Super difficult question. – A middle age woman with 3 episodes of palpitation over the past few months. Apical impulse displaced to left with 3rd heart sound heard at apex in left lateral position. Holosystic murmur heard loudest at apex radiating to axilla. Cause?
a) Bacterial infection of the mitral valve
b) Mitral annular calcification
c) Myxomatous degeneration of the mitral valve
A collegiate soccer player who enjoys trail running. Now come with pain. Foot shows a moderately high arch with no discoloration or deformity. Direct pressure to the bottom of the heel elicits sharp pain, but mediolateral squeezing of the heel causes no discomfort. Cause?
a) Entrapment of the posterior tibial nerve
b) Increased foot compartment pressures
c) Inflammation of the plantar aponeurosis
Breast lump 3 cm in post menopausal woman, her estrogen receptor are positive. And spread to the her 3 bones vertebral bone. What is your initial management?
a) Mastectomy
b) Radio
c) Chemo
d) Tomoxifen
e) Etarnacept
A patient came with high bp . Lives with her daughter. She was prescribed anti hypertensive By previous GP. She didn’t see any doctor last 8 months. She didn’t continue medicine . She was surprised to know that she was supposed to continue the medicines.
a) Call the previous doctor
b) Ask her to come with her daughter
c) Check with pharmacy about the medicines dispensing record
d) Refer the patient to psychiatrist
A 60 years old male had several occasions where his left side would go numb for a while 3-4 times a month with Double vision, extreme fatigue and vertigo. What is your probable diagnosis?
a) Meningioma
b) PICA ischemia
c) DM
d) Multiple sclerosis
e) Inactivity
A woman come to clinic for screening of thrombophilia. She turns out positive for factor V Laiden deficiency. What’s your management?
a) Aspirin
b) IV heparin
c) Subcutaneous enoxaparin
d) Warfarin
Female 17 years old heavy drinker ,drinks a lot, drowsiness about 14 standard per week come for advice ?
a) stop alcohol completely
b) 2 days free alcohol/week
c) 2 standard/day
d) tell her its illegal to drink in this age
Patient has claudication on walking and relieved on rest. On examination, patient femoral pulses are diminished and dorsal is Pedis not felt. ABI one leg 0.8 and another 1.3. What is the most appropriate?
a) CT angio
b) duplex Doppler
c) start on statins
d) LMWH
Mother wants to start weaning of 6 months old who wants breast feed for comfort at night and cries at night wakes up several time. Currently on breastfeeding and infant formula. what’s the preferred option to start with?
a) Formula follow on
b) Rice cereal
c) Family food puree
d) Egg pudding
e) Cow milk
Treatment of ramsay hunt syndrome in normal pts & Immunocompromised Young patient with Bell’s palsy only facial weakness with inability to close eyes and mouth deviated. No other symptoms, otherwise healthy. Ear is normal . How will you manage?
a) Acyclovir
b) Steroid
c) Combined acyclovir and steroid
d) No treatment required
Right side headache followed by severe shooting facial pain- pt has right sided weakness of face and limbs- ct brain normal-. Heretic encephalitis
a) Right parieto temp infarct
b) Right medullary infarct
c) Right pontine infact
35 yr-old gravida 1 para 0, at 35 wks 1 gestation is evaluated for fever & chills. Admitted 3 days ago for acute pyelonephritis. Tenderness over the right flank. Cervix is 1 cm dilated & 25% effaced; irregular contractions & amniotic membranes intact. Next step?
a) Amniocentesis and amniotic fluid culture
b) Emergency cesarean delivery
c) Renal ultrasound
76 yr-old man is brought for evaluation of fecal incontinence of small volume soft stools. History of lung cancer metastatic to the bones & liver; takes opiate analgesics. Has chronic constipation with 1 or 2 hard bowel movements per wk. Having mild nausea & decreased appetite. Next step?
a) Advise as needed loperamide
b) Evaluate for fecal impaction
10 mth-old girl is brought for evaluation of bright red stools with mucus & diffuse abdominal tenderness. The patient goes to day care & several other children have had runny nose, vomiting & diarrhea over the past wk. Diagnosis?
a) Acute dysentery
b) Appendicitis
c) Intussusception
27 yr-old woman comes due to facial weakness on the entire left side including the forehead & incomplete eye closure. Difficulty eating breakfast & orange juice leaked out the left side of her mouth. Next step?
a) Chest x-ray
b) HIV testing
c) No additional testing needed
32 yr-old gravida 1 para 1, is evaluated on postoperative day 1 for difficulty walking. Epidural analgesia was placed during labor & a forceps-assisted delivery was attempted but failed. Underwent a cesarean delivery via Pfannenstiel incision. The right patellar reflex is 2+ & the left 1+. Cause?
a) Hyperflexion of the hips during the second stage of labor
b) Improper placement of the epidural analgesia
67 yr-old man is brought due to progressively worsening insomnia, impaired concentration & judgment. Horizontal nystagmus, mild spasticity, myoclonus & hyperreflexia are present. Cerebral atrophy & diffuse bright signals in the cortical white matter & portions of the basal ganglia. Diagnosis?
a) Carbon monoxide poisoning
b) Leptomeningeal carcinomatosis
c) Pron disease
65 yr-old man comes due to progressively worsening dyspnea & fatigue over the last 2 wks. Lifestyle sedentary. Diagnosed with lung cancer a yr ago & underwent surgical resection followed by chemotherapy. Other medical conditions include chronic kidney disease & hypertension. Next step?
a) CT angiography of the chest
b) Echocardiography
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9 yr-old African Australian boy is brought due to high fever, poor appetite & irritability. BP 80/60 & pulse 140. History of hematuria. Missed several routine vaccinations. Hematocrit 22% & reticulocyte count 12%. Dies several hrs later. Death could be prevented by?
a) Folic acid supplementation
b) Vaccination with a live attenuated virus
c) Vaccination with a conjugate polysaccharide
67-yr-old woman comes due to progressive fatigue & anorexia over the last 6 mths. Medical history significant for hypothyroidism, hypertension & gout. Slightly thin but well nourished; mild mucosal pallor. FISH reveals an abnormality in chromosome Target in treatment?
a) DNA mutations
b) Folic acid metabolism
c) Tyrosine kinase
49 yr-old man comes due to a 3-mth history of fatigue, joint pain, finger swelling & difficulty gripping objects with his right hand. Poorly controlled hypertension. Facial features coarser & differ significantly from 3 yrs ago. Next step?
a) Fasting growth hormone level
b) Growth hormone level following an oral glucose load
c) IGF1 level
33 yr-old woman comes due to low mood & anxiety. Just broke up with her boyfriend & was recently passed over for a promotion at work. Difficulty falling asleep & often lies awake at night worrying about her future. No psychiatric history; no suicidal ideation. Management?
a) Bupropion
b) Escitalopram
c) Psychotherapy
47 yr-old man is evaluated for progressively worsening dyspnea on exertion for several mths. Frequent awakenings at night due to a choking sensation & feels tired all the time. BP 166/100; BMI 48. Trace bilateral pitting edema is present. Additional findings?
a) Anemia due to low erythropoietin
b) Decreased chloride due to bicarbonate retention
34 yr-old woman was recently discharged on oral hydrocortisone therapy from syncopal episode due to low serum cortisol level & subnormal response to ACTH stimulation. Intermittent episodes of light-headedness & nausea after discharge; consumes excessive amounts of salty foods. Next step?
a) Add fludrocortisone
b) Add midodrine
40 yr-old woman was diagnosed with preeclampsia with severe features after delivery at 38 wks gestation. Magnesium sulfate infusion was initiated for seizure prophylaxis & BP improved with intermittent hypertensive therapy. Deep tendon reflexes absent; bilateral pitting edema. Next step?
a) Calcium gluconate
b) Intravenous heparin infusion
34 yr-old woman is brought after a syncopal episode. Currently on day 10 of her menstrual cycle. On speculum exam, multiple blood clots are removed from the vaginal vault. Active bleeding from the cervical os. Bimanual exam shows a 12-wk- size, irregularly shaped, enlarged uterus. Cause?
a) Cyclic bleeding of ectopic endometrial glands
b) Endometrial glands and stroma within the myometrium
c) Proliferation of smooth muscle within the myometrium
42yo came for f/up. was diagnosed with acute appendicitis and done op. HPE shows adenocarcinoma with length 2mm. What is the next step of management?
a) left hemicolectomy
b) right hemicolectomy
c) chemo
d) reassurance
e) colonoscopy
56 yr-old man vomits bright red blood several times during the past 2 hrs. History of peptic ulcer disease & alcoholic cirrhosis. Rectal exam shows internal hemorrhoids & maroon stool positive for occult blood. Given a normal saline infusion through a peripheral intravenous catheter. Next step?
a) Administer octreotide infusion
b) Obtain second intravenous access
46 yr-old man comes due to bilateral ankle & facial swelling, especially prominent in the periorbital area. Exam shows bilateral 1+ pitting ankle edema. Dipstick urinalysis is positive for protein. 24- hour urine collection shows proteinuria of 4.6 g/day. Cause?
a) Decreased 1-alpha-hydroxylation of 25-OH vitamin D
b) Decreased 25-hydroxylation of vitamin D
c) Decreased serum albumin
33 yo man wants preoperative evaluation. no chest pain, shortness of breath but has difficulty sleeping. BMI is 28.2 kg/m2. Blood pressure is 128/76 mm Hg, pulse is 82/min. Required tests to check perioperative risk?
a) Chest x-ray
b) Coagulation profile
c) No further testing is required
15yo girl, painful menstrual periods. irregular menses, increasingly painful. lower abdominal pain lasts 2 days, fatigue, dizziness, and diarrhea. Depression history. diagnosis?
a) Adenomyosis
b) Endometriosis
c) Primary dysmenorrhea
37 yo man tachypnea., fell off during work. femur fracture, need urgent operative repair. history with chronic low back pain, take opioids. findings?
a) Excessive saline infusion
b) Illicit opioid use
c) Inadequate pain control
31yo woman, 10 weeks gestation. history type 1 diabetes mellitus, multiple daily insulin injections. Urinalysis reveals 2+ protein. Cause of proteinuria?
a) Diabetic nephropathy
b) Gestational hypertension
41 yo man HIV infection. 3 weeks of headache, vomiting. Stiff neck. CT scan head shows hydrocephalus. diagnosis?
a) Herpes encephalitis
b) Neurocysticercosis
c) Tuberculosis
6yo boy rhinorrhea. cough that is worse at night. mild pain upper cheeks. appetite decreased, drinking fluids normally. Nasal yellow- green in color. upper cheeks mild discomfort. next step?
a) Antihistamine therapy
b) Inhaled bronchodilator therapy
c) Supportive care
4yo boy behavioral concerns. difficult remain calm during thunderstorms. disrupt sleep schedule. starts to cry when hears thunder. recommendation to parents?
a) Allow the patient to continue behaviors that provide him relief during storms
b) Provide to the patient examples of classmates who are not afraid of storms
c) Read stories that depict storms with the patient
2yo boy pallor. no fever, vomiting, diarrhea, or rashes. appears pale. Abdominal shows marked splenomegaly. extremities are cyanotic. most likely laboratory profiles?
a) Reticulocytes – Decreased, Platelets – Decreased
b) Reticulocytes – Decreased, Platelets – Normal
c) Reticulocytes – Increased, Platelets – Decreased
21yo man, hematuria, right flank pain. no dysuria or fever. Smokes cigarettes occasionally. Renal ultrasound shows increased echogenicity of the renal medulla, but no hydronephrosis. cause?
a) Glomerulonephritis
b) Nephrolithiasis
c) Papillary necrosis
74yo man, lumbar laminectomy due to degenerative disc disease. Include hypertension and chronic kidney disease. takes lisinopril and acetaminophen/hydrocodone as needed for pain. next step?
a) Chest x-ray
b) CT scan of the head
62yo man, 7 hours of epigastric pain, nausea, vomiting containing bile. Medications include atorvastatin, lisinopril, metoprolol, warfarin, insulin lispro, and glargine. x- ray shows a small amount of free air under the right diaphragm. appropriate interventions?
a) Intravenous colloid infusion
b) Intravenous desmopressin
c) Prothrombin complex concentrate
5yo boy, bed-wetting, twice a week. frequent nighttime bed-wetting. liquid stool frequently leaked onto the underwear. height and weight, 50th percentile. left side abdomen is firmer compared to the right. next step?
a) Laxative therapy
b) Lumbosacral MRI
63yo man, palpitations and lightheadedness. history of coronary artery disease. Taken metoprolol, lisinopril, aspirin, clopidogrel, and rosuvastatin. ECG shows mild left ventricular dilation, a left ventricular ejection fraction of 30%, and no major valvular abnormality. next step?
a) Amiodarone
b) Carotid sinus massage
34yo man, lethargy. history of heroin injection. pupils are dilated. unable to hold head up, and respirations are shallow. Mechanical ventilation is begun. Next step?
a) Comprehensive drug screen
b) Equine botulinum antitoxin
4 week-old girl in nursery for 3 weeks of phototherapy. skin and eyes remain yellow. blood type is A, Rh-D positive. Weight and length at 50th percentile. cause?
a) ABO incompatibility
b) Beta thalassemia
c) Hereditary spherocytosis
1 week-old neonate, rash on back and bilateral groin areas. breastfed every 2 hours. no fever. bilateral groin areas similar lesions. next step?
a) Apply high-potency topical corticosteroid
b) Apply topical antihistamine
c) Avoid overbundling and switch to thin, cotton clothing
39yo man, anal pain during defecation. no abdominal pain, diarrhea, or blood in the stool. perianal skin inflamed. next step?
a) Anorectal manometry
b) Colonoscopy
c) Surgical evaluation
61yo woman, right-sided headache, ocular pain, and nausea. decreased vision in the right eye. right eye has red conjunctival flushing and nonreactive to light. next step?
a) Dilated fundus examination
b) Fluorescein eye examination
c) Intravenous acetazolamide
31yo physician insomnia for 7 weeks. restless at night. drinks 3-4 beers on the weekends. does not use tobacco or illicit drugs. tired and speaks in a low volume. next step?
a) Advise the patient to discontinue caffeine use
b) Prescribe low-dose lorazepam
c) Prescribe paroxetine
49 yo woman, nausea, right flank pain. abdominal hysterectomy and tumor debulking. tachycardia with weak pulses. urine is dark red. diagnosis?
a) Blood culture
b) Cystoscopy
c) Direct Coombs test
