hypertension is brought to the emergency department 30 minutes after the sudden onset of severe chest pain that radiates to his back and arms. His blood pressure is 180/80 mm Hg in his left arm; no pressure reading can be obtained from the right arm. Cardiac examination shows a murmur of aortic insufficiency. Which of the following is the most likely diagnosis? A. Acute aortic dissection B. Acute myocardial infarction C. Embolus to the right subclavian artery D. Pulmonary embolism 32. A 45-year-old man is brought to the emergency department 30 minutes after the sudden onset of crushing chest pain. His father, maternal aunt, and paternal uncle all died of myocardial infarctions under the age of 50 years. Physical examination shows tendinous xanthomas on the hands and thickened Achilles tendons. Serum lipid studies show a total cholesterol concentration of 410 mg/dL, HDL-cholesterol concentration of 30 mg/dL, and triglyceride concentration of 140 mg/dL. The diagnosis of myocardial infarction is made. This patient most likely has a deficiency of which of the following? A. Apo B48 B. HMG-CoA reductase activity C. LDL receptor D. Lipoprotein lipase activity 33. A 65-year-old man is admitted to the hospital because of a 12-hour history of chest pain. Physical examination shows no abnormalities. Serum studies show an increased troponin I concentration. The diagnosis of myocardial infarction is made. It is suspected that this patient's condition deteriorated as a result of ischemia-reperfusion injury. The increased serum troponin I concentration in this patient most likely occurred as a result of which of the following processes? A. Increased enzyme synthesis B. Lysis of the endoplasmic reticulum C. Lysis of the plasma membrane D. Mitochondrial swelling 34. A 29-year-old lady presented to the clinic complaining of tremorm abnormal menses, and weight loss. on examination: pulse rate was 110, eye proptosis and diffuse swelling in the neck anteriorly was observed. Laboratory: TSH level was undetectable. T4: 40 pmol/L (normal 10-26 pmol/L). Thyroid scan showed diffuse homogenous uptake. The most likely diagnosis of this patient is: A. Grave’s Disease B. Subacute Thyroiditis C. Toxic Adenoma D. Toxic Multinodular Goiter 35. A 64-year-old man has inguinal, axillary and cervical lymphadenopathy. The nodes are firm and non-tender A biopsy of the cervical node shows a histologic pattern of nodular aggregates of small, cleaved lymphoid cells (centrocytes) and larger cells with open chromatin, several nucleoli, and moderate amount of cytoplasm (centroblast). What is the most likely diagnosis? A. Hodgkin lymphoma, nodular sclerosis subtype B. Follicular lymphoma C. Diffuse large B-cell lymphoma. D. Burkitt lymphoma 36. A healthy 29-year-old woman comes to the physician for a health maintenance examination. Palpation of the neck reveals a firm, 0.5-cm nodule in the right thyroid lobe. The remainder of the gland is normal. The physical examination is otherwise unremarkable. The patient denies any symptoms attributable to hyperthyroidism. The results of thyroxine and TSH immunoassays are within normal limits. Which of the following is the most precise diagnostic screening procedure for differentiating benign thyroid nodules from malignant ones? A. MRI scan of the neck B. CT scan of the neck C. Radioactive iodine scan D. Fine needle aspiration 37. An 80 year old woman who was suspected for subclinical hyperthyroidism. She has been complaining of intermittent palpitations, being generally unwell, with low mood and some degree of weight loss (3 kg within the last 6 months). She had BP of 110/80 and her heart rate was 96 beats per minute with slightly increased respiratory rate. What is the best test to do if there was no thyroid uptake scan in the center? A. TSH receptor Ab B. Anti TPO C. Thyroglobulin D. Thyroid uptake scan again 38. A 46-year-old woman comes to the office because of a small mass she found on palpation of her neck, more likely related to her thyroid. A small nodule is found in the thyroid. There is no tenderness. She is otherwise asymptomatic and uses no medications. What is the most appropriate next step in the management of this patient? A. Fine-needle aspiration. B. Radionuclide iodine uptake scan. C. T4 and TSH levels. D. Thyroid ultrasound. E. Surgical removal (excisional biopsy). 39. A 46-year-old woman with a neck mass presented to the clinic. A thyroid nodule is found after a neck examination. Her thyroid was known to have normal thyroid function testing. The fine-needle aspirate comes back as “indeterminant for follicular adenoma.” What is the most appropriate next step in the management of this patient? A. Neck CT. B. Surgical removal (excisional biopsy). C. Ultrasound. D. Calcitonin levels. 40. A 30-year-old male came to the emergency department complaining of shortness of breath, unable to swallow, feeling warm and loss of strength. He had unintentional weight loss over the last 6 months. A clear central neck mass was detected during examination. A diagnosis of Grave’s disease was confirmed after blood smear detection of elevated Thyroid antibody (TRAbs) and Anti-TPO antibodies. Thyroid size was estimated as (100 mL). What is the best management for this case? A. Iodine supplementation B. Scheduled follow ups and no need for intervention C. Near-total thyroidectomy D. Radioiodine therapy 41. A 42-year-old patient known to have central painless neck mass for months. Recently enlarged and complicated with unexplained hoarseness and sour throat for more than 3 weeks. A diagnosis of Follicular thyroid carcinoma was confirmed. He was given radioactive Iodine to decrease his tumor size and planned to remove a part of his thyroid. Which of the following drugs should be given after a month? A. Potassium Iodide B. Levothyroxine C. Diiodotyrosine D. Monoiodotyrosine 42. A 67-year-old woman comes to the clinic complaining of shortness of breath during sleeping, cough, fatigue, weight gain, and abdominal pain. Physical examination showed respiratory distress, Ascites, and pitting edema in both legs. Her doctor is considering heart failure. Which one of the following tests is used to diagnose heart failure? A. BNP B. Ck MB C. Troponin D. LFTs 43. A 73-year-old man came to the hospital with severe dyspnea, cough, orthopnea and bilateral edema, the doctor has done physical examination and found the patient cyanosed, and heard rales in lungs, what is the best method to confirm diastolic heart failure? A. Chest X-ray B. LDH C. Cardiac MRI D. Echocardiography 44. A 35-year-old man presents to the emergency department complaining of a cough and runny nose of 1-week duration. While being evaluated, it is discovered that his blood pressure is 230/120 mm Hg. An antihypertensive is immediately administered. Later, he develops lactic acidosis, headache, vertigo, and confusion. Which antihypertensive was given to him? A. A Enalapril B. B Labetalol C. C Losartan D. D Nitroprusside 45. A 33-year-old Caucasian male comes to the clinic with a 4-day history of chest pain. The pain radiates to the right side of the neck and is worsened by deep inspiration and improved by leaning forward. Several weeks ago, he had a fever and cough, which have both since improved. He is afebrile, BP is 130/85, and pulse is 88. On examination, there is a scratching sound heard over the left sternal border on expiration. ECG shows ST elevation in leads I, II, III, avL, and V2 to V6. The patient is offered treatment but refuses all medications. Which of the following is the most common complication if this disease remains untreated? A. Cardiac tamponade B. Recurrent pericarditis C. Constrictive pericarditis D. Ventricular free wall rupture 46. A 67-year-old man is hospitalized recovering from a left wall myocardial infarction. He begins to show signs of fluid retention. His doctors want to start a drug regimen for congestive heart failure, including either an ACE inhibitor or an angiotensin receptor blocker (ARB). ACE inhibitors and ARBs treat hypertension in a similar fashion and have similar side effects. Which of the following is a side effect of ACE inhibitors only? A. Dizziness B. Dry cough C. Erectile dysfunction D. Hypotension 47. A 16-year-old girl is brought to the physician for recurrent episodes of shortness of breath, nonproductive cough, and chest tightness for 3 months. These episodes occur especially while playing sports and resolve spontaneously with rest. She appears healthy. Her pulse is 63/min, respirations are 15/min, and blood pressure is 102/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. Physical examination shows no abnormalities. An x-ray of the chest shows no abnormalities. Spirometry shows a FEV1:FVC ratio of 85% and an FEV1 of 85% of predicted. Which of the following is the most appropriate next step in management? A. Albuterol before exercise B. Physical conditioning C. Echocardiography D. Prednisone therapy 48. A 22-year-old woman comes to the physician because of a 12-week history of persistent cough. The cough is nonproductive and worse at night. She otherwise feels well. She has not had any changes in appetite or exercise tolerance. For the past year, she has smoked cigarettes occasionally when with friends. Use of herbal cough medications has not provided any symptom relief. She has no history of serious illness but reports getting a runny nose every morning during winter. Her temperature is 37.0°C (98.6°F), pulse is 68/min, respirations are 12/min, and blood pressure is 110/76 mm Hg. Cardiopulmonary examination and an x-ray of the chest show no abnormalities. Her FEV1 is normal. Which of the following is the most appropriate next step in management? A. Smoking cessation B. Oral amoxicillin-clavulanate C. Oral pantoprazole D. Oral diphenhydramine 49. A 14-year-old girl is brought by her parents to the physician because of recurrent episodes of shortness of breath and nonproductive cough over the past 3 months. She has had two episodes per week, which have resolved spontaneously with rest. Once a month, she wakes up at night with shortness of breath. Spirometry shows an FVC of 95% and an FEV1 of 85% of predicted. Treatment with inhaled budesonide-formoterol as needed is begun. Two weeks later, she is brought to the physician with acute onset of dyspnea and wheezing. Her pulse is 95/min and respirations are 32/min. Which of the following is the most appropriate initial pharmacotherapy? A. Albuterol inhaler B. Cromolyn sodium C. Guaifenesin D. Montelukast sodium 50. 28-year-old man has been newly diagnosed with asthma. He has never been admitted to hospital with asthma exacerbation and experiences symptoms once or twice a week. You discuss the treatment options with him. His peak expiratory flow reading is currently 85 per cent of the normal predicted value expected for his age and height. Which of the following is the most appropriate first step in treatment? A. Short-acting beta-2 agonist inhaler B. Low-dose steroid inhaler C. Leukotriene receptor antagonists D. High-dose steroid inhaler 51. A 55-year-old male with a history of IV drug use presents to the emergency department with complaints of fever, chills, and chest pain for the past week. On the physical exam, his temperature is 101°F, heart rate is 110 bpm, and blood pressure is 130/80 mmHg. There is a grade II/VI systolic murmur at the left sternal border and multiple petechial skin lesions on the hands and feet. Which of the following symptoms is most commonly associated with cardiac infections? A. Diarrhea B. Shortness of breath C. Abdominal pain D. Skin rash 52. A 62-year-old male patient presents to the emergency department with chest pain, shortness of breath, and diaphoresis. His electrocardiogram (ECG) shows ST-segment elevation in leads II, III, and aVF. What are the appropriate investigations for diagnosing cardiac infarction in this patient? Which of the following cardiac biomarkers is the most sensitive and specific for diagnosing acute myocardial infarction? A. Troponin I B. Creatine kinase-MB (CK-MB) C. Myoglobin D. LDH 53. A 58-year-old male patient presents to the emergency department with chest pain that radiates to his left arm. The patient has a history of hypertension and hypercholesterolemia. ECG shows ST-segment elevation in the anterior leads. Which of the following investigations should be performed to confirm the diagnosis of acute myocardial infarction? A. Cardiac biomarkers B. Chest X-ray C. Echocardiogram D. Coronary angiogram 54. Which medication should be prescribed to all anginal patients to treat an acute attack? A. Isosorbide dinitrate B. Nitroglycerin patch C. Nitroglycerin sublingual tablet or spray D. Ranolazine 55. A 60-year-old woman had a myocardial infarction. Which of the following should be used to prevent life-threatening arrhythmias that can occur post-myocardial infarction in this patient? A. Digoxin B. Flecainide C. Metoprolol D. Procainamide 56. Which of the following is most commonly recognized as an absolute contraindication to fibrinolytic therapy in patients with STEMI? A. Prior ischemic stroke within the past 6 months B. Suspected aortic dissection. C. Systolic blood pressure > 160 mm Hg or diastolic blood pressure > 100 mm Hg D. Pregnancy 57. A 55-year-old man was admitted to the hospital 2 weeks ago for rapid onset of cough, fatigue, and pleuritic chest pain. He has worked as a sandblaster for the past year. When first seen in the hospital, he denied hemoptysis and smoking. Currently, the patient is intubated and on assist-control ventilation. His temperature is 36.7°C (98°F), the pulse is 96/min, blood pressure is 138/85 mm Hg, and respiratory rate is 18/min. A recent arterial blood gas study showed a pH of 7.42, partial pressure of arterial carbon dioxide of 36 mm Hg, and partial pressure of arterial oxygen of 110 mm Hg while on 100% fraction of inspired oxygen. Physical examination is significant for diffuse crackles throughout both lung fields, a loud pulmonic component of the second heart sound, and jugular venous distention of 9 cm with a prominent A wave, a left parasternal heave, and symmetric 3+ lower extremity pitting edema. Which of the following is the correct diagnosis? A. Asbestosis B. Berylliosis C. Silicosis D. Coal worker’s pneumoconiosis 58. A 35-year-old HIV-positive man (CD4+ count 150/mm3) is seen in the ED with right- sided chest pain. The patient has become progres- sively dyspneic over the past few days. Sud- denly, 30 minutes ago he noticed a sharp pain in his chest associated with shortness of breath. His temperature is 37.7° (99.9°F), blood pres- sure is 128/84 mm Hg, pulse is 102/min and regular, respiratory rate is 25/min, and oxygen saturation is 90% on room air. Physical exami- nation reveals diminished right-sided breath sounds and hyperresonance. Jugular venous distention is 5 cm and there is no tracheal de- viation. ECG shows sinus tachycardia. X-ray of the chest shows a right-sided pneumothorax occupying approximately 10% of the right tho- racic cavity. Which of the following etiologies most likely caused this patient’s presentation? A. Intravenous drug use B. Kaposi’s sarcoma C. Mycobacterium tuberculosis D. Pneumocystis jiroveci (formerly carinii) pneumonia 59. Differential diagnosis of PE is challenging. PE should be considered in the differential diagnosis of patients suspected of having cardiac ischemia, heart failure, COPD exacerbation, pneumothorax, pneumonia, sepsis, acute chest syndrome (in patients with sickle cell disease), and acute anxiety with hyperventilation. Which of the following is the preferred imaging technique for diagnosing acute PE? A. V/Q scans B. Duplex ultrasonography C. CT angiography D. Echocardiography 60. A 27-year-old woman is 7 months pregnant with her first child. Her pregnancy has been uncomplicated to date. She presents to the ED complaining of sudden-onset, right-sided chest pain that is exacerbated with deep breathing, and shortness of breath, which began 1 hour ago. She denies leg pain and says the swelling that is apparent has been unchanged since the sixth month of her pregnancy. Her tempera- ture is 37.9°C (100.3°F), blood pressure is 130/87 mm Hg, pulse is 107/min and regular, respiratory rate is 24/min, and oxygen satura- tion is 90% on room air, increasing to 98% with 4 L oxygen via nasal cannula. Physical ex- amination is significant for crackles at the lower right lung field and a negative Homans’ sign bilaterally. X-ray of the chest appears nor- mal, D-dimer is elevated, and ECG shows si- nus tachycardia, right-axis deviation, S wave in lead I, Q wave in lead III, and an inverted T wave in lead III. Which of the following is the most appropriate next step in diagnosis? A. Arterial blood gas analysis B. MRI C. C)Pulmonary angiography D. Ventilation/perfusion scan 61. A 23-year-old man is seen in the ED for sud- den-onset, right-sided pleuritic chest pain that developed 30 minutes ago while he was watching television. The patient also complains of difficulty breathing. He has no prior medical history, denies smoking and intravenous drug use, and does not take any medications. His temperature is 37.3°C (99.1°F), blood pressure is 130/82 mm Hg, pulse is 92/min and regular, respiratory rate is 20/min and shallow, and oxy- gen saturation is 98% on room air. He is 196 cm (6 ft 5 in) tall with a body mass index of 18 kg/m2. Diminished breath sounds, hyperresonance, and decreased tactile fremitus are prominent in the right lung field. The trachea is midline. X-ray of the chest shows a 10% pneumothorax on the right. Which of the following is the most appropriate initial management? A. Observation with supplemental oxygen B. Open thoracotomy with oversewing of the C. pleural blebs and scarification of the pleura D. Needle decompression E. Thoracoscopy with stapling of blebs 62. A 62 year old man presented to the acute medical unit with a three- day history of mild breathlessness on exertion, occasional right sided chest pain and sweats. He looked well and was breathless at rest. He had no significant past medical history. His temperature was 37.7 C. He had a few crackles at the right base, dullness to percussion, and decreased vocal resonance at the right base. What is the next step in management? A. CT scan of chest with contrast timed for pleural enhancement. B. Diuretics and monitoring of response with a chest x-ray. C. Empirical antibiotics and monitoring of response with a chest xray. D. Pleural ultrasound and diagnostic aspiration. 63. A 70-year-old man with a history of heavy smoking and moderately severe chronic obstructive pulmonary disease COPD. has been feeling poorly. He reports cough, chills, pleuritic chest pain, and low-grade fever. Chest x ray reveals a small dense infiltrate in the right lower lobe. Gram's stain of the patient's sputum reveals numerous gram-negative cocci, many of which occur in pairs. The most appropriate therapy would be A. No antimicrobial therapy is required. B. Tetracycline C. Ciprofloxacin D. Trimethoprim/sulfamethoxazole TMP/SMZ. E. Penicillin/clavulanic acid 64. A 72-year-old male is admitted to the hospital from a nursing home with severe pneumonia. He was recently discharged from the hospital 1 week ago after open heart surgery. The patient has no known allergies. Which of the following regimens is most appropriate for empiric coverage of methicillin- resistant Staphylococcus aureus and Pseudomonas aeruginosa in this patient? A. Vancomycin + cefepime + ciprofloxacin B. Vancomycin + cefazolin + ciprofloxacin C. Telavancin + cefepime + ciprofloxacin. D. Daptomycin + cefepime + ciprofloxacin 65. Which of the following drugs is ototoxic? A. Amikacin B. Acetaminophen C. Amphetamine D. Atorvastatin 66. A 23-year-old man presented to the clinic with decreased hearing in his right ear. An otoscopic examination showed impacted wax in the right ear canal. The left ear exam showed a patent canal and normal tympanic membrane. Which of the following represents the result of the tuning fork exam in his case? A. Central Weber B. Weber lateralized to the Right C. Weber Lateralized to the Left D. Equal Weber between sides 67. A 32-year-old female presented to the clinic because of a central neck mass she noticed five months ago. Which of the following points in history indicates a higher risk of malignancy in this mass? A. Family history of Thyroid cancer B. Age less than 40 years C. History of aspirin use D. Presence of pain 68. A 60-year-old man presented to the clinic because of a neck mass located at the angle of the mandible for four weeks. What is the best initial imaging modality to investigate this mass? A. Computed tomography of the neck with contrast B. Ultrasound Neck C. Lateral and Anterior Neck X-ray D. Magnetic resonance imaging 69. A 3- 3-year-old boy presented to the clinic because of a painful mass located at the submandibular area for two days. on the exam, he is febrile, looks ill, and the mass was tender during palpation with warm, erythematous overlying skin. What is the most likely diagnosis? A. Bacterial lymphadenitis B. Congenital branchial cyst C. Cystic hygroma D. Thyroglossal duct mass 70. What is the first-line investigation for neck mass? A- CT Head and Neck IV contrast. B- MRI of Head and Neck with IV contrast. C- Erythrocyte sedimentation rate D- Fine-Needle Aspiration Cytology 71. A-35 year- old man who was diagnosed with atypical pneumonia, what is the most likely causative organism: A.Streptococcus pneumoniae, B.⁠Staphylococcus aureus. C. ⁠Klebsiella pneumoniae, D.⁠Mycoplasma pneumoniae 72. While conducting the nasal examination, Which of the following structures is important to visualize? A. Eyes B.⁠Nasal Septum C.⁠Cervical vertebrae D.Tongue 73. This 46-year-old male presented to the ER with a fever, cough, shortness of breath, and high WBC. Which initial imaging study is best? A. MRI chest B. CT chest C. Chest x-ray D. Ultrasound 74. Ahmed is 56 a 56-year-old male who was diagnosed with pneumonia. Which of the following is considered Infective Pneumonia? a. Aspiration aspiration b. Hypostatic Pneumonia c. Lipid Pneumonia d. Aspergillus fumigatus 75. Which of the following is not considered one of the differential diagnoses of midline neck swelling? A. Ranula B. Thyroglossal duct cyst C. Carotid body tumor D. Lymph node 76. A 3-year-old boy presents to the physician’s office with an asymptomatic neck mass located in the midline, just below the level of the thyroid cartilage. The mass moves with deglutition and on protrusion of the tongue. 1- What is the most appropriate diagnosis? A. Thyroglossal duct cyst. B- Thyroid adenoma. C. Cystic hygroma. D- Thyroid carcinoma 77. Which of the following differential diagnosis of neck mass match the clinical description? A-Ranula represent a c congenital defect from incomplete skin fusion. B- Zenker's diverticulum more common in young patient c- Cystic Hygroma develops from embryonic lymphatic tissue D- Lymphadenopathy in pediatric patient often due malignancy 78. What is the most likely cause of CLL? A. Infection B. Genetic mutation in cell chromosomes C. Radiation exposer D. Blood transfusion 79. A hospitalized 42-year-old woman has a 2-hour history of severe chest pain and blood- streaked sputum 4 days after undergoing hysterectomy and oophorectomy for ovarian cancer. Current medications are oxycodone, prophylactic low-molecular-weight heparin, and a multivitamin. Temperature is 37.0°C (98.6°F), pulse is 90/min, respirations are 22/min, and blood pressure is 110/70 mm Hg. Examination shows a left pleural rub. An x-ray and CT scan of the chest show a triangular pleural-based density in the lower lobe of the left lung. No pulmonary emboli are seen in the major branches. Venous duplex ultrasonography of the lower extremities shows no deep venous thrombosis. Which of the following is the most likely diagnosis? (A) Air embolism (B) Empyema (C) Hemothorax (D) Pericarditis (E) Pulmonary infarction 80.A 23-year-old man comes to student health services because of a 6-month history of increasingly frequent episodes of moderate chest pain. The first episode occurred while he was sitting in traffic and feeling stressed because he was late for a college class. At that time, he had the sudden onset of moderate chest pain, a rapid heartbeat, sweating, and nausea. He says he felt as though he were going to die. The episode lasted approximately 10 minutes. During the past 3 weeks, he has experienced two to three episodes weekly.He has no history of serious illness and takes no medications. He does not drink alcohol or use other substances. Vital signs are within normal limits. Physical examination discloses no abnormalities. On mental status examination, he has an anxious mood and full range of affect. Which of the following is the most likely diagnosis? (A) recurrent pericarditis (B) Generalized anxiety disorder. C) acute coronary syndrome (d)pulmonary embolism 81. A 59-year-old man presents with several episodes of substernal chest pressure of 15 minutes’ duration, which was brought on by an argument with his neighbor. His pain is relieved by nitroglycerine. According to the Forrester and Diamond chest pain classification, this patient’s angina would be described as: A. Noncardiac chest pain B. Atypical angina C. Typical angina D. Walk-through angina 82. A 48-year-old female presents to the emergency department with central chest pain and dyspnea that now occurs after walking one block. The chest pain began six months ago, but the symptoms have become more frequent and occur with even less exertion. She describes an episode of syncope without prodrome. Her family history is significant for a brother having undergone a cardiac surgery at age 52. A systolic ejection click with an associated systolic murmur is noted on exam. Serial troponins are negative. What is the next best course of action? A. Book an exercise stress test B. Proceed with transthoracic echocardiography C. Proceed with coronary angiography D. Start a beta blocker and discharge home with follow-up in clinic 83. Historically, myoglobin, creatine kinase, and the cardiac-specific CK-MB isoform have served as serum biomarkers indicating myocardial injury or necrosis. What is the most significant limitation of these biomarkers for the diagnostic evaluation of patients with presumed cardiac chest pain? A. Cost of the test B. Delay in release into the peripheral blood after onset of injury C. Lack of cardiac specificity D. Difficulty of use E. Instability in vitro 84. Regarding the difference between typical and atypical pneumonia, Which of the :following is a feature of atypical pneumonia ? a. Gradual onset b. High-grade fever c. Productive cough d. Caused by Strep. Pneumonia. ophthalmology 1.Distichiasis is: a. Misdirected eyelashes b. Accessory row of eyelashes c. Downward drooping of upper lid d. Outward protrusion of lower lid ANSWER: B 2. Band shaped keratopathy is commonly caused by deposition of: a. Magnesium salt b. Calcium salt c. Ferrous salt d. Copper salt ANSWER: B 3. Irrespective of the etiology of a corneal ulcer, the drug always indicated is: a. Corticosteroids b. Cycloplegics c. Antibiotics d. Antifungals ANSWER: B 4. Dense scar of cornea with incarceration of iris is known as: a. Adherent Leucoma b. Dense leucoma c. Ciliary staphyloma d. Iris bombe ANSWER: A 5. Corneal sensations are diminished in: a. Herpes simplex b. Conjunctivitis c. Fungal infections d. Marginal keratitis ANSWER: A 6. The color of fluorescein staining in corneal ulcer is: a. Yellow b. Blue c. Green d. Royal blue ANSWER: C 7. Phlycten is due to: a. Endogenous allergy b. Exogenous allergy c. Degeneration d. None of the above ANSWER: A 8. A recurrent bilateral conjunctivitis occurring with the onset of hot weather in young boys with symptoms of burning, itching, and lacrimation with large flat topped cobble stone papillae raised areas in the palpebral conjunctiva is: A. Trachoma B. Phlyctenular conjunctivitis C. Mucopurulent conjunctivitis D. Vernal keratoconjunctivitis ANSWER: D 9. Which of the following organism can penetrate intact corneal epithelium? A. Strept pyogenes B. Staph aureus C. Pseudomonas pyocyanaea D. Corynebacterium diphtheriae ANSWER: D 10. A 12 years old boy receiving long term treatment for spring catarrh, developed defective vision in both eyes. The likely cause is: a. Posterior subcapsular cataract b. Retinopathy of prematurity c. Optic neuritis d. Vitreous hemorrhage ANSWER: A 11. Patching of the eye is contraindicated in: a. Corneal abrasion b. Bacterial corneal ulcer c. Mucopurulent conjunctivitis d. After glaucoma surgery ANSWER: C 12. Ten years old boy complains of itching. On examination, there are mucoid nodules with smooth rounded surface on the limbus, and mucous white ropy mucopurulent conjunctival discharge. He most probably suffers from: a. Trachoma b. Mucopurulent conjunctivitis c. Bulbar spring catarrh d. Purulent conjunctivitis ANSWER: C 13. Corneal Herbert's rosettes are found in: a. Mucopurulent conjunctivitis b. Phlyctenular keratoconjunctivitis c. Active trachoma d. Spring catarrh ANSWER: C 14. A patient complains of maceration of skin of the lids and conjunctiva redness at the inner and outer canthi. Conjunctival swab is expected to show: a. Slaphylococcus aureus. b. Streptococcus viridans. c. Streptococcus pneumonae d. Morax- Axenfeld diplobacilli ANSWER: D 15. Tranta's spots are noticed in cases of: a. Active trachoma b. Bulbar spring catarrh c. Corneal phlycten d. Vitamin A deficiency ANSWER: B 16. A painful, tender, non itchy localized redness of the conjunctiva can be due to: a. Bulbar spring catarrh. b. Episcleritis. c. Vascular pterygium. d. Phlyctenular conjunctivitis. ANSWER: B 17. In trachoma the patient is infectious when there is: a. Arlt's line b. Herbert's pits c. Post-trachomatous concretions. d. Follicles and papillae in the palpebral conjunctiva. ANSWER: D 18. A female patient 18 years old, who is contact lens wearer since two years, is complaining of redness, lacrimation and foreign body sensation of both eyes. On examination, visual acuity was 6/6 with negative fluorescein test. The expected diagnosis can be: a. Acute anterior uveitis. b. Giant papillary conjunctivitis. c. Bacterial corneal ulcer. d. Acute congestive glaucoma ANSWER: B 19. Fifth nerve palsy could cause: a. Ptosis b. Proptosis c. Neuropathic keratopathy d. Lagophthalmos ANSWER: C 20. Topical steroids are contraindicated in a case of viral corneal ulcer for fear of: a. Secondary glaucoma b. Cortical cataract. c. Corneal perforation d. Secondary viral infection. ANSWER: C 21. The sure diagnostic sign of corneal ulcer is a. Ciliary injection b. Blepharospasm c. Miosis d. Positive fluorescein test. ANSWER: D 22. Herpes simplex keratitis is characterized by: a. Presence of pus in the anterior chamber b. No tendency to recurrence c. Corneal hyposthesia d. Tendency to perforate ANSWER: C 23. 40 year-old male had a trauma to his right eye while hammering metallic nail. On examination there is hand motion vision and full thickness corneal laceration in the affected eye. Which of the following must be the immediate action? A. Administer topical antibiotic eye ointment to the eye. B. Put a clear eye shield on the eye. C. Check the intraocular pressure. D. Double Patch the eye with clean gauze. ANSWER: B 24. Chalazion is a chronic inflammatory granuloma of a. Meibomian gland b. Zies’s gland c. Sweat gland d. Wolfring’s gland ANSWER: A 25. Deep leucoma is best treated by: A. Tattooing B. Lamellar keratoplasty C. Keratectomy D. Penetrating keratoplasty ANSWER: D 26. Blood vessels in a trachomatous pannus lie: a. Beneath the Descemet's membrane. b. In the substantia propria. c. Between Bowman's membrane & substantia propria. d. Between Bowman's membrane & Epithelium. ANSWER: D 27. In vernal catarrh, the characteristic cells are: a. Macrophage b. Eosinophils c. Neutrophils d. Epitheloid cells ANSWER: B 28. Ptosis in Horner's syndrome, is due to paralysis of: a. Riolan's muscle b. Horner's muscle c. Muller's muscle d. The levator palpebral muscle e. Orbicularis oculi muscle ANSWER: C 29. Severe congenital ptosis with no levator function can be treated by: A. Levator resection from skin side B. Levator resection from conjunctival side C. Fascia lata sling operation D. Fasanella servat operation ANSWER: C 30. Fleischer ring is found in: a. Keratoconus b. Chalcosis c. Argyrosis d. Buphthalmos e. None of the above ANSWER: A 31. Intercalary staphyloma is a type of: a. Equatorial staphyloma b. Posterior staphyloma c. Scleral staphyloma d. Anterior staphyloma ANSWER: C 32: A 69-year-old woman presents with acute onset of ocular pain, decreased vision, and halos around lights in the right eye associated with nausea and vomiting. The most likely diagnosis is: a. Primary open-angle glaucoma. b. Lens induced glaucoma. c. Pigmentary glaucoma. d. Acute primary angle-closure glaucoma. Answer: d 33: A 30 -year-old woman presents with sudden vision loss of the right eye and mild pain on upgaze movement. Examination reveals that vision is 20/50 on the right and 20/20 on the left. There is a +RAPD on the right and a Visual field testing showed an inferior altitudinal defect on the same side. The left side is normal. Optic discs and fundi are normal in both eyes. What is the most likely diagnosis? a. Branch retinal vein occlusion. b. Anterior ischemic optic neuropathy. c. Retrobulbar optic neuritis. d. Compressive optic neuropathy. Answer: c 34- A 45-year-old male with a history of renal transplant on steroid therapy complaining of gradual painless diminution of vision both eyes, on examination there is lens opacity. What is the most likely type of cataract? A. Cortical cataract. B. Nuclear cataract. C. Posterior subcapsular cataract D. Dot cataract 35-A girl who came to the ER with redness and swelling after wearing her sister's lenses. The culture came as gram negative rods, what's the organism? A.E.coli B. Pseudomonas aeruginosa C. Chlamydia trachomatis D. Yersinia 36- A 20-year-old male is complaining of a gradual decrease in visual acuity for the last 5 years. On examination: red reflex was present, ophthalmoscopy showed diffuse peripheral retinal pigmentary changes, attenuated vessels, and pale discs. What is the earliest manifestation of this disease? A.Central visual loss B.Metamorphopsia C. Loss of color vision D.Nyctalopia 37- A 45-year-old patient has type 1 diabetes for 25 years, his HA1C is 7. Lipid profile is normal. Which of the following increases the risk of having retinopathy? A.Hyperlipidemia B.High glucose level C.Duration of diabetes D.Blood pressure level 38- Which of the following is not true about exudative"wet" age-related macular degeneration A-Lipofuscin deposits B. Subretinal fibrosis C. Central scotoma D.neovascularization 39. Ptosis and mydriasis are seen in: a. Facial palsy b. Peripheral neuritis c. Oculomotor palsy d. Sympathetic palsy ANSWER: C 40. Commonest cause of posterior staphyloma is: a. Glaucoma b. Retinal detachment c. Iridocyclitis d. High myopia ANSWER: D 41. Schirmer’s test is used for diagnosing: a. Dry eye b. Infective keratitis c. Watering eyes d. Horner’s syndrome ANSWER: A 42. A 16 years old boy was involved in a fight where he received a fist on his left eye On examining the EOM you noticed that he cannot look up The most common site of fracture is in this case is A. the roof B. the floor C. lateral wall D. medial wall ANSWER: B 43. Most common cause of adult unilateral proptosis a. Thyroid orbitopathy b. Metastasis c. Lymphoma d. Meningioma ANSWER: A 44. Evisceration is: a. Excision of the entire eyeball b. Excision of all the inner contents of the eyeball including the uveal tissue c. Photocoagulation of the retina d. Removal of orbit contents ANSWER: B 45. Lagophthalmos can occur in all of the following except; a. 7th cranial nerve paralysis b. 5th cranial nerve paralysis c. Thyrotoxic exophthalmos d. Symblepharon ANSWER: B 46. The most important symptom differentiating orbital cellulitis from panophthalmitis is: a. Vision b. Pain c. Redness d. Swelling ANSWER: A 47. In anterior uveitis the pupil is generally: a. Of normal size b. Constricted c. Dilated ANSWER: B 48. Koeppe’s nodules are found in: a. Cornea b. Sclera c. Iris d. Conjunctiva ANSWER: C 49. The earliest feature of anterior uveitis includes: a. Keratic precipitates b. Hypopyon c. Posterior synechiae d. Aqueous flare ANSWER: D 50.A 40-year-old lady presented to the ER complaining of a painful swelling in the left lower lid. On exam there was a tender erythematous localized swelling the left lower lid with positive regurge otherwise rest of exam was normal What is the definitive treatment for this condition? a) Systemic antibiotics b) Topical antibiotics c) Surgery d) Massage ANSWER: C 51. After 48 hours of a cataract extraction operation, a patient complained of ocular pain and visual loss. On examination, this eye looked red with ciliary injection, corneal oedema and absent red reflex. The first suspicion must be: a. Secondary glaucoma. b. Anterior uveitis. c. Bacterial endophthalmitis. d. Acute conjunctivitis ANSWER: C 52. All the following associated open angle glaucoma include all the following except: a. Roenne’s nasal step b. Enlarged blind spot c. Generalized depression of isopters d. Loss of central fields e. Tubular vision ANSWER: D 53. A 40-year construction worker had cement in to his eyes what is the most important initial treatment to be done A. Topical antibiotics B. Debridement C. Topical steroid D. Irrigation with saline ANSWER: D 54. Neovascular glaucoma follows: a. Thrombosis of central retinal vein b. Acute congestive glaucoma c. Staphylococcal infection d. Hypertension ANSWER: A 55.A one-month old baby is brought with complaints of photophobia and watering. Clinical examination shows normal tear passages and clear but large cornea. The most likely diagnosis is: a. Congenital dacryocystitis b. Interstitial keratitis c. Keratoconus d. Buphthalmos ANSWER: D 56. You have been referred a case of open angle glaucoma. Which of the following would be an important point in diagnosing the case? a. Shallow anterior chamber b. Optic disc cupping c. Narrow angle d. visual acuity and refractive error ANSWER: B 57. In retinal detachment, fluid accumulates between: a. Outer plexiform layer and inner nuclear layer. b. Neurosensory retina and layer of retinal pigment epithelium c. Nerve fiber layer and rest of retina. d. Retinal pigment epithelium and Bruch’s membrane. ANSWER: B 58. 100 days glaucoma is seen in: a. Central Retinal Artery Occlusion b. Branch Retinal Artery Occlusion c. Central Retinal Vein Occlusion d. Branch Retinal Vein Occlusion ANSWER: C 59. A young patient with sudden painless loss of vision, with systolic murmur and ocular examination reveals a cherry red spot with clear AC, the likely diagnosis is: a. Central Retinal Artery Occlusion b. Central Retinal Vein Occlusion c. Diabetes Mellitus d. Branch Retinal Vein Occlusion ANSWER: A 60. Amaurotic cat's eye reflex is seen in: a. Papilloedema b. Retinoblastoma c. Papillitis d. Retinitis ANSWER: B 61. Commonest lesion which hinders vision in diabetic retinopathy is: a. Macular oedema b. Microaneurysm c. Retinal hemorrhage d. Retinal detachment ANSWER: A 62. Commotio retinae is seen in: a. Concussion injury b. Papilloedema c. Central retinal vein thrombosis d. Central retinal artery thrombosis ANSWER: A 63. Night blindness is caused by: a. Central retinal vein occlusion b. Dystrophies of retinal rods c. Dystrophies of the retinal cones d. Retinal detachment ANSWER: B 64. In Central retinal artery occlusion, a cherry red spot is due to: a. Hemorrhage at macula b. Increased choroidal perfusion c. Increase in retinal perfusion at macula d. The contrast between pale retina and reddish choroids ANSWER: D 65. A patient of old standing diabetes mellitus noticed sudden muscae volitanes. On examination, the red reflex was dim, with no details of fundus could be seen. He might have: a. Non proliferative diabetic retinopathy b. Cystoid macular edema c. Vitreous hemorrhage d. Central retinal vein occlusion ANSWER: C 66. Retro-bulbar optic neuritis is characterized by: a. Marked swelling of the optic disc. b. Impaired direct light reflex in the affected eye c. Impaired consensual light reflex in the affected eye d. Normal visual acuity ANSWER: B 67. The type of optic atrophy that follows retro-bulbar neuritis is: a. Secondary optic atrophy b. Consecutive optic atrophy c. Glaucomatous optic atrophy d. Primary optic atrophy ANSWER: A 68. A male patient 30 years old with visual acuity of 6/6 in both eyes. Twelve hours ago he presented with drop of vision of the left eye. On examination, visual acuity was 6/6 in the right eye and 6/60 in the left eye. Fundus examination showed blurred edges of the left optic disc. The most probable diagnosis is: a. Raised intra cranial pressure b. Raised ocular tension c. Central retinal artery occlusion d. Optic neuritis ANSWER: D 69. All are seen in 3rd nerve palsy except: a. Ptosis b. Diplopia c. Miosis d. Outwards eye deviation ANSWER: C 70. Homonymous hemianopia is due to lesion at: a. Optic tract b. Optic nerve c. Optic chiasma d. Retina e. Occipital cortex ANSWER: A 71. Optic nerve function is best studied by: a. Direct Ophthalmoscope b. Retinoscope c. Perimetry d. Gonioscopy e. ANSWER: C 72. Papilloedema has all the following characteristics except: a. Marked loss of vision b. Blurring of disc margins c. Hyperemia of disc d. Field defect ANSWER: A 73. D-shaped pupil occurs in: a. Iridocyclitis b. Iridodenesis c. Cyclodialsis d. Iridodialysis ANSWER: D 74. In complete third nerve paralysis the direction of the affected eye in the primary position is: a. Inward b. Outward c. Outward and up d. Outward and down ANSWER: D 75. All the following are extraocular muscle of eye except: a. Superior rectus b. Ciliary muscle c. Inferior oblique d. Superior oblique ANSWER: B 76. The action of superior rectus is: a. Elevation, intorsion, abduction b. Elevation, intorsion, adduction c. Elevation, extorsion, adduction d. Elevation, extorsion, abduction. ANSWER: B 77. The action of inferior oblique is: a. Depression, extorsion, abduction b. Depression, extorsion, adduction c. Elevation, extorsion, adduction d. Elevation, extorsion, abduction ANSWER: D 78. The only extraocular muscle which does not arise from the apex of the orbit is: a. Superior rectus b. Superior oblique c. Inferior oblique d. Inferior rectus ANSWER: C 79. In concomitant squint: a. Primary deviation > Secondary deviation b. Primary deviation < Secondary deviation c. Primary deviation = Secondary deviation d. None of the above ANSWER: C 80. The best treatment for amblyopia is: a. Orthoptic exercises b. Occlusion c. Surgery d. Best treat after age 10 years ANSWER: B Chapter1: Abdominal Pain The total number of MCQs is 12 Q1: A 60-year-old woman with a history of chronic abdominal discomfort presents with the sudden onset of severe generalized abdominal pain. Further history reveals that the patient is a smoker and has had many months of general, centralized abdominal pain. She describes that pain as burning and sometimes causing nausea. She has taken antacid medication on occasion for this chronic pain. The pain she is having now is very different. It is sharp and continuous and started exactly two hours ago. It is not radiating. Movement makes the pain worse. Taking a deep breath makes the pain worse. She has never had pain like this before and has no prior surgery. She denies weight loss, change in bowel habits or change in appetite. On a physical exam, the patient is tachycardic and clearly in distress. She is flat in bed and reluctant to change position. She has a low-grade fever, and her abdomen is diffusely tender and rigid with peritonitis. What is the likely diagnosis? A. Gastritis B. Gastroesophageal reflux C. Peptic ulcer disease D. Pneumonia with referred pain Q2: A 14-year-old boy presents with right lower quadrant pain, low grade fever and anorexia. His mother reports that he was perfectly well until 12 hours ago when he began having a vague centralized abdominal pain. He had an episode of non-bilious emesis after dinner and tried to go to sleep in order to feel better. He awoke in the middle of the night with severe right sided abdominal pain. The patient’s mother brought him to the emergency room because he was having a hard time walking. The patient complains of pain with any movement at all. He has no ill contacts, recent travel or other symptoms. He has never had pain like this before. The pain is now constant. Physical exam reveals an otherwise healthy boy. He has a temperature of 100.5 and is lying still on his side with his legs drawn up. His vital signs are normal. With difficulty he is able to lie on his back. Abdominal exam reveals tenderness to palpation of the right lower quadrant with rebound and involuntary guarding. What is the most likely diagnosis? A. Acute appendicitis B. Acute cholecystitis C. Urinary tract infection D. Crohn’s ileitis Q3: A 40-year-old woman who had a previous open appendectomy as a child presents with generalized abdominal pain, bilious emesis, and anorexia. She was previously healthy until earlier in the day when she began having waves of intermittent, cramping abdominal pain. She has never had pain like this before, but she described the pain as similar to labor pain. Nothing she does makes the pain better. The pain is not exacerbated by anything, but shortly after the pain started, she had two episodes of bilious emesis. She has had no fever or other changes to her bowel function. Her last stool was 12 hours before and was normal. She has two young children and no significant medical history apart from an open appendectomy done at the age of 8 years. On examination, her vital signs are normal. She appears unwell and she complains of intense nausea. Her abdomen is soft but distended and tympanitic to percussion. There is no peritonitis or palpable masses. What is the likely diagnosis? A. Small bowel obstruction B. Colon obstruction C. Ovarian torsion D. Food poisoning Q4: A 41-year-old woman presents with right upper quadrant abdominal pain, nausea and vomiting. She had a baby three weeks ago and had a similar episode during her pregnancy after eating some pizza, but it was short lived and never occurred again. The current pain developed about thirty minutes after eating ice cream. The pain was severe and associated with nausea and a non-bilious emesis. She has had no fever, weight loss, malaise or ill contacts. This attack again began in the right upper quadrant but was much worse than the prior attack. She came to the ER for evaluation, and after about an hour, the pain began to spontaneously get better. Physical exam reveals a moderately obese woman with stable vital signs. Her abdominal exam is normal. What is the likely diagnosis? A. Cholelithiasis B. Choledocholithiasis C. Gallstone pancreatitis D. Cholangitis Q5: A 5-year-old girl is brought to the emergency department because of fever and severe abdominal pain. Acute appendicitis is diagnosed. In the examination room, she keeps her right hip flexed and resists active extension of the hip. The inflamed structure associated with these symptoms is most likely in contact with which of the following structures? A. Abdominal wall and the external oblique muscle B. Obturator internus muscle C. Psoas major muscle D. Quadratus lumborum muscle Q6: A 65-year-old woman is admitted to the hospital for constant, severe abdominal pain that has worsened over the prior week. She has no other associated symptoms, such as nausea or vomiting, but has noticed that her daily urine output has sharply decreased. She has had a constant desire to urinate, but, when she tries, only a small amount of bloody urine is discharged. The patient is a long-time smoker, having smoked three packs per day for more than 45 years, although she claims to have quit 2 days ago. A bladder ultrasound in the emergency department reveals a mass consistent with bladder cancer, as well as significant urinary retention. Which of the following is most likely to be detected upon imaging the patient’s genitourinary system? A. Bilateral hydronephrosis B. Bladder dilation C. Bladder dyskinesis D. Unilateral hydronephrosis Q7: A 44-year-old man comes to the emergency department with abdominal pain and nausea for the past 24 hours. The pain started a few hours after dinner, and he describes it as constant pain in the upper part of his abdomen that radiates to his back and flanks. The patient also reports nausea, intermittent vomiting, and abdominal distention. Family history is significant for recurrent episodes of pancreatitis in his father and paternal uncle. He reports drinking an average of 2 alcoholic drinks per week. His temperature is 37.7ºC (99.9ºF), pulse is 92/min, respirations are 20/min, peripheral oxygen saturation is 96%, and blood pressure is 149/94 mmHg. He appears distressed and anxious. Abdominal examination shows tenderness and rigidity over the epigastric and periumbilical regions. Bowel sounds are diminished. No bruising of the umbilicus or flanks are seen. Which of the following laboratory results is the most specific in diagnosing this patient’s condition? A. Serum amylase > 3 times the upper limit of normal B. Serum lipase > 3 times the upper limit of normal C. Serum bilirubin > 4.0 mg/dL D. Elevated blood alcohol level Q8: A 22-year-old man develops marked right lower quadrant abdominal pain over the past day. On physical examination there is rebound tenderness on palpation over the right lower quadrant. Laparoscopic surgery is performed, and the appendix is swollen, erythematous, and partly covered by a yellowish exudate. It is removed, and a microscopic section shows infiltration with numerous neutrophils. The pain experienced by this patient is predominantly the result of which of the following two chemical mediators? A. Complement C3b and IgG B. Interleukin-1 and tumor necrosis factor C. Histamine and serotonin D. Prostaglandin and bradykinin Q9: A 26-year-old man comes to the physician because of a 6-month history of increasing generalized fatigue. He has been unable to work out at the gym during this period. He has also had mild cramping lower abdominal pain and occasionally bloody diarrhea for the past 5 weeks. His father was diagnosed with colon cancer at the age of 65. He has smoked one-half pack of cigarettes daily for the past 10 years. He drinks 1-2 beers on social occasions. His temperature is 37.3"C (99.1 F), pulse is 88/min, and blood pressure is 116/74 mm Hg. Physical examination shows dry mucous membranes. The abdomen is soft and nondistended with slight tenderness to palpation over the lower quadrants bilaterally. Rectal examination shows stool mixed with blood. His hemoglobin concentration is 13.5 g/dL, leukocyte count is 7500/mm3, platelet count is 480,000/mm3, and erythrocyte sedimentation rate is 15 mm/h. Results of urinalysis are within the reference ranges. Which of the following is the most appropriate next step in management? A. Colonoscopy B. Flexible sigmoidoscopy C. D-xylose absorption test D. CT scan of the abdomen and pelvis with contrast Q10: A 71-year-old man comes to the physician accompanied by his wife because of a 6- month history of worsening episodic upper abdominal pain and an 8-kg (17.6-lb) weight loss The pain is dull, nonradiating, worse after eating, and occasionally associated with bloating and diarrhea, His symptoms have not improved despite 4 weeks of treatment with omeprazole. He attributes his weight loss to recently eating very small portions and avoiding fatty foods. He has hypertension and hypercholesterolemia. He underwent a coronary artery bypass graft operation for coronary artery disease 8 years ago. Current medications include lisinopril, metoprolol, atorvastatin, and aspirin. He has smoked a pack of cigarettes daily for 40 years and drinks 1-2 beers daily. His pulse is 79/min and blood pressure is 138/89 mm Hg. Examination shows a soft abdomen without tenderness to palpation or guarding. Which of the following is most likely to confirm the diagnosis? A. Serum CA 19-9 concentration B. Colonoscopy C. Right upper quadrant abdominal ultrasound D. CT angiography of the abdomen Q11:A 48-year-old woman comes to the physician because of recurrent right upper abdominal pain for 3 weeks. The pain usually occurs after meals and tends to radiate to the right shoulder. She reports that she otherwise feels well. She has more energy since she started an intermittent fasting diet and has rapidly lost 9.0 kg (20 lbs). She is 1 60 cm (5 ft 3 in) tall and weighs 100 kg (220 |b); BMI is 39 kg/m?. Physical examination shows a nontender abdomen. Abdominal ultrasonography shows several small stones in the gallbladder without calcification. When discussing treatment options, she states that she does not wish to undergo surgery and asks about other possibilities. Which of the following is the most appropriate pharmacotherapy to address the underlying cause of this patient's condition? A. Gemfbrozil B. Ursodeoxycholic acid C. Ezetimibe D. Dicyclomine Q12: A 24-year-old woman with Turner synarome comes to the physician because of diarrhea for the past 4 months. She also reports bloating, nausea, and abdominal discomfort that persists after defecation. For the past six months, she has felt tired and has been unable to do normal chores. She went on a backpacking trip across Southeast Asia around seven months ago She is 144 cm (4 ft 9 in) tall and weighs 40 kg (88 Ib); BMI is 19 kg/m2. Her vital signs are within normal limits. Examination shows pale conjunctivae and angular stomatitis. Abdominal examination is normal. Laboratory studies show: Hemoglobin: 9.1 mg/dL, Leukocyte count: 5100/mm3, Mean corpuscular volume: 67 µmm, Serum Glucose: 89 mg/dL, Creatinine: 1.2mg/dL, Ferritin: 8ng/mL, IgA tissue transglutaminase antibody :Positive. Based on the laboratory studies, a biopsy for confirmation of the diagnosis is suggested, but the patient is unwilling to undergo the procedure. Which of the following is the most appropriate next step in management of this patient's gastrointestinal symptoms? A. Probiotic therapy B. Metronidazole therapy C. Avoid milk products D. Gluten-free diet Chapter2: Abdominal Distension The total number of MCQs is 12 Q1: A 68-year-old woman who has had a previous hysterectomy presents with an 8-hour history of cramping periumbilical pain. Each episode of pain lasts 3 to 5 minutes and then abates. Over several hours she develops nausea, vomiting, and abdominal distension. She has been unable to pass stool or flatus for the past 4 hours. What’s the most likely diagnosis? A. Acute pancreatitis B. Acute cholecystitis C. Intestinal obstruction D. Irritable bowel syndrome (IBS) Q2: A 47-year-old man presents complaining of weight gain, on examination there is an abdominal distension with a fluid thrill. Which of the following is Not a cause of ascites secondary to venous hypertension? A. Congestive heart failure B. Liver Cirrhosis C. Constrictive pericarditis D. Nephrotic syndrome Q3: A 12-day-old male born at 33 weeks becomes lethargic and hypothermic over the course of 24 h. He is not tolerating his formula feeds, has two episodes of bilious emesis, and has three episodes of bloody diarrhea. Physical exam reveals abdominal distention, visible loops of bowel, abdominal wall erythema, and absent bowel sounds. What is the most likely diagnosis? A. Hirschsprung’s disease B. Duodenal atresia C. Esophageal atresia with tracheoesophageal fistula D. Necrotizing enterocolitis Q4: A 60-year-old alcoholic man presents with a 12-hour history of severe epigastric pain radiating to the back, nausea, and vomiting. Pain is somewhat better when he leans forward. He drank a 24-pack of beer 2 days ago. He does not take any medications. Physical exam is significant for abdominal distension, decreased bowel sounds, and epigastric tenderness with guarding. Vital signs are temperature 38.1°C, pulse 110 bpm, respirations 27/min, and blood pressure 130/85. What is the most likely diagnosis? A. Acute Pancreatitis B. Irritable Bowel Syndrome C. Splenomegaly D. Peptic Ulcer Q5: A 72-year-old man with a 25-year history of alcoholism and liver disease visits his physician because of sudden weight gain. One year ago the man had a body mass index (BMI) of 24.9 kg/m2; today his BMI is 28.5 kg/m2. Physical examination shows +3 edema in his feet and moderate ascites. Which condition is most likely to have promoted the development of both ascites and peripheral edema in this man? A. Decreased capillary hydrostatic pressure B. Decreased plasma colloid osmotic pressure C. Increased capillary hydrostatic pressure D. Increased plasma colloid osmotic pressure Q6: A 65-year-old woman with hepatic cirrhosis comes to her physician for a checkup. Physical examination shows ascites. The woman’s prothrombin time has doubled since her last visit 3 months ago, and her hematocrit is now 30 percent. What is the most likely cause of this low hematocrit? A. Colon cancer B. Esophageal varices C. Jaundice D. Pancreatitis Q7: A 61-year-old male is admitted to your service for the abdomen distension. You detect ascites on clinical examination and perform a paracentesis. The results show a white blood cell count of 300 leukocytes/µL with35% polymorphonuclear cells. Peritoneal albumin level is 1.2 g/dL, protein is 2.0 g/dL, and triglycerides are 320 mg/dL. Peritoneal cultures are pending. Serum Albumin is 2.6 g/dL. Which of the following is the most likely diagnosis? A. Congestive heart failure B. Peritoneal tuberculosis C. Peritoneal carcinomatosis D. Bacterial peritonitis Q8: A 54-year-old man comes to the emergency department because of abdominal distention for the past 3 weeks.He appears cachectic. His vital signs are within normal limits. Examination shows a distended abdomen and shifting dullness. There is no abdominal tenderness or palpable masses. He has bilateral lower extremity non pitting edema. Diagnostic paracentesis is performed. Laboratory studies shows a cloudy nature of the ascitic fluid, a serum-ascites albumin gradient (SAAG) < 1.1 and a triglyceride count > 200 mg/dL.Gram stain of the peritoneal fluid shows no organismsWhich of the following is the most likely cause of this patient's symptoms? A. Intra Abdominal lymphoma B. Peritoneal tuberculosis C. Nephrotic syndrome D. Bacterial peritonitis Q9: A 75-year-old man develops hematochezia and presents with hemodynamic instability. The patient's vital signs improve slightly with crystalloid and packed red cells infusion. Which of the following is considered the most appropriate next step(s) in management? A. EGD, proctosigmoidoscopy, and a barium enema B. NG tube, proctosigmoidoscopy, and a tagged RBC scan with or without mesentery angiography C. NG tube, mesentery angiography, and colonoscopy D. EGD and colonoscopy Q10: John is a 28-year-old man who presents to his gastroenterologist with a two-week history of abdominal pain, bloody diarrhea, and urgency to have a bowel movement. He has a history of ulcerative colitis, which was previously well-controlled with medication, but he stopped taking his medications several months ago due to financial constraints. After further investigation, the gastroenterologist confirms that John's ulcerative colitis has flared up and that the inflammation has spread throughout his colon. Which one of the following most likely the gastroenterologist performed? A. Stool analysis and culture B. CT scan abdomen C. Colonoscopy D. Vitamin B12 and folate Q11: L is a patient of chronic liver disease presented with altered mental status and flapping tremors. A month ago, on examination the patient had ascites, spider angiomas, and icteric sclerae. Laboratory investigations reveal elevated liver enzymes, bilirubin, and low albumin levels. He was diagnosed with hepatic encephalopathy. He was started lactulose for management. What is rationale for using lactulose in this patient? A. stimulates dopamine receptor in gut. B. it is active against the bacteria producing ammonia in gut it C. is active against hepatitis B. D. inhibits absorption of ammonia in gut Q12: Michael is a 55-year-old man who presents to his primary care physician for a routine check-up. He reports a history of chronic HCV infection, which was poorly managed for two years. The doctor suspected ascites after noticing moderate abdominal distention and performed a shifting dullness which was positive. Regarding his condition, what is the gold standard for documenting response to treatment from HCV ? A. HCV antibody by ELISA B. HCV-RNA C. HCV-DNA D. HCV-antigen by EIA Chapter5: Joint Pain The total number of MCQs is 12 Q1: A 40-year-old woman presents with symmetric stiffness and swelling of the proximal interphalangeal joints of the hands and of the metacarpophalangeal joints, as well as fatigue, malaise, and myalgia. Symptoms are worse in the morning or after extended inactivity and improve with movement and use throughout the day. Ulnar deviation of the fingers symmetrically on both hands is noted. Which of the following is the most likely etiology of this condition? A. Autoimmune disease B. Mechanical injury (*wear and tear") C. Neisseria gonorrhoeae infection D. Secondary manifestation of chronic lung disease or cyanotic cardiac disease Q2: Rheumatoid arthritis (RA) is different from some other forms of arthritis because it… A. Is more painful than other forms B. Occurs below the waist C. Is symmetrical, affecting the right and left sides of the body D. Generally occurs above the waist Q3: A 60- year old male presents to the clinic suffering from weakness and difficulty climbing stairs.He is also stiff at morning and feels pain after activity. On examination he has limited unilateral knee flexion and swollen distal interphalangeal joints, on X-ray of the knee and hand there are osteophytes on the base of DIP joints and on the medial condyle of the tibia. What is the best diagnosis? A. Psoriatic arthritis B. Gout C. Osteoarthritis D. only Gait problems Q4: People with rheumatoid arthritis experience the most stiffness at night. A. True B. False Q5: A 74-year-old, obese woman (BMI = 33 kg/m2) complains of chronic pain in her back, knees, and fi ngers. The pain typically subsides at rest. On physical examination, the distal interphalangeal joints are enlarged and tender. Which of the following best describes the pathogenesis of joint pain in this patient? A. Acute inflammation of the ligaments B. Degeneration of articular cartilage C. Degenerative changes of cortical bone D. Reduction of the volume of synovial fluid Q6: A 72-year-old man presents with an acutely painful right knee. On examination, he had a temperature of 37℃ with a hot, swollen right knee. Of relevance amongst his investigations, was his white cell count which was 12.6 Χ 10 9 /l and a knee X-ray revealed reduced joint space and calcification of the articular cartilage. Culture of aspirated fluid revealed no growth. What is the most likely diagnosis? A. Gout B. Psoriatic monoarthropathy C. Pseudogout D. Rheumatoid arthiritis Q7: Which of the following is true of rheumatoid arthritis? a) Rheumatoid factor is present in 25% of rheumatoid cases b) It is an example of an oligoarthropathy c) Anaemia is a common finding d) Heberden's nodes are a feature Q8: Which of the following is true of psoriatic arthropathy? a) The absence of plaques of psoriasis excludes the diagnosis b) The diagnosis can be confirmed by a blood marker c) Tophi can sometimes be seen over affected joints d) Nail pitting may give a clue to the diagnosis Q9: A 58-year-old woman comes to the physician because of a 3-month history of left knee pain as well as stiffness upon waking for about 10-15 minutes. The pain is worse after standing a lot at work and when she climbs stairs. There is no history of trauma. She does not smoke or drink alcohol. Current medications include atorvastatin, labetalol, and aspirin. Over the past 2 months, she has been taking over-the-counter ibuprofen as needed for the joint pain. She is 163 cm (5 ft 4 in) tall and weighs 84 kg (185 Ib); BMI is 32 kg/m2. Her temperature is 37.0°C (98.6°F), pulse is 88/min, and blood pressure is 114/68 mm Hg. Examination of the left knee shows tenderness on palpation of the anteromedial joint line; there is crepitus and pain with full flexion and extension. Serum uric acid concentration is 8.0 mg/dL, and erythrocyte sedimentation rate is 15 mm/h. Which of the following is the most likely finding on imaging of the left knee? A. Calcification of synovia and cartilage on ultrasound B. Osteophytes with joint space narrowing on x-ray C. Joint effusion and pannus on ultrasound D. Diffuse lytic-sclerotic bone lesions on x-ray Q10: A 39-year-old woman comes to the physician because of progressive pain and swelling of her wrists and hands for the past 2 months. Her hands are stiff in the morning; the stiffness decreases as she starts her chores. She also reports early-morning neck pain at rest for the past 3 weeks. She has no history of serious illness and takes no medications. Her sister has systemic lupus erythematosus. Vital signs are within normal limits. Examination shows bilateral swelling and tenderness of the wrists, second, third, and fourth metacarpophalangeal joints; range of motion is limited by pain. There is no vertebral tenderness. Cardiopulmonary examination shows no abnormalities. Neurologic examination shows no focal findings. Laboratory studies show: Hemoglobin 12.8 g/dL, Leukocyte count 9800/mm3, Erythrocyte sedimentation rate 44 mm/h and Rheumatoid factor positive. Which of the following is the most appropriate next step in management? A. Arthrocentesis B. X-ray of the cervical spine C. CT scan of the chest D. Measurement of anti-Smith antibodies Q11: A 67-year-old woman comes to the physician for the evaluation of bilateral knee pain for the past year. She reports that the pain is worse with movement and is relieved with rest. She has type 2 diabetes mellitus. The patient says her mother takes leflunomide for a "joint condition." The patient's medications include metformin and a multivitamin. She is 165 cm (5 ft 5 in) tall and weighs 85 kg (187 lb); BMI is 31 kg/m2. Vital signs are within normal limits. Physical examination shows pain both in complete flexion and extension, crepitus on joint movement, and joint stiffness and restricted range of motion of both knees. X-ray of the knee joints shows irregular joint space narrowing, subchondral sclerosis, osteophytes, and several subchondral cysts. There is no reddening or swelling. Which of the following is the most appropriate pharmacotherapy? A. Administration of infliximab B. Administration of oral prednisolone C. Administration of ibuprofen D. Administration of methotrexate Q12: A 42-year-old woman comes to the physician because of an 8-monthhistory of intermittent pain and stiffness in her hands and feet. She reports that these episodes occur about three times a month after she wakes up and last for approximately one hour. The episodes are sometimes accompanied by fever and myalgia. She takes ibuprofen during the episodes, which provides sufficient pain relief. She had her last attack 5 days ago. She is otherwise healthy and takes no medications. Her sister has systemic lupus erythematosus. Vital signs are within normal limits. Examination shows mild swelling and tenderness of the wrists and the proximal interphalangeal joints of both hands. The remainder of the examination shows no abnormalities. An x-ray of her hands is shown. Which of the following is the most appropriate pharmacotherapy? A. Methotrexate B. Ceftriaxone C. Adalimumab D. Diclofenac Chapter6: Backache The total number of MCQs is 12 Q1: A 20-year-old man presents to accident and emergency with sudden onset pain in the right eye, with associated blurred vision and discomfort when gazing at the lights. He has a history of back pain and has recently been diagnosed with ankylosing spondylosis. What is the most likely cause of his eye pain? A. Conjunctivitis B. Retinal detachment C. Anterior uveitis D. Corneal ulceration E. Acute glaucoma Q2: A 69-year-old man presents to a clinic with a six-month history of progressive lower back pain which radiates down to his buttock. He found the pain was exacerbated while taking his daily morning walk and noticed that it eased going uphill but worsened downhill. He stopped his daily walks as a result and he now walks only slowly to the shops when he needs to, taking breaks to sit down and ease the pain. He has a history of hypertension, diabetes and prostatic hyperplasia. What is the diagnosis? A. Peripheral vascular disease B. Osteoporotic fracture C. Spinal stenosis D. Sciatica E. Metastatic bone disease Q3: A 45-year-old man presents to accident and emergency with back pain. He works as a builder and the pain started after he had moved a cement mixer. On presentation, he is in considerable distress and unable to walk. He has not passed urine or opened his bowels since the incident. On peripheral neurological examination of the lower limbs, power is reduced throughout due to the pain. Sensation is preserved except for around the perineum. On digital rectal exam, there is poor anal tone. What is the most likely diagnosis? A. Spinal cord compression B. Cauda equina syndrome C. Nerve root compression D. Bony injury E. Muscular strain Q4: A 31-year-old woman presents to accident and emergency with progressive difficulty walking associated with lower back pain. A few days ago she was tripping over things, now she has difficulty climbing stairs. She describes tingling and numbness in both hands which moved up to her elbows, she is unable to write. On examination, cranial nerves are intact but there is absent sensation to vibration and pin prick in her upper limbs to the elbow and lower limbs to the hip. Power is 3/5 in the ankles and 4−/5 at the hip with absent reflexes and mute plantars. Her blood pressure is 124/85, pulse 68 and sats 98 per cent on air. She has a past medical history of type I diabetes and recently recovered from an episode of food poisoning a month or two ago. What is the diagnosis? A. MS B. Guillain–Barré syndrome (GBS) C. Myasthenia gravis D. Diabetic neuropathy E. Infective neuropathy Q5: A 50-year-old woman presents with lower back pain of 3 weeks in duration. Radiologic studies reveal several discrete lytic lesions in the lumbar back and pelvis. Laboratory studies show elevated serum levels of alkaline phosphatase. Serum calcium, serum protein, and peripheral blood smears are normal. Aspiration biopsy of a pelvic lesion shows keratin positive cells. Which of the following is the most likely diagnosis? A. Chondrosarcoma B. Metastatic Carcinoma C. Osteochondroma D. Osteosarcoma Q6: A 74-year-old, obese woman (BMI = 33 kg/m2) complains of chronic pain in her back, knees, and fingers. The pain typically subsides at rest. On physical examination, the distal interphalangeal joints are enlarged and tender. Which of the following best describes the pathogenesis of joint pain in this patient? A. Acute inflammation of the ligaments B. Degeneration of articular cartilage C. Degenerative changes of cortical bone D. Inflammatory synovium with pannus formation Q7:23-year-old man complains of stiffness and pain in his lower back that causes him to awaken at night. He first noticed morning stiffness in his lower back during his college years. He also describes occasional pain in his right eye and sensitivity to light. An X-ray of the sacroiliac region shows fusion of the small joint spaces in the posterior spine and ossification of the intervertebral discs. Serologic tests for rheumatoid factor and antinuclear antibodies are negative. This patient most likely expresses which of the following human leukocyte antigen (HLA) haplotypes? A. B15 B. B19 C. B27 D. B31 Q8: A 46-year-old woman with severe asthma presents with increasing weight and back pain for 9 months. The patient is taking corticosteroids for her asthma. An X-ray of the vertebrae will likely reveal which of the following pathologic findings? A. Dislocation B. Osteomalacia C. Osteomyelitis D. Osteoporosis Q9: A 30-year-old man comes to the clinic due to progressive back pain for the past 2 months. He describes night pain and some morning stiffness that improves with a morning stretching routine. The pain is 3/10 in severity, dull, and located in the lower back. Recently, he started experiencing pain in the right wrist and left ankle, which he attributed to a strenuous basketball game that he took part in. He is working as a computer engineer and has difficulty concentrating due to pain. Vitals are within normal limits. On physical examination, there is limited spine mobility during flexion and some redness and warmth around the right wrist and left knee. The rest of the physical examination is within normal limits. Further evaluation is most likely to reveal which of the following? A. Antibodies against DNA topoisomerase-I B. Antibodies against signal recognition particle C. HLA DR2 positive genotype D. HLA B27 positive genotype Q10: A 70-year-old woman with a history of vertebral crush fractures presents to the osteoporosis outpatient clinic. Which of the following investigations is most useful to assess the extent of her osteoporosis? A. Spinal x-rays B. MRI scan C. Vitamin D levels D. DEXAscan Q11: A 23-year-old man presents to the rheumatology clinic with lower back and hip pain. These have been occurring every day for the past two months. Pain and stiffness are worse in the mornings. He also mentions that his right heel has been hurting. He is previously fit and well, but had occasions of lower back pain when he was a teenager. His symptoms have stopped him from playing tennis. Recent blood tests organized by his GP have shown a raised C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). What is the most appropriate treatment? A. NSAID and spinal exercises B. NSAID and bed rest C. Oral Prednisolone D. Methotrexate plus sulfasalazine Q12: Patient came to FM clinic complaining of intermittent LBP for 2 years that radiates to the thigh and legs, it gets worse with prolonged standing and relieved by forward flexion. No motor deficits or any other worrisome symptoms. How would you manage this patient? A. Increase physical activity time B. Bed rest C. Analgesia (NSAIDS) D. Refer to neurology

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